Bone and joint infection

Matthew Dryden
RHCH
Matthew Dryden
Royal Hampshire County Hospital
Winchester
Winchester
Objectives

1. Understand the causes of bone and

joint infections
2. Recognize the clinical presentation
3. Develop an approach to the diagnosis
of bone and joint infections
4. Discuss antimicrobial management
Complications of an RTA
 Mr BA, retired barrister
 Serious RTA, 3/12 ago, head on collision
 Chest injury; 4 fractured ribs
 Head; subdural haematoma, CSF leak
 Abdomen; lacerated liver/spleen
 Lower limbs; compound fracture of R
femur
 5 weeks in ITU
 Ventilated because of ARDS and hospital
acquired pneumonia
 3 weeks in orthopaedic ward:
intramedullary nail
 Wound infection. Esch. coli isolated
 His wife died in the accident and he has
trouble coping since.
 At orthopaedic clinic, Mr BA is apyrexial
 Discharge of pus from leg wound
 Dull ache
 Wound swab – Staph. aureus
 What should we do with him?
The issues
 Rehabilitation
 Bereavement
 Splenectomy
 Leg infection
Leg infection
 What is the significance of S.aureus in the
wound
 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.aureus
grown from bone
 Diagnosis?
Osteomyelitis and septic arthritis

 Primary  S.aureus 90%

 acute,  Hib, Strep pyogenes
haematogenous,
 Rare -Brucella,
systemic illness
salmonella, gram neg

 Secondary  Polymicrobial, S.aureus,

 Contiguous spread gram neg,
from ulcer, trauma Pseudomonas,
anaerobes
 Vascular problems of
limb eg elderly,
 Coagulase negative
staphylococci esp in
diabetic
prosthetic joint infection
Osteomyelitis
 Microbes invade bone
 Inflammation and pus tracks
through Haversian and
Volkmann’s canals
 Ischaemia and necrosis
 Periosteal elevation
 Osteoblasts generate new
bone
 Old dead bone called
sequestrum; surrounding live
bone called involucrum
 No blood supply to
sequestrum, therefore infection
may persist
 Source of infection
1. Haematogenous
spread
2. Extension from
bone to joint
3. Spread from
adjacent soft
tissue infection
4. Diagnostic,
surgical
interventions
5. Trauma
Clinical features native joint SA
 Monoarticular (90%)
 Mostly acute onset
 Fever
 mild(60 - 80% of cases)
 >39oC (third of cases)

 Movement limitation
 Swelling (effusion)
Osteomyelitis Epidemiology
 Important cause of
morbidity in U.K.
 Incidence
 3,788 cases (England,
1999/2000)
i.e. 7.7/100,000
population (all ages)
 639 cases in children
(6.7/100,000)
 87% of cases treated as
in-patient, mean length of
stay of 14 days

Source: Hospital Episode Statistics, DOH

 Chronic osteomyelitis
Acute OM can progress to chronic
OM

Bone loss and persistent drainage

through sinus.

Squamous cell carcinoma and

amyloidosis are rare
complications
 Tuberculous osteomyelitis
Pott’s disease
Pott’s 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 of
intravenous gadolinium
contrast. The abscess and
subsequent destruction of
the T11-T12 disc
interspace is marked with
arrowheads. Vertebral
body alignment is normal.
Osteomyelitis
 Diagnosis
 Xray,CT, MRI
 Microbiology; bone, pus, blood

 Management
 Antibiotics;combination, prolonged
 Surgical washout; debridement, drainage
 Removal of metalwork, prosthetic joint
 Monitor inflammatory markers; ESR, CRP
Antibiotic treatment
 Be guided by microbiology
 Flucloxacillin 1-2gms qds IV plus oral fusidic
acid 500 tds
 Penicillin allergic consider clindamycin or
ceftriaxone
 Child under 5 consider ceftriaxone to cover Hib
 For MRSA: Vancomycin or teicoplanin plus
fusidic acid (or Linezolid)
Antibiotic treatment
 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

Septic arthritis
Septic arthritis
Joint pus
Osteomyelitis and
diabetes
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
Treatment of PJI
 Antibiotic treatment
with surgical
debridement/ removal
 Monitor WBC and
CRP
 Antibiotic cement
Vertebral
osteomyelitis/discitis