INFECTION OF BONE AND JOINT ธนพจน จ นทร น ม ภาคว ชาออร โธป ด กส โรงพยาบาลรามาธ บด OBJECTIVE Make diagnosis and treatment in bone and joint sepsis Prevent complications i from disease and treatment Use and update on new evidence base Osteomyelitis CONTENT Septic Arthritis Case Male 3 year old Thai Normal labour Hx and development Adequate immunization Ulceration with discharge from right forearm 10 days Case Febrile 38.5 0 Cry when touch his forearm Rest like paralysis => Pseudoparalysis Debridement was done with tissue and pus culture => S. aureus Repeat X-ray in 10 days later 1
OSTEOMYELITIS Classification Pathogenesis Signs & Symptoms Diagnosis Treatment Prognosis OSTEOMYELITIS : CLINICAL CLASSIFICATION ACUTE OSTEOMYELITIS : DERMOGRAPHY Acute (within 14 days of onset) Sub acute (> 14 days of symptoms) Chronic ( > 28 days, sequestra) Decreased incidence Peak incidence in childhood ( Gilmour 5 6 yrs, Trueta 10 1111 yrs ) Male : Female = 2.5 4 : 1 Monostotic & Lower extrem. = 90% Most Common Location = Long bone ( METAPHYSIS ) OSTEOMYELITIS OSTEOMYELITIS : METAPHYSIS, WHY? Morbidity ~ 6 % Delay Rx, Inadequate Rx Failure of identifying organism Vascular loop Theory Immature Phagocyte Theory (Rang 1969, Ogden 1975) Injury Theory & Haynes 1989) (Morrisy 2
PATHOPHYSIOLOGY Bacteria lodge Thrombosis Infection spread on least resistance Down the medullary canal, through the metaphyseal cortex Course of Metaphyseal infection Expansion, temponade to vessel, destroy cortex Periosteal new bone Involucrum Dead bone Sequestrum Rupture of periosteum Osteomyelitis:Pathology 3
Trueta (1959):Pattern of blood supply of long bone Metaphysis is Intraarticular structure in...joints. Shoulder Elbow Hip Ankle Acute Hemato. Osteomyelitis : Clinical Features Early acute 2/3 >Febrile Avoid using the extremity,limps, pseudoparalysis localize tenderness, swelling Late acute Febrile(4 7days) Obviously sick,sepsis esp. Neonates Sympathetic effusion(knee) Acute Hemato. Osteomyelitis : Lab.& Routine Investigation CBC, ESR, CRP Blood C/S +50% X ray changes after 7 days,look for new bone, mottling Aspiration No abscess >ATB,observe Abscess >ATB, surgical drainage Osteomyelitis:X ray Osteomyelitis:X ray 5% of radiographs were abnormal initially 33% were abnormal by 1 week 90% were abnormal by 4 weeks 4
Osteomyelitis:X ray Acute osteomyelitis:special studies Bone scan: Technetium Gallium Indium CT / MRI Ultrasound Bone Scan Early, sensitive, show extension & multiple lesions Non-specific, only in center Technetium Bone Scan Uncommonly needed If diagnosis is equivocal If result would alter therapy Three phase: Sensitivity 0.9 to 0.95 Specificity 0.75 to 0.95 Needle aspiration dose not affect for 72 hours MRI Most accurate imaging study Sensitivity 0.97, Specificity 0.92 T1 low to intermediate signal T2 high signal intensity Rarely needed in acute osteomyelitis Reserve for pre op planning of chronic atypical cases: spine,pelvis Ultrasound (US) Current knowledge / Consensus US detects changes sooner than X ray US can localize subperiosteal abscess Stages earliest sign deep soft tissue swelling periosteal elevation,fluid underneath periosteal abscess May detect concurrent septic arthritis 5
DIFFERENTIAL DIAGNOSIS of osteomyelitis Acute osteomyelitis: Diff. Diagnosis Trauma Tumors Osteosarcoma Ewing s sarcoma Metastasis neuroblastoma Eosinophilic granuloma Cellulitis Tropical Pyomyositis Necrotizing fasciitis Leukemia Bone Infarction Cellulitis Pyomyositis Osteosarcoma Ewing sarcoma Leukemia Sickle cell with bone infarction ETIOLOGY Etiology:Common Bacterial organism Neonate Strephylococcus group B Staphylococcus aureus Gram Negative Infant & Preschool Staphylococcus aureus Strephylococcus group A Haemophilus influenzae Children to Adult Staphylococcus aureus Vary 1. Neonate : Staphylococcus aureus Strep. Gr. B Gm. negative 2. Infant & : Staph. aureus, H.influenzae Preschool 3.Children : Staph. aureus Acute osteomyelitis : Management Aspiration Conservative Surgical Acute osteomyelitis:aspiration 16 18 gauge needle inserted at area of maximal tenderness Pus Aspirate, Gm stain OR No Pus Young child into metaphysis C/S 6
Acute Hemato. Osteomyelitis: Conservative treatment ACUTE OSTEOMYELITIS : ANTIBIOTIC THERAPY Admission Intravenous fluid Bed rest, splinting, traction Antibiotics Initial with intravenous route Dose maximum in range e.g. 50 100 mg/kg/d Criteria for switching to oral medication vary in each institute Osteomyelitis: Antibitic Splint & Traction Hematogenous-empiric empiric treatment Etiologies Newborn (0-4 mos.) S. aureus, Gm-neg bacilli, Gr. B strep Children (>4 mos.) Adult (>21yrs) Adult -Drug abuse, dialysis Adult -compromise S. aureus, Gr. A strep, coliforms rare Primary Rx Anti staph Pen + Ceph 3 Anti staph Pen /Ceph 1 +/- Ceph 3 S. aureus, +varies Anti staph Pen 1-2 gm q6 h IV /Cefazolin 1-2 gm IV q8 h S. aureus, P. aeruginosa Anti staph Pen + CIP Salmonella sp. Alternative Rx Vanco + Ceph 3 Vanco/Clinda Vanco 1 gm q12h IV Vanco + CIP Fluoroquinolone Ceph 3 Comments Rx minimum 21 d IV then oral until 3-6 wks. Empiric Rx ACUTE OSTEOMYELITIS : INDICATION FOR OPEN DRAINAGE 1. Present with abscess 2. Present with osteomyelitis adjacent to the joint hip, shoulder, ankle & elbow 3. No improvement after 48 hrs. of conservative treatment 4. To rule out malignancy OSTEOMYELITIS :SURGICAL TREATMENT Incise periosteum Avoid additional elevation of periosteum Suction / copious irrigation of pus Tinydrillholeinmetaphysis?? Tiny drill hole in metaphysis,?? Small abscess close over drain Large abscess leave open 7
ORAL THERAPY : NELSON CRITERIA Prerequisites adequate response to I.V. Rx able to swallow medication compliance assured stable home situation established etiologic agent lab to perform bactericidal titers (1:8) Dosage 2 3 times usual oral dosage 45 60 min. after suspension 11/2 2 hrs. after capsule ORAL THERAPY: GREEN, U. Missouri/ Columbia Early acute * I.V. therapy for 2 to 5 days * If response, discharge on oral ATB without obtaining titers Late acute * Surgical drainage, almost universal * I.V. therapy for 7 to 14 days * Switch to P.O. therapy (Nelson ) Mornitoring Response of Treatment Early fever, constitutinal symptoms, tenderness Intermediate C reactive protein better than ESR CRP normal ESR normal Osteomyelitis only 6 + 3 days 17 + 10 days Osteo+septic jt. 11 + 7 days 25 + 12 days Late(6weeks) persistent tenderness need more therapy X ray, ESR COMPLICATIONS OF OSTEOMYELITIS Concomitant Septic Arthritis Typically, present like septic arthritis With younger age (< 10 months) Longer duration, prior Rx for oteitis media,etc Sequelae common : hip, shoulder Distant seeding pneumonia,pericarditis Pathological fracture Chronic osteomyelitis Growth disturbance Morbidity/mortality SUBACUTE OSTEOMYELITIS CHRONIC OSTEOMYLITIS Clinical Manifestation Sinus Tract Bone Pain Acute Inflammation 8
CHRONIC OSTEOMYLITIS CHRONIC OSTEOMYLITIS CHRONIC OSTEOMYLITIS Chronic Osteomyelitis Factor for Predisposing Degree of bone necrosis Nutrition Age Infecting organism Comorbidity Drug abuse Posttraumatic Osteomyelitis Factors that contribute Presence of hypotension Inadequate debridement of the fracture site Malnutrition Alcoholism Smoking SEPTIC ARTHRITIS Hematogenous spread Direct inoculation Contiguous spread Shoulder proximal humerus Elbow radial neck Hip proximal femur Ankle distal fibula Infection from surgical wound 9
SEPTIC ARTHRITIS: Dx History and physical examinations Classic triad fever, swelling and tenderness (effusion) Limitation of joint motion Resting position e.g. Hip abduction, ext. rotation, flexion Laboratory studies CBC PMN in acute infection ESR occur at 3 5 d, return to normal 3 wk. CRP within 6 hr., return to normal 1 wk. Synovial fluid analysis Microbiologic studies Joint Fluid Analysis Disease WBC Neutrophil Normal <200 <25% Trauma <5000 <25% Toxic Synovitis 5000-15,000 <25% RF 10,000-15,000 50% JRA 15,000-80,000 75% Septic >80,000 >75% Pathology Hyperemia Infiltrate c PMN Cell death, degrade cartilage Bacterial toxin, proteolytic enzymes Destruction of cartilage 4 6 d after infection Complete in 4 wk. Joint dislocation / subluxation / osteomyelitis Pathophysiology Site of Aspiration Bacterial inoculation Macrophage Inflammatory Response IL-1 Metalloproteases Enzyme Chondrocyte Collagen and Cartilage damage 10
Treatment 3 essential principles Joint must be adequately drained ATB must be given to diminish the systemic effects of sepsis Joint must be rested in a stable position o Initial ATB base on age and risk factor S. aureus. requiring 4 6 wk Neisseria, Streptococcus, H. influenza Rapid response to ATB, short duration ( < 2 wk.) Drainage should be perform for all septic arthritis SEPTIC ARTHRITIS: Complications Pathologic dislocation Osteomyelitis Persistent infection AVN Destruction of epiphysis SCFE Prognosis THE END Duration before diagnosis Extreme age Virulence of organisms Adequate surgical treatments 11