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Bone & Joint Infections

Dr Mohammad Adib Khumaidi,SpOT


Bone & joint Infection

• Common Orthopaedic problem


• Despite medical progress osteomyelitis and
septic arthritis are sometimes missed
• Systemic & local factors involved
Bone & Joint Infection

• Osteomyelitis
• Septic arthritis
• Prosthetic infections
• Infection secondary to fracture fixation
Osteomyelitis

• Acute osteomyelitis
• Chronic osteomyelitis
• Acute-on-chronic osteomyelitis
• Brodie’s abscess
Osteomyelitis of bone

Frequency of involvement

• Femur 25%
• Tibia 27%
• Pelvis 12%
• Humerus 6%
• Calcaneum 5%
Osteomyelitis of bone
Causative Organism in Children

Newborn < 5Yrs. >5Yrs.

Staph. Aureus 54% 49% 1%


Haemophilus Inf. 8% 5% 0%
Streptococcus 0% 17% 7%
Others 38% 29% 22%
Pathogenic organisms reach the
bone by one of two pathways

Haematogenous spread

Direct introduction
Haematogenous spread

• 20% of cases
• Underlying sepsis elsewhere
• Areas of increased vascularity

• Children - Metaphysis
• Adults - periosteal vessels, long bone shaft
Pathophysiology of Osteomyelitis

• Bacteria in medullary tissues


• inflammatory response
• Necrotic tissue & debris
• Pus formation
• Increased intra-medullary pressure
• haversian system compromised
• Blood supply disrupted
Pathophysiology of Osteomyelitis

• Pus under pressure escapes via vascular


channels & Volkmann’s canal
• Lifting of the periosteum
• Outer 1/2 of cortical bone forms sequestra
• Nidus for bacteria
• Subperiosteal pus --What happens to it?
Pathophysiology of Osteomyelitis

Subperiosteal pus - route of spread

First year of life - Adjacent joint involved


First year to puberty -Subperiosteal pus
Adults - spread to adjacent joint
Pathophysiology of Osteomyelitis

Consequence of “sequestra”

• If small - completely resorbed and infection


subsides
• If large - cannot be resorbed, reactive new
bone around it - “Involucrum”
Pathophysiology of Osteomyelitis

• Pus under pressure penetrates the dead and


living bone, reaching the surface

• This confluence of channels in living and


dead bone is called “Cloaca”
Pathophysiology of Osteomyelitis

• If pus find its way through the skin, a


“sinus” results
Pathophysiology of Osteomyelitis

• Nidus
• Granulation tissue
• Pus
• Sequestra
• Involucrum
• Cloaca
• Sinuses
Clinical features of Osteomyelitis

1. Age - Childhood & Adult


2. Location - Long bones, vertebral bodies
3. Trauma - one-third have a history of
trauma
4. Bacteria - Staph., Strep. E.Coli,
Salmonella
Clinical features of Osteomyelitis

• Pain
• Fever
• Malaise
• Neurological deficit eg spine
Clinical features of Osteomyelitis

• High ESR, CRP


• High total white count
• Radiological changes
Investigations in Osteomyelitis

• Plain X-ray
• Bone scan
• Ultrasound
• MRI
Differential diagnosis of
osteomyelitis

• Osteoid osteoma
• Neoplasm eg Ewings sarcoma, Lymphoma
Metastatic disease
Management of Osteomyelitis

• Establish the diagnosis


• Blood culture, urine culture
• Bone scan
• CTScan/MRI eg spine infection
Management of Osteomyelitis

• IV antiobiotic 4-6 weeks


• Monitor clinical response
• Consider surgical drainage if indicated
Surgery
• Poor response to antibiotics
• Isolation of organism
• Complications
Osteomyelitis

Spine

• disc space
• biopsy essential for diagnosis
• differential diagnosis is tuberculosis
• often requires surgical drainage
• paraplegia is a real danger
Tuberculous Osteomyelitis

• Thoraco-lumbar junction commonest site


• Often exists as septic arthritis &
osteomyeltis in long bones
• 15% have primary focus in the lungs
• Constitutional symptoms predominate
• Neurological deficits in spine
• Anti-TB treatment with surgery
Foot Osteomyelitis

• Puncture wounds often involve


Psuedomonas as septic arthritis &
osteomyelitis of the bone and joint

• Treatment is debridement and antibiotics


Chronic Osteomyelitis

Cornerstone of management

• Thorough surgical debridement


• Antibiotic of secondary importance
Chronic osteomyelitis

• Repeated debridements
• Reconstructive surgery

Local muscle flap


Free flap
Bone graft & transfer
Infection of Joints

• Acute bacterial arthritis


• Acute gonococcal arthritis
• Tuberculous arthritis
• Fungal arthritis
Acute bacterial arthritis

• Below the age of 2 years

H. influenza is the culprit in 60% of cases

• Adults

Staph. Areus is the culprit in 80% of cases


Acute bacterial arthritis

• Large joints involved


• Monoarticular or polyarticular involvement
• Intra-articular injections
• IV abusers
Acute bacterial arthritis

• Pain
• Swelling
• Fever
• Pseudoparalysis
Acute bacterial arthritis

Differential diagnosis

• Gout
• Pseudogout
• Rheumatoid arthritis
• Reactive arthritis eg Poncet’s arthritis
Acute bacterial arthritis

• Diagnosis

• History & findings


• ESR, CRP
• Joint aspirate - Gram stain
• X-rays
Acute bacterial arthritis

Management

• If you suspect septic arthritis DRAIN the


joint

• Antibiotic therapy
Acute bacterial arthritis

Effects of septic arthritis

articular cartilage destruction


septic necrosis of bone
loss of function
progression to osteomyelitis
Acute bacterial arthritis

X-ray features

• osteoporosis
• sub-articular erosion
• joint destruction
Septic arthritis of the hip

Infancy

• acute febrile illness


• poorly localised to the hip
• subluxation/dislocation may be present
• high association with osteomyelitis
Septic arthritis of the hip

Childhood

• fever
• refusal to walk
• restricted hip motion
• subluxation on X-ray
Septic arthritis of the hip

Organisms involved in children

• Staph. Areus - newborn


• Haemophilus influ. - 1month-5 years
• Streptococcus
• others
Septic arthritis of the hip

Surgery is the treatment of choice

• Open
• Arthroscopic
Antibiotic therapy in infection

• Septic arthritis 6 weeks

• Osteomyelitis 12 weeks

• Prosthetic infection 12-24 weeks


Acute bacterial arthritis

Management

• If you suspect septic arthritis DRAIN the


joint

• Antibiotic therapy

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