1.08k likes | 1.48k Views
BONE AND JOINT INFECTIONS. นพ. ยอดปิติ ตั้งตรงจิตร กลุ่มงานศัลยกรรมกระดูก โรงพยาบาลแพร่ 3 ตุลาคม 2555. SEPTIC ARTHRITIS. Septic Arthritis. Epidemiology ~2 to 10/100,000 in general population ~30-40/100,000 in RA ~40-68/100,000 in joint prostheses 2 age peaks : < 5 years , > 64 years.
E N D
BONE AND JOINT INFECTIONS นพ. ยอดปิติ ตั้งตรงจิตร กลุ่มงานศัลยกรรมกระดูก โรงพยาบาลแพร่ 3 ตุลาคม 2555
Septic Arthritis • Epidemiology ~2 to 10/100,000 in general population ~30-40/100,000 in RA ~40-68/100,000 in joint prostheses • 2 age peaks : < 5 years , > 64 years
knee 40-50% • hip 20-25% • Shoulders, ankles, elbows 10-15% • wrist 10% • in infants and very young children, hip is the most common joint infection.
Acute - < 14days Subacute – 2-6 wks Chronic - > 6wks Monoarthritis – 1 joint Oligoarthritis – 2-3 joints Polyarhritis - > 4 joints Definition
Acute Monoarthritis • Crystal-induced synovitis • Septic arthtitis • Acute traumatic and hemorrhagic arthritis • Acute presentation of systemic rheumatic diseases eg.RA, SNSA • Other rheumatic disorders – Adult still’s disease
Microorganisms Bacteria - the most important Neisseria Non-neisseria Viruses Fungi Parasites
Streptococci S. pyogenes (beta-hemolyticus group A) S. pneumoniae Group B and G hemolytic Streptococci. Staphylococci Staph. aureus Staphylococcus epidermidis Gram-Positive Cocci
Neisseria Neisseria gonorrhoeae septic or reactive forms of arthritis, N. meningitidis, Gram Negative Organism
Non- Neisseria Haemophilus influenzae Gram-negative rods Enterobacteriaceae E. coli Shigella Salmonella Yersinia Klebsiella pneumoniae. Proteus mirabilis Pasteurellaceae ( Pasteurella multocida) Campylobacter jejuni Gram Negative Organism
Viruses HIV parvovirus B19 herpes viruses adenoviruses Anaerobes Clostridium Eubacterium Propionibacterium Bacteroides Fusobacterium Others Mycobacterium Nocardia. Spirochetes Borrelia burgdorferi ( Lyme disease) Chlamydias Mycoplasmas and Ureaplasma. Fungi, Parasites
Clinical features • Acute bacterial infection • Fever 60%-80% (< 39°c ) • Monarticular : inv. 90% • Limited ROM • Swelling (seen synovial effusion) • Most common : knee > hip • Refusal walk ,limping, Irritability, failure to thrive, asymmetry of limb position
Clinical Features • Systemic symptoms - neonatal period • High fever • sepsis • local signs – children, adult • Pain • Swelling • Erythema and warm • Limitation of movement
Predisposing factors. 1) prosthetic joint. 2) age> 60 yrs. 3) present underlying jt. disease( RA, much less for OA ). 4) co morbidity( malignancy, DM, alcoholism, cirrhosis, hemophilia) 5) use of immunosuppressive drug. 6) skin infection.
Abnormal joint RA Crystal induced synovitis Prosthetic joint Severe OA Severe Charcot’s joint Severe hemarthrosis Intrarticular injection Abnormal host Chronic systemic disease - DM ,SLE, CRF, liver disease HIV IVDU Chronic steroid therapy Malignancy Old age New born Predisposing Factors
Risk factors for the development of joint sepsis • rheumatoid arthritis (RA) or osteoarthritis • prosthetic joints • low socioeconomic status • intravenous drug abuse • alcoholism • diabetes • previous intra-articular corticosteroid injection • cutaneous ulcers
Pathogenesis • Mechanism • Hematogenous route. • Skin, oral cavity, respiratory tract, urinary or intestinal tract infections, or endocarditis. • Dissemination from metaphysis or epiphysis. • Vicinity of the joint • Iatrogenic or penetrating trauma
Hematogenous spread Systemic bacteremia Invade synovial cartilaginous junction Synovial infected Increase inflammatory cell Destructionof the articular cartilage Joint dislocation, subluxation, osteomyelitis
1. Hematogenous route. 2,3 Dissemination from bone 4. Vicinity of the joint 5. Iatrogenic or penetrating trauma
Synovial cell proliferation Leukocytes migration Blood flow Exudation Enzymes Tenderness Destruction Erythema Swelling Irreversible destruction Bacteria Synovium Inflammation Pannus
Investigations • CBC,ESR,CRP • Blood culture • Synovium fluid • Plain radiographs ( 2-3 weeks or more) • Scintigraphy • 99mTc phosphate (three-phase bone scan) • 99mTc nanocolloid scanning • Indium 111-labeled leukocytes • Computed tomography (CT) • Magnetic resonance imaging (MRI)
Laboratory • CBC - often normal. - predominance of segmented neutrophil. • ESR( erytrocyte sedimentation rate) - elevation, but not specific for infections. - present for less than 48 hr, return to normal ~3 weeks.
level CRP ESR time 24 48 72 Subside xx 3-5days
Laboratory • CRP ( C- reactive protein). - elevation. - inc. within 6 hr, return to normal 1 week after treatment began. - better way to follow the response to ATB. • Blood culture - positive~ 50%-70%.
Laboratory • Synovial fluid analysis - should be aspirated immidiately if there is suspicious. - recommended: crystals examination.
Diagnosis Joint aspiration
Radiologic Evaluation • Initial plain x-ray • baseline assessment • exclude osteomyelitis • Definitive changes usually take a number of weeks • Rapidity depends on virulence of organism
Radiologic Evaluation • Earliest : joint effusion with displacement of fat pad • During first week – periarticular osteoporosis • Within 7-14 days - joint space narrowing & erosions >20days: bone destruction
Radiologic Evaluation periarticular osteoporosis
Radiologic Evaluation joint space narrowing & erosions
Radiologic Evaluation CT / MRI • Difficulty to evaluate clinically • Complex anatomical structure ( hip, shoulder, SC jt, SI jt ) • Early bony erosions, soft tissue extension Bone scan • Axial joints infections • sensitivity • Cannot differentiate septic from aseptic Jt.
Laboratory • CT scan • good definition of contiguous bone lesions and ability to guide needle aspiration • MRI • better defines soft tissue (distended joint space and extension to periarticular structures)
Laboratory • Radionuclide - physiologic picture. - reflect inflammatory change/ reaction of bone to infection. - 3 most common use 1) Technitium 99m phosphate. 2) gallium 67 citrate. 3) indium 111-labled leukocytes.
Polyarticular Septic Arthritis • 15% • 50% RA • systemic illness/IVDU • Most common • S.aureus • Group G streptococcus • H.influenza • S. Pneumoniae • Polymicrobial • 30% died!!
Treatment Principle in the management of acute septic arthritic(Nade ) • Joint must be adequately drained • Antibiotic must be given to diminish the systemic effects of sepsis • Joint must be rested in a stable position
Treatment. • synovial analysis and blood cultures before IV antibiotic treatment • rapid administration of IV antibiotics IV oxacillin in combination with IV ceftriaxone, cefotaxime, or ceftizoxime. 3. drainage of the septic joint 4. evaluation 5. Arthroscopic drainage or arthrotomy