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

2. 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

3. 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

4. Osteomyelitis

5. 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

6. 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

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

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

9. 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)

10. Osteomyelitis

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

12. Osteomyelitis

13. 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: 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

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

15. 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

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

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

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

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

20. 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

21. Osteomyelitis

22. Osteomyelitis

23. 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

24. Osteomyelitis

25. Osteomyelitis

26. Osteomyelitis

27. 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)

28. Osteomyelitis
Subacute Osteomyelitis
Brodie’s abscess

29. 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

30. Septic Arthritis

31. 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 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

32. 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

33. 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

34. Septic Arthritis

35. 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

36. 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

37. Septic Arthritis

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

42. Bone and Joint Infections

43. 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

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

45. Septic Arthritis Chronic Monoartricular Septic Arthritis Brucella
Mycobacteria tuberculosis
Nocardia
Fungi

46. Septic Arthritis Polyartricular Septic Arthritis Gonococci
Borrelia Burdogferi
Viruses

47. 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

48. 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

49. Thank you …