Lecture 8 PHT2012 Osteonecrosis & Infection in ORT 20231027 PDF

Osteonecrosis of the jaw (may be due to taking of bisulphonates in poor oral hygiene patients) Management: • No clear proof of the best management. • Early treatment (before bone collapse) is best. Early treatment: pain medications + limiting weight-bearing/walking (NWB/PWB) on affected areas:...

Osteonecrosis of the jaw (may be due to taking of bisulphonates in poor oral hygiene patients) Management: • No clear proof of the best management. • Early treatment (before bone collapse) is best. Early treatment: pain medications + limiting weight-bearing/walking (NWB/PWB) on affected areas: • work well for patients with early osteonecrosis in small areas of bone. • For hip or knee osteonecrosis patients with worsening disease and bone collapse, they may need surgical procedures to relieve pain and to prevent bone collapse. Surgery: i) core decompression (removes a piece/core of bone from the affected area to improve blood flow). ii) More advanced cases: osteotomy (remove dead bone and re-position the remaining bone so that healthy bone supports the weight-bearing joint surface). iii) If bone collapse at the joint has occurred, total joint replacement (arthroplasty) of the hip or knee (improve pain and function). iv) Another surgery option for advanced cases: bone grafting (take a small piece of a person’s own healthy leg bone and graft (transplanting) it to the area of dead bone to improve blood flow and support of the surrounding bone. Medicine: no proven medical therapy for ON/AVN. Some studies suggest that short-term bisphosphonate treatment may slow/improve/prevent bone collapse in the hip and knee. Prevention: i). To avoid too much alcohol intake and avoid tobacco use ( smoking raises the risk of osteonecrosis). ii). If you have to take corticosteroids, such as prednisone, work with your doctor to take the smallest dose for the shortest time possible that will control your symptoms. Living with osteonecrosis: Some people will develop OA. PT for treating the pain + joint stiffness + ambulation. Partial weight exercises like the hydrotherapy/cycling is good for the AVN patients. Osteochonditis/osteochondritis dissecans (OCD) 1. Osteochonditis: a painful type of osteochondrosis (the cartilage/bone in a joint is inflamed). 2. Osteochondritis dissecans (OCD): i) dissecans means the "creation of a flap of cartilage that further dissects away from its underlying subchondral attachments". ii) osteochondritis are osteochondritis deformans juvenilis (e.g. osteochondritis of the capitular head of the epiphysis of the femur) and osteochondritis deformans juvenilis dorsi (e.g. osteochondrosis of the spinal vertebrae/ Scheuermann's disease). Osteochondritis dissecans (OCD): • A joint condition: bone underneath the cartilage of a joint dies due to lack of blood flow → this bone and cartilage can then break loose, causing pain and possibly hindering joint motion. • Occurs often in children and adolescents. • Commonly in the knee, elbows, ankles and other joints. S&S: According to the size of the injury + whether the fragment is partially or completely detached + whether the fragment stays in place. 1. If the loosened piece of cartilage and bone stays in place: few or no symptoms. 2. For young children whose bones are still developing, the injury might heal by itself. 3. Symptoms either after an injury to a joint or after several months of activity (as in high-impact activity: jumping and running that affects the joint). 4. Depending on the joint affected): • Pain on weight bearing/physical activity (e.g. walking up stairs, climbing a hill or playing sports). • Swelling + tenderness in the skin around the affected joints. • Joint effusion + unstable: popping/locking, "giving way“/ weakening. • Decreased ROM: unable to straighten the affected limb completely. • Common in knee, elbow, ankles and the other joints that move often. Causes: unknown. • i). Probably due to the reduced blood flow to the end of the affected bone might result from repetitive trauma (small, multiple episodes of minor, unrecognized injury that damage the bone). • ii) genetic component: some people more prone to develop the disorder. Risk factors: in children and adolescents between the ages of 10 and 20 who are highly active in sports. Complications: can increase the risk of developing OA in that joint. Surgery is necessary if the fragment comes loose and gets caught between the moving parts of your joint or on persistent pain. Prevention (Adolescents participating in organized sports): i). educate on the risks to their joints associated with overuse. ii). Learn the proper mechanics and techniques of their sport iii). Use the proper protective gear iv). Participate in strength training + stability training exercises to reduce the chance of injury. Septic arthritis/joint infection/infectious arthritis The invasion of a joint by an infectious agent resulting in joint inflammation. Symptoms: redness, heat and pain in a single joint associated with a decreased ability to move the joint + onset rapid. Fever, weakness and headache. Occasionally, > 1 joint may be involved. Causes: bacteria, viruses, fungi and parasites. Risk factors: an artificial joint, prior arthritis, diabetes and poor immune function. Occurrence: joints become infected via the blood, via trauma or via an infection around the joint. Dx: joint aspiration + culture (joint fluid): +ve if WBC > 50,000 mm3, lactate > 10 mmol/l in the jt. Initial treatment: antibiotics such as vancomycin, ceftriaxone or ceftazidime. Surgery: to clean out the joint. Without early treatment, long-term joint problems may occur. Septic arthritis occurs in about 5 people per 100,000 each year (common in older people). With treatment: 15% of people die Without treatment: 66% die. Signs and symptoms • Pain + swelling + warmth at the affected joint. • Refuse to use the joint/joint rigidly + Fever (less likely in older adults). • P/E to rule out of intra-articular or periarticular cause. Intra-articular arthritis usually results in severe limitation of the ROM of the joint with the joint held in extended position; the joint space will be maximal in this position. In peri-articular arthritis, pain only occurs when the joint is moved, and the lesion usually lies in one specific area around the joint. • Knee is more affected. Hip, shoulder, wrist and elbow joints are less common. • Spine, Sternoclavicular Joint and SIJ can also be involved (due to IV drug use). • Usually, only 1 joint is affected. • > 1 joint are spread through the bloodstream. Prosthetic joint Infections 0.86 - 1.1% in a Knee joint, 0.3 - 1.7% of in a hip joint. 3 phases of artificial joint infection: 1. Early: occurs < 3/12 after the surgery. S&S: fever, joint pain, redness + warmth over the joint operation site. Usual bacteria: Staphylococcus aureus and gram negative bacilli. 2. Delayed: occurs between 3 – 24/12. S&S: persistent joint pain, due to loosening of the implant. Common bacteria: coagulase-negative Staphylococcus and Cutibacterium acnes. 3. Late: > 2 years. S&S: sudden onset of joint pain + fever. The mode of infection is through the bloodstream. The bacteria involved are the same as those in septic arthritis of a normal joint. Cause: by a bacterial infection. Bacteria can enter the joint by: • The bloodstream from an infection elsewhere (most common) • Direct penetration into the joint (arthrocentesis, arthroscopy, trauma) • A surrounding infection in the bone or tissue (from osteomyelitis, septic bursitis, abscess). • Microorganisms in the blood may come from infections elsewhere in the body such as wound infections, urinary tract infections, meningitis or endocarditis. Infection also comes from an unknown location. Risk factors: • Age over 80 years • Diabetes mellitus • OA • RA (increases with anti-tumor necrosis factor alpha treatment). • Immunosuppressive medication • Intravenous drug abuse • Recent joint surgery • Hip or knee prosthesis and skin infection • HIV infection • Other causes of sepsis HIV (Human Immunodeficiency Virus) Surveillance at a glance in HK (2016) 692 HIV reports and 111 AIDS (Acquired Immune Deficiency Synfrome) reports Gender: 86.1% male, Ethnicity: 73.0% Chinese, Age: Median 35 Risks: • 63.7% Homosexual/bisexual contact • 21.1% Heterosexual contact • 0.9% Injecting drug use • 14.3% Undetermined CD4 at reporting: Median 284/ul HIV-1 subtypes: commonest are CRF01_AE and B • Commonest primary AIDS defining illness: PCP (Angel Dust) and TB HIV prevalence • Blood donors: <0.01%, Antenatal women: 0.02%, STI clinic attendees: 0.48%, Methadone clinic attendees: 1.13% Causative Organisms: 1. Most involve only 1 organism 2. Polymicrobial infections in a large open injuries to the joint 1. Mainly caused by bacteria, 2. But may be caused by viral, mycobacterial, and fungal pathogens. Classification: 3 main groups 1. Non-gonoccocal arthritis: over 80% are staphyloccoci or streptococci (from drug abuse, cellulitis, abscesses, endocarditis, and chronic osteomyelitis. Methicillin-resistant Staphylococcus aureus (MRSA) may affect 5 to 25% of the cases while gram negative bacilli affects 14 to 19% of the septic arthritis cases. Gram negative infections are usually acquired through urinary tract infections, drug abuse, and skin infections. Old people who are immunocompromised are also prone to get gram negative infections. Common gram negative organisms are: Pseudomonas aeruginosa and Escherichia coli. Both gram positive and gram negative infections are commonly spread through the blood from an infective source; but can be introduced directly into the joint or from surrounding tissue. 2. Gonococcal arthritis : Neisseria gonorrhoeae is a common cause of septic arthritis in people who are sexually active and under 40 years old. The bacteria is spread through the blood to the joint following sexual transmission. 3. Others : Fungal and mycobacterial infections are rare with a slow onset of joint symptoms. Viruses such as rubella, parvovirus B19, chikungunya, and HIV infection can also cause septic arthritis. Prosthetic joint infection: 1. Staphylococci, 2. Staphylococcus aureus, 3. gram negative bacilli. The risk factors: Previous fracture, Seropositive rheumatoid arthritis, Obesity, Revision arthroplasty, and Surgical site infections. List of organisms (1) • Staphyloccoci (40%) • Staphylococcus aureus – the most common cause (in skin infection, previously damaged jt, prosthetic jt or IV drug use). • coagulase-negative staphylococci – usually due to prosthetic joint • Streptococci – the second-most common cause (28%) • Streptococcus pyogenes – a common cause in children under 5 • Streptococcus pneumoniae • Group B streptococci – a common cause in infants • Haemophilus influenzae List of organisms (2) • Neisseria gonorrhoeae –in young, sexually active adults (Multiple macules or vesicles seen over the trunk are a pathognomonic feature). • Neisseria meningitidis • Escherichia coli – in the elderly, IV drug users and the seriously ill • Pseudomonas aeruginosa – IV drug users or penetrating trauma through the shoe • M. tuberculosis, Salmonella spp. and Brucella spp. – cause septic spinal arthritis • Eikenella corrodens – human bites • Pasteurella multocida, bartonella henselae – animal bites or scratches • Fungal species – immunocompromised state • Borrelia burgdorferi – ticks, causes lyme disease Diagnosis • Considered whenever a person has rapid onset pain + swollen joint, regardless of fever (one or multiple joints can be affected at the same time). • P/E + arthrocentesis: joint fluid culture + blood cultures • WBC count, ESR, CRP, VDRL • In children: Kocher criteria is used for diagnosis of septic arthritis • Gram stain: Synovial fluid cultures are +ve in over 90% of nongonoccocal arthritis (may be -ve if the person received antibiotics prior to the joint aspiration, or in gonoccocal arthritis, or if fastidious organisms are involved). • Positive crystal studies do not rule out septic arthritis, as gout can occur at the same time as septic arthritis. • A lactate level in the synovial fluid of greater than 10 mmol/l makes the diagnosis very likely. • Blood tests: WBC count, ESR and CRP elevated in septic arthritis. • Blood cultures can be +ve in up to 50% septic arthritis cases. • Imaging: x-ray, CT, MRI or US are nonspecific (good in determining the areas of inflammation but cannot confirm septic arthritis). • US is effective at detecting joint effusions and are helpful in guiding arthrocentesis of the joints. Differential diagnosis • Crystal induced arthritis such as gout or pseudo-gout • Inflammatory arthritis • Rheumatoid arthritis • Seronegative spondylo-arthropathy such as ankylosing spondylitis or reactive arthritis • Traumatic arthritis due to hemarthrosis, fracture or foreign body • Osteoarthritis Treatment • Intravenous antibiotics, analgesia and washout +/- aspiration of the joint. • Draining the pus from the jt. by needle (arthrocentesis)/opening the joint surgically (arthrotomy). Empiric antibiotics for suspected bacteria as follows: • Gram positive cocci – vancomycin; Gram negative cocci – Ceftriaxone • Gram negative bacilli – Ceftriaxone, cefotaxime, or ceftazidime • Gram stain negative and immunocompetent – vancomycin • Gram stain negative and immunocompromised – vancomycin + third generation cephalosphorin • IV drug use (possible pseudomonas aeruginosa) – ceftazidime +/- an aminoglycoside • Once cultures are available, antibiotics can be changed to target the specific organism. After a good response to IV antibiotics → switch to oral antibiotics (1–4 weeks depending on the offending organism). • Daily joint aspiration + aspirate sent for culture, gram stain, white cell count to monitor the progress. • Open surgery/Arthroscopy (including lysis of the adhesions, drainage of pus, and debridement of the necrtoic tissues). • Close follow up to make sure the patient is no longer feverish, pain has resolved, improved ROM, and lab values are normalized. • In infection of a prosthetic joint, a biofilm is often created on the surface of the prosthesis which is resistant to antibiotics. Surgical debridement is indicated. • A replacement prosthesis is not inserted at the time of removal to allow antibiotics to clear infection of the region. • Low-quality evidence suggests that the use of corticosteroids may reduce pain and the number of days of antibiotic treatment in children. Osteochondritis or Osteochondritis Dissecans, OCD. • A painful type of osteochondrosis where the cartilage or bone in a joint is inflamed. • Osteochondritis Dissecans: Dissecans means the "creation of a flap of cartilage that further dissects away from its underlying subchondral attachments (dissecans). Other types: • osteochondritis deformans juvenilis (osteochondritis of the capitular head of the epiphysis of the femur) and • osteochondritis deformans juvenilis dorsi (osteochondrosis of the spinal vertebrae, or Scheuermann's disease). Osteochondritis deformans juvenilis A temporary condition in children in which the femoral head loses its blood supply: the femoral head collapses. • Follow on: the body will absorb the dead bone cells and replace them with new bone cells. The new bone cells will eventually reshape the femoral head. S&S: causes the hip joint painful and stiff for a period of time. The majority of cases affect 1 hip; 10-12 % of cases affect both hips. Risk factors: more common in boys (5:1 male-female ratio). • Association of osteochondritis deformans juvenilis with ADHD (attention deficit hyperactivity disorder) and in children who are more active than average (running, jumping, sports, etc). • An increased incidence in children who are small for their age (delayed bone age). • Recent studies that connect osteochondritis deformans juvenilis to prolonged exposure to second hand smoke: prolonged inhalation of cigarette smoke increases the risk of ischemia leading to the osteochondritis deformans juvenilis. Common in the Asian, Eskimo, and Caucasian population. Treatment: supportive therapy and ensure your child's hip retains its normal shape and ROM. Scheuermann's disease • A self-limiting skeletal disorder of childhood. • A condition where the vertebrae grow unevenly with respect to the sagittal plane; that is, the posterior angle is often greater than the anterior. • This uneven growth results in the signature "wedging" shape of the vertebrae, causing kyphosis. S&S: • A form of juvenile osteochondrosis of the spine in teenagers and presents a significantly worse deformity than postural kyphosis. • Scheuermann’s kyphosis: the apex of their curve, located in the thoracic vertebrae, is quite rigid. • Pain in the lower & mid-level back and neck : severe and disabling, aggravated by physical activity and by periods of standing or sitting. • May cause detrimental effect and disability. • Loss of vertebral height, and 'hunchback'/'roundback'. • The 7th and 10th thoracic vertebrae are commonly affected. • In very serious cases: may cause internal organ problems and spinal cord damage, but extremely rare. Management: Physiotherapy for mild case and surgery for sever cases. Chondromalacia • A condition where the cartilage on the undersurface deteriorates and softens • Often seen as an overuse injury in sports • Sometimes taking a few days off from training can produce good results. • Improper knee alignment is the cause and if resting doesn’t provide relief. • The symptoms of runner’s knee are knee pain and grinding sensations • Many people may have it without seeking medical treatment. Chondromalacia patellae (CMP) • A condition where the cartilage on the undersurface of the patella deteriorates and softens. • Also known as Runner Knee. S&S: Pain and discomfort in the patellofemoral joint. The patella may be laterally rotated or tilted. Tight musculatures around the Knee region. Staitrs walking: Pain in downstairs > upstairs). Patellar Friction Test: +ve Prevalence: commonly in young females, young athletic, or in older adults with arthritis of the knee. Dx: Knee Physical examination + XR: Skyline Laurin view in NWB position. Skyline Laurin view Understanding the different locations of Knee Pain Causes: 1. When the knee bends, the retro-patellar surface glides over the cartilage of the femur at the knee in a normal “tracking format”. 2. When the ITB, Hamstrings, Quadriceps, calf tendons and the ligaments around the Knee are tight 3. When any of these components fails to move properly, it can cause the patella to rub up against the femur. 4. The abnormal rubbing can lead to deterioration in the patella, resulting in chondromalacia patellae, or runner’s knee. Improper Patella tracking movement may be resulted from: • poor alignment due to a congenital condition • weak hamstrings and quadriceps • Muscle imbalance between the adductors and abductors (e.g. ITB and Adductor Magnus) • Repeated stress to the knee joint such as from running, skiing, or jumping • A direct blow or trauma to the patella Risk for developing chondromalacia patellae (CMP) 1. Age: Adolescents and young adults at high risk - during growth spurts, the muscles and bones develop rapidly, which may contribute to short-term muscle imbalances. 2. Gender: Females >> males to develop runner’s knee. Less muscle mass in females may cause abnormal knee positioning and more lateral (side) pressure on the patella. 3. Flat feet: place more stress on the knee joints than having higher arches would. 4. Previous injury: prior injury to the patella, e.g. dislocation, may increase the risk of developing runner’s knee. 5. High activity level: place extra pressure on the knee joints, and increase the risk for knee problems. 6. Arthritis Runner’s knee can also be a symptom of arthritis. Inflammation can prevent the kneecap from functioning properly. CMP Management • NSAID • Analgesic Physiotherapy: Stretches to Hamstrings, Quadriceps, ITB, Hip adductors, calves. • Treat the flat foot • Strengthening exercises: Quadriceps and Hamstring • Stretches to tight musculatures around the Knee region • Jenny McConnell Exercises to PFJP • Patellar taping • Home programme and advice References 1. Blom, A., Warwick, DJ, & Whitehouse, M.. (2018). Apley & Solomon’s System Of Orthopaedics And Trauma. (10th ed.). Florida, CRC Press. 2. Cook, G.; Markel, D.; Ren, W.; Lawrence M.; Schemitsch, E. (2015), “Infection in orthopaedics”, Journal of Orthopaedic Trauma: Dec 2015, Vol 29, Issue p S19–S23. 3. 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