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Bone and joint infection
Bone and Joint Infection
W. H. Kirkaldy-Willis
The Chinese civil servant Confucius wrote ‘Wisdom is knowledge, using it, acting on it’. Einstein, a civil servant of 4000 years later. said ‘Imagination is more important than knowledge’. Wisdom in managing bone and joint infections is based on knowledge (pathology), using this to make an accurate diagnosis and acting on it to treat the lesion. Our imagination helps us to picture the battle between the invading organism and the forces of the body. Clinical Presentation Fifty years ago infections were usually acute (staphylococcal) or chronic (tuberculous). With the advent of antibiotics the picture has changed. The commonest infections are subacute, often with only minor symptoms, no pyrexia, a normai white cell count and slightly elevated sedimentation rate. Staphylococcal infections are not uncommon. In patients debilitated from any cause or who have undergone vesical instrumentation the infection is often due to a Gram negative bacillus. Tuberculous lesions are still seen in every part of the world but they often have an atypical presentation in unusual sites. Radiological Evaluation When an infection is suspected it is wise to supplement the radiograph of the affected part with a chest film, a bone scan and sometimes tomograms and CT Scanning. In acute infections there may be no radiographic changes for 3-4 weeks. Repeated radiographs, of good quality, and consultation with the radiologist are essential. W. H. Kirkaldy-Wiiis University Hospital,
MD FRCSC, Department of Orthopaedics, Saskatoon, Saskatchewan. Canada SN7 OX0
Pathology and Bacteriology It is important to obtain material for both histological and bacteriological examination from the sinus, aspiration of the abscess, needle or open biopsy. The surgeon or his resident should take the specimens to the laboratory and discuss the case with pathologist and microbiologist. It is often necessary to search for all types of pyogenic organism, aerobic and anaerobic, tubercle bacilli, fungi, spirochaetes and parasites. Rare kinds of infection are not as rare as one might think. Treatment Antibiotics. These must be given for an adequate length of time, 6 weeks to 3 months for pyogenic and one and a + to 2 years for tuberculous infections. Chronic long-standing bone infections. These usually require an incision the length of the radiographic changes in bone, a gutter in the bone of the same length and careful evacuation of all abscesses and removal of all sequestra. It is then often possible to close the skin, with adequate antibiotic coverage. Traction. The use of traction for lower limb infections permits movement of joints and contraction of muscles. When done with sufficient care this prevents joint stiffness and muscle atrophy and does much to maintain the health of the limb. RecoLleryfrom infection of a joint is tested by removing the traction and if all is well allowing the patient out of bed on crutches, permitting weight bearing and finally walking without crutches. If at any point the symptoms or signs recur it is necessary to go back a step. The Spine. Treatment is virtually the same for children and adults. Serious deformity is more likely to occur in children. The aim is healing of the lesion without ---
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BONE AND JOINT INFECTION
deformity or paraplegia. In pyogenic infections it is often sufficient to evacuate the abscess by aspiration or open operation. The result is often spontaneous bony fusion, An operation to fuse the spine is occasionally needed. In treating tuberculous lesions it is very often necessary to perform an operation to decompress the lesion and then fuse the spine, using grafts of bone from rib, ilium or both. The Hip. Decompression early by open operation is necessary in order to avoid avascular necrosis of the femoral head from vascular occlusion in pyogenic infections. The Hip and Knee. In children the aim is a joint with a useful range of painfree movement. This is possible when the cartilage space is normal or the lesion is extra-articular. In adults a mobile joint is less likely. However, with adequate early treatment it is often possible to gain mobility in the knee but there is less chance in the hip. These comments apply to both pyogenic and tuberculous infections. Prolonged immobilisation for tuberculosis of the immature hip may result in premature
fusion of the lower femoral epiphyseal plate. When the hip is ankylosed or fused in adduction, strain is placed on the knee with resultant valgus deformity and laxity of the medial collateral ligament. Arthrodesis of the Hip. When done by a surgeon experienced in this operation the long-term results are much better than generally thought. Bone grafts as well as internal and external fixation must be employed. The joint must be protected until fusion is firm. For flexion the rule is one degree for every year up to 20 years of age. Otherwise the best position is neutral abduction-adduction with 5-10” of external rotation. A total hip replacement can be done later when the lesion is completely healed. Bone and joint infections do not carry the same morbidity, and mortality as they did 50 years ago and consequently an early diagnosis may not be made because it has not been considered. Awareness of the possibility is paramount especially as we enter an era when it becomes increasingly possible to sustain the life of the extremely ill and when immune deficiency syndromes become more prevalent.
W. H. Kirkaldy-Willis
The Chinese civil servant Confucius wrote ‘Wisdom is knowledge, using it, acting on it’. Einstein, a civil servant of 4000 years later. said ‘Imagination is more important than knowledge’. Wisdom in managing bone and joint infections is based on knowledge (pathology), using this to make an accurate diagnosis and acting on it to treat the lesion. Our imagination helps us to picture the battle between the invading organism and the forces of the body. Clinical Presentation Fifty years ago infections were usually acute (staphylococcal) or chronic (tuberculous). With the advent of antibiotics the picture has changed. The commonest infections are subacute, often with only minor symptoms, no pyrexia, a normai white cell count and slightly elevated sedimentation rate. Staphylococcal infections are not uncommon. In patients debilitated from any cause or who have undergone vesical instrumentation the infection is often due to a Gram negative bacillus. Tuberculous lesions are still seen in every part of the world but they often have an atypical presentation in unusual sites. Radiological Evaluation When an infection is suspected it is wise to supplement the radiograph of the affected part with a chest film, a bone scan and sometimes tomograms and CT Scanning. In acute infections there may be no radiographic changes for 3-4 weeks. Repeated radiographs, of good quality, and consultation with the radiologist are essential. W. H. Kirkaldy-Wiiis University Hospital,
MD FRCSC, Department of Orthopaedics, Saskatoon, Saskatchewan. Canada SN7 OX0
Pathology and Bacteriology It is important to obtain material for both histological and bacteriological examination from the sinus, aspiration of the abscess, needle or open biopsy. The surgeon or his resident should take the specimens to the laboratory and discuss the case with pathologist and microbiologist. It is often necessary to search for all types of pyogenic organism, aerobic and anaerobic, tubercle bacilli, fungi, spirochaetes and parasites. Rare kinds of infection are not as rare as one might think. Treatment Antibiotics. These must be given for an adequate length of time, 6 weeks to 3 months for pyogenic and one and a + to 2 years for tuberculous infections. Chronic long-standing bone infections. These usually require an incision the length of the radiographic changes in bone, a gutter in the bone of the same length and careful evacuation of all abscesses and removal of all sequestra. It is then often possible to close the skin, with adequate antibiotic coverage. Traction. The use of traction for lower limb infections permits movement of joints and contraction of muscles. When done with sufficient care this prevents joint stiffness and muscle atrophy and does much to maintain the health of the limb. RecoLleryfrom infection of a joint is tested by removing the traction and if all is well allowing the patient out of bed on crutches, permitting weight bearing and finally walking without crutches. If at any point the symptoms or signs recur it is necessary to go back a step. The Spine. Treatment is virtually the same for children and adults. Serious deformity is more likely to occur in children. The aim is healing of the lesion without ---
64
BONE AND JOINT INFECTION
deformity or paraplegia. In pyogenic infections it is often sufficient to evacuate the abscess by aspiration or open operation. The result is often spontaneous bony fusion, An operation to fuse the spine is occasionally needed. In treating tuberculous lesions it is very often necessary to perform an operation to decompress the lesion and then fuse the spine, using grafts of bone from rib, ilium or both. The Hip. Decompression early by open operation is necessary in order to avoid avascular necrosis of the femoral head from vascular occlusion in pyogenic infections. The Hip and Knee. In children the aim is a joint with a useful range of painfree movement. This is possible when the cartilage space is normal or the lesion is extra-articular. In adults a mobile joint is less likely. However, with adequate early treatment it is often possible to gain mobility in the knee but there is less chance in the hip. These comments apply to both pyogenic and tuberculous infections. Prolonged immobilisation for tuberculosis of the immature hip may result in premature
fusion of the lower femoral epiphyseal plate. When the hip is ankylosed or fused in adduction, strain is placed on the knee with resultant valgus deformity and laxity of the medial collateral ligament. Arthrodesis of the Hip. When done by a surgeon experienced in this operation the long-term results are much better than generally thought. Bone grafts as well as internal and external fixation must be employed. The joint must be protected until fusion is firm. For flexion the rule is one degree for every year up to 20 years of age. Otherwise the best position is neutral abduction-adduction with 5-10” of external rotation. A total hip replacement can be done later when the lesion is completely healed. Bone and joint infections do not carry the same morbidity, and mortality as they did 50 years ago and consequently an early diagnosis may not be made because it has not been considered. Awareness of the possibility is paramount especially as we enter an era when it becomes increasingly possible to sustain the life of the extremely ill and when immune deficiency syndromes become more prevalent.