2.

4 ORTHOPAEDIC INFECTIONS Biofilm

- Cells irreversely attached to a surface with
I. OSTEOMYELITIS inflammatory tissue interface
- Infection of the bone which involves the following Glyocalyx
o Periosteum - Exopolysaccharide coating that envelopes bacteria
o Cortical bone
o Medullary cavity Resistant to antibiotics:
- Delayed penetration of the antimicrobial agent
CLINICAL FEATURES through the biofilm matrix
- Pain, bony tenderness - Altered growth rate of biofilm organism
- Loss of limb function
- Fever Etiologic Agent
- Swelling - Staphylococcus aureus (80-90%of cases)
- Erythema and/or abscess - Group B streptococcus
- Haemophilus influenza (6mos-4yrs)
DURATION - Salmonella (hemoglobinopathies)
Acute osteomyelitis - Pseudomonas (addicts/puncture wound)
- Are those in their first presentation <2 weeks
- History may be short (days for hematogenous LABORATORY FINDINGS
osteomyelitis) or long (weeks to months for - CBC, WBC (leukocytes)
contigious osteomyelitis) - Elevated ESR, C-reactive protein
Subacute osteomyelitis - Blood culture (positive in 50-70%, must be taken
- More prolonged history, less virulent pathogen before commencement of antibiotics)
- Often presents incidentally on radiology
- No systemic signs of infection Bone aspiration/ Tissue Culture & Sensitivity
- Brodile’s abscess: radiologically a localized - Most essential, positive in 80% cases
translucency in metaphysic - Mycobacterial/ fungal identification must be done
Chronic Osteomyelitis - Isolates from discharging sinus not reliable
- <3 months
- Cases are those that are untreated, failed to respond ANCILLARY FINDINGS
to treatment or have relapsed in a site of previously Radiography
identified disease - Should always be the first imaging modality to start
- Hallmark is infected dead bone within compromised with, as it provides an overview of the anatomy and
soft tissue envelope the pathologic conditions of the bone and soft
tissues of the region of interest
CHRONIC OSTEOMYELITIS - Mild soft tissue swelling can be detected early
Sequestrum - Demineralization/ new bone formation observed
- Infracted bone only after 7-10 days
- Bone may lose vascular supply owing to such factors - CT SCAN
as increased pressure, acidic pH, and effects of o Useful method to detect early osseous
leukocytic enzymes erosion and to document the presence of
- Resulting in a devitalized bone with high inoculums sequestrum, foreign body, or gas formation
of bacteria. but generally is less sensitive than other
Involocrum modalities for the detection of bone
- Circumferential new bone covering around infection
devitalized bone with exuberant periosteal growth - MRI
and new bone formation o The most sensitive and most specific
Cloacae imaging modality for the detection of
- Pores within the involucrum where the pus tracks osteomyelitis and provides superb anatomic
detail and more accurate information of the
MECHANISM OF INFECTION extent of the infectious process and soft
Hematogenous spread tissues involved
- Osteomyelitis results from bacteremia (bacteria - Radionuclide imaging
from nidus of infection to blood stream) seeding in o Particularly useful in identifying multifocal
bone osseous involvement
Ususally at metaphysis CIERNEY-MADER STAGING SYSTEM
- End artery Stage Anatomic type Cause Recommended
- Sluggish blood flow treatment
- Low oxygen tension 1 Intramedullary Infected IM nail ROI and isolated
IM debridement
- Fewer phagocytotic cells
2 Superficial Chronic wound Remove layers of
Exogenous/ Contiguous spread
- no full-thickness leading to infected bone
- Is caused by spread from an adjacent area of involvement of colonization and until viable bone
infection cortex focal involvement is identified
- Postoperative infections of a superficial
- Direct inoculation from trauma area of bone under
- Extension from an area of soft-tissue infection wound
3 Localized Direct trauma with Non-involved
BACTERIAL ADHESION - Full- thickness resultant bone is present

MS1 – Ortho || Domingo, C.

 involvement of devascularization at same axial - Fever, chills
a cortical and seeding of the level, so the - Acute onset of joint pain, swelling, immobility
segment; bone osteomyelitic - Articular pain is induced by even minimal degrees of
endosteum is portion can be joint motion
involved excises without
- Joint is fixed in position of ease
(intramedullar compromising
y spread) stability
- Signs: heat, tenderness, joint effusion
4 Diffuse Major Resection leads
- Infection is devascularization to a segmental LABORATORY FINDINGS
permeative of the bone defect resulting - CBC, WBC (leukocytosis)
in loss of limb - Elevated ESR, C-reactive protein
instability - Blood culture (must be taken before
commencement of antibiotics)
TREATMENT - Synovial fluid Gram stain, Culture & Sensitivity
Surgery and Antibiotics – complimentary (priority)
1. Appropriate antibiotic effective before pus formation
2. Antibiotics will not sterilize avascular tissue (must be Synovial Fluid Analysis
surgically removed) normal Non- Inflammatory Septic
3. If removal effective, antibiotics prevent reformation inflammatory
Color clear Clear yellow Opalescent Turbid
4. Surgery should not damage already ischemic bone
yellow yellow to
5. Antibiotics should be continued after surgery green
Viscosity High High low Low
Surgical Treatment WBC count 25% <2,000 3,000-50,000 50,000 -
- If no improvement within 36-48 hours Cell/mm2 100,000
- Operative sampling of deep specimen
- Debridement/excision of all necrotic and infected PMN <10% <25% 25-75% >75%
Culture negative Negative Negative Positive
tissue
Mucin clot Firm Firm Friable Friable
- Adequate soft tissue coverage
Glucose: % 100 <100 50-75 <50
Antibiotic treatment serum level
- Target common etiologic agent total normal normal elevated elevated
- Must have high bone tissue concentration protein
- Least side effects
- Usually intravenous antibiotics for 2 weeks then oral ANCILLARY FINDINGS
antibiotics for 4 weeks (total to minimum of 6 Radiography
weeks) - Soft tissue swelling, asymmetry
- Clindamycin – bacteriostatic and achieves the - Subchondral bone destruction
highest antibiotic concentrations in bone - Joint space narrowing
- CT, MRI, Bone scans
Antibiotic Beads TREATMENT
- antibiotic laden polymethylmethacrylate (PMMA) - Aspiration is both diagnostic and therapeutic
beads - Open surgical debridement and drainage is indicated
- local antibiotic delivery once diagnosed
- dead space management - If frank pus in diagnostic aspiration, open
- high local concentration (200x serum concentration arthrotomy is indicated
or 100x MIC) - Antibiotic therapy: most important
- very little systemic side effects - Joint must be immobilized in position of maximum
------------------------------------------------------------------ function
II. SEPTIC ARTHRITIS - Empiric therapy can be started after blood samples/
- bacterial infection of a joint Gram stain performed
- invasion of the synovial membrane (no basement
membrane) by microorganisms is the initial event COMPLICATIONS
- avascular cartilage is degraded by bacterial and - Loss of articular cartilage
leukocyte enzymes - Pathologic joint dislocation epiphyseal necrosis
- PMN leukocytes appear to be essential for evolution - Long term joint stiffness/ bone ankylosis
of tissue destruction - Degenerative arthritis almost guaranteed
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MECHANISM OF INFECTION
Direct infection
- Penetration by trauma or diagnostic/ therapeutic
procedure
Local extension
- From neighboring focus of infection (epiphyseal or
metaphyseal osteomyelitis)
Hematogenous
- Form distant source of infection via bloodstream
(dental carries, UTI, URTI)
III. TUBERCULOSIS OF BONE
CLINICAL FEATURES - Tuberculosis of extra pulmonary tissues

MS1 – Ortho || Domingo, C.

 - Spread via blood stream from primary lung focus
- Sets up a chronic granulomatous infection in bone
and joint
EPIDEMIOLOGY
Children and adolescents
- Most vulnerable to skeletal TB especially <10 years
Skeletal tuberculosis
- 10-15% of extra-pulmonary tuberculosis
- 2% of all TB cases
Concurrent active pulmonary tuberculosis
- <50% of cases

ETIOLOGY
- Mycobacterium tuberculosis - most common
pathogen
- Hematogenous seeding – most common route
- Direct extension from adjacent foci: lung, kidney,
lymph nodes

DIAGNOSTIC TESTS
 Synovial tissue biopsy
- Granuloma formation in 95%
- Caseation in 55%
- Tubercle bacillus in 10% of cases
 Ziehl-Neelsen staining of acid fast bacilli
- positive in only 27%
 culture (Lowenstein-Jensen or MTB Bactec)
- positive in 83%

TB OSTEOMYELITIS
- hematogenous spread affects diaphysis
- femur, tibia, small bones of hands and feet
commonly involved
- elderly: TB of tarsal/metatarsal bones

TB ARTHRITIS
- monoarticular infections of weight-bearing joints
(hip. Knee)
- slow disease progression (often missed)
- x-ray: Phimster’s triad
o gradual narrowing of joint space
o subchondralosteoporosis
o peripherally-located osseous erosions
TB SPONDYLITIS
- pott’s disease
- tuberculosis of the spine
- 50% of skeletal TB
- T8-L3 most commonly involved
- Begins in anterior vertebral body
- Globus deformity
- Posterior vertebral structures rarely involved

TREATMENT
- Immobilization
- Assessment of pulmonary disease
- Anti-tuberculous chemotherapy (9-12 mos)
Indications for surgery:
- Persistent effusions or synovial pannus
- Spinal instability/ multiple vertebral involvement
- Severe kyphoscoliosis
- Cord/nerve compression (bladder & bowel
symptoms, impotence)
- Large abscess
- Intractable joint disease
- No response to anti-Koch’s chemotherapy

MS1 – Ortho || Domingo, C.