BONE AND JOINT INFECTIONS JOSE FERNANDO SYQUIA, MD SECTION OF ORTHOPEDIC SURGERY DEPARTMENT OF SURGERY

OSTEOMYELITIS Definition: Modes of transmission: Inflammation of bone caused by infection Modes of transmission: Blood borne Contiguity Direct invasion Open wound Innoculation

OSTEOMYELITIS Types: Acute hematogenous osteomyelitis Subacute osteomyelitis Chronic osteomyelitis

ACUTE HEMATOGENOUS OSTEOMYELITIS By blood borne organisms Children commonly affected Staphylococcus aureus – most common Located at metaphysis Long-term morbidity is > 25%

ACUTE HEMATOGENOUS OSTEOMYELITIS Pathology: Inflammation Suppuration Necrosis New bone formation Resolution Clinical findings: Pain Fever Inflammation Loss of function Soft tissue abscess

ACUTE HEMATOGENOUS OSTEOMYELITIS Radiographic findings: Soft tissue swelling Demineralization (10-14 days) Sequestrum and involucrum later Laboratory findings: Elevated WBC Elevated ESR, CRP (+) blood culture

ACUTE HEMATOGENOUS OSTEOMYELITIS Treatment: Antibiotics IV for 6 weeks Immobilization Surgical drainage Abscess Debridement of infected tissues Failure of nonoperative treatment

ACUTE HEMATOGENOUS OSTEOMYELITIS AGE ORGANISM INITIAL MEDS Newborn Staphylococcus aureus Grp A or B streptococcus Enterobacteriaceae PRSP + third generation cephalosporin Child < 4 years H. influenzae Streptococci Cefuroxime or third generation cephalosporin Child > 4 years Steptococci PRSP or first generation cephalosporin Adult Streptococcus species

ACUTE HEMATOGENOUS OSTEOMYELITIS Complications: Septic arthritis Growth disturbance Chronic osteomyelitis

POST-TRAUMATIC AND POSTOPERATIVE OSTEOMYELITIS Infected open fracture Usual cause of osteomyelitis in adults Staphylococcus aureus – most common

Postoperative infection Predisposing factors: Debility Chronic disease Previous infection Steroid therapy Long operations Use of foreign materials Clinical findings: Fever Pain and swelling over fracture site Wound is inflamed Discharge noted

Laboratory findings: Leucocytosis Elevated ESR and CRP Positive cultures Treatment: Debridement Antibiotics

SUBACUTE OSTEOMYELITIS Due to: Partially treated acute osteomyelitis Infection of fracture hematoma Can cross the physis Commonly affects femur or tibia

Clinical findings: Painful limp No systemic or even local signs or symptoms Radiographic findings: May mimic tumors Brodie’s abscess Localized radiolucency usually in the metaphysis of long bones Laboratory findings: WBC count and cultures may be normal ESR may be elevated Treatment: Surgical curettage or debridement Antibiotics for 6 weeks

CHRONIC OSTEOMYELITIS Due to: Inappropriately treated acute osteomyelitis Trauma (accidental or surgical) Soft tissue spread Epidermoid carcinoma Fistulous tracts may develop into these

CHRONIC OSTEOMYELITIS Pseudomonas Seen with IV drug abusers Salmonella Seen with sickle cell disease Staphylococcus aureus, G- rods, anaerobes Common organisms

CHRONIC OSTEOMYELITIS Clinical findings: Draining sinus Periods of quiescence and acute exacerbations (flare) Pain, pyrexia, redness and tenderness during exacerbation

Radiographic findings: Sequestrum Involucrum Laboratory findings: May be normal, unless in acute exacerbation Treatment: Surgical debridement IV antibiotics based on cultures Coverage of soft tissue defects Amputations

PYOGENIC ARTHRITIS Definition: Joint infection Common in infants and children Adults: Rheumatoid arthritis IV drug abuse Pseudomonas Sexually active Gonococcal arthritis

PYOGENIC ARTHRITIS Modes of transmission: Hematogenous Local spread from osteomyelitis Proximal femur Proximal humerus Radial neck Distal fibula Puncture wound Open wound

PYOGENIC ARTHRITIS AGE ORGANISM INITIAL MEDS < 3 months Staphylococcus aureus Enterobacteriaceae Group B streptococcus PRSP + third generation cephalosporin 3 months – 6 yrs H. influenzae Streptococci (PRSP or first generation cephalosporin) + third generation cephalosporin Adult Group A streptococci [(PRSP or first gen cephalosporin) + (APAG or Ciprofloxacin)] or Timentin or Piperacillin Tazobactam or Unasyn Joint replacement Staphylococcus epidermidis Pseudomonas Vancomycin + ciprofloxacin or aztreonam or APAG

PYOGENIC ARTHRITIS Clinical findings: Red, hot swollen joint Acute pain Fever and chills Constitutional signs of infection Radiographic findings: Widening of joint space Soft tissue swelling

Synovial fluid analysis Treatment: Establish the diagnosis Laboratory findings: Elevated WBC Elevated ESR and CRP Blood cultures Synovial fluid analysis Treatment: Establish the diagnosis Surgical drainage or open drainage Antibiotics Splinting the joint Complications: Dislocation Destruction of epiphysis Ankylosis

TUBERCULOUS ARTHRITIS Caused by Mycobacterium tuberculosis Joint involved by hematogenous spread Lung or intestines A chronic inflammatory process Spine and lower extremities usually involved

TUBERCULOUS ARTHRITIS Clinical findings: Swollen joint Painful joint Muscle wasting Limitation of movement May have constitutional signs of TB Later, stiff and deformed joint

TUBERCULOUS ARTHRITIS Laboratory findings: Positive Mantoux test Elevated ESR Synovial fluid analysis AFB Rice bodies Positive cultures Radiographic findings: Subchondral osteoporosis Cystic changes Joint space narrowing

TUBERCULOUS ARTHRITIS Treatment: Anti-TB medications for 6-12 months Debridement Rest, traction and splintage

TUBERCULOSIS OF THE SPINE Most common site of skeletal TB Pott’s disease Pathology: Blood borne infection Vertebral body involved Destruction and caseation necrosis Spread to disc space and next vertebra Vertebral bodies collapse Cold abscess form

TUBERCULOSIS OF THE SPINE Clinical findings: Long-standing history of poor health Backache Abscess Neurologic deficit Kyphosis Tenderness Muscle spasm Radiographic findings: Paravertebral abscess Collapse of vertebra Deformity

TUBERCULOSIS OF THE SPINE Laboratory findings: Elevated ESR (+) Mantoux test Treatment: Anti-TB chemotherapy for 6-12 months Brace Surgery

Pott’s paraplegia Spinal cord compressed by: Inflammatory material Bone or disc Fibrosis Signs of paraplegia Early-onset paraparesis ADSF with recovery in majority Late-onset paraparesis Due to deformity, disease reactivation, vascular problem

PYOGENIC SPINAL INFECTION Types: Pyogenic spondylitis Discitis Usually staphylococcus Clinical findings: Pain Muscle spasm Restricted spinal movement

Radiographic findings: Narrowing of disc space Destruction of vertebral body Now bone formation in later cases Laboratory findings: Elevated ESR Needle biopsy may be needed Treatment: Bed rest IV antibiotics for 4-6 weeks Spinal brace