Department Of Orthopaedics & Traumatology. Sheed Suhrawardy Medical College Hospital, Dhaka-1207, Bangladesh.

Basic of

From -

OSTEOMYELITIS

CME ON -

Presenting By-

Dr. Golam Mahamud Suhash,From Department Of Orthopedic & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka-1207. Bangladesh.

Prepared By-Dr. Md Nazrul IslamMBBS, M . sc. (B M E).

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LITIS

Osteomyelitis may be defined as an acute or chronic inflammatory process of bone, bone marrow and its structure secondary to infection with micro organisms.04/13/2023 3

Definition of Osteomyelitis:

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The Cierny-Mader staging system is used – It is determined by the status of the disease process regardless of its aetiology, regionality or chronicity. It takes into account the state of the bone, the patient's overall condition and factors affecting the development of osteomyelitis.

Staging Of Osteomyelitis:

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1: Medullary osteomyelitis (infection confined to the bone surface) Stage. 2: Superficial osteomyelitis (contiguous type of infection)Stage. 3: Localised osteomyelitis –(full-thickness cortical sequestration which can easily be removed surgically)Stage .4: Diffuse osteomyelitis (loss of bone stability, even after surgical debridement).

Anatomical Staging Of Osteomyelitis:

In Newborns (younger than 4 mo) - S. aureus, Enterobacter species, and group A and B Streptococcus species

In Children (aged 4 mo to 4 y) - S. aureus, group A Streptococcus species, Haemophilus influenzae, and Enterobacter species

In Children, adolescents (aged 4 y to adult) - S. aureus (80%), group A Streptococcus species, H. influenzae, and Enterobacter species

In Adult - S. aureus and occasionally Enterobacter or Streptococcus species

In Sickle Cell Anemia Patients - Salmonella species

Fungus also causes osteomyelitis.

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Eti

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A. Hematogenous-common in children

B. Direct inoculation (usually traumatic, but also surgical)

C. Local invasion from a contiguous infection (usually decubitus ulcer or periodontal disease)

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Pathogenesis

• Hematogenous osteomyelitis highest in the first two decades of life.

• < 5 years of age.• In adult-Haematogenous is less

common but they suffered due to debility,disease(diabetes mellitus)drugs(immunosuppresion).

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Pathogenesis(cont….)

Discontinuous endothelium of distal metaphyseal vessels ----passage of bacteria through these gaps ---deposition

• Trauma or emboli lead to occlusion of the slow-flowing sinusoidal vessels, further establishing a nidus for infection.

• Metaphyseal capillaries--- lack phagocytic lining cells

• Sinusoidal veins contain - inactive phagocytic cells.

• Necrosis of cortical bone and marrow occurs. • Exudate under pressure is forced through the

Haversian systems and Volkmann canals and into the cortex of the bone.

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Pathogenesis(cont….)

Pus spreads into the bone's blood vessels, impairing their flow, and areas of devitalized infected bone, known as sequestra, form the basis of a chronic infection.Often, the body will try to create new bone around the area of necrosis. The resulting new bone is often called an involucrum.On histologic examination, these areas of necrotic bone are the basis for distinguishing between acute and chronic osteomyelitis.04/13/2023 10

Pathogenesis(cont….)

  Newborns- • Joint involvement is common• Nutrient metaphyseal capillaries perforate the

epiphyseal growth plate, particularly in the hip, shoulder, and knee thin metaphyseal cortex.

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Factors That Turn Acute Bone Infection to Chronic Osteomyelitis:

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Trauma (orthopaedic surgery or open fracture)Prosthetic orthopaedic deviceDiabetesPeripheral vascular diseaseChronic joint diseaseAlcoholismIntravenous drug abuseChronic steroid useImmunosuppressionTuberculosisHIV and AIDSSickle cell diseasePresence of catheter-related blood stream infection.

Signs and symptom

• Temperature >102ºF • long-lasting pain, • Decreased range of motion in the case of

joint involvement. • local warmth, tenderness, swelling

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Diagnosis

• Aspiration of pus and send for culture• W.B.C. CRP and ESR• Blood for culture • Plain films, bone

scintigram,ultrasound,CT Scan and MRI Even a biopsy all show positive results

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Diagnosis(cont….)

• Elevations in the peripheral white blood cell count (WBC),

• Erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) in children with hematogenous osteomyelitis are variable and nonspecific

• Blood culture is positive in half of cases.

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Laboratory findings:

• Lytic and sclerosis, indicating chronic infection.

• Periosteal new bone formation, with compatible clinical findings

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Plain radiographs shows-

Within three to seven days-

• interposed translucent fat planes within muscle are obliterated by edema fluid.

• Periosteal elevation or thickening may represent new bone formation, pus, or reactive edema from adjacent soft tissue infection

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• Age --- neonates, bone destruction is often apparent by the 7th to 10th day of illness

• Type of bone ---Long tubular bones show signs two to three weeks earlier than membranous or irregular bones.

• plain films of the pelvis -- not helpful 04/13/2023 18

Timing

Radiographic evidence of bone destruction finally becomes apparent by 10 to 21 days.04/13/2023 19

Timing

Magnetic resonance imaging

• Modality of choice• Accurate identification of subperiosteal or

soft tissue collections of pus. no radiation.• Excellent anatomic detail and differentiation

among soft tissue, bone marrow, and bone • signal from infected bone marrow can also

be enhanced with intravenous gadolinium contrast – when plain films are normal

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Scintigraphy

• Sensitivity (84 to 100 percent) and specific

(70 to 96 percent) • Usually readily available, • Relatively inexpensive, • Does not require sedation in

young children. • May not perform as well in

neonates• Accuracy in children in 90%

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• CT preferred over plain films

• Planning the surgical approach to debridement of sequestra

• Evaluating the patient being treated for osteomyelitis

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Computed tomography

Differential diagnosis -

Cellulitis\Necrotizing myositisSuppurative ArthritisRheumatismSickle cell crisisGaucher,s diseaseEwing,s sarcoma

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Management And Treatment Of Osteomyelitis: General principles-• Early clinical suspicion, confirmation through i

maging and microbiological tests and prompt treatment are the keys to a successful outcome.

• Analgesia (and limb splinting if a long bone is involved) is an important part of symptom control.

• Exact treatment varies according to the bones involved, the severity of the infection and the immune status of the patient.

• Surgery may be needed to debride the bone and close any defects.

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• In acute osteomyelitis- The principle of treatment are-

1.General supportive treatment Analgesic for relieve pain I/V fluid(fever with shock,septicaemia)2.Spintage of the affected part3.Antibiotics(oral/intravenous)-It should

be started immediately not waiting for culture of blood and pus

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Management And Treatment Of Osteomyelitis (Cont.):

Antibiotics-• In older children who have probably

s.aureus infection use I/V flucloxacillin and fusidic acid for 1 to 2 weeks then orally 3 to 6 wks.

• In children under 4 years who have high incidence of haemophilus influenza use cephalosporins(cefuroxime or cefotaxime) either I/V or orally.Alternatively also use combination of amoxycillin and clavulanic acid

4.Drainage-if necessary04/13/2023 26

Management And Treatment Of Osteomyelitis: (con.)

• If treatment is delayed or the organism insensitive to the chosen antibiotics arise some complications-

1. Metastatic infection

2. Suppurative arthritis

3. Altered bone growth

4. Chronic osteomyelitis 04/13/2023 27

Complications of acute osteomyelitis

Treatment(cont…)

• In chronic osteomyelitis- Treatment options are-

1. Antibiotics- Chronic infection is seldom eradicated by antibiotics alone.Fusidic acid,clindamycin and cephalosporins are good examples.

2. Local treatment- If sinus present-need simply dressing Colostomy paste used to stopped excoriation of skin.

In acute abscess-need urgent incision and drainage but it is temporary.

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Management And TreatmentOf Osteomyelitis (Cont.):

3. Operation-procedures are:• 1.Saucharization and

curettage• 2.Gentamycin impregnated

beads• 3.Papineau technique and

muscle flap transfer.• 4.Ilizarov method of bone

transporting.04/13/2023 29

MONITORING RESPONSE TO THERAPY

• A reduction in fever and pain, as well as increased comfort with movement are expected within seven days, and may be seen in toddlers in as little as three to five days.

• Persistent elevation or prolonged decline in ESR or CRP. The ESR should have substantially decreased (by 20 percent or more) by the end of the first week of therapy, with a 50 percent decline in CRP.

• continue to decline during the second week of treatment. CRP returns to normal in 10 days or less in most patients.

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OUTPATIENT THERAPY-• Treatment with intravenous antibiotics for

periods of seven days or less, followed by oral therapy, appears to be as successful as longer initial parenteral courses

• Followup one- to two-week intervals --monitored clinical improvement, -- complications related to high-dose antibiotic therapy, such as cytopenia, antibiotic associated diarrhea, and pseudomembranous enterocolitis.

• ESR, complete blood count, and biochemical profile, including liver function tests at each visit. drug levels for those children receiving oral therapy

• A radiograph should be repeated at the end of therapy. 04/13/2023 31

Most Common Complications Of Acute Osteomyelitis:• Bone abscess• Septic Arthritis• Bacteraemia• Fracture• Growth arrest• Loosening of the prosthetic implant• Overlying soft-tissue cellulitis• Chronic infection

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Prognosis Of Osteomyelitis:

• This is variable depending on the number of risk factors and the patient's general condition (see Staging above).

• Outcome is best if treatment is started 3-5 days after onset of the infection.

• Timely diagnosis and intervention in an otherwise well patient should lead to full recovery, although follow-up over several months will be required to monitor for relapse.

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General Guide Lines For Evaluation & Management of Osteomyelitis:

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Incepta Pharmaceuticals Ltd.Dhaka, Bangladesh.

Prof. Dr. Shamimul HaqAssociate Prof. Dr. P C. DebenathAssociate Prof. Dr. Ziaul HaqAssociate Prof. Dr. Hafizur RahmanAssistant Prof. Dr. Kazi Shamim uzzaman

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