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Orthopedic
Infections
Orthopedic Infectious
Diseases Hematogenous osteomyelitis
Pyogenic spondylitis and discitis
Pyarthrosis
TBc Arthritis & Sarcoidosis
TBc spondylitis
Leprosy
Luetic infections
Viral osteomyelitis
Fungus infections
Gas forming infections
Hematogenous
Osteomyelitis
Hematogenous Osteomyelitis
Hematogenous osteomyelitis is typically seen in children
in the metaphyseal ends of long bones in the lower extremities.
The proximal end of the tibia is the most common site. Staph
aures bacteria arising from a peripheral site such as the skin or
nose and throat gain access to the peripheral circulation where
they travel to the terminal end-arterial circulation just beneath
the growth plate where a primary focal abscess will arise. The
abscess will then increase in size resulting in local thrombosis
followed by bone necrosis as the purulent mass works its way
thru the adjacent cortex gaining access to the subperiosteal
space thus lifting the periosteum which then goes on to form
a healing involucrum. In the early days prior to antibiotics,
osteomyelitis was a very aggressive disease process associated
with severe local pain, high fevers and septacemia resulting
in high white counts and sed rates. The disease was frequently
multi focal in bones as well as in various organs such as the
lung, liver and brain resulting in death in a high number of
cases. However, since the advent of antibiotics the modern
form of osteomyelitis is far less aggressive and may present
with minimal symptoms of pain with a minimal elevation of
the white count or sed rate and for this reason my go on
without diagnosis or treatment.
8/17/39 8/26/39
10 yr male with acute onset of pain in tibia 4 days before the
1st x-ray with high fever of 104 degrees and a 20,000 WBC
Blood supply to long bones in children
Pathogenesis of primary focus of metaphyseal infection
Early abscess formation
and early osteonecrosis
with reparative
involucrum formation
Medullary abscess with puss and necrotic bone
3 mos 8 mos 2.5 yrs
Natural course of disease without antibiotics
Another old case of
severe osteomyelitis
of tibia with 2 yr followup
4 yr female with excessive debreidment of periosteum
8/93 8/94 1/96
11 year old boy who sprained his wrist in early 8/93 for which an
X-ray was obtained 2 weeks later because of increasing pain
Biopsy and culture
9 year old female
with wrist pain and
low grade fever 6 mos
4 yr male
Early mild pain and afebrile (L) with a followup 1 yr later (R)
Modern day Hematogenous Osteomyelitis
13 yr male with T-1 coronal
MRI and macro section of a
similar case in young adult
Osteomyelitis distal femur
Sclerosing osteomyelitis of Garre
9 yr old female with low grade pain and slight fever 1 yr
Bone scan
Axial CT scan
Axial Gad contrast MRI
13 yr female with 1 mo pain and onion skin periostitis
Bone scan
Ewing’s vs osteomyelitis
Coronal and axial T-2 MRI looks like Ewing’s sarcoma
Reactive bone
Purulent response
5 year old male with pain
in heel and knee for 6 mos
Multifocal Osteomyelitis
Sag T-1 T-2 Gad
Cor T-1 Sag T-2
Axial T-2
10 yr male with contusion to thigh followed with osteo 9 mo later
13 yr old boy with staph osteo of left humerus 3 mos.
Cor T-1 T-2 Axial T-2
13 yr male with slight fever and pain for 2 mos
Cor Gad
Staph osteo looking like Ewing’s sarcoma
3/06 7/07 7/07
14 year old male with pain right arm for 17 months
Osteomyelitis
Cor T-1 T-2 Gad
Axial T-1 T-2 Gad
29 yr female with mild intermittent pain left arm for yrs
Periosteal Osteomyelitis
Cor T-1 T-2 Gad
Axial T-1 T-2
Gad
Staph osteo looking like low grade intramedullary OGS
37 yr male with aching pain in thigh for 1 one yr without fever
Staph osteo looking like osteosarcoma
13 year male with knee pain and slight fever for 2 mos
Incisional biopsy
Sequestrum delivery and biopsy specimen
Chronic Staph osteomyelitis of tibia for years
60 yr Indian male with 50 yr history of intermittent aching pain R leg
CT Scan
Sag T-1 PD FS Gad
Axial T-1 T-2
Gad
Oct 09
May 2010
51 yr male with increasing pain left hip for 9 months
Chronic Osteomyelitis Prox Femur
Cor T-2 Sag T-2 Sag Gad
Axial T-2 Gad
Chronic Staph Osteomyelitis distal femur
45 yr old male with intermittent pain in right thigh since age 17
Cor T-1 T-2 Sag gad
Axial T-1 T-2
Gad
16 yr male with dull aching pain in knee for one year
Cor T-2
Chronic staph osteomyelitis distal femur
04 07 04 07
16 yr male with 3 yr history of intermittent pain and swelling at knee
Bone abscess from staph infection
Bone scan
Cor T-1 T-2 Gad
07
Sag T-1 T-2
Axial T-2 Gad
Soft Tissue Staph Abcess at Elbow
31 yr old female with painless lump at elbow for 3 weeks
Cor T-1 T-2 Gad
Axial T-1 T-2
Gad
Staph osteo crossing the growth plate
10 yr girl with low grade aching pain at ankle for 9 mos
Sag T-
1 Cor T-2
8 year old male with
Brodie’s abscess distal
tibia with gopher sign
13 year male with focal
staph osteo with gopher
tunnels that could be
called a Brodie’s abscess
Brodie’s abscess
13 year male with dull
aching pain for 3 mos
Classic gopher tunnel
crossing the growth plate
42 year old male with
the flue 2 mos ago
followed by acute
onset of pain R thigh
CT scan AP Lat
Axial T-1 Gad
Cor STIR
17 year old male
with Brodie’s
abscess cuboid
looking like an
osteoid osteoma
5 yr female with ring sequestrum 2nd to infected traction pin
Epiphyseal Brodie’s abscess
Sag T-1 Cor T-2
7 yr old female with severe pain in knee 1 mo without fever
Epiphyseal Brodie’s abscess
7 yr male with severe pain in knee for 2 mos
CT with gopher tunnel
Squamous cell CA arising from chronic osteomyelitis
Macro section and microscopic of amputated leg of an older
patient with a long history of chronic osteo of the tibia
Salmonella Osteomyelitis
16 year old black female
with SS disease and 1 yr
history of pain left arm
Chronic salmonella osteo for
2 years in a 32 year old black
male with SS disease involving
multiple limbs
Both arms involved and septic AVN left femoral head
Salmonella Dactylitis hands and feet
Infant black male with 3mo
history of SS disease and
painful swelling of hands
and feet along with diarrhea
and fever
Pyogenic Spondylitis
and Discitis
Infectious discitis of
lumbar spine in a 3 yr
female with acute onset
of severe LBP and fever
most likely second to
staph aures spondylitis
Another case of infectious
discitis in a 4 yr old male
Infectious discitis young adult male
24 yr male shot putter with mild LBP 6 mos without fever
Peudomonas Discitis
22 yr male heroin addict with discogram of infected disc space
Pyogenic spondylitis older adult
63 yr male with sag T-2 MRI image of severe dorsal spondylitis
Pyogenic Spondylosis with Retropharyngeal Abscess
7/83 10/85
64 yr male with progressive neck pain and dysphagia 2 yrs
17 year male with LBP for 6 months with fever
Pyogenic Sarcroiliac Staph Aures
Potential drainage sites seen with spinal infections
Pyarthrosis
1.5 yr female with fever and
extremely irritable left
hip held in flexion and
external rotation
Staph pyarthosis
2 mos following posterior
surgical drainage and
antibiotic therapy
Pathogenesis for
pyarthosis of hip
or knee joint
Septic necrosis of femoral head
Initial
X-ray
2 mos
PO
6 mos
PO
10 yr male with initial diagnosis of rheumatic fever of hip
treated with steroids, ASA and antibiotics without success
Musculoskeletal
Tuberculous
Infections
Musculoskeletal Tubrculous Infections Tuberculous infection of the musculoskeletal system is seen in
about 5% of patients with pulmonary TBc. The problem is more
common in Asian and Mexican populations of the world. In the
USA musculoskeletal TBc is rare in children but is more common
in adults with immunodeficiency conditions related to IV drug
abuse, alcoholism, HIV disorders and patients on corticosteroid
medication. The most common skeletal site for TBc infection is
the spine followed next by the hip and knee. The TB mico-
bacterial organism enters the blood stream in the lung and travels
to a metaphyseal bone site in the spine, hip or knee area which
then results in discitis or psoas abscess of the spine or tuberculous
arthritis of the hip or knee. The tuberculous micobacterium
stimulates the formation of a caseating granulomatous lesion
made up of epithelioid cells, Langhans giant cells and lymphs.
A similar granuloma is seen in sarcoidosis which is none infectious
and none caseating. Antituberculous drugs include streptomycin,
PAS, INAH, myambutol, and rifampin.
9 year old male with knee pain and swelling 1 yr
Tuberculous Osteomyelitis
Pain and swelling in elbow as well
Biopsy shows epithelioid granuloma with Langhans giant cell
10 yr female with knee
pain and swelling 10 mos
with dumbell TBc
granuloma crossing the
tibial growth plate
24 yr male with shoulder
pain for 1 year with x-ray
evidence of tuberculous
granulomas in humeral
head
TBc Arthritis of Hip
29 yr Asian male with hip pain for 2 years
TBc Hip Arthritis
TBc pannus formation
27 yr Asian male with
destructive TBc for 3 yrs
Late TBc Arthritis Hip
30 yr Asian male with untreated disease for many yrs
4 yr 14 yr
Pediatric TBc Arthritis
4 yr Asian male with non treated TBc of hip for 10 years
followed with an extra-articular arthrodesis
15 yr
TBc Carpitis
Untreated TBc
carpitis in a 73 yr
Asian male for
many years
TBc Arthritis Elbow
28 yr male 3 yr male
Mild adult vs severe pediatric TBc of elbow
TBc osteomyelitis of distal fibula
76 year male with pain lateral ankle for 4 months
Bone scan
Cor T-2 Gad
Axial T-2 Gad
TBc Dactylitis
4 yr Eskimo with TBc dactylitis (spina ventosa)
Tuberculous Tenosynovoitis
27 yr male with 1 yr history
of carpal tunnel syndrome
2nd to TBc tenosynovitis
Epithelioid granuloma
Sarcoidosis Sarcoidosis is a nonspecific noncaseating epithelioid granuloma-
tous process that affects the reticuloendothelial system of young
adults that pathologically resembles the histology of TBc, fungus
infections, viruses and even low grade lymphomas such as
Hodgkin’s disease. In the US it is seen more commonly in the
southeastern states and is ten times more common in blacks then
whites. 90% will have pulmonary infiltrates or hialar adenopathy
along with systemic symptoms of fever, coughing, inflammatory
arthropathy and iritis. Other systemic symptoms include weight
loss, lymphadenopathy and hepatosplenomegaly as seen in
lymphomas. Granulomatous skin lesion similar to erythema
nodosum can be seen. Hypercalcemia can be seen in 25% of cases
second to an increase of calcium absorption at the gut level. 70%
of cases will have a positive Kveim skin test to help separate out
other granulomatous disorders such as TBc. 5% of cases involve
the middle and distal phalanges of the hand (most common) and
feet associated with overlying subcutaneous nodularities that
might suggest the diagnosis of TBc, gout, Ollier’s disease or
tuberous sclerosis. The homeycomb or latticework lytic pattern
of sarcoidosis will help differentiate from these other diagnostic
considerations. The bony lesions are asymptomatic unless
associated with a pathologic fracture. Bony changes in large bones
are very rare and can present with a sclerotic pattern seen in low
grade lymphomas such as Hodgkin’s disease. The prognosis
for minor lesions of the hands and feet is excellent but with
greater reticuloendothelial involvement of multi organ systems
the prognosis is more guarded like that of a low grade
lymphoma.
Case #1 Sarcoidosis of Hand
46 yr male with recent path fracture ring finger
None caseating epithelioid granuloma
with Langhans giant cells
Schaumann’s body
Biopsy specimen
Similar cases of bony sarcoidosis
A B
C D
Sub Q nodularity, lymphadenopathy
behind ear and pulmonary lesions
in sarcoidosis
Tuberculous
Spondylitis
Tuberculous Spondylitis
About 60% of all TBc involves the spine and is frequently
seen in Asian or Mexican patients. In Hong Kong where this
disease is common they see over 100 cases per year, 70% of
which are seen in children. L-1 is the most common vertabra
involved and from there it can spread up and down the spine
under the anterior longitudinal ligament or thru the Batson’s
para vertebral plexes. In China multiple vertabrae are involved
compared to only one or two vertabrae in mid aged adults in
the USA. As with pyogenic spondylitis it is felt that the
tuberculous organism gains access to the vertebral body thru
the blood supply to the spine. Even though there is no primary
infection of the avascular disc space, extensive destruction of
the vertebral body with collapse of the disc into the body
results in significant gibbus deformity not common in pyo-
genic spondylitis.
TBc Spondylitis Dorsal Spine
45 yr female with mid dorsal back pain for 6 mos
Thoracotomy Approach
TBc granuloma
aorta
Surgical clean out and fusion
Rib strut grafts
in place
Post op x-rays
Tuberculous Psoas Abscess
47 yr old female with fluid mass in femoral triangle 1 yr
X-ray appearance
L-3 disease
Saddle bag Abscess over sacrum
2 liters of fluid removed
Various sites of psoas abscess drainage
TBc spondylitis with paraplegia (Pott’s dis)
63 yr male with gradual onset spastic paraplegia for 6 mos
Autopsy specimen of LD spine
Modern day case of TBc spondylitis
28 yr female with LD
back pain for 1 yr
MRI
Pediatric TBc spondylitis
3 yr male 9 yr female
Sacroiliac TBc
28 year old male with LBP for 1 year
Brucellar Spondylitis
Looks like TBc
Leprosy
Leprosy Leprosy is not very common in the USA but is seen in other
countries such as South America, Africa, southern Europe
India and China. There are two clinical types of leprosy. The
more common and non infectious form is the neural or
tuberculoid form that is of interest to orthopedic surgeons
because of the peripheral neuropathies and neuropathic joints
that are seen in this form. The lepromatous form which is
infectious because of the draining skin ulcerations has a poor
chance for survival.
In the neural form of leprosy the micobacterium lepri organ-
ism finds its way into periperal nerves causing them to enlarge
resulting in a loss of both motor and sensory components. The
loss of sensation results in trophic skin changes including loss
of pigmentation, hair and ulcerations. Neuropathic joints are
seen in 27% of cases.
Neural or tuberculoid form of leprosy
Neurotrophic foot ulcers and
claw hand deformities
Short finger
Gynecomastia 2nd to
testicular leprosy
Neural leprosy
Loss of skin pigmentation
in areas of anesthesia
Combined median & ulnar N
involvement with trophic skin
changes, clawing, lack of
sweating, and short finger tips
from terminal phylangeal
osteolysis
Neural leprosy
Neuropathic feet with deformity
and shortening due to osteolysis
and neuropathic joints
Social stigma of
eyebrow alopecia
Neural leprosy
Shortening from terminal
osteolysis
Neuropathic joint shortening
Lepromatous (infectious) form of leprosy
Draining facial sores of infectious form of leprosy with
micobacterium lepri organisms seen to right
Luetic Infections
(Syphilis)
Leutic Infections
Syphilis is a disease caused by the treponema pallidum
organism which was first introduced to America by Christopher
Columbus. 50% of cases will involve bone. The two major clinical
types include the adult and congenital forms. The acute form of
the disease is a soft tissue problem and the late or tarda form
of the disease is the type that involves bone and joints that
would be of interest to an orthopedic surgeon . The two most
common bones affected with syphilis include the cranium and
the tibia.
Congenital lues
3 mo female with luetic metaphysitis & facial snuffles
Congenital lues
6 mo. male with luetic metaphysitis
Luetic periostitis
2.5 yr female with saber shin lesion
from congenital lues looking like
hypervitaminosis A, juvenile Paget’s
disease, Englemann’s disease and
Caffey’s disease
Luetic periostitis
6 year female 26 year male
Associated syphilitic abnormalities
Perphorated palate
Luetic keratitis
Notched Hutchinson’s teeth
8th nerve hearing defect
61 year male with incidental finding in pelvis
Heavy metal therapy for syphilis
Viral Osteomyelitis
Rubella infection
Caffey’s disease
Rubella metaphysitis
Infant born with dwarfism,
thrombocytopenia, congenital
heart defects, cataracts, enlarged
liver & spleen, chorioretinitis
and deafness to a mother who
had measles in 1st trimester
Caffey’s disease (viral osteomyelitis ?)
8 mo, old infant with 6 weeks of painful swollen forearm
Biopsy specimen thought to be osteosarcoma
Amputation specimen showing inflammatory periostitis
Original
cortex
Hypertrophic shoulder girdle changes not seen in cong lues
Mandibular hypertrophy seen in Caffey’s and not in lues
Saber shin defect in Caffey,s disease
9 mo. old male with tender shin bone for 3 mos.
Fungus Infections
Coccidiomycosis
The two most common fungus infections seen by orthopedic
surgeons are coccidiomycosis and blastomycosis. Coccidio-
mycosis is most common and seen in the south western part of
the USA whereas, blastomycosis has no special location.
coccidiomycosis is usually seen in the San Joaquin Valley area
where it starts with an upper respiratory infection and a
fever known as valley fever followed in a few weeks by an
acute pneumonitis which usually heals without recurrence.
In a very small percent of cases a granulomatous response is
seen in joints, bone, muscle and skin that can lead to the death
of the patient. The granulation tissue is similar to that seen in
TBc except for the presence of endospores seen in the cytoplasm
of the Langhans type giant cells. Coccidiomycosis replicates
thru a process of endosporulation within the mother cell where-
as in blastomycosis the reproduction takes place thru a process
of external budding from the mother spore.
Coccidiomycosis of knee
82 yr old farmer from Fresno with mild painful swelling of knee
with lytic epiphyseal lesion like GCT except for anterior breakout
Surgical clean out
Yellow arrow sinus track lead to
necrotising cavitary abscess space
with granulomatous granulation
tissue revealing Langhans type
giant cells with blue arrow
endospore of coccidiomycosis
Coccidiomycosis of Knee
40 yr old farmer from Stockton with pain and swelling of knee 3 mos
Bone scan
23 year Asian male with painful swollen knee 2 years
Coccidiomycosis
arthritis
Axial PD Axial T-2
Sag PD Sag T-2
Cor PD
Arthrotomy
Fluconisol treatment
Coccidiomycotic synovial cyst
79 yr male with MRI evidence
of a large popliteal cyst arising
from the knee joint similar to
the appearance of a rheumatoid
synovitis
Coccidiomycosis of knee
23 yr male with mixed synovial
and bony involvement for 1 yr
Sag T-2
Coccidiomycosis osteomyelitis
3 year old female from
Modesto with pain and
swelling below the knee
for 2 months
Lateral view
Endospores being phagocytised by a macrophage
Coccidiomycosis osteomyelitis
4 year old male with pain and swelling of wrist 3 mo.
Coccidiomycosis dactylitis
27 yr old male with pain and swelling of hand 4 mos.
Coccidiomycosis spondylitis
29 year male with
LPB for 1 year
Sagittal T-2 MRI shows the
high signal cocci inflammatory
tissue extruding anteriorly
beneath the anterior longitudinal
ligament in order to spread to
adjacent vertabrae as we see
in TBc spondylitis
Blastomycosis osteomyelitis
32 male with ankle
pain and overlying
skin sore for 6 mos.
Budding spore
Blastomycosis dactylitis
24 yr male with painful
thumb with excoriation
of overlying skin
Sacroiliac cryptococcosis
Silver stain
27 yr male with LBP CT scan
spores in macrophages
Echinococcus spondylitis
31 yr male from India
with LD back pain for
one year
Cor T-1
MRI
Echinococcal osteomyelitis (hydatid disease)
35 yr male from Southern Italy
with hip pain for 2 yrs with chronic
deformation suggestive of
fibrous dysplasia
Large calcific
cyst in liver
Echinococcal osteomylitis
Amputation specimen of femur in adult male
Maduromycosis (Madura foot)
41 yr India male with long history
of painless draining sinuses from
foot Biopsy specimen
Gas myositis
21 yr male sailor with recent puncture wound and sudden
onset of severe pain and swelling of leg with fever & tachycardia
Gas Fasciaitis
62 yr diabetic with gradual onset of mild pain and swelling
of calf with no fever or chills - clostridium infection to rt.