INFLAMMATORY

DISEASES OF THE
BONES & JOINTS
 Osteomyelitis (Reineau, 1831) is
inflammation of all anatomical structures
of bone.

The causal organisms are common

 Staphylococcus aureus,
 Streptococcus pyogenes,
 Streptococcus pneumoniae,
 Haemophilus influenzae.
OSTEOMYELITIS

Incidence
Hematogenous osteomyelitis–
predominantly a disease
of childhood, more common
in males
PATHOGENESIS
OF Terminal branches of
OSTEOMYELITIS 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.
 Sponsored

Medical Lecture Notes – All Subjects

USMLE Exam (America) – Practice

Spread of hematogenous
osteomyelitis

Infectious process may

erode periosteum and form
sinus through soft tissues
and skin to drain externally.
Process influenced by
virulence of organism,
resistance of host,
administration of antibiotics,
and fibrotic and sclerotic
responses.
Spread of hematogenous
osteomyelitis

Abscess, limited by growth

plate, spreads
transversely along
Volkmann canals and
elevates periosteum;
extends subperiosteally
and may invade shaft. In
infants under 1 year of
age, some metaphyseal
arterial branches pass
through growth plate, and
infection may invade
epiphysis and joint.
 Septic arthritis secondary
to concomitant osteomyelitis

Primary routes
of contamination
of joint space
 PATHOGENESIS OF
OSTEOMYELITIS

Acute hematogenous osteomyelitis

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

•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 picture
Fever 38o to 39oC 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

Swelling depends on
Concomitant septic arthritis causes Drainage occurs proximity of bone to
marked restriction of joint motion at later stage skin and duration
of infection
 OSTEOMYELITIS
X-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
 Acute osteomyelitis
X-ray features

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.
 X-ray features

Roentgenogram
showing bony destruction
 Acute
osteomyelitis
X-ray features
Osteomyelitis with
sequestrum (arrow)
and gross signs of
periosteal reaction.
General Treatment
 antibiotics
 analgetics
 desintoxication
 immuno-correction
 correction of metabolism
 nutrition, vitamins

Local Treatment
 osteoperforation
 drainage
 splintage
 anti-inflammatory procedures
Complications
 sepsis
 pathological

fractures
 dislocations

 shortening

 angulation
Phases of Chronic Osteomyelitis

 increase
 active
 fading
 remission
 Clinical Features


Sinuses
 Festering-necrotic wounds
 Trophic ulceres
 Deformities
 Garrè’s
sclerosing
osteomyelitis

Sclerosing osteomyelitis
of the tibia, which appears
deformed by massive
osteoproliferation.
 Subacute osteomyelitis
X-ray features

(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 osteomyelitis

Traumatic infections

Open fractures;
variable degrees, from
small external opening
to Penetrating
gross protrusion of bone wounds
 Operative infections

r e c t
Di of
au s e s s
c y el it i
s t eo m
o

Total joint replacement

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

Secondary to contiguous
focus of infection

Felon (or other infection) Abscess or infected

Retropharyngeal
that involves bones wound adjacent to
abscess that spreads
bone
to cervical vertebrae
Direct causes of osteomyelitis
Infected burns that

involve bones Secondary to contiguous

focus of infection

Pressure ulcers that Retroperitoneal abscess that

extend to sacrum, pelvis, or spine involves vertebrae
Direct causes of osteomyelitis

Contributory or predisposing factors

Vascular
insufficiency
Hematoma in diabetes,
arteriosclerosis
 Post-traumatic osteomyelitis

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.
 Chronic 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).
 Diagnostics
of chronic
osteomyelitis

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

 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 chronic
osteomyelitis

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.
 Surgical
treatment
of chronic
osteomyelitis

A. Chronic osteomyelitis.
B. After debridement and
development of granulation
tissue.
C. Open bone graft.
D. Blood clot in place.
Chronic osteomyelitis -
treatment
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.
Complications

 amyloid disease of
internal organs
 stiffness
 anchylosis
 pathological fractures
 malignant metaplasia
of the sinus walls
 TUBERCULOSIS
 Endemic in many developing countries
 Population at risk:
- homeless
- prisoners
- drug addicts
- recent immigrants
 10% of TB-patients have skeletal involvement
- 50% are in the spine b
a

- 10-45% have concomitant neurological deficit

c
k
 Evolution
of bone-joint
tuberculosis
 Evolution
of bone-joint tuberculosis

Biopsy specimen of
synovial membrane
shows conglomerate
caseating tubercles
 Evolution
of tuberculous
spondylitis
 Tuberculosis of spine
(tuberculous spondylitis)

Tuberculous osteomyelitis of
spine (Pott disease) with
angulation and compression of
spinal cord
 1 2

1.
1 Disturbances of posture and movements in a child
affected with tuberculous spondylitis.
2 Development of spine deformity
2.
Disturbances of posture
and movements in an adult
affected with tuberculous
spondylitis
 Tuberculosis of spine
(tuberculous spondylitis)

Computed tomographic appearances of L4-L5 spondylitis

with erosions of the discovertebral borders
 Development of cervical spine
tuberculosis

Reduction of the Destruction of bone. The outcome: fusion

intervertebral space The cold abscess of two vertebrae
 Development of lumbar spine
tuberculosis

Reduction of the The outcome: fusion Calcification of the cold

intervertebral space of two vertebrae wandering abscess
 Tuberculosis of spine
Computed tomography

Destruction of bone tissue in vertebral bodies is seen

 Tuberculosis of spine
(tuberculous spondylitis)

back muscles contracture

tuberculous kyphosis
 Tuberculosis of spine
(tuberculous spondylitis)
 Tuberculosis of spine
(tuberculous spondylitis)

The spine
affected by
tuberculosis

The cold abscess in case

of tuberculous spondylitis
Tuberculous arthritis

Hip joint involvement

Fullness of groin and lower buttock
with loss of gluteal fold on affected
side, flexion of thigh, and pain on
pressure
 Tuberculous arthritis

Radiograph reveals
degeneration of knee joint and
calcified granulomatous
material

Advanced hip joint involvement

shows extensive destruction
 Tuberculous coxitis
(tuberculosis of the hip)

Early features Fastigium Consequences

(height of disease)
 Tuberculous coxitis
(tuberculosis of the hip)

Destruction of the femoral head Ankylosis (fusion of the joint).

and acetabulum. Osteosclerosis.
 Tuberculous gonitis

1 Patella

2 Condyles of the femur

4
3 Granulation tissue

4 Cavern

5 Condyles of the tibia

1
 Outcomes of the treatment
of bone & joint tuberculosis
 Atypical location of
bone & joint tuberculosis
Joint syphilis
Congenital
syphilis

diffuse periostitis
of many bones
ACQUIRED
SYPHILIS

'sabre tibia'
RHEUMATOID
ARTHRITIS
 o f un
l d isn
i ng o
G ett
 •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).

 Most commonly, small joints of the hands, feet and cervical

spine are affected, but larger joints like the shoulder and knee
can also be involved, differing per individual.
 Synovitis can lead to tethering of tissue with loss of
movement and erosion of the joint surface, causing
deformity and loss of function.
An example showing the differences between a normal,
healthy joint, a joint affected by osteoarthritis, and one affected
by rheumatoid arthritis.
 Rheumatoid arthritis affects about one per cent of the
population – usually younger women, aged 25 or older,
with the peak age of onset at 35-45 years.
 It's three times more common in women than men.
 Children and elderly people can develop it, but less
commonly.
Rheumatoid arthritis is a systemic disease and its
inflammation can affect organs and areas of the body
other than the joints.
Pathogenesis

Rheumatoid
arthritis is an auto-
immune disease in
which the body's
immune system
attacks itself.
 Exposed
bone
Eroding
cartilage

Rheumatoid
synovitis
Cartilage
thinning

Bone
spurs

Eroding
meniscus

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.
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.
 Clinical
Features

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.

 Clinical Features

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.
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;
however, early medical intervention has been
shown to be important in improving outcomes.
 Treatment of RA
in 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 important
in treating rheumatoid arthritis.
 Surgery
for RA
 Surgery may be an option to restore joint mobility, repair damaged joints, or in worst case scenarios, total
artificial joint replacement
 The most common surgical procedures for rheumatoid arthritis are arthroscopy, synovectomy (removal of
the inflamed tissue that lines the joint), and arthroplasty (joint repair, including joint replacement).
 Synovectomy

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)

Posterior blade plate fixation.

Dorsal view of wrist fusion Arthrodesis of the ankle and
with AO wrist fusion plate subtalar joints
 Arthrodesis
(using graft)
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.
Arthrodesis
(using graft)

Types of bone grafts

used in ankle arthrodesis
 Arthrodesis
(using screws)

Transarticular cross-screw fixation: a technique of ankle

arthrodesis
 Osteotomy

Technique of valgus osteotomy with right-angled

compression plate
Osteotomy

Technique of
intertrochanteric
varus osteotomy
Replacement surgery for RA
Total ankle replacement
device
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.
Replacement surgery for RA

Shoulder Replacement
Replacement surgery for RA

Total knee arthroplasty for rheumatoid arthritis

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

Total hip
arthroplasty for
rheumatoid
arthritis

A. Advanced disease with articular cartilage destruction.

B. After total hip arthroplasty.
 Replacement surgery for RA
A B

Total elbow arthroplasty for rheumatoid arthritis.

A. Advanced disease in elbow of 66-year-old woman with
rheumatoid arthritis.
B. After total elbow arthroplasty.
Replacement surgery for RA
implants

In metacarpophalangeal (MP) joint arthroplasty

flexible silicone implants can be used.
 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

The end