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Osteomyelitis (Nutshell)
- 1. Osteomyelitis DR AAKASH NANDU SMIT ORTHOPAEDICS HOSPITAL ANAND
- 2. Osteomyelitis means ? Bone + Marrow + Inflammation Due to bacterial infection (most commonly Staph. Aureus)
- 4. Location •Anywhere in the bone •MC in Adults – Diaphysis •MC in Chidren - Metaphysis
- 5. Why metaphysis in children ? 1. Sluggish blood supply 2. RES absent 3. Periosteum tightly attached at the physis 4. Repeated trauma at metaphysis 5. Infections elsewhere in the body
- 6. Causes (multi factorial) • 1. Patient dependent factors • Malnutrition • Chemotherapy / cancer • Steroid use • Diabetes • Smoking, tobacco, alcohol • Weight loss more than 10 lbs
- 7. Causes •2. Surgeon dependent • Poor skin preparation before operation • Poor aseptic precautions • Absence of pre-op antibiotics
- 9. Acute O.M. 1. Bacteria proliferate – Neutrophilic reaction 2. Bone necrosis in 48 hrs – bone pain 3. Spreads to periosteum via Volkman’s canals – Lifting of periosteum 4. Subperiosteal abscess ruptures – spread to soft tissues
- 10. Chronic O.M. • After 1st week, lymphocytes proliferate • Cytokines released from lymphocytes causes 1. Osteoclastic bone resorption / dead bone (sequestrum) 2. Fibrous ingrowth 3. Sleeve of New bone formation surrounding it (Involucrum) 4. Pressure inside causes sequestrum to burst out through CLOACA
- 13. Variants •Broadie’s abscess Subacute or chronic (atypical) osteomyelitis presenting as a localized pus collection / abscess in the metaphysis of a long bone. (usually tibia)
- 14. Garre’s Osteomyelitis • Rare chronic OM resulting in thickening of bony cortices and loss of medullary canal but lacks signs of active infection. Occurs MC in Mandible
- 15. Clinical manifestations 1. Acute OM • Symptoms - sudden onset, high fever, night sweats, fatigue, anorexia, restriction of movement (pseudo paralysis) • Signs – Erythema, Tenderness, Local edema 2. Chronic OM • Symptoms – Discharge, bony spicules, low grade fever, weight loss, deformity • Signs – Bone exposed, sequestrum, cloaca, scar of previous surgery
- 16. Investigations (Ix) • Blood investigations – CBC, ESR, CRP , culture • Other lab Ix - Biopsy • Pus – Culture and sensitivity • Radio – Xray, CT, MRI, radionucleotide bone scan
- 18. Bone scan
- 19. Treatment CONSERVATIVE SURGICAL Anti-biotic treatment Incision and drainage IV Fluids Debridement Analgesics Antibiotic nailing Comfortable limb positioning Antibiotic cement beads
- 20. Acute Osteomyelitis treatment •Nades principles • 1. Appropriate antibiotic will be effective before pus formation • 2. Antibiotics do not sterilize avascular tissues and abscesses. They require surgical debridement.
- 21. • 3. After debridement, antibiotics should be given for preventing their re-formation. • 4. Surgery should not damage already devitalized/ avascular tissues and bones. • 5. Antibiotics should be continued after surgery.
- 22. Course of antibiotics • IV for 2 weeks • Oral for 4 weeks • Choice of antibiotics should be governed by culture and sensitivity report. • 2 sensitive antibiotics should be combined • If culture report is negative, start broad spectrum antibiotics.
- 24. Indications of surgery • 1. presence of abscess • 2. failure to improve with IV antibiotics • Objective of surgery is to remove dead devitalized tissues from the bone .
- 25. Surgery options • 1. subperiosteal abscess - multiple drill holes to drain the abscess. • 2. intramedullary – cortical window to remove necrotic tissues • Antibiotic coated nailing or antibiotic beads in the surrounding soft tissues. • Wound closure and splitning of the limbs.
- 26. • Corticotomy • Debridement • Antibiotic cement beads
- 27. Antibiotic cement coated nail
- 28. Complications 1. Septicemia 2. Septic arthritis 3. Chronic osteomyelitis 4. Pathological fracture 5. Amputation 6. Limb deformities 7. Recurrence