BONE AND JOINT INFECTIONS

1. BONE AND JOINT INFECTIONS นพ. ยอดปิติ ตั้งตรงจิตร กลุ่มงานศัลยกรรมกระดูก โรงพยาบาลแพร่ 3 ตุลาคม 2555

2. SEPTIC ARTHRITIS

3. Septic Arthritis • Epidemiology ~2 to 10/100,000 in general population ~30-40/100,000 in RA ~40-68/100,000 in joint prostheses • 2 age peaks : < 5 years , > 64 years

4. knee 40-50% • hip 20-25% • Shoulders, ankles, elbows 10-15% • wrist 10% • in infants and very young children, hip is the most common joint infection.

5. Acute - < 14days Subacute – 2-6 wks Chronic - > 6wks Monoarthritis – 1 joint Oligoarthritis – 2-3 joints Polyarhritis - > 4 joints Definition

6. Acute Monoarthritis • Crystal-induced synovitis • Septic arthtitis • Acute traumatic and hemorrhagic arthritis • Acute presentation of systemic rheumatic diseases eg.RA, SNSA • Other rheumatic disorders – Adult still’s disease

7. Microorganisms Bacteria - the most important Neisseria Non-neisseria Viruses Fungi Parasites

8. Streptococci S. pyogenes (beta-hemolyticus group A) S. pneumoniae Group B and G hemolytic Streptococci. Staphylococci Staph. aureus Staphylococcus epidermidis Gram-Positive Cocci

9. Neisseria Neisseria gonorrhoeae septic or reactive forms of arthritis, N. meningitidis, Gram Negative Organism

10. Non- Neisseria Haemophilus influenzae Gram-negative rods Enterobacteriaceae E. coli Shigella Salmonella Yersinia Klebsiella pneumoniae. Proteus mirabilis Pasteurellaceae ( Pasteurella multocida) Campylobacter jejuni Gram Negative Organism

11. Viruses HIV parvovirus B19 herpes viruses adenoviruses Anaerobes Clostridium Eubacterium Propionibacterium Bacteroides Fusobacterium Others Mycobacterium Nocardia. Spirochetes Borrelia burgdorferi ( Lyme disease) Chlamydias Mycoplasmas and Ureaplasma. Fungi, Parasites

12. Bacterial isolation

13. Microbiology

15. Clinical features • Acute bacterial infection • Fever 60%-80% (< 39°c ) • Monarticular : inv. 90% • Limited ROM • Swelling (seen synovial effusion) • Most common : knee > hip • Refusal walk ,limping, Irritability, failure to thrive, asymmetry of limb position

16. Clinical Features • Systemic symptoms - neonatal period • High fever • sepsis • local signs – children, adult • Pain • Swelling • Erythema and warm • Limitation of movement

20. Predisposing factors. 1) prosthetic joint. 2) age> 60 yrs. 3) present underlying jt. disease( RA, much less for OA ). 4) co morbidity( malignancy, DM, alcoholism, cirrhosis, hemophilia) 5) use of immunosuppressive drug. 6) skin infection.

21. Abnormal joint RA Crystal induced synovitis Prosthetic joint Severe OA Severe Charcot’s joint Severe hemarthrosis Intrarticular injection Abnormal host Chronic systemic disease - DM ,SLE, CRF, liver disease HIV IVDU Chronic steroid therapy Malignancy Old age New born Predisposing Factors

22. Risk factors for the development of joint sepsis • rheumatoid arthritis (RA) or osteoarthritis • prosthetic joints • low socioeconomic status • intravenous drug abuse • alcoholism • diabetes • previous intra-articular corticosteroid injection • cutaneous ulcers

23. Differential diagnosis

24. Pathogenesis • Mechanism • Hematogenous route. • Skin, oral cavity, respiratory tract, urinary or intestinal tract infections, or endocarditis. • Dissemination from metaphysis or epiphysis. • Vicinity of the joint • Iatrogenic or penetrating trauma

25. Source of infection

26. Hematogenous spread Systemic bacteremia Invade synovial cartilaginous junction Synovial infected Increase inflammatory cell Destructionof the articular cartilage Joint dislocation, subluxation, osteomyelitis

27. 1. Hematogenous route. 2,3 Dissemination from bone 4. Vicinity of the joint 5. Iatrogenic or penetrating trauma

28. Synovial cell proliferation Leukocytes migration Blood flow Exudation Enzymes Tenderness Destruction Erythema Swelling Irreversible destruction Bacteria Synovium Inflammation Pannus

29. Investigations • CBC,ESR,CRP • Blood culture • Synovium fluid • Plain radiographs ( 2-3 weeks or more) • Scintigraphy • 99mTc phosphate (three-phase bone scan) • 99mTc nanocolloid scanning • Indium 111-labeled leukocytes • Computed tomography (CT) • Magnetic resonance imaging (MRI)

30. Laboratory • CBC - often normal. - predominance of segmented neutrophil. • ESR( erytrocyte sedimentation rate) - elevation, but not specific for infections. - present for less than 48 hr, return to normal ~3 weeks.

31. level CRP ESR time 24 48 72 Subside xx 3-5days

32. Laboratory • CRP ( C- reactive protein). - elevation. - inc. within 6 hr, return to normal 1 week after treatment began. - better way to follow the response to ATB. • Blood culture - positive~ 50%-70%.

33. Laboratory • Synovial fluid analysis - should be aspirated immidiately if there is suspicious. - recommended: crystals examination.

34. Diagnosis Joint aspiration

35. Synovial fluid

37. Streptococci

38. Neisseria gonorrhoeae

39. Radiologic Evaluation • Initial plain x-ray • baseline assessment • exclude osteomyelitis • Definitive changes usually take a number of weeks • Rapidity depends on virulence of organism

40. Radiologic Evaluation • Earliest : joint effusion with displacement of fat pad • During first week – periarticular osteoporosis • Within 7-14 days - joint space narrowing & erosions >20days: bone destruction

42. Radiologic Evaluation periarticular osteoporosis

43. Radiologic Evaluation joint space narrowing & erosions

44. Radiologic Evaluation CT / MRI • Difficulty to evaluate clinically • Complex anatomical structure ( hip, shoulder, SC jt, SI jt ) • Early bony erosions, soft tissue extension Bone scan • Axial joints infections • sensitivity • Cannot differentiate septic from aseptic Jt.

45. Laboratory • CT scan • good definition of contiguous bone lesions and ability to guide needle aspiration • MRI • better defines soft tissue (distended joint space and extension to periarticular structures)

46. Laboratory • Radionuclide - physiologic picture. - reflect inflammatory change/ reaction of bone to infection. - 3 most common use 1) Technitium 99m phosphate. 2) gallium 67 citrate. 3) indium 111-labled leukocytes.

47. Bone scan

48. Polyarticular Septic Arthritis • 15% • 50% RA • systemic illness/IVDU • Most common • S.aureus • Group G streptococcus • H.influenza • S. Pneumoniae • Polymicrobial • 30% died!!

49. Treatment Principle in the management of acute septic arthritic(Nade ) • Joint must be adequately drained • Antibiotic must be given to diminish the systemic effects of sepsis • Joint must be rested in a stable position

50. Treatment. • synovial analysis and blood cultures before IV antibiotic treatment • rapid administration of IV antibiotics IV oxacillin in combination with IV ceftriaxone, cefotaxime, or ceftizoxime. 3. drainage of the septic joint 4. evaluation 5. Arthroscopic drainage or arthrotomy