infection of bones and joints - portal.med.muni.cz
TRANSCRIPT
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Infection of bones and joints
Rozkydal, Z.
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Epidemiology
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 %
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Acute haemotogenous osteomyelitis
• Causal organism: Gram- positive and Gram- negative with aerobic or anaerobic metabolism
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Acute haemotogenous osteomyelitis
• Gram +: • Staphylococcus aureus in 80 % Streptococcus pyogenes • Staphylococcus epidermidis • Haemofilus influenzae
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Acute haemotogenous osteomyelitis
• Gram - : • Escherichia coli • Klebsiella • Proteus vulgaris • Pseudomononas aeruginosa • Salmonella, Shigella • Clostridium
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MRSA MRSE Multirezistentní gram negativní tyčinky Clostridium difficile
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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)
• Dirrect transport (open fracture)
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Typical localisation - Metaphysis of long bone More often in children
Acute haemotogenous osteomyelitis
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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
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In children up to six months: spreading through growth plate In children above six months: growth plate is a barrier
0-6 months more than 6 months
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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
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Laboratory tests
• Leucocytosis • ESR • CRP • Differential blood test • Electrophoresis of proteins • Metabolic acdosis • Bacteriological examination from the pus • Haemoculture
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Radiological finding Swelling of soft tisseue Irregular rarefaction in bone Osteolysis in the metaphysis Elevated periosteum Sequestra
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Radiological finding Swelling of soft tissues Irregular rarefaction in bone Osteolysis in the metaphysis Elevated periosteum Sequestra
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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 to bacteriological examination
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Surgical treatment Aspiration of the abscess Drilling of the bone and decompression Drainage Local application of antibiotics Systemic antibiotics
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Antibiotics Debridement Jet lavage Rinsing lavage 7 days Removal of internal fixation External fixator Local application of antibiotics
Posttraumatic osteomyelitis
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Subacute osteomyelitis Less virulent organism Mild symptoms
Sclerosis of bone
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Chronic osteomyelitis Cause: not succesfull treatment of acute stage imunodeficiency high virulent organism
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Sequestra -! necrotic bone surrounded by pus and granulation tissue Pyogenic membrane Sclerotic surrounding -! prevents revasculation and transport of antibiotics Diffuse rarefaction and osteolysis
Pathological anatomy
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Symptoms Pain, tenderness, limited function Discharging sinuses with small sequestra Recurrence of acute stage Fatique Cachexia
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Combination of rarefication and sclerosis of bone Sequestra Periosteal apposition of bone
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Combination of rarefaction and sclerosis of bone Sequestra Periosteal apposition of bone Fistulography MRI CT
Radiological finding
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Management of chronic osteomyelitis The rule: ubi pus, ibi evacua ! Sequestrotomy, lavage Local antibiotics – garamycin Systemic antibiotics Support of imunity Seldom: conservative treatment
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Slow onset Fewer Back ache Limited movements Tenderness Spasm of paravertebral muscles
Osteomyelitis of the vertebra
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Radiological finding Swelling of soft tissue Erosion of the end plates Osteolysis and destruction Narrowing of intervertebral space MRI Scintigraphy
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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
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Differencial diagnostics
Tumors Tumor like lesions Stress fractures Entesopathies
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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
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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
Biofilm
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Biofilm
Adhesion of bacteria - reversible
Exopolymers - glycolalyx - extracelular matrix irreversible
Dispersal
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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 Prolonged cultivation 5-7 dayes
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Therapy in THA
Long antibiotic supression Debridement, synovectomy One stage reimplantation Two stages reimplantation (spacer) Resection arthroplasty
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Spacers
Better movement Better walking Correct distance Release of antibiotics - 90 % of all pathogens + MRSA, MRSA, Entero + Enteroccoci Easier revision
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Therapy in TKA
- Up to 2 weeks: debridement,
lavage, synovectomy
- Later: one stage revision
two stage revision
Prostalac
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Consequences Recurrence of infection Growth arrest – shortening of the extremity Weakness of muscles Joint contracture Septic arthritis Amyloidosis Epidermoid carcinoma Patological fracture Sepsis
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Septic arthritis Suppurative arthritis of the joint
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Septic arthritis
• Gram +: • Staphylococcus aureus • Streptococcus pyogenes • Staphylococcus epidermidis • Haemofilus influenzae • Gonococcus • Pneumococcus
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Septic arthritis
• Gram - : • Escherichia coli • Klebsiella • Proteus Hauseri • Pseudomononas aeruginosa • Salmonella
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The way of infection Haemotogenous seeding From metaphysis – hip, elbow Direct way- by aspiration, surgery, trauma
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Pathological anatomy 1. Synovitis purulenta synovial membrane is thick, pus
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Pathological anatomy 2. Phlegmone of joint capsule The whole joint capsule is involved, pus and granulation tissue, erosions of the cartilage, pannus formation
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Pathological anatomy 3. Panarthritis. Inflamation involves the joint and periarticular tissues, abscesses, destruction of cartilage, fibrous or osseous ankylosis
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Local symptoms Rubor, calor, dolor, tumor, functio laesa tenderness, discharge from sinuses
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Systemic symptoms Fever ( septic fever – two degress between in the morning and in the afternoon) Shivering Fatique Tachycardia, tachypnoe, hypotension Nausea, stomach problems
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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
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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
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Laboratory tests
• Leucocytosis • ESR • CRP • Differential blood test • Electrophoresis of proteins • Metabolic acdosis • Bacteriological examination from the pus • Haemoculture
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Management Aspiration Splinting, analgetics Antibiotics i.v., after 2 weeks oraly 6-8 weeks Arthroscopy and lavage Incision and drainage
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Consequences Osteoarthritis Epiphyseal destruction Necrosis Disturbace of growth plate Ancylosis Subluxation or dislocation Sepsis
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Tuberculosis Granuloma formations Nodes 1-2 mm connecting together The cause- Mycobacterium tuberculosis Mycobacterium bovis Haemotogenous seeding (from lungs)
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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
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Cold abscess Hydrops Fungus Starts as synovitis or spreads from epiphysis Slow progression Destruction of cartilage Fibrous or osseous ankylosis
Pathological anatomy
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TB coxitis
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TB of the knee joint
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TB paraarticular lesion in metaphysis
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TB of the knee joint- subluxation
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Diagnostics Aspiration Biopsy Histology Mantoux II PCR (polymerase chain reaction) Serology: IgM, IgA, IgG QuantiFERON –TB Gold
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TB coxitis healed by extraarticular arthrodesis
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TB arthrisis of the knee joint Arthrodesis
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Management Antituberculous chemotherapy: Combination of bactericid agent: Isoniazid, rifampicin, PAS, ethambutol, pyrazinamid, cycloserin, capreomycin, STM. Therapy is long- 9 months at least Rest, orthesis Surgery- debridement, synovectomy, In the hip – Girdlestone resection arthrodesis
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Spina ventosa
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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
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Symptoms Back ache, tenderness, spasm Sharp gibbus Spasticity, paraparesis, paraplegia Sinuses from cold abscess
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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
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Management Debridement of the lesion Revision of abscess Decompression of spinal cord and nerve roots Stabilisation of the spine