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
Brodies 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%
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 & Volkmanns 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

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
 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

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 Poncets 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