Infection of bones and joints Rozkydal, Z. Orthopaedics Inlamations of bones, joints and tendons 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 % Infection of bones- osteomyelitis 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 methicilin resistant staphylococcus aureus MRSE methicilin resistant staphylococcus epidermidis Multiresistant G- bacteria 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) • •Direct 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 •Bacteriological examination from the pus •Haemoculture •Differential blood test •Electrophoresis of proteins •Metabolic acidosis • 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 sensitivity to bacteriological examination Surgical treatment Aspiration of the abscess Drilling of the bone and decompression, curretage 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 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 rarefication 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 Záněty- OM subacuta Chronic osteomyelitis Sclerosis of bone 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 - spondylodiscitis 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, oraly 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 Bacteriological examination Prolonged cultivation 5-7 dayes r trnka 4 Therapy in THA Debridement, synovectomy One stage reimplantation Two stages reimplantation (spacer) Resection arthroplasty Long antibiotic supression 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 of chronic inflamation of bone Recurrence of infection Growth arrest – shortening of the extremity Weaknes of muscles Joint contracture Septic arthritis Amyloidosis Epidermoid carcinoma Patological fracture Sepsis Pyogenic (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 ancylosis 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- TB 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 absces 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- spina ventosa Spina ventosa 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 lasting- 9 months at least Rest, orthesis Surgery- debridement, synovectomy, In the hip – Girdlestone resection arthrodesis 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 Antibiotics for TB Debridement of the lesion Revision of abscess Decompression of spinal cord and nerve roots Stabilisation of the spine