Infection of bones and joints Rozkydal, Z. •Epidemiology •Osteomyelitis occurs often in childhood • •Infection in compound fractures type II. III. • 7- 20 % • •Infection in elective orthopaedic procedures •0,5-3 % • •Periprosthetic infection – primary up to 2% • revision 2-14 % Acute haemotogenous osteomyelitis •Causal organism: • Gram- positive and Gram- negative • with aerobic or anaerobic metabolism Acute haemotogenous osteomyelitis •Gram +: •Staphylococcus aureus in 80 % • Streptococcus pyogenes •Staphylococcus epidermidis •Haemofilus influenzae Acute haemotogenous osteomyelitis •Gram - : •Escherichia coli •Klebsiella •Proteus vulgaris •Pseudomononas aeruginosa •Salmonella, Shigella •Clostridium •MRSA •MRSE •Multirezistentní gram negativní tyčinky •Clostridium difficile The way of infection •Haematogenous seeding • from infection focus in the body • •Suppurative focus in the vicinity (phlegmona, absces, Batson plexus in urinary tract infection) • •Dirrect transport (open fracture) Záněty- OM schema •Typical localisation - •Metaphysis of long bone • •More often in children • •Acute haemotogenous osteomyelitis •Pathological anatomy •Hyperemia, swelling, pus •Subperiostal abscess •Disturbace in circulation, •infective trombosis •Osteolytic lesion •Necrosis of bone, sequestra •Sequestra of the whole diaphysis •- involucrum •Destruction of growth plate •Spread into the lungs and other bones •Sepsis Záněty- OM schema •In children up to six months: spreading through growth plate •In children above six months: growth plate is a barrier Inf 1 •0-6 months more than 6 months •Local symptoms: •Rubor, calor, dolor, tumor, functio laesa •Tenderness, fistula, discharge • •Systemic symptoms: •Fever ( septic fever – two degress between in the • morning and in the afternoon) •Shivering •Fatique •Tachycardia, tachyponoe,hypotension •Nausea, stomach problems Laboratory tests •Leucocytosis •ESR •CRP •Differential blood test •Electrophoresis of proteins •Metabolic acdosis •Bacteriological examination from the pus •Haemoculture • Záněty- OM acuta2 •Radiological finding • •Swelling of soft tisseue •Irregular rarefaction in bone •Osteolysis in the metaphysis •Elevated periosteum •Sequestra Záněty-OM acuta1 •Radiological finding • •Swelling of soft tissues •Irregular rarefaction in bone •Osteolysis in the metaphysis •Elevated periosteum •Sequestra • •Management • •Bed rest, splinting •Analgetics •Antibiotics i.v. for 2 weeks, than oraly 6-8 weeks •Amoxicilin/ ac. clavulanicum •Ciprofloxacin, cefalosporins, dalacin •Gentamycin •Vancomycin - MRSA infection •Change of antibiotics – according to bacteriological • examination •Surgical treatment • •Aspiration of the abscess •Drilling of the bone and decompression •Drainage •Local application of antibiotics •Systemic antibiotics INf 2 •Antibiotics •Debridement •Jet lavage •Rinsing lavage 7 days •Removal of internal fixation •External fixator •Local application of •antibiotics • •Posttraumatic osteomyelitis Zl Záněty- OM subacuta •Subacute osteomyelitis •Less virulent organism • •Mild symptoms •Sclerosis of bone •Chronic osteomyelitis • •Cause: not succesfull treatment of acute stage • imunodeficiency • high virulent organism •Sequestra - necrotic bone surrounded by • pus and granulation tissue • •Pyogenic membrane •Sclerotic surrounding - prevents revasculation and transport • of antibiotics • •Diffuse rarefaction and osteolysis Záněty- OM Brodieho absces •Pathological anatomy •Symptoms •Pain, tenderness, limited function •Discharging sinuses with small sequestra •Recurrence of acute stage •Fatique •Cachexia Záněty •Combination of rarefication and sclerosis •of bone •Sequestra •Periosteal apposition of bone • Záněty- OM chronica2 •Combination of rarefaction and sclerosis •of bone •Sequestra •Periosteal apposition of bone • •Fistulography •MRI •CT •Radiological finding •Management of chronic osteomyelitis • •The rule: ubi pus, ibi evacua ! •Sequestrotomy, lavage •Local antibiotics – garamycin •Systemic antibiotics •Support of imunity • •Seldom: conservative treatment • •Slow onset •Fewer •Back ache •Limited movements •Tenderness •Spasm of paravertebral •muscles •Osteomyelitis of the vertebra Záněty- spondylitis rtg 2 •Radiological finding • •Swelling of soft tissue •Erosion of the end plates •Osteolysis and destruction •Narrowing of intervertebral space • •MRI • •Scintigraphy Záněty- spondylitis rtg 2 •Management • •Bed rest, orthesis •Antibiotics i.v., after 2-3 weeks oraly 6-10 weeks •If not succesul – aspiration from the abscess •Drainage, debridement, sequestrotomy •Antibiotics localy •Differencial diagnostics •Tumors •Tumor like lesions •Stress fractures •Entesopathies T pisařovic 2 •Clostridium difficile • •After antibiotic therapy- postantibiotic colitis •- aminopenicilins, fluorochinolons, cefalosporins. •Toxin A- enterotoxin, efect on GI mucose membrane •Toxin B- cytotoxin, 10-100 more efective •Risk of colonisation of GI during hospitalisation 10-20 % •Causes severe enterocolitis with diarrhoea, sepsis •Management: Metronidazol, Vancomycin, Meropenem •Periprosthetic infection •St. aureus •St. coagulase negative •Streptoccoci •Enteroccoci •MRSA, MRSE •Polyresistant G- bacteria •to betalactam antibiotics • •Planctonic and sesssile forms •Bacteria- race for surface •- Glycocalyx (mucouse substance of glycoproteins) •Leads to high resistance to antibodies and antibiotics biofilmLifeCycle.jpg •Biofilm •Biofilm biofilmLifeCycle.jpg •Adhesion of •bacteria •- reversible •Exopolymers •- glycolalyx •- extracelular matrix •irreversible •Dispersal •Periprosthetic infection - diagnosis •Symptoms:- pain, oedema, readness, fistula • loss of function •Labor: CRP, leu, ESR • bacteriological ex. •X-ray- osteolysis, rdiolucency •USG-soft tissues •Scintigraphy Tc-99 • •Perioperative finding- liquid, pus •Sonication of implant • •Prolonged cultivation 5-7 dayes r trnka 4 •Therapy in THA •Long antibiotic supression •Debridement, synovectomy •One stage reimplantation •Two stages reimplantation (spacer) •Resection arthroplasty Park Hájková 3 copy r černý 6 H spacer 1 •Spacers •Better movement •Better walking •Correct distance •Release of antibiotics •- 90 % of all pathogens •+ MRSA, MRSA, Entero •+ Enteroccoci • •Easier revision • H spacer 2 H spacer 3 •Therapy in TKA - Up to 2 weeks: debridement, • lavage, synovectomy •- Later: one stage revision • two stage revision • Prostalac TKA rev Chylíková 10 TKA rev Chylíková 11 TKA rev Chylíková 4 TKA rev Chylíková 3 •Consequences • •Recurrence of infection •Growth arrest – shortening of the extremity •Weakness of muscles •Joint contracture •Septic arthritis •Amyloidosis •Epidermoid carcinoma •Patological fracture •Sepsis •Septic arthritis • •Suppurative arthritis of the joint • Inf 3 Septic arthritis •Gram +: •Staphylococcus aureus •Streptococcus pyogenes •Staphylococcus epidermidis •Haemofilus influenzae •Gonococcus •Pneumococcus • Septic arthritis •Gram - : •Escherichia coli •Klebsiella •Proteus Hauseri •Pseudomononas aeruginosa •Salmonella •The way of infection • •Haemotogenous seeding • •From metaphysis – hip, elbow • •Direct way- •by aspiration, surgery, trauma Záněty- OM schema Pathological anatomy 1.Synovitis purulenta synovial membrane is thick, pus Inf 3 Pathological anatomy 2. Phlegmone of joint capsule The whole joint capsule is involved, pus and granulation tissue, erosions of the cartilage, pannus formation Inf 3 Pathological anatomy 3. Panarthritis. Inflamation involves the joint and periarticular tissues, abscesses, destruction of cartilage, fibrous or osseous ankylosis Inf 3 •Local symptoms • •Rubor, calor, dolor, tumor, functio laesa •tenderness, discharge from sinuses Inf •Systemic symptoms • •Fever ( septic fever – two degress between in the • morning and in the afternoon) •Shivering •Fatique •Tachycardia, tachypnoe, hypotension •Nausea, stomach problems • • Záněty - coxitis novoroz •Newborn septic arthritis •X-ray: •Soft tissue swelling •Widening of joint space •Pathological subluxation •Periostal thickening •Rarefication of epiphysis •and metaphysis •Later on narrowing •of joint space • • •Adult septic arthritis •X-ray: •Soft tissue swelling •Widening of joint space •Pathological subluxation •Periostal thickening •Rarefaction of epiphysis •and metaphysis •Later on narrowing •of joint space • • M 000 Boháček jeřabkova ct 4 jeřabkova 6 Laboratory tests •Leucocytosis •ESR •CRP •Differential blood test •Electrophoresis of proteins •Metabolic acdosis •Bacteriological examination from the pus •Haemoculture • •Management • •Aspiration •Splinting, analgetics •Antibiotics i.v., after 2 weeks oraly 6-8 weeks •Arthroscopy and lavage •Incision and drainage cox- anterola •Consequences • •Osteoarthritis •Epiphyseal destruction •Necrosis •Disturbace of growth plate •Ancylosis •Subluxation or dislocation •Sepsis Záněty- OM pozáň dysostoza Gaža 15 •Tuberculosis •Granuloma formations •Nodes 1-2 mm connecting together •The cause- Mycobacterium tuberculosis • Mycobacterium bovis •Haemotogenous seeding (from lungs) Inf •Pathological anatomy • •1. Proliferative form (tbc granuloma, fungus) •2. Exsudative form (caseation, hydrops, empyema) •Miliar TB nodes: •Langerhans cells (with Mycobacteria) •Epiteloid celles, lymfoid cells •Nodes form TB granuloma Inf •Cold abscess •Hydrops •Fungus •Starts as synovitis or spreads from epiphysis •Slow progression •Destruction of cartilage •Fibrous or osseous ankylosis •Pathological anatomy Inf Záněty- TBC coxitis •TB coxitis Záněty - gonitis TBC •TB of the knee joint Záněty- TBC paraart •TB paraarticular •lesion in metaphysis Záněty- TBC destrukce kolena •TB of the knee joint- subluxation •Diagnostics • •Aspiration •Biopsy •Histology •Mantoux II •PCR (polymerase chain reaction) •Serology: IgM, IgA, IgG •QuantiFERON –TB Gold • • Záněty - TBC coxitis déza •TB coxitis healed by extraarticular arthrodesis Záněty - TBC kolena déza • •TB arthrisis of the knee joint •Arthrodesis • Záněty - TBC kolena déza •Management • •Antituberculous chemotherapy: •Combination of bactericid agent: Isoniazid, rifampicin, •PAS, ethambutol, pyrazinamid, •cycloserin, capreomycin, STM. •Therapy is long- 9 months at least •Rest, orthesis •Surgery- debridement, synovectomy, •In the hip – Girdlestone resection •arthrodesis • Záněty- spina ventosa •Spina ventosa • •TB spondylitis • •Half of all cases •Thoracic and lumbar spine- malum Potti •Cervical spine -malum Rusti • •Osteolytic lesion in anterior part •of the body •Paravertebral abscess •Narrowing of disc space •Spreading into the adjacent vertebra •Collapse forwards •Angular kyphosis TBC • •Symptoms • •Back ache, tenderness, spasm •Sharp gibbus •Spasticity, paraparesis, paraplegia •Sinuses from cold abscess Záněty TBC páteře1 •Radiological finding • •Osteolytic lesion in anterior part •of the body •Paravertebral abscess •Narrowing of disc space •Spreading into the adjacent vertebra •Collapse forwards •Angular kyphosis Záněty TBC páteře2 Záněty TBC páteře 3 Záněty- spondylitis MRI •Management • •Debridement of the lesion •Revision of abscess •Decompression of spinal cord and •nerve roots •Stabilisation of the spine •