BONE & JOINT INFECTION

Punto Dewo
Dept. of Orthopaedics & Traumatology
Bone and Joint Infection

 Osteomyelitis
 Septic arthritis
 General aspect of Infection

Infection
A condition I which pathogenic organisms multiply and
spread within the body tissues

The signs of inflammation:

 Redness
 Swelling
 Heat
 Pain
 & loss of function
How do infecting organisms enter
bones or joints

 Hematogenous spread
 Inoculation through wounds
 Extension from adjacent infected
structures
Inoculation
through
traumatic
wounds,
operations
Extension
from adjacent
infected
structures
Hematogenous spread
 Bacteremia
 Sluggish circulation in metaphysis
(in children)
 Foci  spread  subperiosteal
abscess () draining sinus
 (infants) foci  spread through
growth plate
• Involucrum : new bone formation
encircling cortical shaft

• Sequestrum : dead bone surrounded by pus

or scar tissue
Acute hematogenous osteomyelitis

 Male : female = 2 : 1
 > 90% monostotic
 > 90% lower extremity
 The child limp or refuse to walk or
refuse to use the extremity involved
 Early acute : w/in 24-48 hrs, only pain
and fever
 Late acute : 4-5 days after onset,
subperiosteal abscess needs
surgical drainage
– Neonates
– Older children
– Premature infants
Evaluation of Acute Osteomyelitis
 CBC, ESR, CRP
 Blood culture : ident. causative
organism in 50%
 Bone aspiration : for subperiost
abscess, ident. 70%
 X-Ray : could be normal
 Bone scan Tc 99m
 MRI scan
Treatment of Acute Osteomyelitis

 I.V Antibiotic started promptly

 S. aureus most common infecting
agent
 Gram (–)ve organism in vertebrae
and immunocomp pts
 Surgery for late acute (draining
abscess)
Complications
 Recurrent osteomyelitis : to minimize
 AB coverage for 6 weeks
 Distant seeding
 Septic arthritis
 Pathologic fracture due to
osteonecrosis
 Growth arrest due to damaged gr. pl.
Subacute Hematogenous
Oeteomyelitis
 Less virulent org + effective immune
response
 Less clear onset, older children ( 2-
16 y.o), equiv sex ratio
 No or mild fever, mild tenderness
 Lab findings inconclusive
 AB for 6 weeks
Chronic Hematogenous
Osteomyelitis
 Sx several weeks-months
 Developed vs developing countries
– Child : neglected cases
– Adult : secondary
 Sequestra, involucrum, draining
sinus
 Needs culture from bone/deep tissue
 Imaging Procedure
 In early infection : Not so helpful
(demineralization due to infection may not be seen after 10 days of infection)

 Accumulation of fluid (hematoma, seroma or abses)

may be diagnosed via USG

 X ray’s :
Soft tissue swelling, trabecular destruction, pin loosening, etc
(33% of x ray are evident in 1st week, 90% are evident in 4 weeks)

 Bone scans : sensitivity up to 100%

(using Indium -111; labeled leukocyte)

Wheat J. Diagnostic strategies in osteomyelitis. Am J Med 1985;78(6B):218–224.

Chronic Osteomyelitis
TA, M, 46 yo,
Chronic osteomyelitic of the distal third of the
left tibia and fibula post ORIF
 Chronic Osteomyelitis

 In the early 1900s, about 20% of patients with osteomyelitis

died, and patients who survived had significant morbidity.

 The overall surgical site infection rate has been estimated by

the U.S. Centers for Disease Control and Prevention (CDC) to
be 2.8% in the United States.

 Sardjito general hospital  3 years case evaluation of 50

chronic osteomyelitis cases
(high morbidity with several cases lead to amputation)

Lazzarini, et al, 2004, Current Concepts Review, Osteomyelitis in Long Bones, The Journal of bone and joint surgery
Barie, 2002. Barie PS: Surgical site infections: epidemiology and prevention. Surg Infect 2002; 3:S-9.
Gregory D Dabov, Chapter 16, Osteomyelitis, Part V, Infection, Canale and Beaty, Campbell’s Operative Orthopaedics 11th edition, 2006.
Hilmi M*, Magetsari R** Dewo P**, Bacterial and Antibiotic Resistance Pattern in Chronic Osteomyelitis at Sardjito General Hospital during January 2007 to June 2010
 Chronic Osteomyelitis

Classification
The mechanism of infection can be exogenous or
hematogenous. Exogenous osteomyelitis is caused by open
fractures, surgery (iatrogenic), or contiguous spread from
infected local tissue. The hematogenous form results from
bacteremia

Microorganism
Staphylococcus Aureus; Staphylococcus Epidermidis;
Pseudomonas Aeroginosa  the most common microorganism

Mast, N.H., L Horwitz, D.L., Osteomyelitis: A Review Of Current Literature And Concepts. Elseiver.2002

Gregory D Dabov, Chapter 16, Osteomyelitis, Part V, Infection, Canale and Beaty, Campbell’s Operative Orthopaedics 11th edition, 2006.
Hilmi M*, Magetsari R** Dewo P**, Bacterial and Antibiotic Resistance Pattern in Chronic Osteomyelitis at Sardjito General Hospital during January 2007 to June 2010
13 different microbial strains in osteomyelitis case
in Sardjito Hospital, Yogyakarta

Hilmi M*, Magetsari R** Dewo P**

Bacterial and Antibiotic Resistance Pattern in Chronic Osteomyelitis at Sardjito General Hospital during January 2007 to June 2010
 Patophysiology of osteomyelitis

 Osteomyelitis  different than other infection in which the

high success rate achieved with antibiotic therapy
  the physiological and anatomical characteristics of bone

Physiology of infection
(localize and creates boundary to limit the process) + Anatomical
characteristic of bone

 Unique condition of bone infection  occurred within a firm

structure and enclosed in a dense sclerotic avascular bone.
(good) example of which bacterial existance are in favor of the local condition created by the host)

 Antibiotics and inflammatory cells cannot adequately access

the area and resulted to
 failure of systemic antibiotic treatment
Gregory D Dabov, Chapter 16, Osteomyelitis, Part V, Infection, Canale and Beaty, Campbell’s Operative Orthopaedics 11th edition, 2006.
 Patophysiology of osteomyelitis

Hematogenous Exogenous
 The race for the surface

Cell

Bacteria
Biomaterial-Centered Infection:
Microbial Adhesion vs. Tissue Integration
Gristina A.G. Science 1987:237; 1588

Daniëlle Neut, et.al, 2001, Biomaterial-

associated infection of gentamicin-loaded
PMMA beads in orthopaedic revision
surgery
 Patophysiology
INJURY

Traumatized tissue Management

(bone and soft tissue damage )

Compromised Type of fixation Prolonged hypovolemia

blood supply Improper debridement
Poor material
properties

Create potensial binding site to bacteria

INFECTION
 Risk factors
General Local
Overall state of the patient Extensive tissue damage
(age and nutritional status) (bone and soft tissue)

Comorbid condition Soft tissue  damage of the

(DM, suppressive agent,
malignancy, AIDS, etc)
Pre injury habits
Alcoholism, smoking
envelope
Comunitive fracture
 Dead bone segment
Skin infection

↑↑↑ susceptibility of INFECTION

 Target of the chronic osteomylitis treatment

Aggressive surgical debridement Combined with

(dead bone and microorganism evacuation +‘re-vascularize’) + Antibiotic treatment

Problems : Problems :
- Bone defect leads to ↓ stability - Difficulties on providing
- Dead space leads to ↑ bacterial harboring
high level of local antibiotics
- Bone gap that hindered bone union
- Invisible bacteria  slime ? - Biofilm formation of the persisters

Nonbiodegradable material
Autograft : (high level of local antibiotics)
good biologic and material
Limitations:
properties
Synthetic HA - Secondary operation procedure
Limitations: - Hindered bone union
- Availability - ↑ morbidity
- Reproducibility - Antibiotic dissolution
- Secondary operation site Mechanical properties ↓ ↓ - New residence for persisters
- ↑ morbidity

Daniëlle Neut, et.al, 2001, Biomaterial-associated infection of gentamicin-loaded PMMA beads in orthopaedic revision surgery, Journal of antimicrobial chemotherapy
Lewis, K. (2001). Riddle of biofilm resistance. Antimicrobial agents and chemotherapy, 45(4), 999-1007
Lazzarini, et al, 2004, Current Concepts Review, Osteomyelitis in Long Bones, The Journal of bone and joint surgery
Gregory D Dabov, Chapter 16, Osteomyelitis, Part V, Infection, Canale and Beaty, Campbell’s Operative Orthopaedics 11th edition, 2006.
Treatment of Chronic Osteomyelitis

 Aggressive debridement
 Bone grafting
 Antibiotic beads (local)
 Soft tissue coverage
 Systemic antibiotic for 6-12 weeks
Septic Arthritis
 More common in children < 5 y.o
 S. aureus, > 95% monoarticular,
hematogenous or extension from
adjecent structures
 41% knee, 23% hip, 14% ankle, 12%
elbow, 4% wrist, 4% shoulder
 Cartilage eroded
Clinical feature
 Pain and swelling in affected joint
 Malaise, fever, limp, refuse to walk,
refuse to move extremity
(pseudoparalysis)
 Joints held in comfy positions
 CBC, ESR, X-Ray, joint aspiration
Synovial fluid analysis :
-Turbid
-Yellow to creamy pus
-WBC > 50.000/mm3
-Glucose decreased
Treatment of Septic Arthritis
 i.v antibiotic promptly
 Surgical irrigation and drainage
Open or arthroscopic
complications
 Joint destruction
 Bony ankylosis
 Soft tissue ankylosis (Tuberculosis)