Quiz 3 - Spivak - Bone and Joint

Question 1

Osteomyelitis - How is it caused?

Answer 1

Result of trauma or surgery

Contiguous spread

Hematogenous - S aureus - thru blood

Question 2

What happens in osteomyelitis?

Answer 2

Inflammatory exudate leads to increased intramedullary pressure and extension to cortex and periosteum

Blood supply interrupted which leads to necrosis - sequestra is separated dead bone

Question 3

What is the development of osteomyelitis?

Answer 3

Initial infection -> Blood supply blocked -> Subperiosteal abscess -> Dead bone -> pus escape

Question 4

Stage I - Osteomyelitis - ?

Stage II - “ - ?

Stage III - “ - ?

Stage IV - “ - ?

Answer 4

I - Medulla of bone

II - Superficial

III - Localized (cortical and medullary bone, but not entire diameter of bone)

IV - Diffuse - Entire bone and loss of stability

Question 5

Acute vs chronic classification

Answer 5

Acute

• Infection prior to development of sequestra
• Usually less than 2 weeks

Chronic

• Infection after sequestra have formed
• Other hallmarks include formation of involucrum (new bone), bone loss, and sinus tract formation

Question 6

Clinical presentation of acute osteomyelitis?

Answer 6

• Gradual onset over several days
• Dull pain/local tenderness
• Warm, erythemous, swelling, fevers may occur
• Can present as septic arthritis

Question 7

Clinical presentation of chronic osteomyelitis?

Answer 7

• Mild pain over several weeks
• May have localized swelling or erythema
• Draining sinus tract

Question 8

Diagnosis of osteomyelitis?

Answer 8

Clinical presentation may or may not bacteremia with typical organisms - bone pain with other symptoms

• Imaging, poorly healing wounds, diabetes mellitus, vascular disease, decubitus ulcers
• Need an MRI
• Blood tests
• Definitive diagnosis based on culture of bacteria from bone biopsy and pathology with inflammation and osteonecrosis

Question 9

Acute osteomyelitis treatment?

Answer 9

3-6 weeks antibiotics may or may not need to debride abscess or due to instability

Difference b/t IV vs. oral antibiotic therapy not well established

Question 10

Chronic osteomyelitis treatment?

Answer 10

3-6 weeks antibiotics, may or may not need surgery, but is common

Greater role for surgery due to necrotic bone and lack of drug penetration to devascularized bone (usually means an amputation)

Question 11

T/F - Oral antibiotics are acceptable and actually more data in support of them than IV.

Answer 11

TRUE

Question 12

T/F - Better cure rates of osteomyelitis with adjunctive surgical debridement.

Answer 12

TRUE

Question 13

Osteomyelitis of the jaw - tell me about it.

Answer 13

Odontogenic infections can spread continuously to the jaw (oral aerobes and anaerobes)

Rare

Mandible more susceptible than maxilla due to thinner cortical plates and poorer vascular supply

What happens? Periosteum penetrated with chronic infection w/ formation of mucosal or cutaneous abscesses and fistulae- lingual aspect of posterior mandible at greatest risk

Risks: Dental infection, fractures, radiation, diabetes mellitus, steroid use

Question 14

What are some symptoms of osteomyelitis of the jaw?

Answer 14

Mandibular pain, anesthesia/ paresthesia on affected side, lymphadenopathy and can progress to trismus

Question 15

Treatment of osteomyelitis of the jaw?

Answer 15

Combo of surgery and antibiotics targeting oral flora

Question 16

Definitive diagnosis of osteomyelitis of the jaw is helped by what?

Answer 16

Medication related osteonecrosis of the jaw

Antiresorptive (bisphosphonates) and antiangiogenic

Question 17

In general, how does hematogenous osteomyelitis come about?

Answer 17

Bacteria in blood

Spinal cord injuries

Trauma

Surgery

• In adults - seen in spine
• In kids - seen in long bones

Question 18

T/F - Joint replacements (arthroplasty) are highly effective and improve patients’ quality of life, mobility, and independence.

Answer 18

TRUE

Question 19

What is the leading cause of arthroplasty failure?

Answer 19

Prosthetic joint infections (PJIs) - This leads to more surgery, prolonged antimicrobials - Difficult to treat with failure rates of 10-20%

Question 20

What are some risk factors for PJIs?

Answer 20

Surgical site infection not involving joint prosthesis

Prior surgery at site of prosthesis

Extended operative times

Diabetes mellitus, immunosuppression

Question 21

Microbiology of PJIs?

Answer 21

65% - Gram + cocci

-Coagulase-negative staph
—Aureus
-Streptococcus species
-Enterococcus species

Question 22

6% of the microbiology of BJIs is from what bugs?

Answer 22

Aerobic gram - bacilli

• Enterobacteriacae
• Psuedomonas aeruginosa

Question 23

Anaerobes account for what % of osteomyelitis?

Answer 23

4%

Propionibacterium species (shoulder arthroplasty)

Peptostreptococcus

Finegoldia magna

Question 24

About _________% of osteomyelitis has been found to be polymicrobial.

Answer 24

20

Question 25

How do bugs colonize on a prosthesis?

Answer 25

Using a biofilm that allows them to adhere to the surface

Question 26

What is the definition of early PJI? What are the clinical presentations of early PJI?

Answer 26

W/in 1-3 months, acquired during prosthesis implantation, virulent organisms (S aureus, gram negative) ``` Local erythema Swelling Pain Drainage Delayed healing May or may not have a fever ```

Question 27

What is the definition of delayed PJI? How is this presented clinically?

Answer 27

3 months - 2 yrs Acquired during prosthesis implantation Less virulent organisms (CoNS, P acnes) Chronic pain Draining sinus

Question 28

What is the definition of late PJI? How is this presented clinically?

Answer 28

>1-2 yrs Hematogenous seeding or late manifestation of surgical infection Chronic pain Draining sinus or acute septic arthritis with sudden pain (hematogenous)

Question 29

Treatment = ? + ?

Answer 29

Treatment = surgery + antimicrobials

Question 30

What are surgical options to cure osteomyelitis?

Answer 30

``` Debridement and retention Two stage exchange One stage exchange Resection arthroplasty w/ arthrodesis Amputation ```

Question 31

T/F - In general, for patients with prosthetic joint implants, prophylactic antibiotics are NOT recommended prior to dental procedures to prevent prosthetic joint infection

Answer 31

TRUE *Randy does this, probably as a CYA.

Question 32

What is the antibiotic therapy associated with debridement and retention?

Answer 32

Staph Infection - 2-6 wks of IV therapy + rifampin - Follow by oral therapy + rifampin (Tetracycline, levofloxacin) - Duration (IV + oral): THA - 3 months, TKA - 6 months

Question 33

What is the antibiotic therapy for 1 stage exchange surgery?

Answer 33

Staph Infection - 2-6 wks of IV therapy + rifampin - Follow with oral therapy + rifampin (Tetracycline, levoloxacin) - Duration (IV + oral): 3 months

Question 34

What is the antibiotic therapy for 2 stage exchange surgery?

Answer 34

4-6 wks IV therapy or highly bioavailable oral therapy - Rifampin NOT recommended b/c prosthesis removed - Antibiotic-impregnated cement spacer used to maintain limb length (May decrease infection recurrence) - Re-implantation (stage 2): 6 wks - 3 months

Question 35

How is osteomyelitis classified?

Answer 35

Based on chronicity and whether hematogenous or contiguous

Question 36

Conclusions about bone and joint infections?

Answer 36

- Treatment for bone and joint infection involve antibiotics and surgical debridement - NO role for antibiotic prophylaxis prior to dental procedures to prevent orthopedic implant infection in most patients