Acute and Chronic Osteomyelitis - Infection of Bone
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Acute and Chronic Osteomyelitis - Infection of Bone ...

Acute and Chronic Osteomyelitis - Infection of Bone

http://essentialinspiration4u.blogspot.com

Osteomyelitis is defined as an acute or chronic inflammatory process of bone, bone marrow and its structure secondary to infection with micro organisms.

Duration , Mechanism & Host response.

Duration - Acute / Subacute / Chronic
Mechanism - Heamatogenous (tonsil , lungs , ear/ GIT) - Exogenous (injection , open fractures)
Host response - Pyogenic / Granulomatous
Introduction of bacteria from :

Outside through a wound or continuity from a neighboring soft tissue infection
Hematogenous spread from a pre existing focus (most common route of infection)

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Acute and Chronic Osteomyelitis - Infection of Bone Presentation Transcript

  • 1. Osteomyelitis  Presented by  http://essentialinspiration4u.blogspot.c om/ 1
  • 2. Defination of Osteomyelitis Osteomyelitis is defined as an acute or chronic inflammatory process of bone, bone marrow and its structure secondary to infection with micro organisms. 2
  • 3. CLASSIFICATION  Duration , Mechanism & Host response.  Duration - Acute / Subacute / Chronic  Mechanism - Heamatogenous (tonsil , lungs , ear/ GIT) - Exogenous (injection , open fractures)  Host response - Pyogenic / Granulomatous 3
  • 4. ACUTE OSTEOMYELITIS  Age : Infancy and childhood.  Sex : Males predominate 4:1  Location : Metaphysis of long bone.  Poor nutrition, unhygienic surroundings. 4
  • 5. Etiological Agents  Infants < 1 year – Group B streptococci Staph aureus E.coli  1- 16 years – S. aureus , S. pyogens , H. Influenza  > 16 years – S.aureus , S.epidermidis , Gram –ve bacteria 5
  • 6. Pathogenesis Introduction of bacteria from :  Outside through a wound or continuity from a neighboring soft tissue infection  Hematogenous spread from a pre existing focus (most common route of infection) 6
  • 7. Pathogenesis  Preexisting focus / Exogenous Infection  Infective embolus enters nutrient artery  Trapped in a vessel of small Caliber(metaphysis)  Blocks the vessel  Active hyperemia + PMN cells exudate
  • 8.  Hyperemia and immobilization causes decalcification.  Proteolytic enzymes destroy bacteria and medullary elements.  The debris increase and intramedullary pressure increases.
  • 9.  Follows paths of least resistance.  Passes through Haversian canal and Volkmann canal.  Local cortical necrosis.
  • 10.  Enter subperiosteal space.  Strips periosteum.  Perforation of periosteum / reach joint by piercing capsule.  Enters soft tissue and may drain out
  • 11. Acute Osteomyelitis Infants  Joint involvement is common  Nutrient metaphyseal capillaries perforate the epiphyseal growth plate, particularly in the hip, shoulder, and knee. 11
  • 12. CLINICAL FEATURES Fever (High Grade) Child refuses to use limb (pseudoparalysis) Local redness , swelling , warmth , oedema Newborn – failure to thrive , drowsy , irritable. 12
  • 13. Laboratory Tests  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. 13
  • 14. Differential Diagnosis  Rheumatic fever : Onset is more gradual, pain and tenderness are less intense. Involvement is polyarticular. Response to salicylates and ACTH is dramatic.  Acute suppurative arthritis : Pain and tenderness are , limted to the joint, joint movements is greatly restricted, muscle spasm is intense, and aspiration reveals purulent synovial fluid. 14
  • 15. Management of acute osteomyelitis.
  • 16. Drainage technique of acute Hematigenous Osteomyelitis of tibia  Use tourniquet whenever possibe.  Make an anteromedial incision 5 – 7.5 cm long over the affected part of tibia.  Incise periosteum longitudinally, gently elevate the periostum 1.5 cm on each side.  Drill several holes 4mm in diameter through the cortex into the medullary cannal. If pus escapes through these holes, use drill to outline a corticle window 1.3 × 2.5 cm and remove the cortex with osteotome. 16
  • 17.  Evavuate the intramedullary pus and remove the necrotic tissue.  Irrigate the cavity with at least 3 L of saline with a pulsatile lavege system.  Close the skin loosely over drains.  Limb is splinted in neutral position.  Generally 6 weeks course of antibiotics is given. 17
  • 18.  Bone abscess  Septic Arthritis  Septicemia  Fracture  Growth arrest  Overlying soft-tissue cellulitis  Chronic infection 18
  • 19. Subacute Osteomyelitis  It has an insidious onset, mild symptoms, lack of systemic reaction  Its relative mildness is due to:  a) Organism being less virulent OR  b) Patient more resistant OR  c) (Both)  Most common site: Distal femur, Proximal & Distal Tibia 19
  • 20. Causative Organism a) Staphyloccocus aureus (30-60%) b) Others (Streptococcus, Pseudomonas, Haemophilus influenzae) c) Pseudomonas aeruginosa (IV drug user) d) Salmonella (patient with sickle cell anaemia) 20  Gram Positive Staph aureus
  • 21. Clinical Features  Pain (several weeks / months)  Limping  Swelling & Local tenderness  Muscle wasting  Body temperature usually normal (no fever) 21
  • 22. Radiological Finding Brodie’s abscess  A circumscribed, round/oval cavity containing pus and pieces of dead bone (sequestra) surrounded by sclerosis.  Most commonly seen in tibial / femoral metaphysis.  May occur in epiphysis / cuboidal bone (eg: calcaneum).  Metaphyseal lesion cause no / little periosteal reaction.  Diaphyseal lesion may be associated with periosteal new bone formation and marked cortical thickening. 22
  • 23. 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.
  • 24. Investigation’s a) X-ray (may resemble osteoid osteoma / malignant bone tumour) b) Biopsy c) Fluid aspiration & culture d) ESR raised e) WBC count may be normal 24
  • 25. 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 25
  • 26. Chronic Osteomyelitis  Definition: “ A severe, persistent and incapacitating infection of bone and bone marrow ” 26
  • 27. Aetiological Agents Usual organisms (with time there is always a mixed infection)  Staph.aureus(commonest)  Staph.pyogenes  E.coli  Pseudomonas  Staph.epidermidis (commonest in surgical implant) 27
  • 28. Clinical Features a) Pain b) Pyrexia c) Redness d) Tenderness e) Discharging sinus (seropurulent discharge) 28
  • 29. Pathogenesis Inadequate treatment of acute OM /Foreign implant / Open fracture Inflammatory process continues with time together with persistent infection by Staphylococcus aureus Persistent infection in the bone leads to increase in intramedullary pressure due to inflammatory exudates (pus) stripping the periosteum 29
  • 30. Pathogenesis (Contd.) Vascular thrombosis Bone necrosis (Sequestrum formation) New bone formation occur (Involucrum) Multiple openings appear in this involucrum, through which exudates & debris from the sequestrum pass via the sinuses (Sinus formation) 30
  • 31. 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. 32
  • 32. The Cierny-Mader Classification 33
  • 33. The Cierny-Mader Classification  1: Medullary Osteomyelitis - Infection confined to medullary cavity.  2: Superficial Osteomyelitis - Contiguous type of infection. Confined to surface of bone.  3: Localized Osteomyelitis - Full-thickness cortical sequestration which can easily be removed surgically.  4: Diffuse Osteomyelitis - Loss of bone stability, even after surgical debridement. 34
  • 34. Radiographic Findings 1) X-ray examination - Usually show bone resorption (patchy loss of density / osteolytic lesion) - Thickening & sclerosis around the bone - Presence of sequestra - Occasionaly it may present as a Brodie’s abscess surrounded by vascular tissue and area of sclerosis 2) Radioisotope scintigraphy - Sensitive but not specific - Technetium labelled hydroxymethylene diphosphonate (99mTc-HDP) may show increased activity in both perfusion phase and bone phase 3) CT scan & MRI - Show the extent of bone destruction, reactive oedema, hidden abscess and sequestra 35
  • 35. MRI OF OSTEOMYELITIS OF METATARSAL Active osteomyelitis displays a decreased signal in T1 weighted images and appears bright in T2 weighted images. 36
  • 36. 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.
  • 37. 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, Cefazolin) - 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] 38
  • 38. 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 - Wound is left open EXCEPT: a) Compromised hosts (Class B host); ankle, hand, spine b) Type II lesions (primary soft tissue reconstruction and/or host alteration) c) Minimal necrosis osteomyelitis 39
  • 39. 40 - After debridement is done, a large dead space is left in the bone - Among the methods of managing dead space: a) Open cancellous grafting (Papineau technique) b) Primary closure with local tissue (+/- cancellous grafts) c) Primary closure with transferred tissues (+/- cancellous grafts) d) Primary closure over antibiotic impregnated beads
  • 40. 41 - Papineau technique: Cavity is packed with small cancellous bone graft (preferably autogenous) mixed with an antibiotic and fibrin sealant - Primary closure with transferred tissue: 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 - Primary closure with antibiotic impregnated beads: 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
  • 41. Complications 1) Pathological Fracture - This occurs in the bone weakened by chronic osteomyelitis 2) Deformity – In children the focus of osteomyelitis destroys part of the epiphysis growth plate. 3) Shortening/ lengthening - Destruction of growth plate arrest growth. - Stimulation of growth plate due to hyperemia. 42
  • 42. 43