Musculoskeletal Infection

rainbow sign osteomyelitis

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Dr. Thongchai Laohathaimongkol

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Orthopedic Department
Queen Savang Vadhana Memorial Hospital
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CONTENT
• General Principles
• Osteomyelitis
• Infectious Arthritis
• Tuberculosis of Bone and Joint
GENERAL PRINCIPLES OF
INFECTION
ETIOLOGY
• Direct inoculation
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• Inflammation & immune response of bone & joint
• Adequate no. of virulence organism overcome
natural response
PATIENT-DEPENDENT FACTORS 


Malnutrition
• Affect humeral & cell-mediated immunity
• Impair neutrophil chemotaxis & bactericidal function
• Diminish bacterial clearance
• Decrease delivery of inflammatory cell to infectious foci
• Decrease serum complement components
PATIENT-DEPENDENT FACTORS 

Nutritional status
• Anthropometric measurements (height, weight, triceps skin fold
thickness, and arm muscle circumference)
• Measurement of serum proteins or cell types (albumin < 3.4 g/dl or
total lymphocyte < 1500 cell/mm3 )
Uonsig Immune n92in
PATIENT-DEPENDENT FACTORS
Immunological status
(1) Neutrophil response : DM, alcoholism, hematological malignancy, cytotoxic Rx
(2) Humoral immunity (immunoglobulin & complement) : splenectomy,
hypogammaglobulinemia
(3) Cell-mediated immunity (T lymphocytes & macrophage) : Steroid Rx,
malnutrition, lymphoma, SLE, immunodeficiency in elderly pts, aids
(4) The reticuloendothelial cells : (Hep B, HIB vac)
PATIENT-DEPENDENT FACTORS
• CONGENITAL
Ch. granulomatous dis.,Hemophilia, Hypogammaglobulinemia,
Sickle cell hemoglobinopathy,
• ACQUIRED
DM, Hematological malignancy, HIV, Pharmacutical
Immunosuppression (Organ transplantation, Collagen vascular
dis.), Uremia, Malnutrition, Radiation Rx
SURGEON-DEPENDENT FACTORS
• Skin preparation - decrease wound contaminate, shave in OR
• Operating room environment - laminar air flow system to decrease
airborne bacterial concentration
• Prophylactic antibiotic therapy
- S.aureus, S.epidermidis, E.coli, Proteus
2gm a ihr hominoid
- 1# cepharosporin, begin immediate before surgery
- ~ 24 hr, if >72 hr ; thrombophlebitis, allergic reaction,
superinfection, drug fever
DIAGNOSIS
• The classic triad
• fever

• swelling

3• tenderness or pain - most common

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• Other features of fever, chills, nausea, vomiting,
malaise, erythema, swelling, and tenderness may or
may not be present
LABORATORY STUDIES
MN tosteroid Mat WBCGianni
• CBC - not reliable, increase neutrophil in acute infection
• ESR - increase in infection, Fx.
- unreliable in steroid pts., symptom < 48 hr
- peak 3-5 days after infection
- normal ~ 3 wk after Rx begin
• CRP - increase within 6 hr
- peak ~ 2 days after infection
- normal ~ 1 wk after Rx begin
IMAGING STUDIES

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X-ray - not useful in diagnosis of acute case
- show soft tissue sweelling, joint space narrowing or
widening, bone destruction (10-21 days)
CT - identify sequestrum, subchondral bony plate destruction
- determine extent of medullary involvement, pus in
medullary cavity, adjacent soft tissue abscess

Kondor late stage in

IMAGING STUDIES
• Radionuclide scanning - reflect inflam. change or reaction
of bone to infection
• technetium 99m phosphate

• detect OM within 24 hr after infection

• uptake related to osteoblastic activity, regional

blood flow, ‘‘hot spot’’

• “cold spot” in subperiosteal pus, sequestrum, joint

effusion, vasospasm, soft tissue sweelling

• Gallium 67 citrate

• Indium 111-labeled leukocytes

IMAGING STUDIES
• Magnetic resonance imaging (MRI) sing
• classing findings - decrease marrow signal on T1 hyposignall

- normal or increase signal on T2 hypersignal

• suggest signs - abscesses, subperiosteal fluid collections
• Ultrasound
• localize an abscess cavity

• detect joint effusion

• guide aspiration
 CSF

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CULTURE STUDIES
• Superficial wound or sinus tract - unreliable,
polymicrobialwww18onhddivnht
• Aspirate fluid, Deep wound biopsy - acceptable
• Staph. aureus - most frequent
• N.gonorrhea - common in adults < 30 yr
• H. influenzae type B - common in child < 2 yr
• Salmonella - common in neomatal OM, sickle cell
anemia pts.
TREATMENT Most common 9 aureus

• Antimicrobial treatment
• oral - most common used
• intravenous - serious case not respond
to oral ATB.
• Surgical treatment
• debridement, remove sequestrum;
bacteria; bacterial products; pus and
abscess
Cherax destructor
OSTEOMYELITIS
Definition
• an inflammation of bone caused by an infecting

organism
• involve single part or marrow, cortex, periosteum and
surrounding soft tissue debridement
Aro
• key to successful Rx - early diagnosis, appropriate
surgical & antimicrobial treatment
CLASSIFICATION
(1) the duration and type of symptoms
acute, subacute, chronic
(2) the mechanism of infection
exogenous - open Fx, surgery, spread from infected
local tissue BUN
YNN A
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goingabcess
hematogenous - from bacteremia aimspreadMor
(3) the type of host response to the infection
pyogenic, nonpyogenic (granulomatous)
ACUTE HEMATOGENOUS
OSTEOMYELITIS
• most common type
• usually seen in children

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more common in male in all age groups
•

• most common at hip joint

• < 2 yr - blood vessel cross physis > spread to joint
• > 2 yr - thick metaphysis > spread to diaphysis
• intraarticular physis - prox.humerus, radial neck, distal fibula
ACUTE HEMATOGENOUS
OSTEOMYELITIS
• Staph.aureus - most common
• Pseudomonas - IV drug abusers
• Fungal - in long term IV Rx,or parenteral nutrition
• Salmonella - in hemoglobinopathies
• Strep.gr B - in infant
• H.influenzae - in child 6 mo - 4 yr
DIAGNOSIS
• History
• Physical examination
• WBC - often normal, ESR & CRP increase
• Blood culture - identify ~ 50 %
TREATMENT
Antibiotic treatment principles
Agressive debridement
1) appropriate ATB effective before pus formation
2) not sterilize avascular tissue or abscess
3) prevent reformation, safe wound closure
4) surgery not damage ischemic bone, soft tissue
5) ATB continue after surgery
• IV fluid, analgesic, comfortable positioning affected limb or
splinted limb
TREATMENT
Surgical indication
1) presence of abscess requiring drainage
2) failure to improve despite appropriate IV antibiotic
Objective of surgery
1) drain abscess cavity
2) remove nonviable or necrotic tissue
SUBACUTE HEMATOGENOUS
OSTEOMYELITIS
• Indolent course > 2 week
• Sign & symptom - minimal
• Clinical - result of increase host resistance, decrease bacterial
virulence, ATB before symptoms
Acutedrains
• WBC - normal, ESR elevated 50%, blood cultures - neg.
• Rx - simple abscess - IV ATB 48 hr > oral 6 wk
- aggressive lesions or not respond to ATB > biopsy or
curettage id drain
CHRONIC OSTEOMYELITIS
Hallmark - infected dead bone within a compromised soft
tissue envelope surrouned by sclerotic, avascular bone
covered by thickened periosteum, scarred muscle &
subcutaneous tissue
Dx - based on clinical, lab, imaging studies
Clinical - integrity of skin, soft tissue, area of tenderness,
assess bone stability, N/V status of limb
Lab - ESR, CRP - increase most, WBC - increase 35 %
Imaging - cortical destruction, periosteal reaction, sequestrum
Gold standard - obtain biopsy with culture & sensitivity

Broken subacute a cute endowment

CHRONIC OSTEOMYELITIS
Pathophysiology
Bacterial seeding --> Inflam. reaction --> Local ischemic necrosis
of bone

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Extensive
sequestra Chronic OM Abscess formation
formation

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Subperiosteal Cortical Increase
abscess thickness intramedullary
pressure
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evolucrum

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seavestrum
CLASSIFICATION of COM (Cierny &
Mader)
Anatomical type
• 1) medullary - endosteal dis.
• 2) superficial - cortical
infected because of
coverage defect
• 3) localized - cortical
sequestrum
• 4) diffuse - mechanical
instability
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TREATMENT
• Surgery - sequestrectomy and resection of scarred and infected
bone & soft tissue
• Goal : eradication of infection by achieving viable and vascular
environment
• Postop. ATB - traditional 6 wk
- IV 1 wk + oral 6 wk - 91 % success rate
• Postop. - limb-splinted to prevent pathological fracture
• Hyperbaric oxygen therapy - not proved effective, recommended
adjuvant to traditional methods
White Cherax destructor
INFECTIOUS ARTHRITIS
• results from bacterial invasion of a joint space
• can occur through toopronounosteomyelitis
• hematogenous spread

• direct inoculation from trauma or surgery

3• adjacent site of osteomyelitis or cellulitis

• occur at any age, more common in young children,elderly,
previous trauma of joint,hemophilia, OA, RA
• Lower limb predominantly affected
 PATHOGENESIS
joint
Fomenko
Systemic bacteremia ---> Spread through synovium, synovial fluid

Hyperemia, increase PMN

Joint dislocation, Degradation of ground

subluxation, substance
osteomyelitis
Alteration of articular
memo cartilage

Complete destruction
of articular cartilage Wear

at ~ 4 wk apringonbuan
 Organism Found in Common Clinical
Settings
Clinical factors Organism
Neonate Staph.aureus
< 2 yr H.influenzae, S.aureus
> 2 yr Staph. Aureus
Young adults (healthy, active) N. gonorrhoeae
Adults (elderly), Hemophilia S.aureus(50%), Streptococci,
Gram-neg bacilli

Aspiration or injection, RA S.aureus

Trauma Gram-neg bacilli, Anaerobes,
S. aureus

Injecting drug use Pseudomonas species

 Differential Diagnosis in Monoarticular
Arthritis
pit
• Infection

2nd
• Crystal - induced arthritis (eg.gout)

• Trauma

• Hemarthrosis (hemophilia, sickle cell anemia)

• Osteomyelitis

• Periarticular syndrome (bursitis, tendinitis)

• Ruptured Baker’s cyst

• Deep vein thrombosis

• Pigmented villonodular synovitis

tumorn'moilo effusion
• Mechanical derangement
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• Foreign body
DIAGNOSIS
• Fever, swelling, erythema, and pain, infection at another site
(e.g., the umbilical catheter), irritability, failure to thrive,
asymmetry of limb position, displeasure at being handled
• Aspiration : gram staining, culture, cell counts, crystal
analysis
• ESR or CRP levels
• Indication of infection - synovial leukocyte counts >50,000/
mm3, PMN > 90%
TREATMENT
• Three essential principles
• 1) joint must be adequately drained

• 2) ATB must be given to diminish systemic effects

of sepsis
• 3) joint must be rested in a stable position

• Suspected infected joint > aspiration

• Antibiotic regimens continued 4-6 wks, depending up to physician,
type of organism, response to therapy
TREATMENT
Unlv AIB union Amputation
• Therapy to restore normal joint function as infection
resolve
• functional splinting initially to prevent deformity

• isometric muscle strengthening

• active range-of-motion exercises

• Treatment with traction, dynamic splints, serial casting,

and passive exercises
TUBERCULOSIS
• 1 - 8 % osseous disease
• 30 - 50 % osseous disease have vertebral involvement
• Occur from hematogenous spread, lymphogenous, contiguous
extension to other tissue & organ systems
• Symptoms - pain, fever, chills, weight loss, fatigue
• TL spine, vertebral end plate, body, adjacent disc
• Lab - bone culture, sputum, transbronchial biopsy 60-86 %

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TREATMENT
• Objectives - halting infection, limit deformity,
maintain mobility, reducing discomfort
• 90 % conservative with chemotherapy
• 6 - 12 month course of Isoniazid, Rifampicin,
Pyrazinamide, Ethambutol or Streptomycin
TREATMENT (SURGICAL)
• (1) arthrotomy including biopsy, synovectomy,
curettage with bone grafting of articular erosions
• (2) curettage and bone grafting of extraarticular skeletal
lesions
• (3) resection of joints
• (4) resection of bones
• (5) evacuation or excision of soft tissue abscess
• (6) arthrodesis
• (7) amputation
Thank You for Your Attention