Osteomyelitis Septic Arthritis

1. OsteomyelitisSeptic 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 • 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: 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

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 • 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 • 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 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

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 …