bone and joint infection n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Bone and joint infection PowerPoint Presentation
Download Presentation
Bone and joint infection

Loading in 2 Seconds...

play fullscreen
1 / 45

Bone and joint infection - PowerPoint PPT Presentation


  • 122 Views
  • Uploaded on

Bone and joint infection. Dr. Katia Sitnitskaya. Osteomyelitis. Acute hematogenous osteomyelitis (AHO) Subacute contiguous osteomyelitis Chronic osteomyelitis (recurrence) . AHO. 1/2 in < 5 y.o. 1/3 report minor trauma Metaphyses of long bones: 85%

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Bone and joint infection' - maribel


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
bone and joint infection

Bone and joint infection

Dr. Katia Sitnitskaya

osteomyelitis
Osteomyelitis
  • Acute hematogenous osteomyelitis (AHO)
  • Subacute contiguous osteomyelitis
  • Chronic osteomyelitis (recurrence)
slide3
AHO
  • 1/2 in < 5 y.o.
  • 1/3 report minor trauma
  • Metaphyses of long bones: 85%
  • Multiple locations: 5%, in JRA
aho pathogenesis
AHO: pathogenesis
  • Source: episode of bacteremia
  • Slow blood flow in metaphyseal capillary loops
  • Microcolonies surrounded by glycocalix plug capillaries, blocking the access for PMNs and antibiotics
  • M/o escape through endothelial gaps to the tissue
  • Expression of adhesinsallows m/o to attach to the components of bone matrix, e.g. sialoglycoprotein
  • Staph. aureus survives in osteoblasts: hard to eradicate
aho pathogenesis1
AHO: pathogenesis

Attraction of inflammatory cells

Cellulitis of bone marrow

Lymphocytes release IL-I, TNF PMNs produce proteolytic enzymes

Osteolysis

Inraosseous spread + pressure

Ischemia, necrosis, subperiosteal abscess

aho sites
AHO: sites

Radius 4% ulna 3%

Humerus 12%

Pelvis 9%

Femur 27%

Hands & feet 13%

Tibia 22%fibula 5%

joint involvement in aho
Joint involvement in AHO
  • Transphyseal vessels in < 18 mo.o.
  • Proximal femur / humerus: metaphysis is within joint capsule
  • Finland: in 16% of Staph. aureus AHO in a 3 mo-14 y.o (# 50)
  • Prospective LA study: 1988 – 96, # 58 AHO, 1 mo –17 y.o.

(J. Ped Ortho, 2000)

- Dx was based on bone and synovial cultures

- 1/3 of AHO pts had septic joint (@ any age)

- knee 31%, hip 23%, ankle 18%, shoulder 14%

MRI demonstrated sub-periosteal spread of infection in a few images

aho bacteriology
AHO: bacteriology
  • < 3 mo.o.: Staph. aureus, enteric GNRs, GBS (3%)
  • < 3 y.o.: Staph. aureus, HiB in non-immunized
  • > 3 y.o.: - 2/3 Staph. aureus

- 15% GAS

- 2% Pneumococcus

aho presentation wu
AHO: presentation & WU
  • Fever: low-grade or high, may be absent
  • Localpain + tumor, rubor, color
  • Point tenderness, limping
  • WBC elevated in 1/3
  • CRP (Finland. Ped, 1994)

# 44 pts, 2 we – 14 y.o., culture-confirmed AHO

CRP > 19 mg/L in 98%, peak on D # 2

sequela prone aho
Sequela-prone AHO
  • 6% have sequaelae:- growth arrest

- restricted motility

- pathological Fx (very rare)

  • Costa Rica, 1992 – 94, # 83 AHO, 3 mo – 13 y., FU min 6 mo.,

55 (-) sequelae vs. 28 (+) sequelae; bone drill in 3/4

Patients with sequalae had: - CRP > 50 mg/L on D # 1 – 6

- fever > 7 d. / local symptoms > 10 d.

Sensitivity of the combination of 2 factors = 92% @ > 6 mo. FU

(CID, 1997)

aho imaging
AHO: imaging
  • Baseline x-ray:Fx, tumor

the earliest sign = soft tissue swelling on D # 3

periosteal elevation / lytic lesions on 2d- 3d week

lysis of bone is seen when up to ½ of bone matrix has been destroyed

  • Gallium67 scan : - uptake by PMNs, in 24 hrs

- sensitivity: 91%

aho imaging1
AHO: imaging
  • 3-phase Tc99 scan: sensitivity: 92%

1-st phase = blood flow = “angiography” (in 20 sec)

2-d phase = soft tissue (in 10 min)

3-d phase = uptake by osteoblasts & WBCs(in 2 hrs)

*Early: “cold” spot (ischemia), or may be false-(-) with prompt Tx

  • Tc99-tagged WBC scan:

imaging in post-surgical or equivocal osteo

20 ml of blood, separation of WBCs, incubation with Tc99 x 2 hrs,

scan in 3 hrs

Gallium >> Tc uptake and incongruence of distribution

indicates osteomyelitis

aho imaging2
AHO: imaging
  • CT: - cortical destruction

- periosteal reaction

- sequestra

- intraosseeous gas

  • MRI: T1 =low signal, T2 = high signal ,

sensitivity 97%, specificity: 92%

- marrow inflammation / ischemia

- poor interface between NL & abnormal marrow = acute

- the best for spinal and pelvic osteo

- the best for pre-operative evaluation

ct scan mri
CT scan & MRI

CT scan MRI

a bone abscess brodie s abscess
A bone abscess (Brodie's abscess)

X-ray CT scan T99 scan

aho bacteriology1
AHO: bacteriology

Needle aspiration: for “S” and SBT

Bone culture (+) in 2/3

Blood culture (+) in 1/2

18 gauge spinal needle + Lidocaine

“Needle is part of physical diagnosis”

definitive tx of aho
Definitive Tx of AHO

SBT: > 1:16serum @ 1 hr after 4-th dose is incubated with patient’s isolate x 18 hrs

aho indications for surgery
AHO: indications for surgery
  • Soft tissue or ubperiosteal abscess
  • Purulent aspirate
  • Failure of Abx in 72 hrs
  • Sequestrum

**Debridement in proximity to the growth plate is risky

aho duration of tx
AHO: duration of Tx

Switch to PO: - resolution of symptoms and fever

- CRP approaching NL

- SBT > 1:8 + compliance assured

Duration of Tx:- asymptomatic

- CRP NL

- min 3 weeks

*Get an X-ray at the end of Tx (sequestrum?)

aho duration of tx1
AHO: duration of Tx

Prospective randomized study of of Staph. aureus AHO

# 50 pts,3 mo – 14 y.o., 1982 – 1996, Finland ( Ped, 1997)

-Cephradine vs. Cld IV, switch to PO after 4 d. with defevrescence

- 2/3 = no dril; no SBTs, no sequalae in 1 yr

-CRP was NL (< 20 mg/L) within 9 days, total duration of Tx: 3 – 4 we

contiguous subacute osteomyelitis
Contiguous subacute osteomyelitis
  • Punctured wound (in 3 – 5 d.)

Foot: osteo in 1.5% of injuries

  • Animal bite (cat)
  • Ulcer (anesthetic limb, decubiti)
  • 2o to sinusitis (Pott’s puffy tumor) / mastoiditis
  • Open Fx
  • Post ortho surgery ( in 2 – 4 we)
contiguous subacute osteomyelitis1
Contiguous subacute osteomyelitis
  • D # 3 – 5: Staph. aureus, GNRs (incl. Pseudomonas), anaerobes

>1/2 = polymicrobial

  • Usually NO fever, NL WBC count and CRP
  • Dx: biopsy culture
  • Recurrence rate: 40%
  • Tx: Timentin + Gent
  • Duration: - Pseud. = > 7 d. IV, total 3 – 4 we.

- decubitus: debridement + up to 6 mo. ABx

contiguous subacute osteomyelitis2
Contiguous subacute osteomyelitis

NYU cohort of # 24 pts, 8 mo. – 18 y.o., 1980 – 85

  • 15/18 (+) bone culture: 9 Staph. aur, 4 Pseud, 8 enteric GNRs
  • Compound Fx = 12, decubiti = 6, foot puncture = 3
  • Post-Fx: 3/4 had purulent d/c
  • NL CBC = 60% & NL SED = 40%, only few had fever
  • Duration of Tx: min 4 we
  • Recurrence rate: 42%
scd aho vs infarct
SCD: AHO vs. infarct
  • Pain, swelling, fever, high WBC coun, elevated SED
  • MRI: edema mimics osteo
  • T99 –colloid marrow scan (WBC uptake), followed by T99 methylene diphosphonate scan (osteoblast uptake)

Infarct: NO uptake on marrow scan + abnormal bone scan

Osteo: NL marrow uptake + abnormal bone scan

  • LA cohort of # pts with SCD, 9 mo – 19 y.o., 1988 – 1998 (JBJS, 2001)

# 79 SCD

# 4 NL m. /abn b. 3 confirmed osteo

# 70 low m. / abn b.

66 no ABx, resolved

# 5 NL m & b No ABx, resolved

aho in scd
AHO in SCD
  • Second most common infection after pneumonia
  • Salmonella 70%, Staph. aureus 10%, Pneumoc, Proteus, Serratia
  • Diaphyses of long bones, flat bones, small bones of hands and feet
  • May be multifocal, symmetrical involvement
  • Longer IV Tx: up to 6 –8 we
septic arthritis
Septic arthritis
  • Peak incidence: < 3 y.o., common Hx of trauma
  • > 90% monoarticular ( multiple in N.gon)
  • Knee (40%) >> hip (1/4) > ankle > elbow
  • Staph. aureus >> GAS > Pneumococcus ( in < 5 y.o.)
  • Sequalae = late (15%): - stiff joint (cartilage damage)

- unstable joint (chronic dislocation)

- arrest of bone growth

sa high risk for sequalae
SA: high risk for sequalae
  • < 6 mo. o.
  • joint + bone
  • hip & shoulder
  • > 4 d. delay in aspiration and ABx
  • long sterilization time
septic arthritis pathogenesis
Septic arthritis: pathogenesis
  • Highly vascular synovial tissue, no basal membrane
  • Hematogenous spread, adhesion to sialoprotein in synovial fluid
  • Chondrocytes and synovial WBCs release proteases that destroy ground substance of articular surface
  • Bacterial endotoxins stimulate release of IL-1 & TNF that induce release of proteases
septic arthritis1
Septic arthritis
  • Fever, pain, swelling, redness, decreased motility
  • Hip: favoring = “frog position” (flection + abduction)
  • Elevated WBC count and CRP in 1/2
  • Synovial fluid: WBC > 50 000, PMN > 90%, glu: low / NL
  • Aspirate culture (+) in > 2/3, Gram stain (+) in 1/2

* send in a blood bottle + container for Gram stain

  • Blood culture (+) in 1/3
slide35

Imaging:- US: fluid collection (hip, shoulder) - X-ray: swelling of the capsule, widened joint space- MRI: most sensitive early, the best for sacroiliitis & bone involvement

imaging
Imaging

Marked widening of the medial joint space in the R hip

as compared to the left hip (arrows)

Michael Richardson, 1994, University ofWashington

septic arthritis differential dx
Septic arthritis: differential Dx

SA = only 6% of acute arthritis

Always save some fluid (Rapid Strep, Lyme PCR)

sa principles of tx
SA: principles of Tx
  • Open drainage: - SA of hip & shoulder

- need in aspiration on D # 4

  • Aspirate for c/s prior to Tx
  • Prompt IV ABx, switch to PO when: - afebrile x 48 hrs

- improvement of symptoms

- no need in repeated aspiration

  • SBT 1 hr after 4-th dose: > 1:8
  • Duration: - 2 we afebrile

- min 3 we (GAS, Pneum.: min 2 we)

sa duration of tx
SA: duration of Tx

Retrospective review of # 20 cases of proven SA of the hip

Hospital for sick children, Torronto

(J Ped Ortho, 2000)

  • Infants # 9, pre-school # 5, 5 – 15 y.o. # 6, 1992 – 96
  • Staph. aureus 9, Pneumococcus 5, other hemolytic Streps 4
  • All had surgical drainage (# 3 had repeated I & D for fever)
  • IV ABx: 16/20 < 10 d.
  • Mean duration of Tx: 4 we
  • FU: mean 14 mo. No recurrence.
lyme arthritis
Lyme arthritis
  • 1 – 2 mo. after EM
  • Knee > shoulder > elbow > temporomand. > ankle
  • Sudden onset of pain & swelling, usually in 1 joint
  • Not ill, afebrile, moderate limitation of movements
  • PCR (+)
  • Synovial: WBC > 50 K, PMN > 75%
  • Amox/Doxy x 4 we
  • Recurrence: Ceftriaxone x 2 – 3 we
reactive arthritis
Reactive arthritis
  • Sterile inflammation, but (+) DNA / AGs
  • 80% have HLA type B27
  • 1 – 3 we. after Chlamydia, Yersinia, Campylobac., Shigella
  • Large joints of lower extremity, oligoarticular
  • Synovial fluid: WBC < 50 K, PMN > 2/3
  • Tx: NSAID
  • Recurrence: rare in children
gonococcal arthritis
Gonococcal arthritis
  • 1% of acute GU infection, within 1 mo
  • Low-grade fever, often during menstruation
  • Rash: in 40%, few papules on extremities (inf. vasculitis)
  • Septic: knee > hands. Sterile arthritis: hands > knee
  • Polyarthritis in 1/2
  • GU culture (+) in 80%, blood c/s (+) in < 10%
  • Synovial: Gram stain (+) in < 1/4, c/s (+) in 1/3
  • Tx: Ceftriaxone x 7 – 14 d.