Osteomyelitis Septic Arthritis Melih Güven, M.D Assoc. Prof. Yeditepe University Hospital Department of Orthopaedics and Traumatology Istanbul

Learning Objectives 1. Should be able to do the classification of osteomyelitis and septic arthritis 2. Should be able to explain the pathogenesis of osteomyelitis and septic arthritis 3. Should be able to list the possible pathogens of osteomyelitis and septic arthritis due to classification and patient age 4. Should be able to define the laboratory findings of osteomyelitis and septic arthritis 5. Should be able to list the clinical and pathological findings of osteomyelitis and septic arthritis 6. Should be able to list the drugs that are being used for the treatment of different pathogens

Bone and Joint Infections Osteomyelitis Infection of the bone and bone marrow (osteo, myelitis) Mostly bacterial, can be fungal Septic Arthritis Infection of joints Mostly bacterial, can be fungal and viral

Osteomyelitis

Osteomyelitis Well known disease since Egyptians Pre-antibiotic era had 25% mortality Significant morbidity/disability worldwide due to lack of access to care Leading cause for amputations Significant cause of pediatric disability worldwide

Osteomyelitis Acute Hematogeneus Osteomyelitis Acute osteomyelitis Newborn Children Adults Sickle Cell Anemia Hemodialysis and iv Drug abused patients Acute osteomyelitis Chronic Osteomyelitis Subacute Osteomyelitis Chronic Sclerosing Osteomyelitis

Osteomyelitis Microorganisms enter bone (Phagocytosis) Phagocyte contains the infection Release enzymes Lyse bone

Osteomyelitis Bacteria escape host defenses by: Adhering tightly to damage bone Persisting in osteoblasts Protective polysaccharide-rich biofilm

Osteomyelitis Pus spreads into vascular channels Raising intraosseous pressure Impairing blood flow Chronic ischemic necrosis and abscess Separation of large devascularized fragment (Sequestra) New bone formation (involucrum)

Osteomyelitis

Osteomyelitis Acute Infiltration of PMNs Congested or thrombosed vessels Chronic  Necrotic bone Absence of living osteocyte Mononuclear cells predominate Granulation & fibrous tissue

Osteomyelitis

Osteomyelitis Acute Hematogeneus Osteomyelitis Bone and bone marrow infection caused by blood-borne organisms commonly in children In children infection starts in metaphysis and epiphysis especially in lower extremity Radiology Soft tissue swelling: Early Bone demineralisation: 10-14 days Sequestra and involucrum : > 2 weeks Pain, loss of function, fever, elevated WBC, ESR and CRP and positive blood culture MRI, PET and X ray can be used CRP is the most sensitive monitor of the course in children

Osteomyelitis Acute Hematogeneus Osteomyelitis Newborn(<4 months of age) S. Aureus Gr- bacilli Group B str. Treatment Treat like sepsis Oxacilin+3. generation cephalosporin

Osteomyelitis Acute Hematogeneus Osteomyelitis Children(>4 years of age) S. Aureus Group A str. H. Influenza Treatment Oxacilin/ vancomycin/ clindamycin 3. generation cephalosporin is included wheather Gr- bacilli is involved

Osteomyelitis Acute Hematogeneus Osteomyelitis Adults S. Aureus Treatment Nafcilin/oxacilin/cefazolin/vancomycin

Osteomyelitis Acute Hematogeneus Osteomyelitis Sickle Cell Anemia Salmonella Treatment Flouroquinolones/3. generation cephalosporine

Osteomyelitis Acute Hematogeneus Osteomyelitis Hemodialysis and iv Drug abused patients S.aureus S. Epidermidis P.Aeruginosa Treatment Vancomycin+ciprofloxacin

Osteomyelitis Acute Hematogeneus Osteomyelitis Operative indications No improvement with conservative treatment Drainage of an abscess Debridement of soft tissues Obtaining cultures

Osteomyelitis Acute Osteomyelitis S.aureus After open fracture, enfected wounds or ORIF Clinical findings are similar to acute hem. OM. S.aureus S. Epidermidis P.Aeruginosa Coliforms Treatment Operation: Radical irrigation+debridement+removal of ortopaedic hardware Vancomycin+ciprofloxacin/3.generation cephalosporine

Osteomyelitis

Osteomyelitis

Osteomyelitis Chronic Osteomyelitis Inappropriately treated acute OM, trauma, soft tissue spread Altered immunity (DM) Skin and soft tissues are mostly involved Sinus tract: squamous cell carcinoma Acute exacerbations followed by periods of quiescence Deep tissue cultures obtained in operation Multiple bacterial involvement can be seen S.aureus, enterobacteriaceae, p.aeruginosa mostly seen Treatment Operation: Radical irrigation+debridement+removal of ortopaedic hardware+soft tissue covers Vancomycin+ciprofloxacin/3.generation cephalosporine Amputation

Osteomyelitis

Osteomyelitis

Osteomyelitis

Osteomyelitis Subacute Osteomyelitis S. Aureus is the main cause Usually discovered radiologically in a patient with a painfull limp and no systemic sign and symptom May arise from inappropriately treated acute OM, or in a fracture hematoma Brodie’s abscess A localised radiolucency in the metaphyses of long bones Differential diagnosis with Ewing’s sarcoma S. Aureus is the main cause Treatment Surgical drainage+curettage+iv Antibiotics(48 hours)+ oral Antibiotics ( 6 weeks)

Osteomyelitis Subacute Osteomyelitis Brodie’s abscess

Osteomyelitis Chronic Sclerosing Osteomyelitis (Garre) Primarily involves diaphysis Usually seen in adolescents Typified by intense proliferation of periosteum leading to bony deposition Anaerobic microorganisms Localized pain and tenderness with dense progressive sclerosis are common Malignancy must be ruled out

Septic Arthritis

Septic Arthritis Commonly follows hematogeneus spread to synovial membrane or extansion of metaphyseal OM in children Can happen in direct innoculation (esp. İatrogenic) In the US and Europe there are approx 20000 cases a year Commoner in children, the elders and the immune-compromised Morbidity and mortality depends on organism, with N gonorrhoeae being very low while S. aureus is high

Septic Arthritis Most cases involve infants (HIP) and children 40% are aged 65 years and over The most common scenerio is septic arthritis follows acute OM of proximal femur in the hip Examination consist aspiration of the pus, US shows effusion, MRI is useful for soft tissue edema, plain xrays only shows effusion Surgical drainage and debridement still gold standart Artroscopic debridement Daily aspiration Open arthrotomy Parental antibiotics must be used after operation

Septic Arthritis With healing can be Complete resolution and a return to normal Partial loss os cartilage and fibrosis of the joint Loss of cartilage and bony ankylosis Bone destruction and permanent deformity of the joint

Septic Arthritis

Septic Arthritis Newborn (<4 months) Children Acute Monoartricular Septic Arthritis in Sexually Active Adults Acute Monoartricular Septic Arthritis in not Sexually Active Adults Chronic Monoartricular Septic Arthritis Polyartricular Septic Arthritis

Septic Arthritis Newborn (<4 months) Especially seen in hip Newborn with sore hip and tenderness and irritable and sometimes fever is the thypical scenerio S. Aureus, Gr. B Strep., Enterobacteriaceae Adjacent bony involvement seen in %70 Blood cultures mostly positive PRSP + 3. generation cephalosporin

Septic Arthritis

Septic Arthritis Children Especially seen in knee and hip (pseudoparalysis) S. Aureus, H. Influenzae.,Str. Pyogenes, Str. Pneumoniae PRSP+3. generation cephalosporin

Bone and Joint Infections

Septic Arthritis Acute Monoartricular Septic Arthritis in Sexually Active Adults Especially seen in knee, wrist and ankle N. Gonorrhoaeae, S. Aureus, Streptococci Ceftriaxone/cefotaxime/ceftizoxime +/-oxacillin

Septic Arthritis Acute Monoartricular Septic Arthritis in not Sexually Active Adults Especially seen in knee S. Aureus, Streptococci, Gr- Bacilli PRSP+3. generation cephalosporin

Septic Arthritis Chronic Monoartricular Septic Arthritis Brucella Mycobacteria tuberculosis Nocardia Fungi

Septic Arthritis Polyartricular Septic Arthritis Gonococci Borrelia Burdogferi Viruses

Specific Infections Tuberculosis Commonly seen in large joints and spine Causes granulomatous reaction which is associated with necrosis and caseation %5 Tbc patients have bone and joint involvement İliopsoas abycess and pott disease Mostly heals with fibrous ankylosis

Bone and Joint Infections Brucellosis Subacute or chronic granulomatous infection B.Melitensis, B. Abortus, B. Suis Chronic inflammatory granuloma with giant cells is characteristic and seen mostly in vertebral bodies and synovium of large joints Undulant Fever, headache, generalizes weakness and generalized joint pain and backache Positive agglutination test Tetracycline+streptomycin for 4 weeks

Thank you …