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BONE AND JOINT INFECTIONS
นพนพ . . ยอดปิ�ติ ติ��งติรงจิติรยอดปิ�ติ ติ��งติรงจิติรกลุ่��มงานศั�ลุ่ยกรรมกระด�ก โรงกลุ่��มงานศั�ลุ่ยกรรมกระด�ก โรงพยาบาลุ่แพร�พยาบาลุ่แพร�
3 3 ติ�ลุ่าคม ติ�ลุ่าคม 255525551
SEPTIC ARTHRITISSEPTIC ARTHRITIS
2
Septic ArthritisSeptic 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
3
• 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.
4
Definition Definition • Acute - < 14days• Subacute – 2-6 wks• Chronic - > 6wks
• Monoarthritis – 1 joint• Oligoarthritis – 2-3 joints• Polyarhritis - > 4 joints
5
Acute MonoarthritisAcute 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
6
MicroorganismsMicroorganisms
• Bacteria - the most important – Neisseria– Non-neisseria
• Viruses • Fungi • Parasites
7
Gram-Positive CocciGram-Positive Cocci
Streptococci• S. pyogenes (beta-hemolyticus group A) • S. pneumoniae • Group B and G hemolytic Streptococci.
Staphylococci • Staph. aureus • Staphylococcus epidermidis
8
Gram Negative OrganismGram Negative Organism
Neisseria
• Neisseria gonorrhoeae – septic or reactive forms of
arthritis,
• N. meningitidis,
9
Gram Negative OrganismGram Negative Organism
Non- Neisseria • Haemophilus influenzae • Gram-negative rods
– Enterobacteriaceae• E. coli • Shigella • Salmonella • Yersinia • Klebsiella pneumoniae.• Proteus mirabilis • Pasteurellaceae ( Pasteurella multocida)• Campylobacter jejuni
10
• 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
11
Bacterial isolationBacterial isolation
Organism Percentage of cases Staphylococcus aureus 40–50
Staphylococcus edidermis 10–15
Streptococcal species 20
Gram-negative bacteria 15
S. pneumoniae 2
H. influenzae 2
Anaerobes 5 12
Microbiology
13
14
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
15
Clinical FeaturesClinical Features
• Systemic symptoms - neonatal period– High fever – sepsis
• local signs – children, adult– Pain– Swelling – Erythema and warm – Limitation of movement
16
17
18
19
• 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.
20
Predisposing FactorsPredisposing Factors
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
21
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
22
Differential diagnosis
23
PathogenesisPathogenesis
• 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
24
Source of infection
25
Hematogenous spreadSystemic bacteremia
Invade synovial cartilaginous junction
Synovial infected
Increase inflammatory cell
Destruction of the articular cartilage
Joint dislocation, subluxation, osteomyelitis 26
1. Hematogenous route. 2,3 Dissemination from bone
4. Vicinity of the joint 5. Iatrogenic or penetrating trauma 27
SynoviumBacteria
Inflammation
Pannus
Leukocytes migration Synovial cell proliferation
Blood flow Exudation Enzymes
Erythema Swelling DestructionTenderness
Irreversible destruction 28
InvestigationsInvestigations
• 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)
29
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.
30
time
level
24 48 72
CRP
ESRxx
Subside
3-5days
31
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%.
32
Laboratory
• Synovial fluid analysis
- should be aspirated immidiately if there is suspicious.
- recommended: crystals examination.
33
DiagnosisJoint aspiration
disease WBC % PMN
normal <200 <25
traumatic <5,000+rbc <25
Toxic synovitis 5,000-15,000 <25
Acute rheumatic 10,000-15,000 50
JRA 15,000-80,000 75
Septic arthritis >80,000 >7534
Synovial fluidSynovial fluid
Method Percent
Gram positive
Gram negative
N. gonorrhea
Gram strain 80 50 25
Synovial C/S 80-90 60-70 40
35
36
Streptococci37
Neisseria gonorrhoeae38
Radiologic EvaluationRadiologic Evaluation
Initial plain x-ray baseline assessment exclude osteomyelitis
Definitive changes usually take a number of weeks
Rapidity depends on virulence of organism
39
Radiologic EvaluationRadiologic Evaluation
Earliest : joint effusion with displacement of fat padDuring first week
– periarticular osteoporosis Within 7-14 days
- joint space narrowing & erosions
>20days: bone destruction40
41
Radiologic EvaluationRadiologic Evaluation
periarticular osteoporosis 42
Radiologic EvaluationRadiologic Evaluation
joint space narrowing & erosions 43
Radiologic EvaluationRadiologic EvaluationCT / MRIDifficulty to evaluate clinically Complex anatomical structure
( hip, shoulder, SC jt, SI jt ) Early bony erosions, soft tissue extension
Bone scanAxial joints infectionssensitivityCannot differentiate septic from aseptic Jt. 44
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)
45
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.46
Bone scan
47
Polyarticular Septic ArthritisPolyarticular Septic Arthritis
15% 50% RA
systemic illness/IVDU Most common
S.aureusGroup G streptococcusH.influenza S. Pneumoniae Polymicrobial
30% died!!49
TreatmentPrinciple in the management of acute septic arthritic
(Nade )
1. Joint must be adequately drained
2. Antibiotic must be given to diminish the systemic effects of sepsis
3. Joint must be rested in a stable position
50
Treatment.1. synovial analysis and blood cultures before IV a
ntibiotic treatment2. rapid administration of IV antibiotics IV oxacillin in combination with IV ceftriaxone, cefotaxime, or ceftizoxime. 3. drainage of the septic joint4. evaluation5. Arthroscopic drainage or arthrotomy
51
Treatment & OutcomeTreatment & Outcome
ATB should be started as soon as
ATB selected on the basis of gram
stain and clinical picture
Adjust ATB on the basis of sensitivity,
toxicity and cost
Most iv ATB at least 2 weeks ,followed
by 1-2 weeks of oral ATB52
53
Organism ATB of choice Alternative
S. Aureus
MRSA
Cloxacillin
Vancomycin
Cefazilin,clindamycin
Streptococcus
Group A
non group A
pneumococci
Penicillin
PG + aminoglycoside
Penicillin
Cefazolin
Cefazolin + aminoglycoside
vancomycin
N. Gonorrhea 3rd cephalosporin Ciplofloxacin, olfloxacin
H. Influenza Amox. + calvulanate 3rd cephalosporin, Ciplofloxacin
Enterobacteria 3rd cephalosporin Imipenem
Ps. Aeruginosa Antipseudomonas Imipenem
Anaerobe Metronidazole, doxycycline
Clindamycin
54
Treatment• Recommendation for arthrotomy/ arthroscope
1) Hip joint.
2) Immunocompromised host
3) Joint that are difficult to access: sacroiliac, sternoclavicular jt.
4) Difficult to completely drain: shoulder, wrist.
5) Close needle aspiration> 7 days.
6) P.aeruginosa or gram negative bacteria.
55
Treatment• Recommendation for arthrotomy/ arthroscope
7) Sepsis
8) Extension into soft tissue or secondary
osteomyelytis
9) Fungal infection
10) Prosthetic or FB
11) Unresponse to ATB
12) Superimpose on joint disease - RA
56
Closed needle aspiration should be the initial Rx of choice
Serial synovial fluid c/s & wbc count
Acute,suppurative phase : sling/splint/cast should be used to maintain
the joint in optimal position
: muscle-tightening exercises
57
Poor prognosis factors– Immunodeficiency– RA – prematurity – osteomyelitis, – hip – prosthetic infections– + blood cultures,– symptoms >1 week,– >4 joints,– + cultures after aspiration after 7 days of abx tx
58
Complication
– arthritis stiffness
– Dislocation or subluxation
– AVN
– local growth distrubance
– Osteomyelitis
– postinfection synovitis
59
Postinfectious arthritis
recurrent inflammatory when begin
ambulate, but sterile effusion
DDx - incompletely treated infection
NSAIDs
60
Results of Rx 10-15% mortality 25-50% chronic joint damage & disability
Poor outcome Persist/ Recurrent infection Marked decrease ROM/ankylosis Persistent pain
Outcome Outcome
61
Factors associated to poor outcome Duration of infection
Virulense of bacteria
The infected joints
Host defences
Age of patient
Comorbidity
Effective therapy
62
OSTEOMYELIS
63
Osteomyelitis
• Inflammation of the bone by organism.
– single portion.
– surrounding regions ; marrow , cortex & periosteum
64
Classification
1. Acute , subacute , chronic
2. Exogenous , hematogenous
3. Pyogenic , nonpyogenic
4. Neonate , children , adult
65
Source of infection •Blood circulation :
– infection in Oral, Throat, Ear, Gastrointestinal tract, Urinary tract, Skin and soft tissue
•Trauma (30-50%)– หกล้�ม กระแทก– Minor traumaCaution : in infant < 18 month ม�กเก ด
septic arthritis ร�วมก�บ Osteomyelitis 66
Acute Hematogenous Osteomyelitis
• Most common usually seen in children.
• Infection involve the metaphyses of rapidly growing long bones
67
Natural history and Pathogenesis of Acute hematogenous osteomyelitis
•Almost at “metaphysis”– lower extremities > upper
extremities 5 เท�า โดยเฉพาะท�� di st al f e mur แล้ะ proximal tibia
– met aphysi s ( no phagocytosis cell) ≠ diaphysis (diaphysis = reticuloendot
hel i al t i ssue +phagocyt osi s cel ls)
68
Why organism seeding the metaphyses ?
• nutrient capillaries form sharp loops to establishment of infection
• metaphysis has relatively fewer phagocytetic cell than the physis or diaphysis.
69
Pathogenesis
Source of Infection
Metaphysis
Bacterial colonization
Blood stream
Venous stasis
70
Inflammation: acute osteomyelitis • First 24 hours
• Vascular congestion• Polymorphonuclear leukocyte
infiltration• Exudation
71
• 2-3 day No treat with antibiotic
Intraosseus pressure intense pain
intravascular thrombosis ischemia
เด�กจิะร�องปิวดมาก
Inflammation: acute osteomyelitis
72
Suppuration 4-5 days Pus formation Subperiosteal abscess
via Volkmann canals Pus spreading
epiphysis joint medullary cavity soft tissue
73
Necrosis
• Bone death by the end of a week
• Bone destruction ← toxin ← ischemia
• Epiphyseal plate injury• Sequestrum formation
– small removed by macrophage,osteoclast.
– large remained74
New bone formation• By the end of 2nd week
(10 – 14 days)
• Involucrum (new bone formation from deep layer of periosteum ) surround infected tissue.
• If infection persist- pus discharge through sinus to skin surface Chronic osteomyelitis 75
PrimaryPrimary osteomyelitisosteomyelitis76
PrimaryPrimary osteomyelitisosteomyelitis
77
• Children < 2 yr. blood vessel cross the physis & spread infection into epiphysis.
• Children > 2 yr. , the physis effectively barrier to spread.
78
• In adult , after the physes closed , acute osteomyelitis is less common ; ; infection extend directly metaphysis to epiphysis to joint & hematogenous seeding in compromised host
79
• Spread to joint in children < 2 yr. , most commonly is hip joint . ( proximal humerous , radius neck , distal fibular are intraarticular , can lead to septic arthritis. )
80
Diagnosis
• History , Physical exam.
• Clinical : fever , malaise , fatigue , irritability , pain , local tenderness , swelling , restriction of movement
81
82
• Investigation : X- Ray , WBC , ESR , CRP , Bone scan , MRI , Blood culture , Bone aspiration for gram strain , culture & sensitivities.
83
X-ray soft tissue swelling , periosteal reaction , bony destruction , 10–12 day after onset.
WBC often normalESR elevatedCRP elevated
84
• Bone scan can confirm diagnosis 24-48 hr. after onset.
• MRI show early inflamation changes in bone marrow and soft tissue
85
Treatment acute osteomyelitis
• Sequestered abscesses drainage.
• Simple inflammation without abscess ; antibiotic based on Gram strain
• Gram strain not found ; empirical antibiotics for most likely organism.
• CRP every 2-3 days
86
Two main indications for surgery
• abscess requiring drainage.
• failure iv antibiotic treatment. ( no clinical response 24-48 hr. )
87
Nade proposed five principles for treatment
1. appropriate antibiotic will be effective before pus formation.
2. avascular tissues or abscesss require surgical remove.
3. if such removal is effective , antibiotics should prevent their reformation & primary wound closure should be safe.
88
4. surgery should not further damage already ischemic bone & soft tissue.
5. antibiotics should be continuous after surgery.
89
Organism
Patient Type Propable Organism
NeonateGrp. B Strep , S. aureus , Gram-neg. rod (H. influenza)
Infants & children S. aureus
Sickle cell disease S. aureus , Sallmonella
90
Antibiotic
• Appropriate ; infection type , organisms , sensitivity , host , antibiotic
• Iv 4 – 6 wk. , switch iv 1 wk. + oral 6 wk.
91
Subacute osteomyelitis
• insidious onset & lacks the severity of symptom
• diagnosis delayed for more than 2 wks.
• systemic signs & symptoms are minimal.
• WBC normal
• ESR elevation ( 50% )
• blood culture ; usually negative.
92
• bone aspirate or biopsy ; 60% pathogen identified
• x-ray & bone scan ; positive.
• course ; increased host resistance , decreased bacterial virulence ,
antibiotic before the onset of symptom.
• differentiation lesion from a primary bone tumor.
93
Classification of subacute osteomyelitis
94
DifferentialType
I Langerhans’cell histiocytosis , Brodie abscess
II Eosinophilic granuloma , Osteogenic sarcoma
III Osteoid osteoma
IV Ewing sarcoma
V Chondroblastoma
VI Tuberculosis ; osteogenic sarcoma
95
Treatment subacute osteomyelitis
• Ross & Cole recommended biopsy & currettage aggressive lesions and antibiotics.
• biopsy not recommended in simple abscess lesion
96
Chronic osteomyelitis• Systemic symptom subside ; bone
contain purulant material , infection tissue
• Intermittant acute exacerbation ; respond antibiotic & rest
• Multiple organism ; culture & biopsy
97
98
Cierny & Mader Staging System for Chronic Osteomyelitis
Anatomical type
I Medullary
II Superficial
III Localized
IV Diffuse
Physiological class
A host Normal
B host Compromised
C host Prohibitive99
100
Diagnosis
• Gold standard ; biopsy , microbiological
• PE. skin , soft tissue , neurovascular
• ESR & CRP ; elevation
• WBC ; normal
• X-ray ; cortical destruction , periosteal reaction
• Bone scan
• MRI
101
Treatment
• Sequestrectomy , resection scar & infection bone
• Antibiotics 6 wk. ( 1 wk. for iv , 6 wk. for oral form)
• Reconstruction of bone & soft tissue ( bone graft , bone transfer , myoplasty , flap )
102
103
Fracture management
•Active infection ; sequestrectomy , debridement , antibiotics ( > 6 m.) & immobilization
•Active infection without involucrum ; debridement , bone graft , antibiotics & immobilization
•Inactive infection & no involucrum ; immobilization & bone graft.
104
Amputation for osteomyelitis
• malignant change
• arterial insufficiency , major nerve paralysis , joint stiffness
105
106