osteomyelitis Moderator: Dr peeyush sharma Presenter:  Dr Pramod mahender
osteomyelitis <ul><li>Nelaton  (1834):coined osteomyelitis </li></ul><ul><li>osteon:bone </li></ul><ul><li>myelo:marrow </...
Osteomyelitis >3months Chronic: Less virulent – more immune 2weeks—3months  Subacute: <ul><li>Early acute  </li></ul><ul><...
Organisms Commonly Isolated in Osteomyelitis Based on Patient Age  <ul><li>Infants (<1 year)  Group B streptococci  Staphy...
Risk factors <ul><li>Trauma (orthopaedic surgery or open fracture)  </li></ul><ul><li>Prosthetic orthopaedic device  </li>...
osteomyelitis  <ul><li>General factors   </li></ul><ul><li>Anaemia </li></ul><ul><li>Debility </li></ul><ul><li>Infection ...
pathophysiology Primary & secondary spongiosa Limit reticuloendothelial cells Immature cell, anoxia Hairpin bend ( metaphy...
Clinical feature <ul><li>Spurulent  drainage </li></ul>Chornic <ul><li>Vague </li></ul><ul><li>Cannot pinpoint onset </li>...
lab <ul><li>COMPLETE BLOOD COUNT  </li></ul><ul><li>CULTURE (24-48hrs later) </li></ul><ul><li>1-JOINT FLUID 2-BLOOD 3-DEE...
MORREY AND PETERSON”S CRITERIA <ul><li>DEFINITION- THE PATHOGEN IS ISOLATED FROM BONE OR ADJACENT SOFT TISSUE AS THERE IS ...
Peltola and vahvanen’s criteria <ul><li>-Pus on aspiration  -Positive bacterial culture from bone or blood  -Presence of c...
 
<ul><li>Plain-film radiograph showing osteomyelitis of the second metacarpal (arrow). </li></ul><ul><li>Periosteal elevati...
 
WALDVOGEL 1970 <ul><ul><li>HEMATOGENOUS  </li></ul></ul><ul><ul><li>CONTIGEUOUS FOCUS </li></ul></ul><ul><ul><li>OSTEOMYEL...
WEILAND 1984 <ul><li>TYPE  1 – </li></ul><ul><li>-OPEN EXPOSED BONE WITHOUT  OSSEOUS INFECTION BUT SOFT TISSUE INFECTION <...
GORDON’S 1988 <ul><li>TYPE A – NONUNION WITHOUT SEGMENTAL LOSS </li></ul><ul><li>TYPE B - >3cm SEGMENTAL LOSS WITH INTACT ...
GER’S 1982 <ul><li>SIMPLE SINUS </li></ul><ul><li>CHRONIC SUPERFICIAL </li></ul><ul><li>MULTIPLE SINUSES </li></ul><ul><li...
KELLY’S 1984 <ul><li>HEMATOGENOUS OSTEOMYELITIS </li></ul><ul><li>OSTEOMYELITIS WITH FRACTURE UNION </li></ul><ul><li>OSTE...
MAY’S 1989 <ul><li>TYPE 1- WITHSTAND FUNCTIONAL LOAD – 6-12weeks </li></ul><ul><li>TYPE 2- INTACT TIBIA NEEDED GRAFT- 3-6m...
TABLE 1   Waldvogel Classification System for Osteomyelitis  <ul><li>Hematogenous osteomyelitis  </li></ul><ul><li>Osteomy...
The Penny classification of chronic osteomyelitis in children includes both diaphyseal and metaphyseal types . <ul><li>Dia...
 
 
DE CIERNY-MADER <ul><li>12 STAGES </li></ul><ul><li>DISEASE PROCESS – REGARDLESS OF – 1-ETIOLOGY  </li></ul><ul><li>2-REGI...
The Cierny-Mader Staging System <ul><li>Anatomic </li></ul><ul><li>Type Description </li></ul><ul><li>Stage 1 Medullary os...
Systemic or Local Factors That Affect Metabolism, Local Vascularity, and Immune Surveillance <ul><li>Local (Bl) </li></ul>...
Nade’s principles <ul><li>Antibiotic is effective before pus forms </li></ul><ul><li>Antibiotic cannot sterilise avacular ...
Nade’s indications for surgery <ul><li>Abscess formation </li></ul><ul><li>Severely ill & moribund child </li></ul><ul><li...
management <ul><li>Antibiotic: stage1----  2week iv  </li></ul><ul><li>change to oral </li></ul><ul><li>(avoid quinolones)...
Surgical mx <ul><li>Debridement surgery is fondation of osteomyelitis treatment </li></ul><ul><li>External fixator prior/d...
<ul><li>Antibiotic impregnated Acrylic beads </li></ul><ul><li>removed in 2-4 wks </li></ul><ul><li>Replased with cancello...
Cierney mader Soft tissue coverage After debridement Bone exposed Stage2 :NO hardware-Nosurgery Intramedulary reaming+/- b...
Cierney mader Structural stability Obliterating debridement gaps -bone graft -Illizarov - free flaps  -vascular bone insta...
Osteomyelitis and hiv <ul><li>Uncommon (.5%-2%) </li></ul><ul><li>Mortality(20%) </li></ul><ul><li>S.aureus(mc) </li></ul>...
Musculoskeletal &hiv <ul><li>Arthritis </li></ul><ul><li>Myositis </li></ul><ul><li>Osteomyelitis </li></ul>
<ul><li>Spondylarthropathy </li></ul><ul><li>reiter’s </li></ul><ul><li>psoriatic </li></ul><ul><li>Acute symmetric polyar...
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osteomylitis

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  • osteomylitis

    1. 1. osteomyelitis Moderator: Dr peeyush sharma Presenter: Dr Pramod mahender
    2. 2. osteomyelitis <ul><li>Nelaton (1834):coined osteomyelitis </li></ul><ul><li>osteon:bone </li></ul><ul><li>myelo:marrow </li></ul>
    3. 3. Osteomyelitis >3months Chronic: Less virulent – more immune 2weeks—3months Subacute: <ul><li>Early acute </li></ul><ul><li>Late acute(4-5days) </li></ul><2weeks Acute:
    4. 4. Organisms Commonly Isolated in Osteomyelitis Based on Patient Age <ul><li>Infants (<1 year) Group B streptococci Staphylococcus aureus Escherichia coli </li></ul><ul><li>Children (1 to 16 years) S. aureus Streptococcus pyogenes Haemophilus influenzae </li></ul><ul><li>Adults (>16 years) Staphylococcus epidermidis S. aureus Pseudomonas aeruginosa Serratia marcescens E. coli </li></ul>
    5. 5. Risk factors <ul><li>Trauma (orthopaedic surgery or open fracture) </li></ul><ul><li>Prosthetic orthopaedic device </li></ul><ul><li>Diabetes </li></ul><ul><li>Peripheral vascular disease </li></ul><ul><li>Chronic joint disease </li></ul><ul><li>Alcoholism </li></ul><ul><li>Intravenous drug abuse </li></ul><ul><li>Chronic steroid use </li></ul><ul><li>Immunosuppression </li></ul><ul><li>Tuberculosis 7 </li></ul><ul><li>HIV and AIDS </li></ul><ul><li>Sickle cell disease </li></ul><ul><li>Presence of catheter-related blood stream infection 4 </li></ul>
    6. 6. osteomyelitis <ul><li>General factors </li></ul><ul><li>Anaemia </li></ul><ul><li>Debility </li></ul><ul><li>Infection </li></ul><ul><li>Poor nutrition </li></ul><ul><li>Poor immune status </li></ul><ul><li>Local factor </li></ul><ul><ul><li>Hair pin bend vessels </li></ul></ul><ul><ul><li>Metaphyseal haemorrhage </li></ul></ul><ul><ul><li>Defective Phagocytosis </li></ul></ul><ul><ul><li>Rapid groth at metaphysis </li></ul></ul><ul><ul><li>Trabeculae of degenerating cartilage </li></ul></ul><ul><ul><li>Vasospasm </li></ul></ul><ul><ul><li>Anoxia </li></ul></ul>
    7. 7. pathophysiology Primary & secondary spongiosa Limit reticuloendothelial cells Immature cell, anoxia Hairpin bend ( metaphyseal arteries) Sluggish circulation infection
    8. 8. Clinical feature <ul><li>Spurulent drainage </li></ul>Chornic <ul><li>Vague </li></ul><ul><li>Cannot pinpoint onset </li></ul><ul><li>Fever/swelling-mild </li></ul>Sub acute <ul><li>(Infant;premature neonates) </li></ul><ul><li>Swelling </li></ul><ul><li>pain </li></ul>Late Acute <ul><li>Febrile illness </li></ul><ul><li>Limping to walk </li></ul><ul><li>Avoidance of using the extremity </li></ul>Early Acute
    9. 9. lab <ul><li>COMPLETE BLOOD COUNT </li></ul><ul><li>CULTURE (24-48hrs later) </li></ul><ul><li>1-JOINT FLUID 2-BLOOD 3-DEEP BONE BIOPSY </li></ul><ul><li>LEUKERGY </li></ul><ul><li>ESR </li></ul><ul><li>C REACTIVE PROTIEN </li></ul><ul><li>LEUCOCYTE COUNT </li></ul><ul><li>X RAY-LAGS 2wks BEHIND </li></ul><ul><li>RADIONUCLEOTIDE SCAN- Disadvantage-fracture healing,osteomyelitis,tumour </li></ul><ul><li>C T SCAN- NECROTIC PORTION </li></ul><ul><li>TECHNETIUM 99 BONE SCAN(85% PPV)-when diag unclear-clavicle,pelvis,fibula </li></ul><ul><li>SPECT </li></ul><ul><li>INDIUM/GALLIUM SCAN </li></ul><ul><li>USG-SUBPERIOSTEAL ABSCESS </li></ul><ul><li>MRI- BEST </li></ul>
    10. 10. MORREY AND PETERSON”S CRITERIA <ul><li>DEFINITION- THE PATHOGEN IS ISOLATED FROM BONE OR ADJACENT SOFT TISSUE AS THERE IS HISTOLOGIC EVIDENCE OF OSTEOMYELITIS </li></ul><ul><li>PROBABLE- A BLOOD CULTURE IS POSITIVE IN SETTING OF CLINICAL AND RADIOLOGICAL FEATURES OF OSTEOMYELITIS </li></ul><ul><li>LIKELY- TYPICAL CLINICAL FINDING AND DEFINITE RADIOGRAFFIC EVIDENCE OF OSTEOMYELITIS ARE PRESENT AND RESPONSE TO ANTIBIOTIC THERAPY </li></ul>
    11. 11. Peltola and vahvanen’s criteria <ul><li>-Pus on aspiration -Positive bacterial culture from bone or blood -Presence of classic signs and symptoms of acute osteomyelitis -Radiographic changes typical of osteomyelitis *--Two of the listed findings must be present for establishment of the diagnosis . </li></ul>
    12. 13. <ul><li>Plain-film radiograph showing osteomyelitis of the second metacarpal (arrow). </li></ul><ul><li>Periosteal elevation, </li></ul><ul><li>cortical disruption and </li></ul><ul><li>medullary involvement are present. </li></ul>
    13. 15. WALDVOGEL 1970 <ul><ul><li>HEMATOGENOUS </li></ul></ul><ul><ul><li>CONTIGEUOUS FOCUS </li></ul></ul><ul><ul><li>OSTEOMYELITIS WITH VASCULAR INSUFFICIENCY </li></ul></ul>
    14. 16. WEILAND 1984 <ul><li>TYPE 1 – </li></ul><ul><li>-OPEN EXPOSED BONE WITHOUT OSSEOUS INFECTION BUT SOFT TISSUE INFECTION </li></ul><ul><li>TYPE 2 – </li></ul><ul><li>CIRCUMFERENTIALCORTICAL+ENDOSTEAL INFECTION </li></ul><ul><li>INCREASE SCLEROTIC THICKENING OF CORTEX </li></ul><ul><li>INCREASE DENSITY </li></ul><ul><li>AREAS OF BONY RESORPTION+SEQUESTRUM </li></ul><ul><li>TYPE 3 – </li></ul><ul><li>CORTICAL+ENDOSTEAL INFECTION+A SEGMENTAL BONE DEFECT </li></ul>
    15. 17. GORDON’S 1988 <ul><li>TYPE A – NONUNION WITHOUT SEGMENTAL LOSS </li></ul><ul><li>TYPE B - >3cm SEGMENTAL LOSS WITH INTACT FIBULA </li></ul><ul><li>TYPE C - >3cm SEGMENTAL LOSS WITHOUT INTACT FIBULA </li></ul>
    16. 18. GER’S 1982 <ul><li>SIMPLE SINUS </li></ul><ul><li>CHRONIC SUPERFICIAL </li></ul><ul><li>MULTIPLE SINUSES </li></ul><ul><li>MULTIPLE SKIN-LINED SINUSES </li></ul>
    17. 19. KELLY’S 1984 <ul><li>HEMATOGENOUS OSTEOMYELITIS </li></ul><ul><li>OSTEOMYELITIS WITH FRACTURE UNION </li></ul><ul><li>OSTEOMYELITIS WITH FRACTURE NONUNION </li></ul><ul><li>POST OPERATIVE OSTEOMYELITIS WITHOUT FRACTURE </li></ul>
    18. 20. MAY’S 1989 <ul><li>TYPE 1- WITHSTAND FUNCTIONAL LOAD – 6-12weeks </li></ul><ul><li>TYPE 2- INTACT TIBIA NEEDED GRAFT- 3-6months </li></ul><ul><li>TYPE 3- DEFECT < 6cm, INTACT FIBULA – 6-12months </li></ul><ul><li>TYPE 4- > 6cm,INTACT FIBULA – 12-18months </li></ul><ul><li>TYPE 5- > 6cm- UNUSABLE FIBULA- > 18months </li></ul>
    19. 21. TABLE 1 Waldvogel Classification System for Osteomyelitis <ul><li>Hematogenous osteomyelitis </li></ul><ul><li>Osteomyelitis secondary to contiguous focus of infection </li></ul><ul><li>No generalized vascular disease </li></ul><ul><li>Generalized vascular disease </li></ul><ul><li>Chronic osteomyelitis (necrotic bone) </li></ul>
    20. 22. The Penny classification of chronic osteomyelitis in children includes both diaphyseal and metaphyseal types . <ul><li>Diaphyseal </li></ul><ul><li>osteomyelitis may be broken down into the following types: </li></ul><ul><li>type I (typical, A), </li></ul><ul><li>type II (atrophic, B), </li></ul><ul><li>type III (sclerotic, C), </li></ul><ul><li>type IV (cortical, D), type </li></ul><ul><li>V (multiple walled-off abscesses, E), and </li></ul><ul><li>type VI (multiple microabscesses, F). metaphyseal osteomyelitis is shown in G. </li></ul>
    21. 25. DE CIERNY-MADER <ul><li>12 STAGES </li></ul><ul><li>DISEASE PROCESS – REGARDLESS OF – 1-ETIOLOGY </li></ul><ul><li>2-REGIONALITY </li></ul><ul><li>3-CHRONICITY </li></ul><ul><li>DYNAMIC </li></ul>
    22. 26. The Cierny-Mader Staging System <ul><li>Anatomic </li></ul><ul><li>Type Description </li></ul><ul><li>Stage 1 Medullary osteomyelitis </li></ul><ul><li>Stage 2 Superficial osteomyelitis </li></ul><ul><li>Stage 3 Localized osteomyelitis </li></ul><ul><li>Stage 4 Diffuse osteomyelitis </li></ul><ul><li>Physiologic </li></ul><ul><li>Class </li></ul><ul><li>A host Normal host </li></ul><ul><li>B- host Systemic compromise (Bs) </li></ul><ul><li>Local compromise (Bl) </li></ul><ul><li>Systemic and local compromise (Bls) </li></ul><ul><li>C host Treatment worse that the disea </li></ul>
    23. 27. Systemic or Local Factors That Affect Metabolism, Local Vascularity, and Immune Surveillance <ul><li>Local (Bl) </li></ul><ul><li>Arteritis </li></ul><ul><li>Chronic lymphedema </li></ul><ul><li>Extensive scarring </li></ul><ul><li>Major vessel compromise </li></ul><ul><li>Neuropathy </li></ul><ul><li>Radiation fibrosis </li></ul><ul><li>Small vessel disease </li></ul><ul><li>Tobacco abuse </li></ul><ul><li>2 packs/day) </li></ul><ul><li>Venous stasis </li></ul><ul><ul><li>Systemic (Bs) </li></ul></ul><ul><li>Chronic hypoxia </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Extremes of age </li></ul><ul><li>Immune disease </li></ul><ul><li>Immunosuppression or </li></ul><ul><li>immune deficiency </li></ul><ul><li>Malignancy </li></ul><ul><li>Malnutrition </li></ul><ul><li>Renal and/or hepatic </li></ul><ul><li>failure </li></ul>
    24. 28. Nade’s principles <ul><li>Antibiotic is effective before pus forms </li></ul><ul><li>Antibiotic cannot sterilise avacular tissue </li></ul><ul><li>Antibiotic prevents reformation of pus once removed </li></ul><ul><li>Pus removal restores periosteum---- restores blood flow </li></ul><ul><li>Antibiotic should be continued after surgery </li></ul>
    25. 29. Nade’s indications for surgery <ul><li>Abscess formation </li></ul><ul><li>Severely ill & moribund child </li></ul><ul><li>Failure to respond to IV antibiotics for >48 hrs </li></ul>
    26. 30. management <ul><li>Antibiotic: stage1---- 2week iv </li></ul><ul><li>change to oral </li></ul><ul><li>(avoid quinolones) </li></ul><ul><li>stage 2 – 2wk+ </li></ul><ul><li>superficial debridement </li></ul><ul><li>stage3& 4 -4-6wk iv </li></ul><ul><li>(from last major deb) </li></ul>
    27. 31. Surgical mx <ul><li>Debridement surgery is fondation of osteomyelitis treatment </li></ul><ul><li>External fixator prior/during </li></ul><ul><li>Complete wound closure;wherever </li></ul><ul><li>Sution irrigation(not recommended) </li></ul><ul><li>Secondary intention-discouraged </li></ul><ul><li>Local flap+/- cancellous bone </li></ul><ul><li>Illizarov external fixation-9mth </li></ul>
    28. 32. <ul><li>Antibiotic impregnated Acrylic beads </li></ul><ul><li>removed in 2-4 wks </li></ul><ul><li>Replased with cancellous bone </li></ul><ul><li>-vanco/tobra/genta </li></ul><ul><li>-degrada beads </li></ul><ul><li>-implantable pump </li></ul><ul><li>Infected pseudorthosis .>3cms vascu.b transfer </li></ul>
    29. 33. Cierney mader Soft tissue coverage After debridement Bone exposed Stage2 :NO hardware-Nosurgery Intramedulary reaming+/- bone grafting +/- brace/cast Children Adult Stage1
    30. 34. Cierney mader Structural stability Obliterating debridement gaps -bone graft -Illizarov - free flaps -vascular bone instability Stage4 Deberidment Reconstruction of bone &soft tissue Sequestered +above Stage3
    31. 35. Osteomyelitis and hiv <ul><li>Uncommon (.5%-2%) </li></ul><ul><li>Mortality(20%) </li></ul><ul><li>S.aureus(mc) </li></ul><ul><li>m.tuberculosis (not common) </li></ul><ul><li>Atypical –mac </li></ul><ul><li>Bortonella </li></ul><ul><li>cmv </li></ul><ul><li>fungi </li></ul><ul><li>DD -kaposi’s sarcoma </li></ul><ul><li>-avn </li></ul><ul><li>-lymphoma </li></ul>
    32. 36. Musculoskeletal &hiv <ul><li>Arthritis </li></ul><ul><li>Myositis </li></ul><ul><li>Osteomyelitis </li></ul>
    33. 37. <ul><li>Spondylarthropathy </li></ul><ul><li>reiter’s </li></ul><ul><li>psoriatic </li></ul><ul><li>Acute symmetric polyarthritis </li></ul><ul><li>Hiv asso Arthritis </li></ul><ul><li>Painful articular syn </li></ul><ul><li>Septic arthritis </li></ul><ul><li>Myositis— </li></ul><ul><li>AZt </li></ul><ul><li>hiv related polymyositis </li></ul>
    34. 38. THANK YOU
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