Bone & Joint InfectionsDr. Mohamed M. ZamzamAssociate Professor & Consultant Pediatric Orthopedic Surgeon

OsteomyelitisThe term osteomyelitis does not specify the causative organism or the disease process

OsteomyelitisClassification: Duration Acute, Subacute or ChronicRoute of infection Hematogenous or ExogenousHost response Pyogenic or Granulomatous

Acute Pyogenic OsteomyelitisDefinition:AO is an infection of bone involving the periosteum, cortical bone and the medullary cavity.

Acute Pyogenic OsteomyelitisIncidence:Age more in children Sex boys > girlsBone affected all bonesSite of infection metaphysis

Acute Pyogenic OsteomyelitisOrganism:

Neonates: Staph aureus, Strept, E coliChildren:Staph aureus, E coli, Serriata, Pseudomonas, H inf Sickle-cell anemia:Staph aureus, Salmonella

Acute Pyogenic OsteomyelitisSource of Infection:

Hematogenous Direct spread Exogenous

Acute Pyogenic OsteomyelitisPathology:Primary focus and stage of inflammationSpread of infection with pus formationFormation of subperiosteal abscessPus tracks toward skin to form a sinusBone infarction (Sequestrum)New bone formation (involucrum)

Acute Pyogenic OsteomyelitisAge variationNeonates:Extensive bone necrosisIncreased ability to absorb large sequestrumIncreased ability to remodelEpiphysio-metaphyseal vascular connection leading to secondary septic arthritis

Acute Pyogenic OsteomyelitisAge variationAdults:No subperiosteal abscess due to adherent periosteumSoft tissue abscessVascular connection with the joint leading to secondary septic arthritis

Acute Pyogenic OsteomyelitisClinical PicturesHistory: Skin lesion Sore throat Trauma

Acute Pyogenic OsteomyelitisClinical PicturesSymptoms:Pain, restlessMalaise and fever The limb is held still (pseudo paralysis)Sometimes mild or absent (neonates)

Acute Pyogenic OsteomyelitisClinical PicturesSigns:General and LocalLaboratory Tests:CBCESR+CRPBlood culture (+ve in 50-70%)Aspiration (Gram stain + culture and sensitivity)

Acute Pyogenic OsteomyelitisRadiographyPlain X-rayUltrasoundBone & gallium scan (Sensitive but not specific)CT scan MRI

Acute Pyogenic OsteomyelitisDifferential DiagnosisAcute Septic ArthritisAcute monoarticular rheumatoid arthritis Sickle cell crisisCellulitisEwings Sarcoma

Acute Pyogenic OsteomyelitisTreatment General:HospitalizationHydrationElectrolyte replacementAnalgesiaImmobilization

Acute Pyogenic OsteomyelitisTreatment Antibiotics:Type?Route?When to start?When to stopMonitoring?

Acute Pyogenic OsteomyelitisTreatment Surgical Drainage:Indications?Procedure?Drilling?

Acute Pyogenic OsteomyelitisPrognosisFactors affecting prognosis:Organisms Infected Bone Age of the PatientTreatment

Acute Pyogenic OsteomyelitisComplicationsSepticemia & metastatic abscessesSeptic arthritisGrowth disturbance (children)Pathological fractureChronic osteomyelitis

Subacute OsteomyelitisLonger history and less virulent organism Insidious onset, Mild symptoms Pain is the most consistent symptomUsually no constitutional symptoms

Subacute OsteomyelitisAbnormal initial radiographs Inconclusive laboratory data Negative cultures/ biopsyDifficult to distinguish from bone tumors e.g. Ewings, osteosarcoma

Chronic OsteomyelitisFactors responsible for chronicityLocal factors: Cavity, Sequestrum, Sinus, Foreign body, Degree of bone necrosisGeneral: Nutritional status of the involved tissues, vascular disease, DM, low immunity Organism: Virulence Treatment: Appropriateness and complianceRisk factors: Penetrating trauma, prosthesis, Animal bite

Chronic OsteomyelitisTypesA complication of acute OsteomyelitisPost traumaticPost operative

Chronic OsteomyelitisClinical pictureContinuous or intermittent suppuration and sinus formation with acute exacerbations.Pain, fever, redness, and tenderness during acute exacerbations.Discharging sinus with +ve/-ve culture.Pathological fracture.

Chronic OsteomyelitisInvestigationLab tests/ culture Plain X-ray: Bone rarefaction surrounded by the dense sclerosis, sequestration and cavity formationSinogram Bone scan & gallium scan To detect chronic multifocal osteomyelitisCT Scan & MRIBiopsy

Chronic OsteomyelitisTreatmentAntibioticsSurgical treatment Preoperative assessment & preparation Derbridement Sequestrectomy Local antibiotics Stability Treatment of bone cavity

Chronic OsteomyelitisComplications Recurrence & Recurrence & RecurrencePathological fractures Growth disturbance Amyloid diseaseEpidermoid carcinoma of the fistula

Septic ArthritisSeptic arthritis is an infection of the joint usually bacterial, as viral arthritis is usually self limiting and treatment is supportive.50% of cases in children

Acute Septic ArthritisOrganism?Route of infection?Pathology: Serous or acute synovitis Serofibrinous Suppurative (purulent) arthritis

Acute Septic ArthritisClinical PicturesGeneral manifestations: constitutional symptoms and signs of acute infectionLocal manifestation: Swelling, hotness and redness Deformity with muscle spasm Restriction of all movements of the joint The joint is fixed in the position of ease

Acute Septic ArthritisInvestigationsLab tests/ cultures Plain X-ray Bone scan & Gallium scanUltrasound Aspiration: if WBC >50,000with >90% PMNLs suspect septic arthritis even if culture is negative.

Acute Septic ArthritisDifferential DiagnosisAcute osteomyelitisTransient synovitis of the hip (

Acute Septic ArthritisTreatmentAspiration Antibiotics SplintageSurgical drainageTreatment of complications

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