Top Banner
Bone Infection (osteomyelitis) รศ.นพ.ยงศักดิ หวังรุ่งทรัพย์ ภาควิชาออร์โธปิดิกส์ คณะแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย
72

Bone Infection (osteomyelitis)

Mar 22, 2022

Download

Documents

dariahiddleston
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Bone Infection (osteomyelitis)

Bone Infection

(osteomyelitis)

รศ.นพ.ยงศักดิ์ หวังรุ่งทรัพย์ ภาควิชาออร์โธปิดิกส์ คณะแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย

Page 2: Bone Infection (osteomyelitis)

Types of organism

Pyogenic osteomyelitis or arthritis

Chronic granulomatous reaction

Fungal infection

Parasitic infestation

Page 3: Bone Infection (osteomyelitis)

Route of Infection

Hematogenous system

Direct invasion: Open Fx,

operation, skin puncture

Direct spreading

Page 4: Bone Infection (osteomyelitis)

Acute

Hematogenous

Osteomyelitis

Page 5: Bone Infection (osteomyelitis)

Acute Hematogenous

Osteomyelitis Common in children

Adult – lowered resistance by drug:

immunosuppressive drug, debility disease:

DM, AIDS

- more common in vertebrae than

long bone

Post-trauma: hematoma or fluid collection

in bone

Page 6: Bone Infection (osteomyelitis)

Pathogenesis

Source of Infection

Metaphysis

Bacterial colonization

Blood stream

Venous stasis

Page 7: Bone Infection (osteomyelitis)
Page 8: Bone Infection (osteomyelitis)
Page 9: Bone Infection (osteomyelitis)

Etiology Aerobic organisms -Gram positive : Staphylococcus aureus , Streptococcus pyogens

Streptococcus pneumoniae

-Gram negative : Haemophilus influenza,

E.coli, Pseudomonas aeruginosa,

Proteus mirabilis,

Anaerobic organisms Bacteroides fragilis

Page 10: Bone Infection (osteomyelitis)

Pathology

Inflammation

Suppuration

Necrosis

New bone formation

Resolution

Page 11: Bone Infection (osteomyelitis)

Inflammation

First 24 hours

Vascular congestion

Polymorphonuclear leukocyte infiltration

Exudation

Intraosseus pressure intense pain

intravascular thrombosis ischemia

Page 12: Bone Infection (osteomyelitis)

Suppuration

2-3 days

Pus formation

Subperiosteal abscess

via Volkmann canals

Pus spreading epiphysis

joint

medullary cavity

soft tissue

Page 13: Bone Infection (osteomyelitis)

Necrosis Bone death by the end of a week

Bone destruction ← toxin

← ischemia

Epiphyseal plate injury

Sequestrum formation – small removed by

macrophage,osteoclast.

– large remained

Page 14: Bone Infection (osteomyelitis)

New bone formation

By the end of 2nd week

Involucrum (new bone

formation from deep

layer of periosteum )

surround infected tissue.

If infection persist- pus

discharge through sinus

to skin surface Chronic

osteomyelitis

Page 15: Bone Infection (osteomyelitis)

Resolution

Antibiotics Surgical drainage

Infection is controlled

Bone remodeling

Page 16: Bone Infection (osteomyelitis)

Resolution

Infection is controlled

Intraosseous pressure release

With healing – new bone formation +

periosteal reaction bone thickening and

sclerosis

Remodeling to normal contour or deformity

Page 17: Bone Infection (osteomyelitis)

Infection persist

Chronic drainage

Chronic Osteomyelitis

Page 18: Bone Infection (osteomyelitis)

Signs and Symptoms in infant

Drowsy

Irritable

Fails to thrive

history of birth difficulties

History of umbilical artery

catheterization

Metaphyseal tenderness and

resistance to joint movement

Page 19: Bone Infection (osteomyelitis)

Signs and Symptoms in child

Severe pain

Malaise

Fever

Toxemia

History of recent infection

Local inflammation pus

escape from bone

Lymphadenopathy

Page 20: Bone Infection (osteomyelitis)

Acute osteomyelitis in adult

1.Uncommon

2.History of DM.

3.Immunosuppressive drug

4.Drug addict

5.Elderly patients.

Page 21: Bone Infection (osteomyelitis)

Signs and Symptoms in adult

Fever

Pain

Inflammation

Acute tenderness

Common site is thoraco-

lumbar spine

Page 22: Bone Infection (osteomyelitis)

Radiographic studies

มักจะเปล่ียนแปลงหลังจากการติดเช้ือนานกว่า 10 วัน

เริ่มจาก rarefaction, area of lytic and

sclerotic lesion, sequestrum and involucrum.

ควรเริ่มให้การรักษาทันทีก่อนจะเห็นการเปล่ียนแปลงในภาพถ่าย X-ray

Page 23: Bone Infection (osteomyelitis)
Page 24: Bone Infection (osteomyelitis)

Bone Scan

99m TC-HDP - sensitive

- not specific

67 Ga-citrate or 111 In-labeled

leukocyte more specific

Page 25: Bone Infection (osteomyelitis)
Page 26: Bone Infection (osteomyelitis)

MRI

ช่วยแยก pus กับ blood ได้

Page 27: Bone Infection (osteomyelitis)

Aspiration pus

confirm diagnosis

smear for cell and organism

culture and sensitivity test

Page 28: Bone Infection (osteomyelitis)

Investigations

CBC

ESR

Hemoculture positive ~ 50%

Antistaphylococcal antibody

titer (in doubtful case)

Page 29: Bone Infection (osteomyelitis)

Differential diagnosis

Cellulitis

Acute suppurative arthritis

Acute rheumatism

Gaucher’s disease – Pseudo- osteitis, resembling osteomyelitis, enlargement of spleen and liver. Because of predisposing to infection, antibiotics should be given.

Sickle-cell crisis – mimic osteomyelitis, in endemic area of Salmonella, it is wise to treat with antibiotics until infection is excluded

Page 30: Bone Infection (osteomyelitis)

Treatment for acute

osteomyelitis

Supportive treatment

Splint

Antibiotic therapy

Surgical drainage

Page 31: Bone Infection (osteomyelitis)

Supportive treatment

Analgesics

Correction of dehydration

Page 32: Bone Infection (osteomyelitis)

Splint

- Plaster slab

- traction

- Prevent joint contracture

Page 33: Bone Infection (osteomyelitis)
Page 34: Bone Infection (osteomyelitis)
Page 35: Bone Infection (osteomyelitis)

Surgical drainage

Early treatment no need surgery

Late treatment surgical

drainage about 1/3 of cases. If pus

found and release no need to drill bone.

But drilling one or two holes if no

obvious abscess.

Page 36: Bone Infection (osteomyelitis)

Antibiotics

Initial antibiotics “ BEST GUESS ”

- according to smear findings

- according to incidences , age.

Proper antibiotics

- according to culture and

sensitivities test

Page 37: Bone Infection (osteomyelitis)

Guideline for initial antibiotics

Age Pathogen Drugs

1.Older children and

previously fit adults

-Staphylococcal

infection

- Fluclaxocillin and

fusidic acid IV 3-4 day

oral 3-6 wks

2.Children <4 years -Gram neg. infection

-Haemophilus

infection

-2nd generation

Cephalosporins or

Amoxycillin with

clavulanic acid

3.Sickle-cell patient -Salmonella infection - Co-trimoxazole

- Amoxycillin with

clavulanic acid

4.Heroin addicts and

immuno-compromised

patients

-Unusual infection :

pseudomonas ,

proteus, bacteroides

-3rd or newer generation

Cephalosporins

Page 38: Bone Infection (osteomyelitis)

Acute osteomyelitis

When infection subside, movement is

encourage. Walk with crutches and

full weight bearing is possible after 3-

4 weeks.

Page 39: Bone Infection (osteomyelitis)

Complication

lethal outcome – rare

metastatic infection (multifocal

infection)

suppurative arthritis

very young patient

metaphysis is intracapsular

metastatic infection

Page 40: Bone Infection (osteomyelitis)

Complication

altered bone growth

chronic osteomyelitis

- delay diagnosis and

treatment

- debilitated patients

- compromised host

Page 41: Bone Infection (osteomyelitis)

Chronic

Osteomyelitis

Page 42: Bone Infection (osteomyelitis)

Chronic osteomyelitis

Sequel to acute hematogenous osteomyelitis

Usual organisms are staph. aureus, Escherichia coli, Strep. pyogens, Proteus and Pseudomonas (always mixed infections)

In the presence of foreign implants : Staph. Epidermidis is the commonest pathogen.

Page 43: Bone Infection (osteomyelitis)

Pathology of chronic

osteomyelitis Bone is destroyed in a discrete area or diffuse

Cavities containing pus and sequestrum are surrounded by vascular bone and sclerosis bone resulted from reactive new bone formation

Sequestra, foreign implants act as substrates for bacterial adhesion, ensuring the persistence of infection and sinus drainage

Pathological fracture

Page 44: Bone Infection (osteomyelitis)

Signs and Symptoms of

chronic osteomyelitis

Pain

Pyrexia

Redness

Tenderness

Draining sinus

Excoriation of skin

Page 45: Bone Infection (osteomyelitis)
Page 46: Bone Infection (osteomyelitis)

Radiographic study

A patchy loss of bone density with

thickening and sclerosis of the

surrounding bone

Sequestra : dense fragment in contrast

to surrounding vascularized bone

Sinogram may help to localize the site

of infection

Page 47: Bone Infection (osteomyelitis)

Sequestrum

Page 48: Bone Infection (osteomyelitis)

Radioisotope scanning

99m TC-HDP Up take 67 Ga-citrate or 111In-labelled

leukocyte more specific

Page 49: Bone Infection (osteomyelitis)

CT – Scan and MRI

Show extent of bone destruction

and reactive edema, hidden abscess

and sequestrum

Pre-op planning investigation

Page 50: Bone Infection (osteomyelitis)

Other Investigations

CBC

ESR

Antistayphylococcal antibody titers – Dx hidden infection and tracking progress to recovery

C/S from draining discharge R/O resistance bacteria

Page 51: Bone Infection (osteomyelitis)

Treatment for chronic

osteomyelitis

Medical treatment

Local treatment

Surgical treatment

Page 52: Bone Infection (osteomyelitis)

Antibiotics

To stop spreading of infection

To control acute flare

Capable of penetrating sclerotic

bone and non-toxic to body

Page 53: Bone Infection (osteomyelitis)

Surgical treatment

Sequestrectomy :

sulphan blue

stained only vital

tissue

Continuous

irrigation 3-6

weeks.

Gentamicin beads

Page 54: Bone Infection (osteomyelitis)

Space filling techniques

Papineau technique (Papineau et al

1979)

Muscle flap + skin graft (Fitzgerald et al

1985)

Myocutaneous island flap. (Yoshimura

et al 1989)

Page 55: Bone Infection (osteomyelitis)

Prognosis

Local trauma must be avoided

Any recurrent of symptoms should be

taken seriously and investigated

Page 56: Bone Infection (osteomyelitis)

Acute Suppurative Arthritis

Route of infection

1. direct invasion

2. eruption of a bone abscess

3. hematogenous spreading

Page 57: Bone Infection (osteomyelitis)

Causal Organisms

Staphylococcus aureus

Hemophilus influenza

E. coli

Streptococcus

Proteus

Page 58: Bone Infection (osteomyelitis)

Oganism

Synovial membrane

Seropurulent exudate pus

Bacterial enzyme Synovial enzyme

Joint destruction

Acute inflammatory

reaction

Page 59: Bone Infection (osteomyelitis)

Septic Arthritis

Page 60: Bone Infection (osteomyelitis)

TB Arthritis

Page 61: Bone Infection (osteomyelitis)

Signs and symptoms in newborn

Clinical of septicemia : irritable,

refuses to feed, rapid pulse

Joint swelling

Tenderness and resistance to

movement of the joint

Look for umbilical infection

Page 62: Bone Infection (osteomyelitis)

Signs and symptoms

in children

acute pain in single joint : hip.

Pseudoparesis.

Swelling and inflammation of the

joint.

Child looks ill.

Limit movement of the joint.

Look for a source of infection : toe,

boil, otitis media

Page 63: Bone Infection (osteomyelitis)

Signs and symptoms in adult

Often superficial joint : knee, wrist,

ankle

Pain

Swelling and inflammation

Restricted movement

Examined for gonococcal infection or

drug abuse.

Page 64: Bone Infection (osteomyelitis)

Radiographic study

Early : usually normal , joint space

may seem to be widened (because of

fluid in the joint)

Late : osteoporosis ,narrowing and

irregularity of the joint apace.

with E. coli infection there is

sometime gas in the joint

Page 65: Bone Infection (osteomyelitis)
Page 66: Bone Infection (osteomyelitis)

Investigation

CBC

ESR

Gram stain of synovial

fluid

C/S

Page 67: Bone Infection (osteomyelitis)

Differential diagnosis

Acute osteomyelitis: in children indistinguishable from septic joint

Trauma: traumatic synovitis

Irritable joint : the patient does not look ill

Hemophilic bleeding

Rheumatic fever

Gout and pseudogout

Page 68: Bone Infection (osteomyelitis)

Treatment of septic arthritis

Supportive care

: analgesics, fluid supplement ,

splint, traction

Antibiotics

: same as acute osteomyelitis

Drainage

: Aspiration, arthrotomy

Page 69: Bone Infection (osteomyelitis)

Once the conditions improved, if the

articular cartilage is preserved – gentle and gradually increasing active motion

If articular cartilage is destroyed – the joint

is immobilized in optimal position until ankylosis is sound

Treatment of septic arthritis

Page 70: Bone Infection (osteomyelitis)

Outcome After Healing

Complete resolution

Partial loss articular cartilage and

fibrosis of joint.

Loss of articular cartilage and bony

ankylosis

Bone destruction and permanent

deformity of the joint.

Page 71: Bone Infection (osteomyelitis)
Page 72: Bone Infection (osteomyelitis)

Complication

Cartilage destruction

Growth disturbance

Bone destruction