Inflammatory disease of bones

INFLAMMATORYINFLAMMATORY
DISEASES OF THEDISEASES OF THE
BONES & JOINTSBONES & JOINTS

Osteomyelitis (Reineau, 1831) isOsteomyelitis (Reineau, 1831) is
inflammation of all anatomical structuresinflammation of all anatomical structures
of bone.of bone.
The causal organisms are commonThe causal organisms are common
 Staphylococcus aureus,Staphylococcus aureus,
 Streptococcus pyogenes,Streptococcus pyogenes,
 Streptococcus pneumoniae,Streptococcus pneumoniae,
 Haemophilus influenzae.Haemophilus influenzae.

OSTEOMYELITISOSTEOMYELITIS
Incidence
Hematogenous osteomyelitis–
predominantly a disease
of childhood, more common
in males

PATHOGENESISPATHOGENESIS
OFOF
Terminal branches of
metaphyseal arteries form
loops at growth plate
and enter irregular afferent
venous sinusoids. Blood flow
slowed and turbulent,
predisposing to bacterial
seeding. In addition, lining
cells have little or no phago-
cytic activity. Area is catch
basin for bacteria, and foci of
osteomyelitis may form.

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Spread of hematogenousSpread of hematogenous
osteomyelitisosteomyelitis
Infectious process mayInfectious process may
erode periosteum and formerode periosteum and form
sinus through soft tissuessinus through soft tissues
and skin to drain externally.and skin to drain externally.
Process influenced byProcess influenced by
virulence of organism,virulence of organism,
resistance of host,resistance of host,
administration of antibiotics,administration of antibiotics,
and fibrotic and scleroticand fibrotic and sclerotic
responses.responses.

Spread of hematogenousSpread of hematogenous
Abscess, limited by growthAbscess, limited by growth
plate, spreadsplate, spreads
transversely alongtransversely along
Volkmann canals andVolkmann canals and
elevates periosteum;elevates periosteum;
extends subperiosteallyextends subperiosteally
and may invade shaft. Inand may invade shaft. In
infants under 1 year ofinfants under 1 year of
age, some metaphysealage, some metaphyseal
arterial branches passarterial branches pass
through growth plate, andthrough growth plate, and
infection may invadeinfection may invade
epiphysis and joint.epiphysis and joint.

Septic arthritis secondarySeptic arthritis secondary
to concomitant osteomyelitisto concomitant osteomyelitis
Primary routes
of contamination
of joint space

PATHOGENESIS OFPATHOGENESIS OF
Acute hematogenous osteomyelitis
Right side of slide demonstrates “new” woven bone formation.
On the left is typical inflammatory response with neutrophils and
lymphocytes.

PATHOGENESIS OFPATHOGENESIS OF
•Phagocytosis →
generates toxic radicals and
releases proteolytic enzymes →
tissue lysis →
• Pus → 1) spread into vascular
channel →
2) increasing intra-
osseous pressure
and blood flow →
3) ischemic necrosis
of bone (sequestrum)

Clinical pictureClinical picture
Swelling depends on
proximity of bone to
skin and duration
of infection
Concomitant septic arthritis causes
marked restriction of joint motion
Drainage occurs
at later stage
Fever 38o
to 39o
C present in almost all
cases of late acute osteomyelitis, but often
absent of low grade in early acute, subacute,
and chronic osteomyelitis. Children often
show higher fever than adults.
Pain, tenderness and mild
limitation of adjacent joint
motion are typical

X-Ray and CT featuresX-Ray and CT features
PLAIN X-RAY
- Early : soft tissue swelling, obliteration of fat
layer
-14 days later -periosteal new bone formation,
bone destruction, sequestrum.
CT
- For subperiosteal and soft tissue abscesses

The first x-ray, 2 days after symptoms began, is normal –
it always is; metaphyseal mottling and periosteal changes
were not obvious until the second film, taken 14 days later;
eventually much of the shaft was involved.
Acute osteomyelitisAcute osteomyelitis
X-ray featuresX-ray features

Roentgenogram
showing bony destruction

Osteomyelitis with
sequestrum (arrow)
and gross signs of
periosteal reaction.
AcuteAcute

General TreatmentGeneral Treatment
 antibiotics
 analgetics
 desintoxication
 immuno-correction
 correction of metabolism
 nutrition, vitamins
Local TreatmentLocal Treatment
 osteoperforation
 drainage
 splintage
 anti-inflammatory procedures

ComplicationsComplications
 sepsissepsis
 pathologicalpathological
fracturesfractures
 dislocationsdislocations
 shorteningshortening
 angulationangulation

Phases of Chronic OsteomyelitisPhases of Chronic Osteomyelitis

increaseincrease
 activeactive
 fadingfading

remissionremission

Clinical FeaturesClinical Features

SinusesSinuses
 Festering-necrotic woundsFestering-necrotic wounds
 Trophic ulceresTrophic ulceres
 DeformitiesDeformities

Garrè’sGarrè’s
sclerosingsclerosing
Sclerosing osteomyelitis
of the tibia, which appears
deformed by massive
osteoproliferation.

Subacute osteomyelitisSubacute osteomyelitis
(a, b) The classic Brodie's abscess looks like a small walled-
off cavity in the bone with little or no periosteal
reaction;
(c) Sometimes rarefaction is more diffuse and there may
be cortical erosion and periosteal reaction.

Direct causes of osteomyelitisDirect causes of osteomyelitis
Open fractures;
variable degrees, from
small external opening
to
gross protrusion of bone
Penetrating
wounds
Traumatic infections

Operative infections
Total joint replacement
(loosening of prosthesis
usually occurs but does
not necessarily indicate
infection)
Tumor resection
with bone graft
for limb salvage
Internal
fixation of
fractures
Direct
causes of
osteomyelitis

Retropharyngeal
abscess that spreads
to cervical vertebrae
Abscess or infected
wound adjacent to
bone
Felon (or other infection)
that involves bones
Secondary to contiguous
focus of infection

Secondary to contiguous
focus of infection
Pressure ulcers that
extend to sacrum, pelvis, or spine
Retroperitoneal abscess that
involves vertebrae
Infected burns that
involve bones

Vascular
insufficiency
in diabetes,
arteriosclerosis
Contributory or predisposing factors
Hematoma

Scars are a map of the past. The faded scar on this patient's
thigh tells of an old operation - internal fixation of a femoral
fracture. The scar behind this is where the postoperative
infection was drained. Chronic osteomyelitis has also left the
scars of sinuses, one of them still draining.
Post-traumatic osteomyelitisPost-traumatic osteomyelitis

Chronic osteomyelitisChronic osteomyelitis
Chronic bone infection, with a persistent sequestrum, may be
a sequel to acute osteomyelitis (a). More often it follows an open
fracture or operation (b) Occasionally it presents as a Brodie's
abscess (c).

DiagnosticsDiagnostics
of chronicof chronic
Roentgenograms made in
two planes after injection
of radiopaque liquid into
sinus often are helpful in
locating focus of infection
in chronic osteomyelitis.

TREATMENTTREATMENT
 Surgical Treatment
- Complete debridement
- Skeletal stabilization
- Local antibiotics delivery
- Repeated debridement
- Wound closure
 Antibiotics
- 4-6 weeks intravenous therapy
- Followed oral antibiotics

Surgical treatment of chronicSurgical treatment of chronic
Sequestrectomy and curettage
A. Affected bone is exposed, and sequestrum is removed.
B. All infected matter is removed.
C. Wound is either packed open or closed loosely over drains.

SurgicalSurgical
treatmenttreatment
of chronicof chronic
A. Chronic osteomyelitis.
B. After debridement and
development of granulation
tissue.
C. Open bone graft.
D. Blood clot in place.

Chronic osteomyelitis -Chronic osteomyelitis -
treatmenttreatment
The surest way of delivering
antibiotics to the site of infection
is by one or more doublelumen
tubes. A narrow catheter is
threaded (like an intravenous line)
into the wider suction tube;
antibiotic solution is run in through
the catheter and sucked out through
the drainage tube.

ComplicationsComplications
 amyloid disease ofamyloid disease of
internal organsinternal organs
 stiffnessstiffness
 anchylosisanchylosis
 pathological fracturespathological fractures
 malignant metaplasiamalignant metaplasia
of the sinus wallsof the sinus walls

TUBERCULOSISTUBERCULOSIS
 Endemic in many developing countriesEndemic in many developing countries
 Population at risk:Population at risk:
- homeless- homeless
- prisoners- prisoners
- drug addicts- drug addicts
- recent immigrants- recent immigrants
 10% of TB-patients have skeletal involvement10% of TB-patients have skeletal involvement
- 50% are in the spine- 50% are in the spine
- 10-45% have concomitant neurological deficit- 10-45% have concomitant neurological deficit
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EvolutionEvolution
of bone-jointof bone-joint
tuberculosistuberculosis

EvolutionEvolution
of bone-joint tuberculosisof bone-joint tuberculosis
Biopsy specimen ofBiopsy specimen of
synovial membranesynovial membrane
shows conglomerateshows conglomerate
caseating tuberclescaseating tubercles

EvolutionEvolution
of tuberculousof tuberculous
spondylitisspondylitis

Tuberculosis of spineTuberculosis of spine
(tuberculous spondylitis)(tuberculous spondylitis)
Tuberculous osteomyelitis ofTuberculous osteomyelitis of
spine (Pott disease) withspine (Pott disease) with
angulation and compression ofangulation and compression of
spinal cordspinal cord

1. Disturbances of posture and movements in a child
affected with tuberculous spondylitis.
2. Development of spine deformity
2
1
2
1

Disturbances of posture
and movements in an adult
affected with tuberculous
spondylitis

Computed tomographic appearances of L4-L5 spondylitis
with erosions of the discovertebral borders

Development of cervical spineDevelopment of cervical spine
Reduction of the
intervertebral space
The outcome: fusion
of two vertebrae
Destruction of bone.
The cold abscess

Development of lumbar spineDevelopment of lumbar spine
Reduction of the
intervertebral space
The outcome: fusion
of two vertebrae
Calcification of the cold
wandering abscess

Computed tomographyComputed tomography
Destruction of bone tissue in vertebral bodies is seen

back muscles contracture
tuberculous kyphosis

The cold abscess in case
of tuberculous spondylitis
The spine
affected by
tuberculosis

Tuberculous arthritisTuberculous arthritis
Hip joint involvementHip joint involvement
Fullness of groin and lower buttockFullness of groin and lower buttock
with loss of gluteal fold on affectedwith loss of gluteal fold on affected
side, flexion of thigh, and pain onside, flexion of thigh, and pain on
pressurepressure

Tuberculous arthritisTuberculous arthritis
Advanced hip joint involvement
shows extensive destruction
Radiograph reveals
degeneration of knee joint and
calcified granulomatous
material

Tuberculous coxitisTuberculous coxitis
(tuberculosis of the hip)(tuberculosis of the hip)
Early features Fastigium
(height of disease)
Consequences

Destruction of the femoral head
and acetabulum.
Ankylosis (fusion of the joint).
Osteosclerosis.
Tuberculous coxitisTuberculous coxitis
(tuberculosis of the hip)(tuberculosis of the hip)

Tuberculous gonitisTuberculous gonitis
3
1
Granulation tissue
4
2
5
Condyles of the femur
Patella
Condyles of the tibia
4 Cavern
1

Outcomes of the treatmentOutcomes of the treatment
of bone & joint tuberculosisof bone & joint tuberculosis

Atypical location ofAtypical location of
bone & joint tuberculosisbone & joint tuberculosis

CongenitalCongenital
syphilissyphilis
diffuse periostitis
of many bones

ACQUIREDACQUIRED
SYPHILISSYPHILIS
'sabre tibia'

RHEUMATOIDRHEUMATOID
ARTHRITISARTHRITIS

 Most commonly, small joints of theMost commonly, small joints of the hands, feethands, feet andand cervicalcervical
spinespine are affected, but larger joints like the shoulder and kneeare affected, but larger joints like the shoulder and knee
can also be involved, differing per individual.can also be involved, differing per individual.
 Synovitis can lead to tethering of tissue withSynovitis can lead to tethering of tissue with loss ofloss of
movement and erosion of the joint surface, causingmovement and erosion of the joint surface, causing
deformity and loss of function.deformity and loss of function.
•The arthritis of joints known
as synovitis, is
inflammation of the
synovial membrane that
lines joints and tendon
sheaths. Joints become
swollen, tender and warm,
and stiffness limits their
movement. With time, RA
nearly always affects multiple
joints (it is a polyarthritis).

An example showing the differences between a normal,
healthy joint, a joint affected by osteoarthritis, and one affected
by rheumatoid arthritis.

 Rheumatoid arthritis affects aboutRheumatoid arthritis affects about one per cent of theone per cent of the
populationpopulation – usually younger women, aged 25 or older,– usually younger women, aged 25 or older,
with the peak age of onset at 35-45 years.with the peak age of onset at 35-45 years.
 It's three times more commonIt's three times more common in womenin women than men.than men.
 Children and elderly people can develop it, but lessChildren and elderly people can develop it, but less
commonly.commonly.

Rheumatoid arthritis is a systemic disease and its
inflammation can affect organs and areas of the body
other than the joints.

PathogenesisPathogenesis
Rheumatoid
arthritis is an auto-
immune disease in
which the body's
immune system
attacks itself.

The lining of the joints – the synovium – swells and becomes
inflamed. As the pathology progresses, the inflammatory
activity leads to tendon tethering and erosion and destruc-
tion of the joint surface, which impairs range of movement
and leads to deformity.
Rheumatoid
synovitis
Cartilage
thinning
Eroding
cartilage
Bone
spurs
Eroding
meniscus
Exposed
bone

As the condition
progresses, the muscles
around the joint waste
away, the cartilage in the
joint and the bone
underneath erode away,
and eventually the whole
joint is filled with fibrous
scar tissue until it freezes
completely.

ClinicalClinical
FeaturesFeatures
The joints – usually in the hands,
wrists, knees or feet, on both sides
of the body – swell and become
warm, painful and tender.
Increased stiffness early in the
morning is often a prominent
feature of the inflammatory disease
which the person may experience
and may last for more than an hour.

The person feels tired and unwell,
especially in the afternoons.

Sometimes, lumps appear under the
skin near the joints (called rheuma-
toid nodules).
The typical rheumatoid nodule may be a few millimetres to a few centi-
metres in diameter and is usually found over bony prominences, such as
the olecranon, the calcaneal tuberosity, the metacarpophalangeal joints,
or other areas that sustain repeated mechanical stress.
Clinical FeaturesClinical Features

Severe deformities in patients with
rheumatoid arthritis

X-ray of foot. Erosions (arrows)
are visible in the metatarsal heads
and in some of the phalanges. X-ray of the hand in
rheumatoid arthritis.

There is no known cure for rheumatoid arthritis;There is no known cure for rheumatoid arthritis;
however, early medical intervention has beenhowever, early medical intervention has been
shown to be important in improving outcomes.shown to be important in improving outcomes.

Treatment of RATreatment of RA
in orthopedicsin orthopedics
The aim of treatment is to provide pain relief, decrease joint
inflammation, maintain or restore joint function, prevent bone
and cartilage destruction, and to maximize quality of life.
Rest and exercise -Physical Therapy helpful to manage a
good balance.
Joint protection - splints, braces, supports, assistive devices
Surgery - most commonly performed on the knee, elbow and
shoulder joints.

A balance of rest and exercise is importantA balance of rest and exercise is important
in treating rheumatoid arthritisin treating rheumatoid arthritis..

SurgerySurgery
for RAfor RA
 Surgery may be an option to restore joint mobility, repair damaged joints, or in worst case scenarios, totalSurgery may be an option to restore joint mobility, repair damaged joints, or in worst case scenarios, total
artificial joint replacementartificial joint replacement
 The most common surgical procedures for rheumatoid arthritis are arthroscopy,The most common surgical procedures for rheumatoid arthritis are arthroscopy, synovectomysynovectomy (removal(removal
of the inflamed tissue that lines the joint), andof the inflamed tissue that lines the joint), and arthroplasty (joint repair, including joint replacementarthroplasty (joint repair, including joint replacement).).

SynovectomySynovectomy
A. Dorsal surface, left wrist at time of dorsal synovectomy.
Florid proliferative tenosynovitis is seen. Thumb is at top
right.
B. Same wrist after removal of rheumatoid tenosynovium.

A. Flexor surface, left hand and wrist with rheumatoid
tenosynovium bulging to palmar and ulnar (medial) side
of distal forearm.
B. At flexor tenosynovectomy. Excised tenosynovial mass
lies to medial side of hand.

Arthrodesis (using plates)Arthrodesis (using plates)
Dorsal view of wrist fusion
with AO wrist fusion plate
Posterior blade plate fixation.
Arthrodesis of the ankle and
subtalar joints

A. Radial view showing slot
cut in distal radius,
carpal bones, and bases
of second and third
metacarpals.
B. Dorsal view showing
shape of graft and its
final position (broken
line) in slot.
ArthrodesisArthrodesis
(using graft)(using graft)

Types of bone grafts
used in ankle arthrodesis
(using graft)(using graft)

Transarticular cross-screw fixation: a technique of ankle
arthrodesis
(using screws)(using screws)

OsteotomyOsteotomy
Technique of valgus osteotomy with right-angled
compression plate

OsteotomyOsteotomy
Technique of
intertrochanteric
varus osteotomy

Total ankle replacement
device
Replacement surgery for RAReplacement surgery for RA

A. Radiograph of wrist affected by severe rheumatoid
arthritis with carpal collapse and radiocarpal disease.
B. After replacement of wrist joint with Swanson silicone
implant and titanium grommets.

Shoulder Replacement

Total knee arthroplasty for rheumatoid arthritis
A. Advanced rheumatoid arthritis with articular
cartilage destruction.
B. After total knee arthroplasty

A. Advanced disease with articular cartilage destruction.
B. After total hip arthroplasty.
Total hip
arthroplasty for
rheumatoid
arthritis
implants

Total elbow arthroplasty for rheumatoid arthritis.
A. Advanced disease in elbow of 66-year-old woman with
rheumatoid arthritis.
B. After total elbow arthroplasty.
BA

In metacarpophalangeal (MP) joint arthroplasty
flexible silicone implants can be used.
implants

It is not always possible to stop progression of the disease,
but surgery is a very useful part of a combined approach to
control the disease and correct its effect.
Hand Surgery - before and
after operation
Foot Surgery - before
and after operation

Inflammatory disease of bones

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