Bone and Joint Infection MD2009

8/8/2019 Bone and Joint Infection MD2009

1/29

Bone and joint infection

Matthew Dryden

RHCH

WinchesterMatthew DrydenRoyal Hampshire County Hospital

Winchester


2/29

Objectives

1. Understand the causes of bone and

joint infections

2. Recognize the clinical presentation3. Develop an approach to the diagnosis

of bone and joint infections

4. Discuss antimicrobial management


3/29

Complications of an RTA

Mr BA, retired barrister

Serious RTA, 3/12 ago, head on collision

Chest injury; 4 fractured ri

bs

Head; subdural haematoma, CSF leak

Abdomen; lacerated liver/spleen

Lower limbs; compound fracture of Rfemur


4/29

5 weeks in ITU

Ventilated because of ARDS and hospitalacquired pneumonia

3 weeks in orthopaedic ward:intramedullary nail

Wound infection. Esch. coli isolated

His wife died in the accident and he hastrouble coping since.


5/29

At orthopaedic clinic, Mr BA is apyrexial

Discharge of pus from leg wound

Dull acheWound swab Staph. aureus

What should we do with him?


6/29

The issues

Rehabilitation

Bereavement

SplenectomyLeg infection


7/29

Leg infection

What is the significance of S.aureus in thewound

It is reported as resistant to pen, flucloxacillin,erythromycin, ciprofloxacin. Is this unusual?

X ray of femur; shows sclerosis of the bone &periosteum, soft tissue swelling

BA taken to theatre, bone debrided, S.aureusgrown from bone

Diagnosis?


8/29


9/29

Osteomyelitis and septic arthritis

Primary

acute,

haematogenous,

systemic illness

Secondary

Contiguous spread

from ulcer, trauma Vascular problems of

limb eg elderly,

diabetic

S.aureus 90%

Hib, Strep pyogenes

Rare -Brucella,salmonella, gram neg

Polymicrobial,

S.aureus, gram neg,

Pseudomonas,anaerobes

Coagulase negative

staphylococci esp in

prosthetic joint

infection


10/29

Osteomyelitis

Microbes invade bone

Inflammation and pus tracksthrough Haversian andVolkmanns canals

Ischaemia and necrosis

Periosteal elevation Osteoblasts generate newbone

Old dead bone calledsequestrum; surrounding livebone called involucrum

No blood supply tosequestrum, therefore infectionmay persist


11/29


12/29

Source of infection

1. Haematogenousspread

2. Extension frombone to joint

3. Spread from

adjacent softtissue infection

4. Diagnostic,surgicalinterventions

5. Trauma


13/29

Clinical features native joint SA

Monoarticular (90%)

Mostly acute onset

Fevermild (60 - 80% of cases)

>39oC (third of cases)

Movement limitation

Swelling (effusion)


14/29


15/29

Chronic osteomyelitis

Acute OM can progress to chronicAcute OM can progress to chronic

OMOM

Bone loss and persistent drainageBone loss and persistent drainagethrough sinus.through sinus.

Squamous cell carcinoma andSquamous cell carcinoma and

amyloidosis are rareamyloidosis are rarecomplicationscomplications


16/29

Tuberculous osteomyelitis

Potts disease

Potts disease: T and L spine bone destruction,

deformity, and paraplegia.

MRI of a 31-year-old man

with tuberculosis of the

spine. Images show the

thoracic spine before and

after an infusion ofintravenous gadolinium

contrast. The abscess and

subsequent destruction of

the T11-T12 disc

interspace is marked with

arrowheads. Vertebralbody alignment is normal.


17/29

Osteomyelitis

DiagnosisXray, CT, MRI

Microbiology; bone, pus, blood

ManagementAntibiotics; combination, prolonged

Surgical washout; debridement, drainage

Removal of metalwork, prosthetic jointMonitor inflammatory markers; ESR, CRP


18/29

Antibiotic treatment

Be guided by microbiology

Flucloxacillin 1-2gms qds IV plus oral fusidicacid 500 tds

Penicillin allergic consider clindamycin orceftriaxone

Child under5 consider ceftriaxone to cover Hib

For MRSA: Vancomycin or teicoplanin plus

fusidic acid (or Linezolid)


19/29


Oral treatment can start after 10-14 days

and needs to continue for 6-12 weeks.

Monitor CRP + ESR

Combinations include

Flucloxacillin + fusidic acid

Rifampicin plus doxycycline or fusidic acid

Ciprofloxacin plus clindamycin


20/29

Septic arthritis


21/29

Septic arthritis


22/29

Joint pus


23/29

Osteomyelitis anddiabetes


24/29

Prosthetic-device septic arthritis or

osteomyelitis

Incidence should be under 1% of joint

replacements

Presents with swollen, hot joint, sinus,pain, loosening

Prosthetic joint usually requires removal

Culture of tissue and molecular diagnosis Bacterial 16s ribosomal DNA

Two stage replacement


25/29


26/29


27/29

Treatment of PJI


with surgical

debridement/ removal

Monitor WBC andCRP

Antibiotic cement


28/29

Vertebralosteomyelitis/discitis


29/29

Bone and Joint Infection MD2009

Documents

Transcript of Bone and Joint Infection MD2009