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introduction , types , clinical manifestation , diagnosis , management of osteomyelitis

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  1. 1. OSTEOMYELITIS Dr. Sunil pahari 2nd Year Resident Department of Orthopedics Yangtze University
  2. 2. OSTEOMYELITIS  Nelaton coined osteomyelitis in 1834 It includes three root words  osteon (bone)  myelo (marrow)  Combination: itis (inflammation) to define the clinical state in which bone is infected with microorganisms.
  3. 3.  Infection of bone and marrow is known as osteomyelitis.  It may remain localized, or it may spread through the bone to involve the marrow, cortex, periosteum, and soft tissue surrounding the bone.
  4. 4. CLASSIFICATION Duration  Acute / Subacute / Chronic Mechanism  Heamatogenous (tonsil , lungs , ear/ GIT)  Exogenous (injection , open fractures) Host response  Pyogenic / Granulomatous
  5. 5. Osteomyelitis is divided into 3 forms as per duration: 1. 1. Acute osteomyelitis 2. 2. Subacute osteomyelitis 3. 3. Chronic osteomyelitis
  6. 6. OSTEOMYELITIS BASED ON THE DURATION AND TYPE OF SYMPTOMS Acute: <2weeks Early acute Late acute(4- 5days) Subacute : 2weeks — 3months Less virulent – more immune Chronic: >3month s
  7. 7. Three basic mechanisms allow an infection to reach the bone; 1. Haematogenous spread 2. Contagious source of infection 3. Direct implantation
  8. 8. - Primary haematogenous osteomyelitis is characterized by an acute infection of bone caused by seeding of bacteria within the bone from a remote source - Haematogenous osteomyelitis usually occurs during period of growth and thus occur primarily in children. However, all ages may be affected and cases are even found in old age. HAEMATOGENOUS OSTEOMYELITIS
  9. 9. CAUSES: OSTEOMYELITIS  General factors  Anaemia  Debility  Infection  Poor nutrition  Poor immune status  Local factors  Hair pin bend vessels  Metaphyseal haemorrhage  Defective Phagocytosis  Rapid growth at metaphysis  Vasospasm
  10. 10. TYPE OF ORGANISMS  Bacteria, viruses and fungi can all infect bone, soft tissues and joints. Generally, bacterial infections are more destructive and move rapidly.  Fungi tend to produce slow and chronic infections.  Tuberculosis and brucellosis range from aggressive to reparative
  11. 11. PATHOPHYSIOLOGY:  Metaphysis of the long bones are highly vascularized zones.  From the diaphysis the medullary arteries reach upto the growth plate—the area of greatest activity and branch into capillaries. The venous systems in this area drains towards diaphysis  Thus, the vessel in this zone are arranged in the form of loop (hair pin arrangement) resulting in “sluggish flow” of blood, leading to bacterial enlodgement and thus haematogenous osteomyelitis.
  12. 12. CLINICAL FEATURES Early Acute •Febrile illness •Limping to walk •Avoidance of using the extremity Late Acute • Swelling • pain Sub acute Cannot pinpoint onset Fever/swelling-mild Chronic purulent drainage
  13. 13.  Fever  Fatigue  Irritability  Malaise  Restriction of movement of limb  Local edema, erythema and tenderness GENERAL SYMPTOMS OF OSTEOMYELITIS ARE :-
  15. 15. RISK FACTORS  Trauma (orthopaedic surgery or open fracture)  Prosthetic orthopaedic device  Diabetes  Peripheral vascular disease  Intravenous drug abuse  Chronic steroid use  Immunosuppression  Tuberculosis  HIV and AIDS  Sickle cell disease
  16. 16. DIAGNOSIS  Early diagnosis of acute osteomyelitis is critical because prompt antibiotic therapy may prevent necrosis of bone.  Osteomyelitis is primarily a clinical diagnosis, although the clinical picture may be confusing.  An inadequate or late diagnosis significantly diminishes the cure rate and increases the degree of complications and morbidity.
  17. 17. LAB FINDINGS:  Aspirate pus or fluid, a smear is examined for cells and organisms(to identify a type of infection)  WBC counts are elevated with increased polymorphoneuclear leukocyte count.  C-reactive proteins – level is elevated  ESR usually elevate up to 90%.  Blood culture results are positive in patients with haematogenous osteomyelitis.
  18. 18. RADIOLOGICAL FINDINGS  Plain X-ray  The earliest radiographic signs of bone infection are soft tissue swelling and loss of fascial planes.  These are usually encountered with in 24 to 48 hours of infection.  Plain radiographs shows:  Ist week: No abnormality of bone  2nd week : Faint extra cortical outline due to periosteal new bone formation ( a classic x-ray sign of early pyogenic osteomyelitis.)  7 to 10 days : destructive lytic lesion, usually occurs.  3 to 6 weeks : elevation of periosteum and layered new bone formation .  3-8 weeks :The dead bone (i.e. sequestrum formation) occurs.
  20. 20.  Sequestra surrounded by involucrum
  21. 21. ULTRASOUND  Ultrasound may detect a sub periosteal collection of fluid in the early stage of osteomyelitis but it cannot distinguish between hematoma and pus.
  22. 22. CT SCANNING  CT is useful method to detect early osseous erosion and to document the presence of sequestrum, foreign body, or gas formation  Though of less value in diagnosis, CT demonstrates changes in subacute or chronic osteomyelitis well.  Sequestra, as on conventional films is shown as area of dense or high attenuation spicules of bone lying in areas of osteolysis.
  23. 23. M.R.I. FINDINGS  MRI can be helpful in case of doubtful diagnosis  It is highly sensitive for detecting osteomyelitis as early as 3 to 5 days after the onset of infection  It is best method of demonstrating bone marrow inflammation.  It helps to differentiate between soft tissue infection and osteomyelitis.
  24. 24. DIFFERENTIAL DIAGNOSIS:  Cellulitis  Acute suppurative arthritis  Streptococcal necrotising myositis  Sickle –cell crisis  Gaucher’s Disease  Tuberculosis –  Ewing sarcoma
  25. 25. TREATMENT 1. General treatment: nutritional therapy or general supportive treatment by intaking enough caloric, protein, vitamin etc. 2. Antibiotic therapy 3. Surgical treatment  I&D 4. Immobilization  Splintage of affected part
  26. 26. COMPLICATIONS  Chronic osteomyelitis  Septic arthritis  Growth disturbance  Septicemia  DVT  Pulmonary embolism  Pathological fracture  Metastatic infection
  28. 28. SUB ACUTE OM TREATMENT Conservative : a) Immobilization b) Antibiotics (flucloxacillin + fusidic acid) for 6weeks Surgical (if the diagnosis is in doubt / failed conservative treatment) : a) Open biopsy b) Perform curettage on the lesion 28
  29. 29. CHRONIC OSTEOMYELITIS “ A severe, persistent and incapacitating infection of bone and bone marrow ” 29 CHRONIC OSTEOMYELITIS
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  33. 33. INVOLUCRUM (the new bone) 33 CHRONIC OSTEOMYELITIS
  34. 34. STAGING OF OSTEOMYELITIS:  The Cierny-Mader staging system.  It is determined by the status of the disease process.  It takes into account the state of the bone, the patient's overall condition and factors affecting the development of osteomyelitis. 34 CHRONIC OSTEOMYELITIS
  36. 36. THE CIERNY-MADER CLASSIFICATION  Stage 1: Medullary Osteomyelitis - Infection confined to medullary cavity.  Stage 2: Superficial Osteomyelitis Contiguous type of infection. Confined to surface of bone.  Stage 3: Localized Osteomyelitis - Full-thickness cortical sequestration which can easily be removed surgically.  Stage 4: Diffuse Osteomyelitis -Loss of bone stability, even after surgical debridement. CHRONIC OSTEOMYELITIS
  38. 38. TREATMENT - ANTIBIOTICS - Chronic infection is seldom eradicated by antibiotics alone. - Bactericidal drugs are important to: a) Stop the spread of infection to healthy bone b) Control acute flares - Antibiotics used in treating chronic osteomyelitis (Fusidic acid, Clindamycin, Vancomycin, Cefazolin) CHRONIC OSTEOMYELITIS
  39. 39. ANTIBIOTIC CHOICE  Guided by microbiology department  Clindamycin and vancomycin have good bone penetration  Minimum length 6 weeks with 3 months being the standard treatment course  May need to treat for 6-12 months  Antibiotic (IV route) is given for 10 days prior to surgery.  After the major debridement surgery, antibiotic is continued for another 6 weeks (min) but usually >3months. [treat until inflammatory parameters (ESR) are normal] 39 CHRONIC OSTEOMYELITIS
  40. 40. SURGICAL TREATMENT - After 10 days of antibiotic administration, debridement is done to remove: a) All the infected tissue b) Dead / devitalised bone (Sequestrectomy ) c) Sinus tract 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.
  41. 41. Closure of dead space - After debridement is done, a large dead space is left in the bone - Among the methods of managing dead space: Open cancellous grafting – Papineau technique  Useful for bone deficiencies of less than 4cm  (preferably autogenous) mixed with an antibiotic and fibrin sealant Vascularised bone graft  Heals as a segmental fracture  Indicated when defect is > 6cm  Iliac crest for defects > 8cm  Fibula 6-35cm can be bridged Bypass graft  Involves the establishment of a cross union between the fibula and tibia proximally and distally to the defect which has been debrided and bone grafted CHRONIC OSTEOMYELITIS
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  45. 45.  M.C.Q:- 1) involucrum is found A. underneath the sequestrum B.metaphysis C. around the sequestrum D.beneath the periostium 2) acute haematogenous osteomyelitis is treated with all except : A.antibiotics B.splinting C.anelgesics D. surgery
  46. 46.  3)Chronic osteomyelitis is diagnosed mainly by: A.Sequestrum B. Bone fracture C. Deformity C.Brodie’ abscess 4) Osteomyelitis of spine most common organism is: A.Staphylococcus aureus B. pseudomonas C.Tuberculosis C. Streptococcus
  47. 47.  6)When does the boney lesion of osteomyelitis appear on x-ray: A.2week B.24hours C.1week D.2hours 7)Osteomyelitis most commonly starts at: A.Metaphysis B.Epiphysis C.Diaphysis D. None 8)The most common causing osteomyelitis in drug abusers is: A.Pseudomonas B.staphylococcus Aureus C. E.coli D. Kiebsiella.
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