<ul><li>Subacute Osteomyelitis </li></ul>Prepared by: Tg.Putri Madina bt Tg.Ariff @ Zainuddin
<ul><li>Introduction </li></ul><ul><li>It is a distinct type of osteomyelitis </li></ul><ul><li>It has an  insidious onset...
<ul><li>Causative Organism </li></ul><ul><li>Staphyloccocus aureus  (30-60%) </li></ul><ul><li>Others ( Streptococcus, Pse...
<ul><li>Clinical Features </li></ul><ul><li>Pain (several weeks / months) </li></ul><ul><li>Limping </li></ul><ul><li>Swel...
<ul><li>Radiological Finding </li></ul><ul><li>Classic Brodie’s abscess </li></ul><ul><li>A  circumscribed ,  round/oval c...
A circumscribed, oval cavity surrounded by a zone of sclerosis at the proximal tibia (Brodie’s abscess)  This is a lateral...
<ul><li>Modified Classification of Subacute Osteomyelitis </li></ul><ul><li>Type I –  Metaphyseal </li></ul><ul><li>Ia - p...
 
<ul><li>Investigation </li></ul><ul><li>a) X-ray (may resemble osteoid osteoma / malignant bone tumour) </li></ul><ul><li>...
<ul><li>Treatment </li></ul><ul><li>Conservative (if the diagnosis is not in doubt) </li></ul><ul><li>Immobilization </li>...
Chronic Osteomyelitis Prepared by: Tg.Putri Madina bt Tg.Ariff @ Zainuddin
Introduction <ul><li>Definition: </li></ul><ul><li>“  A severe,persistent and incapacitating infection of bone and bone ma...
Causes <ul><li>-  It can be due to: </li></ul><ul><li>a)  progression / sequel / inadequate treatment of acute osteomyelit...
Aetiological Agents <ul><li>Usual organisms (with time there is always a mixed infection) </li></ul><ul><li>Staph.aureus (...
<ul><li>Clinical Features </li></ul><ul><li>Pain </li></ul><ul><li>Pyrexia </li></ul><ul><li>Redness </li></ul><ul><li>Ten...
<ul><li>Pathogenesis </li></ul><ul><li>Inadequate treatment of acute OM / </li></ul><ul><li>Foreign implant / </li></ul><u...
 
Anatomical Type Cierney and Mader staging system of  Chronic Osteomyelitis Stage Characteristic Features I Medullary Endos...
Physiological class Class Host’s immune system Features A host Normal Immunocompetent with good local vascularity B host  ...
<ul><li>Imaging </li></ul><ul><li>1) X-ray examination </li></ul><ul><li>Usually show  bone resorption  (patchy loss of de...
AP & lateral view of the left wrist show a lobulated osteolytic lesion with well-defined borders and surrounding sclerosis...
Sclerosing osteomyelitis of the lower tibia. Note the bone expansion and marked sclerosis.  Sequestrum at lower tibia
<ul><li>Other Investigation </li></ul><ul><li>ESR & WBC may be increased </li></ul><ul><li>Antistaphyloccocal antibody tit...
<ul><li>Treatment </li></ul><ul><li>Patient evaluation </li></ul><ul><li>(History taking, PE, Investigation) </li></ul><ul...
<ul><li>1)  Antibiotics </li></ul><ul><li>-  Chronic infection is seldom eradicated by antibiotics alone </li></ul><ul><li...
<ul><li>2) Surgical Treatment </li></ul><ul><li>-  After 10 days of antibiotic administration, debridement is </li></ul><u...
<ul><li>After debridement is done, a large dead space is left in </li></ul><ul><li>the bone </li></ul><ul><li>Among the me...
<ul><li>-  Papineau technique : </li></ul><ul><li>Cavity is packed with small cancellous bone graft (preferably autogenous...
<ul><li>1)  Pathological Fracture </li></ul><ul><ul><li>-  This occurs in the bone weakened by chronic osteomyelitis </li>...
<ul><li>Thank You </li></ul>
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Chronic osteomyelitis

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Chronic osteomyelitis

  1. 1. <ul><li>Subacute Osteomyelitis </li></ul>Prepared by: Tg.Putri Madina bt Tg.Ariff @ Zainuddin
  2. 2. <ul><li>Introduction </li></ul><ul><li>It is a distinct type of osteomyelitis </li></ul><ul><li>It has an insidious onset, mild symptoms, lack of systemic reaction </li></ul><ul><li>Its relative mildness is due to: </li></ul><ul><li>a) Organism being less virulent OR </li></ul><ul><li>b) Patient more resistant OR </li></ul><ul><li>c) (Both) </li></ul><ul><li>- Subacute osteomyelitis occurs in a much wider variety of bones than acute osteomyelitis </li></ul><ul><li>Most common site : Distal femur, Proximal & Distal Tibia </li></ul>
  3. 3. <ul><li>Causative Organism </li></ul><ul><li>Staphyloccocus aureus (30-60%) </li></ul><ul><li>Others ( Streptococcus, Pseudomonas, Haemophilus influenzae ) </li></ul><ul><li>Pseudomonas aeruginosa (IV drug user) </li></ul><ul><li>Salmonella (patient with sickle cell anaemia) </li></ul>Gram positive Staphylococcus aureus
  4. 4. <ul><li>Clinical Features </li></ul><ul><li>Pain (several weeks / months) </li></ul><ul><li>Limping </li></ul><ul><li>Swelling & Local tenderness </li></ul><ul><li>Muscle wasting </li></ul><ul><li>Body temperature usually normal (no fever) </li></ul>
  5. 5. <ul><li>Radiological Finding </li></ul><ul><li>Classic Brodie’s abscess </li></ul><ul><li>A circumscribed , round/oval cavity containing pus and pieces of dead bone ( sequestra ) surrounded sclerosis </li></ul><ul><li>- Most commonly seen in tibial / femoral metaphysis </li></ul><ul><li>*may occur in epiphysis / cuboidal bone (eg: calcaneum) </li></ul><ul><li>- Metaphyseal lesion cause no / little periosteal reaction </li></ul><ul><li>- Diaphyseal lesion may be associated with periosteal new bone formation and marked cortical thickening </li></ul>
  6. 6. A circumscribed, oval cavity surrounded by a zone of sclerosis at the proximal tibia (Brodie’s abscess) This is a lateral view X-ray of left tibia and fibula. There is a marked periosteal reaction at the diaphysis (Type IIb subacute OM)
  7. 7. <ul><li>Modified Classification of Subacute Osteomyelitis </li></ul><ul><li>Type I – Metaphyseal </li></ul><ul><li>Ia - punched-out central metaphyseal lesion </li></ul><ul><li>Ib - eccentric metaphyseal cortical erosion </li></ul><ul><li>Type II – Diaphyseal </li></ul><ul><li>IIa - localized cortical and periosteal reaction </li></ul><ul><li>IIb - medullary abscess in the diaphysis without cortical destruction but with onionskin periosteal reaction </li></ul><ul><li>Type III – Epiphyseal </li></ul><ul><li>IIIa - primary epiphyseal osteomyelitis </li></ul><ul><li>IIIb - lesion that crosses the epiphysis and involves both the epiphysis and the metaphysis </li></ul><ul><li>Type IV - Metaphyseal equivalent </li></ul><ul><li>IVa - vertebral body with an erosive or destructive process </li></ul><ul><li>IVb - involves the flat bones of the pelvis </li></ul><ul><li>IVc - involves the small bones, such as the tarsal bones </li></ul>
  8. 9. <ul><li>Investigation </li></ul><ul><li>a) X-ray (may resemble osteoid osteoma / malignant bone tumour) </li></ul><ul><li>b) Biopsy </li></ul><ul><li>c) Fluid aspiration & culture </li></ul><ul><li>d) ESR raised </li></ul><ul><li>e) WBC may be normal </li></ul>
  9. 10. <ul><li>Treatment </li></ul><ul><li>Conservative (if the diagnosis is not in doubt) </li></ul><ul><li>Immobilization </li></ul><ul><li>Antibiotics (flucloxacillin + fusidic acid) for 6weeks </li></ul><ul><li>Surgical (if the diagnosis is in doubt / failed conservative </li></ul><ul><li>treatment) </li></ul><ul><li>Open biopsy </li></ul><ul><li>Perform curettage on the lesion </li></ul>
  10. 11. Chronic Osteomyelitis Prepared by: Tg.Putri Madina bt Tg.Ariff @ Zainuddin
  11. 12. Introduction <ul><li>Definition: </li></ul><ul><li>“ A severe,persistent and incapacitating infection of bone and bone marrow ” </li></ul>
  12. 13. Causes <ul><li>- It can be due to: </li></ul><ul><li>a) progression / sequel / inadequate treatment of acute osteomyelitis </li></ul><ul><li>( presence of infection after 3 months of antibiotic treatment ) </li></ul><ul><li>b) open fracture </li></ul><ul><li>c) foreign implant (internal fixation) </li></ul>
  13. 14. Aetiological Agents <ul><li>Usual organisms (with time there is always a mixed infection) </li></ul><ul><li>Staph.aureus (commonest) </li></ul><ul><li>Staph.pyogenes </li></ul><ul><li>E.coli </li></ul><ul><li>Pseudomonas </li></ul><ul><li>Staph.epidermidis </li></ul><ul><li>(commonest in surgical implant) </li></ul>
  14. 15. <ul><li>Clinical Features </li></ul><ul><li>Pain </li></ul><ul><li>Pyrexia </li></ul><ul><li>Redness </li></ul><ul><li>Tenderness </li></ul><ul><li>Discharging sinus </li></ul><ul><li>(seropurulent discharge) </li></ul>
  15. 16. <ul><li>Pathogenesis </li></ul><ul><li>Inadequate treatment of acute OM / </li></ul><ul><li>Foreign implant / </li></ul><ul><li>Open fracture </li></ul><ul><li>Inflammatory process continues with time </li></ul><ul><li>together with persistent infection by Staphylococcus aureus </li></ul><ul><li>Persistent infection in the bone leads to increase </li></ul><ul><li>in intramedullary pressure due to inflammatory exudates (pus) </li></ul><ul><li>stripping the periosteum </li></ul><ul><li>Vascular thrombosis </li></ul><ul><li>Bone necrosis (Sequestrum formation) </li></ul><ul><li>New bone formation occur (Involucrum) </li></ul><ul><li>Multiple openings appear in this involucrum, through which exudates & debris from the sequestrum pass via the sinuses </li></ul><ul><li>(Sinus formation) </li></ul>
  16. 18. Anatomical Type Cierney and Mader staging system of Chronic Osteomyelitis Stage Characteristic Features I Medullary Endosteal disease II Superficial Cortical surface infected because of coverage defect III Localised Cortical sequestrum that can be excised without compromising stability IV Diffuse I, II and III plus mechanical instability before or after debridement.
  17. 19. Physiological class Class Host’s immune system Features A host Normal Immunocompetent with good local vascularity B host Compromised Local or systemic factors that compromise immunity or healing C host Prohibitive Minimal disability, prohibitive morbidity anticipated, poor prognosis for cure, treatment worse than disease
  18. 20. <ul><li>Imaging </li></ul><ul><li>1) X-ray examination </li></ul><ul><li>Usually show bone resorption (patchy loss of density / osteolytic lesion) </li></ul><ul><li>Thickening & sclerosis around the bone </li></ul><ul><li>Presence of sequestra </li></ul><ul><li>Occasionaly it may present as a Brodie’s abscess surrounded by vascular tissue and area of sclerosis </li></ul><ul><li>2) Radioisotope scintigraphy </li></ul><ul><li>Sensitive but not specific </li></ul><ul><li>Technetium labelled hydroxymethylene diphosphonate (99mTc-HDP) may show increased activity in both perfusion phase and bone phase </li></ul><ul><li>3) CT scan & MRI </li></ul><ul><li>Show the extent of bone destruction, reactive oedema, hidden abscess and sequestra </li></ul>
  19. 21. AP & lateral view of the left wrist show a lobulated osteolytic lesion with well-defined borders and surrounding sclerosis at the distal radius. Minimal expansion, mild periosteal reaction and soft tissue swelling are present.
  20. 22. Sclerosing osteomyelitis of the lower tibia. Note the bone expansion and marked sclerosis. Sequestrum at lower tibia
  21. 23. <ul><li>Other Investigation </li></ul><ul><li>ESR & WBC may be increased </li></ul><ul><li>Antistaphyloccocal antibody titres may be elevated </li></ul><ul><li>Fluid aspiration from sinus + culture & sensitivity </li></ul><ul><li>Isolation of the agent from the bone or the blood. </li></ul><ul><li>In hematogenous OM, positive blood cultures often obviate the need for a bone biopsy when there is associated radiographic or radionuclide scan evidence of OM. </li></ul><ul><li>In chronic OM, sinus tract cultures are not reliable </li></ul><ul><li>Antibiotic treatment should not be based on the results of sinus tract cultures. </li></ul><ul><li>In most instances, bone biopsy cultures are mandatory to guide specific antimicrobial therapy. </li></ul>
  22. 24. <ul><li>Treatment </li></ul><ul><li>Patient evaluation </li></ul><ul><li>(History taking, PE, Investigation) </li></ul><ul><li>Disease assessment </li></ul><ul><li>(Anatomic & Physiologic classification) </li></ul><ul><li>Identification of organism </li></ul><ul><li>(Biopsy + Culture) </li></ul><ul><li>Antibiotic administration </li></ul><ul><li>Host alteration </li></ul><ul><li>(No smoking, no alcohol, nutrition, control DM, BP) </li></ul><ul><li>Surgical treatment </li></ul><ul><li>(Debridement, Deep space management) </li></ul><ul><li>Follow up </li></ul>
  23. 25. <ul><li>1) Antibiotics </li></ul><ul><li>- Chronic infection is seldom eradicated by antibiotics alone </li></ul><ul><li>- Bactericidal drugs are important to: </li></ul><ul><li>a) Stop the spread of infection to healthy bone </li></ul><ul><li>b) Control acute flares </li></ul><ul><li>- The choice of antibiotic used must be: </li></ul><ul><li>a) Capable of penetrating sclerotic bone </li></ul><ul><li>b) Non toxic with long term use </li></ul><ul><li>- Eg of antibiotics used in treating chronic osteomyelitis </li></ul><ul><li>( Fusidic acid, Clindamycin, Cefazolin ) </li></ul><ul><li>- Antibiotic (IV route) is given for 10 days prior to surgery </li></ul><ul><li>- After the last major debridement surgery, antibiotic is </li></ul><ul><li>continued for another 6 weeks (min) but usually >3months </li></ul><ul><li>[*treat until inflammatory parameters (ESR) are normal] </li></ul>
  24. 26. <ul><li>2) Surgical Treatment </li></ul><ul><li>- After 10 days of antibiotic administration, debridement is </li></ul><ul><li>done to remove: </li></ul><ul><li>a) All the infected tissue </li></ul><ul><li>b) Dead / devitalised bone (Sequestrectomy) </li></ul><ul><li>c) Sinus tract </li></ul><ul><li>- Debridement approach used is direct & atraumatic </li></ul><ul><li>- Wound is left open (stent dressing) EXCEPT: </li></ul><ul><li>a) Compromised hosts (Class B host); ankle, hand, spine </li></ul><ul><li>b) Type II lesions (primary soft tissue reconstruction and/or host alteration) </li></ul><ul><li>c) Minimal necrosis osteomyelitis </li></ul>
  25. 27. <ul><li>After debridement is done, a large dead space is left in </li></ul><ul><li>the bone </li></ul><ul><li>Among the methods of managing dead space: </li></ul><ul><li>a) Open cancellous grafting (Papineau technique) </li></ul><ul><li>b) Primary closure with local tissue (+/- cancellous grafts) </li></ul><ul><li>c) Primary closure with transferred tissues (+/- cancellous grafts) </li></ul><ul><li>d) Primary closure over antibiotic impregnated beads </li></ul>
  26. 28. <ul><li>- Papineau technique : </li></ul><ul><li>Cavity is packed with small cancellous bone graft (preferably autogenous) mixed with an antibiotic and fibrin sealant </li></ul><ul><li>- Primary closure with transferred tissue : </li></ul><ul><li>In muscle flap transfer, a suitable large wad of muscle with its blood supply intact can be mobilized and laid into the cavity. The surface is later closed with a split-skin graft </li></ul><ul><li>- Primary closure with antibiotic impregnated beads : </li></ul><ul><li>Porous gentamicin-impregnated beads are used to sterilize the cavity. It is easier but less successful. Furthermore, they are extremely difficult to be removed if not taken out by 2-3 weeks </li></ul>
  27. 29. <ul><li>1) Pathological Fracture </li></ul><ul><ul><li>- This occurs in the bone weakened by chronic osteomyelitis </li></ul></ul><ul><li>2) Deformity </li></ul><ul><ul><li>In children the focus of osteomyelitis destroys part of the epiphysis growth plate. </li></ul></ul><ul><li>3) Shortening/ lengthening </li></ul><ul><ul><li>Destruction of growth plate arrest growth. </li></ul></ul><ul><ul><li>Stimulation of growth plate due to hyperemia. </li></ul></ul>Complications
  28. 30. <ul><li>Thank You </li></ul>
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