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

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

3. OSTEOMYELITIS Types: Acute hematogenous osteomyelitis
Subacute osteomyelitis
Chronic osteomyelitis

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

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

6. 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

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

8. 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

9. ACUTE HEMATOGENOUS OSTEOMYELITIS
Complications:
Septic arthritis
Growth disturbance
Chronic osteomyelitis

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

11. 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

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

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

14. 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

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

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

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

18. 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

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

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

21. 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

22. 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

23. 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

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

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

26. 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

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

28. 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

29. 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

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

31. 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

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

33. 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