Book Reading
dr. Francisco Gilbert Timothy
dr. Adam Moeljono, [Link] (K) Spine
Section 1
General Orthopaedics
Chapter 2
Infection
2
General aspects of infection
• Classical sign of inflammation
• Bone vs soft tissue vs joint
• Host susceptibility
• Bacterial colonization and resistance
• Treatment
• Effective antibiotic
• Analgesia and general supportive
• Release pus
• Eradicate avascular and necrotic tissue
• Stabilize bone
• Soft tissue and skin cover
3
Acute haematogenous osteomyelitis
• Etiology and pathogenesis
• Staphylococcus aureus (>70% )
• Hairpin loop of nutrient artery
• Pathology
• Children, infants, adults
• Clinical features
• Children, infants, adults
4
• Diagnostic imaging
• Plain X-ray, USG, CT scan, radionuclide scanning, SPECT/CT, MRI
• Laboratory investigation
• Pus aspiration, blood culture, CRP and ESR
• Differential diagnosis
• Cellulitis, acute suppurative arthritis, streptococcal necrotizing
myosits, acute rheumatism, sickle cell crisis, Gaucher disease
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• Treatment
• Antibiotics (mainly flucloxacillin)
• Surgical drainage
• Splintage
• General supportive treatment
• Complication
• Epiphyseal damage and altered bone growth
• Suppurative arthritis
• Metastatic infection
• Pathological fracture
• Chronic osteomyelitis
6
Subacute haematogenous osteomyelitis
• Anatomical classification • Diagnosis
• Metaphyseal with or without • X-ray, culture
cortical erosion
• Treatment
• Diaphyseal cortical or
periosteal • Conservative
• Epiphyseal • Curretage
• Vertebral
• Pathology
• Well defined cavity in
cancellous bone
• Clinical features
• Weeks to months
• Imaging
• Brodie’s abscess
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Post traumatic osteomyelitis
• Most common cause of osteomyelitis in adults
• Staphylococcus aureus, Escherichia coli, Proteus mirabilis,
Pseudomonas aeruginosa
• Clinical features
• Fever, pain swelling over the fracture site
• Microbiological investigation
• Wound swab
• Treatment
• Prophylaxis of infection in open fracture
• Bone and soft tissue debridement
• Implant
8
Chronic osteomyelitis
• Open fracture or an operation
• Staphylococcus aureus, escherichia coli, Streptococcus pyogenes,
Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus
epidermidis
• Pathology
• Cavities containing pus, sequestrum, involucrum
• Clinical features
• Pain, pyrexia, redness and tenderness, seropurulent discharge
9
• Imaging
• X-ray, radioisotope scintigraphy, CT, MRI
• Investigations
• Staging of chronic osteomyelitis
• Cierny and colleagues in 2003 based on local pathological anatomy
and host background
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• Treatment
• Antibiotics
Fusidic acid, clindamycin, cephalosporin, vancomycin
• Local treatment
• Operation
Chronic haematogenous infections vs post traumatic infections vs
postoperative infection
• Debridement
• Dead space
• Soft tissue cover
• Aftercare
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Periprosthetic infection
• Classification
• Early onset PJI (<3 months)
• Delayed onset PJI (>3 months but <12-24
months)
• Late onset PJI (>12-24 months)
• Race for the surface
• Diagnosis
• Clinical findings
• Radiographic results
• Laboratory results (blood, synovial)
• Microbiological data
• Intraoperative inspection
• Histological evaluation
• Treatment
12
Garre’s sclerosing osteomyelitis
• Marked sclerosis and
cortical thickening without
abscess
• Treatment by operation
• Excision of abnormal area
and the exposed surface
thoroughly curreted
13
Multifocal non suppurative
osteomyelitis
• SAPHO (synovitis, acne,
pustulosis, hyperostosis,
osteitis)
• Subacute recurrent multifocal
osteomyelitis
• Children and adolescents
• Long bone metaphyses, medial
ends of the clavicle, vertebral
segment
• Sterno-costo-clavicular
hyperostosis
• Middle age
• Cutaneous pustulosis
• Sternoclavicular joint
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Infantile cortical hyperostosis
• Caffey’s disease
• Painful swelling over the tubular bones and/or mandible
• X-ray: periosteal new bone formation
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Acute suppurative arthritis
• Route f infection
• Direct invasion, direct spread, blood spread
• Pathology
• Clinical features
• Newborn infants,
• Children
• Adults
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• Imaging
• Ultrasonography, X-ray, MRI and
radionuclide imaging
• Investigations
• Joint fluid aspiration
• Differential diagnosis
• Acute osteomyelitis, trauma,
irritable joint, haemophilic bleed,
rheumatic fever, juvenile
rheumatoid arthritis, sickle cell
disease, Gaucher’s disease, gout
and pseudogout
17
• Treatment (mostly like acute osteomyelitis)
• Drainage
• Antibiotics
• Splintage
• General supportive care
• After care
• Complications
• Delay in diagnosis and treatment (>4 days)
18
Gonococcal arthritis
• Clinical features
• Disseminated gonococcal infection
• Septic arthritis of a single joint
• Treatment
• Third generation cephalosporin; quinolone; penicillin
Septic arthritis and HIV-1 infection
• Clinical features
• Single, unusual site
• Several joints affected simultaneously
19
Spirochaetal infections
Syphilis
• Clinical features of acquired syphilis
• Early features: periostitis and thickening of
the cortex
• Late features: local bone resorption and
adjacent area of sclerosis
• Clinical features of congenital syphilis
• Early: osteochondritis, periostitis
• Late: tertiary syphilis
• Treatment
• Benzylpenicillin intramuscular injection
weekly for 3-4 doses.
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Tropical ulcer
• Fusiformis fusiformis and Borrelia
vincentii
• Clinical features
• Small inflamed scratch large
pustule ulcer erodes soft tissue
and bone
• Treatment
• Benzylpenicillin
• Erythromycin
• Third generation cephalosporin
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Tuberculosis
• Pathology
• Primary complex, secondary spread, tertiary lesion
• Clinical features
• Night cries
• X-ray
• Soft tissue swelling, periarticular osteoporosis
• Investigations
• ESR, Mantoux, synovial fluid aspiration
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• Diagnosis
• Transient synovitis, monoarticular rheumatoid arthritis, subacute
arthritis, haemorrhagic arthritis, pyogenic arthritis
• Treatment
• Rest
• Chemotherapy: intensive phase, continuation phase, prophylactic
phase
• Operation: cold abscess
23
Brucellosis
• Brucella melitensis, Brucella abortus, Brucella suis
• Pathology
• Chronic inflammatory granuloma with round-cell infiltration and
giant cells.
• Clinical features
• Joint pains and backache that begins insidiously
• Investigations
• X-ray: subacute arthritis with loss of articular space
• Positive agglutination test (titre above 1/80)
• Treatment
• Antibiotics, operation
24
Leprosy
• Type of leprosy
• Tuberculoid, lepromatous, borderline,
lepromatous reaction
• Clinical features
• Skin, nerve
• Diagnosis
• Skin smear examination, serological test,
skin or nerve biopsy
• Patterns of nerve involvement
25
• Treatment
Paucibacillary vs multibacillary
• Multidrug therapy
• Nerve decompression
• Treatment of nerve abscess
26
Mycotic infections
Superficial mycoses
• Maduromycosis
• No effective chemotherapy
• Candidiasis
• Immunocompromised
• Actinomycosis
• Mandible, vertebrae, pelvis
Deep mycoses
• Histoplasmosis, blastomycosis, coccidioidomycosis
• Immunosuppresive
27
Hydatid disease
• Echinococcus tape worm, sheep
farmers
• Clinical features
• Pathological fracture, compression
of the spinal cord
• Imaging
• X-ray, CT, MRI
• Treatment
• Anti helminthic drug
• Surgery
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Thanks!