2015/02/06

BONE AND JOINT

INFECTIONS

(Osteomyelitis, Infectious
Arthritis)

Bone and Joint Infections

1. Osteomyelitis
2. Infectious (Septic) Arthritis
3. Mycetoma
4. Infections associated with
Prostheses of Bones and Joints

1
 2015/02/06

BONE AND JOINT INFECTIONS

(Osteomyelitis and Infectious Arthritis)

OSTEOMYELITIS
(Can be either Acute, Subacute or
Chronic)

OSTEOMYELITIS

USEFUL TERMS
Osteomyelitis (osteo = bone; myelitis = bone marrow)
Infection of bone and bone marrow, with ongoing
inflammatory destruction.
Epiphysis… …Suppuration …Mycetoma
Diaphysis… …Inflammation
Metaphysis… …Infectious Arthritis
Sequestrum … …Acute osteomyelitis
Involucrum… …Subacute osteomyelitis 4

Pott’s disease …Chronic osteomyelitis

2
 2015/02/06

OSTEOMYELITIS

3
 2015/02/06

OSTEOMYELITIS

o  Capillaries of nutrient artery of bone make sharp loops in

areas of epiphyseal growth plates and enter a system of
sinusoidal veins connected to the venous network of the
medullary cavity.
o  In loops of the capillaries - blood flow is slow and
turbulent
o  Loops adjacent to epiphyseal growth plate are essentially
end arteries – obstruction of which leads to avascular
necrosis. 7

OSTEOMYELITIS

HOW DO WE CLASSIFY
OSTEOMYELITIS?

4
 2015/02/06

OSTEOMYELITIS

(a) According to Duration of Infection

Acute (the gist of this lecture)
Subacute, and
Chronic
(b) According to the Route of Infection
(i) Hematogenous – Via blood from a distant focus of
infection. e.g. URTI.
(ii) Exogenous - From outside the body.
e.g. MVA, Domestic violence.
9

OSTEOMYELITIS

ROUTE OF INFECTION

Hematogenous – Most common route of infection, usually from a

distant focus of infection.
e.g. URTI (Otitis Media & Tonsillitis)

Direct Invasion:- e.g.

…Compound fracture (MVA, domestic violence)
…Operation
…Skin Puncture

Direct Spreading – From skin superimposed on bone.

10

5
 2015/02/06

ROUTE OF INFECTION

11

OSTEOMYELITIS

What are the etiologic agents of

osteomyelitis?

12

6
 2015/02/06

ETIOLOGY OF OSTEOMYELITIS

Different microorganisms affect persons of Different age

groups & conditions:
o  Neonates: Staphylococcus aureus, Enterobacteriaceae
(e.g. E coli), Group B, Streptococcus.
o  Children: Staphylococcus aureus, GAS, Haemophilus
influenzae, Enterobacteriaceae.
Salmonella sp - Common in patients with Sickle Cell
Disease
o  Adults: Staphylococcus aureus, Pseudomonas
aeruginosa, Staphylococcus epidermidis,
Anaerobes (especially Peptostreptococcus).
13

ETIOLOGY OF OSTEOMYELITIS
(cont’d)

Illicit Drug Users:- Staphylococcus aureus, Candida

albicans, Pseudomonas aeruginosa, Serratia
marcescens

NB: Staphylococcus aureus - Most common

etiologic agent at all age groups & conditions.

14

7
 2015/02/06

INCIDENCE OF ACUTE HEMATOGENOUS

OSTEOMYELITIS

o  Age - Mostly in children

o  Sex - Boys (5-15 years) more
than girls
o  Bone affected - Primarily long bones
o  Site of infection - Metaphysis

15

Pathophysiology of Acute Hematogenous

Osteomyelitis

…The growth plate is closed in the adult, so the blood vessels become
looping, we call it ‘hairpin loop.’ We have large blood vessels
which become smaller gradually and at the end we have narrowing
of the blood vessels so that stasis occurs for the blood, and by stasis
we have exudates which result in a focus of infection.
…In infants and children the growth plate is still open, it is still
cartilage and not a mature bone. Here we have penetration through
this cartilage and infection of the epiphysis as well. In adults
with the closure of the growth plate, infection is
metaphysial, but in the younger age group it starts
at metaphysis and end with the epiphysis
infection since the growth plate is still open.
16

8
 2015/02/06

Pathophysiology of Acute Hematogenous

Osteomyelitis

17

Pathophysiology of Acute Hematogenous

Osteomyelitis (cont’d)

o  Infection provokes acute suppurative response that leads to

n  Necrosis of tissue (bone marrow)

n  Breakdown of bone
n  Removal of calcium from bone

o  Osteomyelitis in Adults – Most commonly affects the vertebrae, the

pelvis and the feet.

18

9
 2015/02/06

OSTEOMYELITIS

…In the pathogenesis of acute Hematogenous osteomyelitis we have a source of

infection like Tonsillitis or Otitis media.

…Spread of the microorganism through the blood stream occurs, which settle
in the metaphysis, and then we have venous stasis and then gathering or
colonization of the bacteria that develops into a focus of infection.
19

PATHOGENESIS OF OSTEOMYELITS

○ In the Metaphysis (Slow blood flow in metaphyseal capillary loops)

(venous stasis)
○ Bacterial Colonization → Focus of Infection
○ Microcolonies surrounded by glycocalix, plug capillaries,
blocking the access for PMNs and antibiotics.
○ Bacteria escape through endothelial gaps to the tissue
○ Expression of adhesins allows the bacteria to attach to the
components of bone matrix, e.g. sialoglycoprotein .

Staphylococcus aureus survives in osteoblasts: hard to eradicate.

20

10
 2015/02/06

The most common sites of the bone affected by

infections is the metaphysis, because of certain
blood arrangement inside this part of the bone.

21

PATHOLOGY OF OSTEOMYELITIS

Any infection passes thru stages. For Osteomyelitis:

(a) Inflammation….vascular congestion, PMN infiltration via

blood vessels, exudation, increase
intraosseous pressure.
(b) Suppuration …..period of pus formation.
….If growth plate is open → septic arthritis;
….If closed, pus → medullary cavity.

(c) Necrosis… bone destruction (sequestrum).

22

11
 2015/02/06

PATHOLOGY OF OSTEOMYELITIS
(cont’d)

(d) New bone formation…lamella (layer by layer) new bone

formation (Involucrum)

(e) Complete Resolution …infection is controlled with

antibiotics and surgical drainage.
This results in:

(i) Decrease in intraosseous pressure.

(ii) New bone formation with thickening
(iii) Bone remodelled to normal contour
23

Clinical Features of Acute Hematogenous

Osteomyelitis

Infants: Drowsiness, Irritability, Failure to thrive, Metaphyseal

tenderness and resistance to joint movement.

Child : (approx. 5 yrs): Pain, Fever, h/o recent URTI (e.g. Otitis
Media, Tonsillitis), Local inflammation, draining pus,
Lymphadenopathy.

24

12
 2015/02/06

Clinical Features of Acute Osteomyelitis

o  Osteomyelitis of the tibia of a young child. Numerous

abscesses in the bone show as radiolucency.

25

Clinical Features of Hematogenous

Osteomyelitis

Adult: Osteomyelitis is uncommon in adults, unless patient

has risk factors such as:
…Immune deficiency (e.g. HIV)
…Diabetes (poorly controlled)
…IV Drug abusers
…Corticoid steroid therapy,
…Sickle Cell Disease
…Hemodialysis.

Fever, Pain, Acute tenderness.

26
Most common site is the thoraco-lumbar spine.

13
 2015/02/06

Laboratory Diagnosis of Acute Osteomyelitis

…CBC
…ESR, CRP
…Blood cultures
…Aspiration, for C/S
…Radiography : …. Simple X-Ray
…. Bone Scan
…. MRI Scan

27

Management of Acute Osteomyelitis

General: ….Hospitalization
…. Hydration
…. Analgesics
…. Immobilization: …Splint
… Surgical Drainage
…Antibiotics
Antibiotics: Empiric:
Definitive:

28

14
 2015/02/06

COMPLICATIONS OF ACUTE
OSTEOMYELITIS

…. Altered bone growth – destruction and premature

closure. One limb shorter than
the other.
…. Septic (Suppurative) Arthritis
…. Pathologic Fracture
…. Chronicity

29

OSTEOMYELITIS

Subacute Osteomyelitis

o  Longer history and less virulent organism.

o  Symptoms are mild and onset insidious
o  Pain is the most consistent symptom.
o  Laboratory Data not conclusive

30

15
 2015/02/06

Chronic Osteomyelitis

…Usually a sequel to acute osteomyelitis

Organisms are usually: Staphylococcus aureus, E. coli, GAS,

Proteus, Pseudomonas aeruginosa
…In the presence of foreign implants, S. epidermidis is most
common

S/S: Pain, Fever, Tenderness, Draining sinus, Excoriation of skin

Investigations: Same as for Acute Osteomyelitis

Treatment: Antibiotics & Surgery

Complications: Pathological fracture 31

Epidermoid carcinoma of the fistula

BONE AND JOINT INFECTIONS

32

16
 2015/02/06

Bone and Joint Infections

Infectious Arthritis

33

Infectious Arthritis

What organisms are associated

with Infectious Arthritis?

34

17
 2015/02/06

Etiology of Infectious Arthritis

Bacteria Viruses
Staphylococcus aureus Hepatitis B and C
Neisseria gonorrhoeae Parvovirus B19
Streptococci (Group B streptococcus, GAS) Varicella-Zoster
Pasteurella multocida Epstein Barr Virus
Pseudomonas aeruginosa Coxsackie (A9, B2,
Haemophilus influenzae B3, B4, B6)
Enterobacter
Serratia marcescens
Kingella kingae, Eikenella corrodens
Anaerobes (e.g. Bacteroides, Fusobacteria, Clostridia)
35

Infectious Arthritis

What is the Pathogenesis of

Infectious Arthritis?

36

18
 2015/02/06

PATHOGENESIS OF INFECTIOUS
ARTHRITIS

o  Organisms reach the joints via:

n  Bloodstream (from a distant focus of infection,

e.g. Skin, Lung, GIT, UTI).

n  Direct Penetration (e.g. Trauma, Surgery, Bites,

Injection).

n  Extension into the joint from an adjacent

infection
(e.g. Osteomyelitis, infected wound, soft tissue abscess)

37

PATHOGENESIS OF INFECTIOUS
ARTHRITIS (cont’d)

After entry into the joint space, organisms multiply in the

synovial fluid and synovial tissue.

PMN's migrate into the joint to phagocytize the infecting

pathogens.

Phagocytosis results in PMN autolysis with release

lysosomal enzymes into the joint causing damage to the
synovial membrane, ligaments and cartilage.

38

19
 2015/02/06

Infectious Arthritis

What Predisposing Factors are

associated with Infectious
Arthritis?

39

Predisposing Factors to Infectious

Arthritis
Patients that are vulnerable include those with a
history of:

n  Penetrating Trauma, e.g. MVA, Domestic Violence

n  Animal and human bites
n  Joint implants
n  Systemic Disease, e.g. Diabetes, Malignancies
n  Immunosuppressive drugs, e.g. Corticosteroids

40

20
 2015/02/06

Infectious Arthritis

What Clinical Features are associated

with Infectious Arthritis?

41

Clinical Features of Infectious

Arthritis

o  More than 90% are monoarticular

o  About 10% are polyarticular
n  Pain and swelling
n  Limitation of movement
n  Fever

42

21
 2015/02/06

Infectious Arthritis

Laboratory Investigations of
Infectious Arthritis

43

Laboratory Investigations of
Infectious Arthritis

o  Blood....CBC, ESR, CRP and Culture

o  Synovial Fluid: Macroscopic examination: color, turbidity
Microscopic: Gram stain, culture

o  Others include: X-Ray, Bone Scan

44

22
 2015/02/06

Management of Acute Infectious Arthritis

General: ….Hospitalization
…. Hydration
…. Analgesics
…. Immobilization: …Splint
… Surgical Drainage
…Antibiotics
Antibiotics: Empiric:
Definitive:

45

COMPLICATIONS OF INFECTIOUS
ARTHRITIS

…. Destruction of the articulating surface of joint leading to a

frozen joint.
…. Osteoarthritis

46

23
 2015/02/06

MYCETOMA
ETIOLOGY:
Mycetoma is caused by at least 20 species of actinomycetes and
fungi. The most common infecting agents are
…Nocardia spp and
…Madurella mycetomi.

OVERVIEW:
Mycetoma is a local chronic and progressive infection of the skin,
subcutaneous tissues and bone. It is characterized by swelling that is
often grotesque and disfiguring and by multiple sinus tracts that drain
granules containing pus
47

PATHOLOGY AND CLINICAL SYMPTOMS OF

MYCETOMA:

The disease is acquired by traumatic implantation in the

skin. The microorganisms grow through the subcutaneous
tissue into the bone. As this occurs, there is hyperplasia of
the tissues, formation of pus containing granules (which are
actually colonies of microorganisms), expression of pus to
the surface of the skin and granuloma formation at the
periphery of the infected area.

48

24
 2015/02/06

PATHOLOGY AND CLINICAL SYMPTOMS OF

MYCETOMA

The classical triad of symptoms are:

(i). Gross deformity of the infected area
(ii). Draining sinuses
(iii). Granules in the pus

49

DIAGNOSIS AND TREATMENT

OF MYCETOMA

Diagnosis is made by the presence of the classical triad

of symptoms and by culture of the pus draining from
the wound.
Treatment is initially with Sulfonamides for Nocardia
or Amphotericin B for fungi.
If the fungal infection does not respond to
Amphotericin B then amputation is required
50

25
 2015/02/06

BONE AND JOINT INFECTIONS

(Osteomyelitis, Infectious Arthritis

Dr. Fitzroy A. Orrett, MB.BS, D (ABMM), FCCM

Senior Lecturer, Department of Paraclinical Sciences
Faculty of Medical Sciences
University of the West Indies
St. Augustine Campus

51

26