vol 18 infections

Orthopedic

Infections

Orthopedic Infectious

Diseases Hematogenous osteomyelitis

Pyogenic spondylitis and discitis

Pyarthrosis

TBc Arthritis & Sarcoidosis

TBc spondylitis

Leprosy

Luetic infections

Viral osteomyelitis

Fungus infections

Gas forming infections

Hematogenous

Osteomyelitis

Hematogenous Osteomyelitis

Hematogenous osteomyelitis is typically seen in children

in the metaphyseal ends of long bones in the lower extremities.

The proximal end of the tibia is the most common site. Staph

aures bacteria arising from a peripheral site such as the skin or

nose and throat gain access to the peripheral circulation where

they travel to the terminal end-arterial circulation just beneath

the growth plate where a primary focal abscess will arise. The

abscess will then increase in size resulting in local thrombosis

followed by bone necrosis as the purulent mass works its way

thru the adjacent cortex gaining access to the subperiosteal

space thus lifting the periosteum which then goes on to form

a healing involucrum. In the early days prior to antibiotics,

osteomyelitis was a very aggressive disease process associated

with severe local pain, high fevers and septacemia resulting

in high white counts and sed rates. The disease was frequently

multi focal in bones as well as in various organs such as the

lung, liver and brain resulting in death in a high number of

cases. However, since the advent of antibiotics the modern

form of osteomyelitis is far less aggressive and may present

with minimal symptoms of pain with a minimal elevation of

the white count or sed rate and for this reason my go on

without diagnosis or treatment.

8/17/39 8/26/39

10 yr male with acute onset of pain in tibia 4 days before the

1st x-ray with high fever of 104 degrees and a 20,000 WBC

Blood supply to long bones in children

Pathogenesis of primary focus of metaphyseal infection

Early abscess formation

and early osteonecrosis

with reparative

involucrum formation

Medullary abscess with puss and necrotic bone

3 mos 8 mos 2.5 yrs

Natural course of disease without antibiotics

Another old case of

severe osteomyelitis

of tibia with 2 yr followup

4 yr female with excessive debreidment of periosteum

8/93 8/94 1/96

11 year old boy who sprained his wrist in early 8/93 for which an

X-ray was obtained 2 weeks later because of increasing pain

Biopsy and culture

9 year old female

with wrist pain and

low grade fever 6 mos

4 yr male

Early mild pain and afebrile (L) with a followup 1 yr later (R)

Modern day Hematogenous Osteomyelitis

13 yr male with T-1 coronal

MRI and macro section of a

similar case in young adult

Osteomyelitis distal femur

Sclerosing osteomyelitis of Garre

9 yr old female with low grade pain and slight fever 1 yr

Bone scan

Axial CT scan

Axial Gad contrast MRI

13 yr female with 1 mo pain and onion skin periostitis

Bone scan

Ewing’s vs osteomyelitis

Coronal and axial T-2 MRI looks like Ewing’s sarcoma

Reactive bone

Purulent response

5 year old male with pain

in heel and knee for 6 mos

Multifocal Osteomyelitis

Sag T-1 T-2 Gad

Cor T-1 Sag T-2

Axial T-2

10 yr male with contusion to thigh followed with osteo 9 mo later

13 yr old boy with staph osteo of left humerus 3 mos.

Cor T-1 T-2 Axial T-2

13 yr male with slight fever and pain for 2 mos

Cor Gad

Staph osteo looking like Ewing’s sarcoma

3/06 7/07 7/07

14 year old male with pain right arm for 17 months

Osteomyelitis

Cor T-1 T-2 Gad

Axial T-1 T-2 Gad

29 yr female with mild intermittent pain left arm for yrs

Periosteal Osteomyelitis

Cor T-1 T-2 Gad

Axial T-1 T-2

Gad

Staph osteo looking like low grade intramedullary OGS

37 yr male with aching pain in thigh for 1 one yr without fever

Staph osteo looking like osteosarcoma

13 year male with knee pain and slight fever for 2 mos

Incisional biopsy

Sequestrum delivery and biopsy specimen

Chronic Staph osteomyelitis of tibia for years

60 yr Indian male with 50 yr history of intermittent aching pain R leg

CT Scan

Sag T-1 PD FS Gad

Axial T-1 T-2

Gad

Oct 09

May 2010

51 yr male with increasing pain left hip for 9 months

Chronic Osteomyelitis Prox Femur

Cor T-2 Sag T-2 Sag Gad

Axial T-2 Gad

Chronic Staph Osteomyelitis distal femur

45 yr old male with intermittent pain in right thigh since age 17

Cor T-1 T-2 Sag gad

Axial T-1 T-2

Gad

16 yr male with dull aching pain in knee for one year

Cor T-2

Chronic staph osteomyelitis distal femur

04 07 04 07

16 yr male with 3 yr history of intermittent pain and swelling at knee

Bone abscess from staph infection

Bone scan

Cor T-1 T-2 Gad

07

Sag T-1 T-2

Axial T-2 Gad

Soft Tissue Staph Abcess at Elbow

31 yr old female with painless lump at elbow for 3 weeks

Cor T-1 T-2 Gad

Axial T-1 T-2

Gad

Staph osteo crossing the growth plate

10 yr girl with low grade aching pain at ankle for 9 mos

Sag T-

1 Cor T-2

8 year old male with

Brodie’s abscess distal

tibia with gopher sign

13 year male with focal

staph osteo with gopher

tunnels that could be

called a Brodie’s abscess

Brodie’s abscess

13 year male with dull

aching pain for 3 mos

Classic gopher tunnel

crossing the growth plate

42 year old male with

the flue 2 mos ago

followed by acute

onset of pain R thigh

CT scan AP Lat

Axial T-1 Gad

Cor STIR

17 year old male

with Brodie’s

abscess cuboid

looking like an

osteoid osteoma

5 yr female with ring sequestrum 2nd to infected traction pin

Epiphyseal Brodie’s abscess

Sag T-1 Cor T-2

7 yr old female with severe pain in knee 1 mo without fever

Epiphyseal Brodie’s abscess

7 yr male with severe pain in knee for 2 mos

CT with gopher tunnel

Squamous cell CA arising from chronic osteomyelitis

Macro section and microscopic of amputated leg of an older

patient with a long history of chronic osteo of the tibia

Salmonella Osteomyelitis

16 year old black female

with SS disease and 1 yr

history of pain left arm

Chronic salmonella osteo for

2 years in a 32 year old black

male with SS disease involving

multiple limbs

Both arms involved and septic AVN left femoral head

Salmonella Dactylitis hands and feet

Infant black male with 3mo

history of SS disease and

painful swelling of hands

and feet along with diarrhea

and fever

Pyogenic Spondylitis

and Discitis

Infectious discitis of

lumbar spine in a 3 yr

female with acute onset

of severe LBP and fever

most likely second to

staph aures spondylitis

Another case of infectious

discitis in a 4 yr old male

Infectious discitis young adult male

24 yr male shot putter with mild LBP 6 mos without fever

Peudomonas Discitis

22 yr male heroin addict with discogram of infected disc space

Pyogenic spondylitis older adult

63 yr male with sag T-2 MRI image of severe dorsal spondylitis

Pyogenic Spondylosis with Retropharyngeal Abscess

7/83 10/85

64 yr male with progressive neck pain and dysphagia 2 yrs

17 year male with LBP for 6 months with fever

Pyogenic Sarcroiliac Staph Aures

Potential drainage sites seen with spinal infections

Pyarthrosis

1.5 yr female with fever and

extremely irritable left

hip held in flexion and

external rotation

Staph pyarthosis

2 mos following posterior

surgical drainage and

antibiotic therapy

Pathogenesis for

pyarthosis of hip

or knee joint

Septic necrosis of femoral head

Initial

X-ray

2 mos

PO

6 mos

PO

10 yr male with initial diagnosis of rheumatic fever of hip

treated with steroids, ASA and antibiotics without success

Musculoskeletal

Tuberculous

Infections

Musculoskeletal Tubrculous Infections Tuberculous infection of the musculoskeletal system is seen in

about 5% of patients with pulmonary TBc. The problem is more

common in Asian and Mexican populations of the world. In the

USA musculoskeletal TBc is rare in children but is more common

in adults with immunodeficiency conditions related to IV drug

abuse, alcoholism, HIV disorders and patients on corticosteroid

medication. The most common skeletal site for TBc infection is

the spine followed next by the hip and knee. The TB mico-

bacterial organism enters the blood stream in the lung and travels

to a metaphyseal bone site in the spine, hip or knee area which

then results in discitis or psoas abscess of the spine or tuberculous

arthritis of the hip or knee. The tuberculous micobacterium

stimulates the formation of a caseating granulomatous lesion

made up of epithelioid cells, Langhans giant cells and lymphs.

A similar granuloma is seen in sarcoidosis which is none infectious

and none caseating. Antituberculous drugs include streptomycin,

PAS, INAH, myambutol, and rifampin.

9 year old male with knee pain and swelling 1 yr

Tuberculous Osteomyelitis

Pain and swelling in elbow as well

Biopsy shows epithelioid granuloma with Langhans giant cell

10 yr female with knee

pain and swelling 10 mos

with dumbell TBc

granuloma crossing the

tibial growth plate

24 yr male with shoulder

pain for 1 year with x-ray

evidence of tuberculous

granulomas in humeral

head

TBc Arthritis of Hip

29 yr Asian male with hip pain for 2 years

TBc Hip Arthritis

TBc pannus formation

27 yr Asian male with

destructive TBc for 3 yrs

Late TBc Arthritis Hip

30 yr Asian male with untreated disease for many yrs

4 yr 14 yr

Pediatric TBc Arthritis

4 yr Asian male with non treated TBc of hip for 10 years

followed with an extra-articular arthrodesis

15 yr

TBc Carpitis

Untreated TBc

carpitis in a 73 yr

Asian male for

many years

TBc Arthritis Elbow

28 yr male 3 yr male

Mild adult vs severe pediatric TBc of elbow

TBc osteomyelitis of distal fibula

76 year male with pain lateral ankle for 4 months

Bone scan

Cor T-2 Gad

Axial T-2 Gad

TBc Dactylitis

4 yr Eskimo with TBc dactylitis (spina ventosa)

Tuberculous Tenosynovoitis

27 yr male with 1 yr history

of carpal tunnel syndrome

2nd to TBc tenosynovitis

Epithelioid granuloma

Sarcoidosis Sarcoidosis is a nonspecific noncaseating epithelioid granuloma-

tous process that affects the reticuloendothelial system of young

adults that pathologically resembles the histology of TBc, fungus

infections, viruses and even low grade lymphomas such as

Hodgkin’s disease. In the US it is seen more commonly in the

southeastern states and is ten times more common in blacks then

whites. 90% will have pulmonary infiltrates or hialar adenopathy

along with systemic symptoms of fever, coughing, inflammatory

arthropathy and iritis. Other systemic symptoms include weight

loss, lymphadenopathy and hepatosplenomegaly as seen in

lymphomas. Granulomatous skin lesion similar to erythema

nodosum can be seen. Hypercalcemia can be seen in 25% of cases

second to an increase of calcium absorption at the gut level. 70%

of cases will have a positive Kveim skin test to help separate out

other granulomatous disorders such as TBc. 5% of cases involve

the middle and distal phalanges of the hand (most common) and

feet associated with overlying subcutaneous nodularities that

might suggest the diagnosis of TBc, gout, Ollier’s disease or

tuberous sclerosis. The homeycomb or latticework lytic pattern

of sarcoidosis will help differentiate from these other diagnostic

considerations. The bony lesions are asymptomatic unless

associated with a pathologic fracture. Bony changes in large bones

are very rare and can present with a sclerotic pattern seen in low

grade lymphomas such as Hodgkin’s disease. The prognosis

for minor lesions of the hands and feet is excellent but with

greater reticuloendothelial involvement of multi organ systems

the prognosis is more guarded like that of a low grade

lymphoma.

Case #1 Sarcoidosis of Hand

46 yr male with recent path fracture ring finger

None caseating epithelioid granuloma

with Langhans giant cells

Schaumann’s body

Biopsy specimen

Similar cases of bony sarcoidosis

A B

C D

Sub Q nodularity, lymphadenopathy

behind ear and pulmonary lesions

in sarcoidosis

Tuberculous

Spondylitis

Tuberculous Spondylitis

About 60% of all TBc involves the spine and is frequently

seen in Asian or Mexican patients. In Hong Kong where this

disease is common they see over 100 cases per year, 70% of

which are seen in children. L-1 is the most common vertabra

involved and from there it can spread up and down the spine

under the anterior longitudinal ligament or thru the Batson’s

para vertebral plexes. In China multiple vertabrae are involved

compared to only one or two vertabrae in mid aged adults in

the USA. As with pyogenic spondylitis it is felt that the

tuberculous organism gains access to the vertebral body thru

the blood supply to the spine. Even though there is no primary

infection of the avascular disc space, extensive destruction of

the vertebral body with collapse of the disc into the body

results in significant gibbus deformity not common in pyo-

genic spondylitis.

TBc Spondylitis Dorsal Spine

45 yr female with mid dorsal back pain for 6 mos

Thoracotomy Approach

TBc granuloma

aorta

Surgical clean out and fusion

Rib strut grafts

in place

Post op x-rays

Tuberculous Psoas Abscess

47 yr old female with fluid mass in femoral triangle 1 yr

X-ray appearance

L-3 disease

Saddle bag Abscess over sacrum

2 liters of fluid removed

Various sites of psoas abscess drainage

TBc spondylitis with paraplegia (Pott’s dis)

63 yr male with gradual onset spastic paraplegia for 6 mos

Autopsy specimen of LD spine

Modern day case of TBc spondylitis

28 yr female with LD

back pain for 1 yr

MRI

Pediatric TBc spondylitis

3 yr male 9 yr female

Sacroiliac TBc

28 year old male with LBP for 1 year

Brucellar Spondylitis

Looks like TBc

Leprosy

Leprosy Leprosy is not very common in the USA but is seen in other

countries such as South America, Africa, southern Europe

India and China. There are two clinical types of leprosy. The

more common and non infectious form is the neural or

tuberculoid form that is of interest to orthopedic surgeons

because of the peripheral neuropathies and neuropathic joints

that are seen in this form. The lepromatous form which is

infectious because of the draining skin ulcerations has a poor

chance for survival.

In the neural form of leprosy the micobacterium lepri organ-

ism finds its way into periperal nerves causing them to enlarge

resulting in a loss of both motor and sensory components. The

loss of sensation results in trophic skin changes including loss

of pigmentation, hair and ulcerations. Neuropathic joints are

seen in 27% of cases.

Neural or tuberculoid form of leprosy

Neurotrophic foot ulcers and

claw hand deformities

Short finger

Gynecomastia 2nd to

testicular leprosy

Neural leprosy

Loss of skin pigmentation

in areas of anesthesia

Combined median & ulnar N

involvement with trophic skin

changes, clawing, lack of

sweating, and short finger tips

from terminal phylangeal

osteolysis

Neural leprosy

Neuropathic feet with deformity

and shortening due to osteolysis

and neuropathic joints

Social stigma of

eyebrow alopecia

Neural leprosy

Shortening from terminal

osteolysis

Neuropathic joint shortening

Lepromatous (infectious) form of leprosy

Draining facial sores of infectious form of leprosy with

micobacterium lepri organisms seen to right

Luetic Infections

(Syphilis)

Leutic Infections

Syphilis is a disease caused by the treponema pallidum

organism which was first introduced to America by Christopher

Columbus. 50% of cases will involve bone. The two major clinical

types include the adult and congenital forms. The acute form of

the disease is a soft tissue problem and the late or tarda form

of the disease is the type that involves bone and joints that

would be of interest to an orthopedic surgeon . The two most

common bones affected with syphilis include the cranium and

the tibia.

Congenital lues

3 mo female with luetic metaphysitis & facial snuffles

Congenital lues

6 mo. male with luetic metaphysitis

Luetic periostitis

2.5 yr female with saber shin lesion

from congenital lues looking like

hypervitaminosis A, juvenile Paget’s

disease, Englemann’s disease and

Caffey’s disease

Luetic periostitis

6 year female 26 year male

Associated syphilitic abnormalities

Perphorated palate

Luetic keratitis

Notched Hutchinson’s teeth

8th nerve hearing defect

61 year male with incidental finding in pelvis

Heavy metal therapy for syphilis

Viral Osteomyelitis

Rubella infection

Caffey’s disease

Rubella metaphysitis

Infant born with dwarfism,

thrombocytopenia, congenital

heart defects, cataracts, enlarged

liver & spleen, chorioretinitis

and deafness to a mother who

had measles in 1st trimester

Caffey’s disease (viral osteomyelitis ?)

8 mo, old infant with 6 weeks of painful swollen forearm

Biopsy specimen thought to be osteosarcoma

Amputation specimen showing inflammatory periostitis

Original

cortex

Hypertrophic shoulder girdle changes not seen in cong lues

Mandibular hypertrophy seen in Caffey’s and not in lues

Saber shin defect in Caffey,s disease

9 mo. old male with tender shin bone for 3 mos.

Fungus Infections

Coccidiomycosis

The two most common fungus infections seen by orthopedic

surgeons are coccidiomycosis and blastomycosis. Coccidio-

mycosis is most common and seen in the south western part of

the USA whereas, blastomycosis has no special location.

coccidiomycosis is usually seen in the San Joaquin Valley area

where it starts with an upper respiratory infection and a

fever known as valley fever followed in a few weeks by an

acute pneumonitis which usually heals without recurrence.

In a very small percent of cases a granulomatous response is

seen in joints, bone, muscle and skin that can lead to the death

of the patient. The granulation tissue is similar to that seen in

TBc except for the presence of endospores seen in the cytoplasm

of the Langhans type giant cells. Coccidiomycosis replicates

thru a process of endosporulation within the mother cell where-

as in blastomycosis the reproduction takes place thru a process

of external budding from the mother spore.

Coccidiomycosis of knee

82 yr old farmer from Fresno with mild painful swelling of knee

with lytic epiphyseal lesion like GCT except for anterior breakout

Surgical clean out

Yellow arrow sinus track lead to

necrotising cavitary abscess space

with granulomatous granulation

tissue revealing Langhans type

giant cells with blue arrow

endospore of coccidiomycosis

Coccidiomycosis of Knee

40 yr old farmer from Stockton with pain and swelling of knee 3 mos

Bone scan

23 year Asian male with painful swollen knee 2 years

Coccidiomycosis

arthritis

Axial PD Axial T-2

Sag PD Sag T-2

Cor PD

Arthrotomy

Fluconisol treatment

Coccidiomycotic synovial cyst

79 yr male with MRI evidence

of a large popliteal cyst arising

from the knee joint similar to

the appearance of a rheumatoid

synovitis

Coccidiomycosis of knee

23 yr male with mixed synovial

and bony involvement for 1 yr

Sag T-2

Coccidiomycosis osteomyelitis

3 year old female from

Modesto with pain and

swelling below the knee

for 2 months

Lateral view

Endospores being phagocytised by a macrophage

Coccidiomycosis osteomyelitis

4 year old male with pain and swelling of wrist 3 mo.

Coccidiomycosis dactylitis

27 yr old male with pain and swelling of hand 4 mos.

Coccidiomycosis spondylitis

29 year male with

LPB for 1 year

Sagittal T-2 MRI shows the

high signal cocci inflammatory

tissue extruding anteriorly

beneath the anterior longitudinal

ligament in order to spread to

adjacent vertabrae as we see

in TBc spondylitis

Blastomycosis osteomyelitis

32 male with ankle

pain and overlying

skin sore for 6 mos.

Budding spore

Blastomycosis dactylitis

24 yr male with painful

thumb with excoriation

of overlying skin

Sacroiliac cryptococcosis

Silver stain

27 yr male with LBP CT scan

spores in macrophages

Echinococcus spondylitis

31 yr male from India

with LD back pain for

one year

Cor T-1

MRI

Echinococcal osteomyelitis (hydatid disease)

35 yr male from Southern Italy

with hip pain for 2 yrs with chronic

deformation suggestive of

fibrous dysplasia

Large calcific

cyst in liver

Echinococcal osteomylitis

Amputation specimen of femur in adult male

Maduromycosis (Madura foot)

41 yr India male with long history

of painless draining sinuses from

foot Biopsy specimen

Gas myositis

21 yr male sailor with recent puncture wound and sudden

onset of severe pain and swelling of leg with fever & tachycardia

Gas Fasciaitis

62 yr diabetic with gradual onset of mild pain and swelling

of calf with no fever or chills - clostridium infection to rt.