Osteomyelitis and its management

1. OSTEOMYELITIS
AND ITS
MANAGEMENT
PRESENTED BY:
MISS.SHWETA SHARMA
M.SC. NURSING
1ST YEAR
AIIMS, JODHPUR

2. INTRODUCTION
Osteomyelitis is an infection of the bone that results in
inflammation, necrosis and formation of new bone. Osteomyelitis is
classified as:
•Hematogenous osteomyelitis (i.e. due to bloodborne spread of
infection)
•Contiguous-focus osteomyelitis- from contamination from bone
surgery, open fracture or traumatic injury (e.g., gunshot wound)
•Osteomyelitis with vascular insufficiency, seen most commonly
among patients with diabetes and peripheral vascular disease, most
commonly affecting the feet.

3. EPIDEMIOLOGY
•Incidence increases with every decade of life.
•Acute hematogenous osteomyelitis is most commonly seen
in children, with 85% of affected individuals usually under the
age of 1.
•The prevalence among children is 1 in 5,000. Among
individuals who have been treated for an episode of acute
osteomyelitis, the prevalence of chronic osteomyelitis is about
5% to 25% in the India.
•Prevalence can be as high as 30% to 40% in individuals with
diabetes and 16% after foot puncture.

4. AT RISK PATIENTS
•Older adults
•Poorly nourished
•Obese
•Impaired immune system
•Chronic illness (e.g. diabetes, rheumatoid arthritis)
•Receiving long-term corticosteroid therapy or
immunosuppressive agents
•Intravenous drug users

7. CAUSATIVE ORGANISMS
•Staphylococcus aureus (more than 50% of bone
infections)
•Gram-positive organisms streptococci and enterococci
•Gram-negative bacteria- pseudomonas
•Salmonella
•E. coli
•Mycobacterium tuberculosis
•Neisseria gonorrhoea

8. PATHOPHYSIOLOGY
Sequestrum formation

9. CLINICAL MANIFESTATIONS
•Sepsis (e.g., chills, high fever, rapid pulse, general malaise)
•The infected area becomes painful, swollen and extremely
tender.
•Constant, pulsating pain that intensifies with movement as
a result of the pressure of the collecting purulent material
(i.e. pus)
•Chronic osteomyelitis- non- healing ulcer that overlies the
infected bone with a connecting sinus that will intermittently
and spontaneously drain pus.

10. ASSESSMENT AND DIAGNOSTIC
FINDINGS
Acute osteomyelitis
•X-ray- soft tissue edema
•Radioisotope bone scan
•Isotope labelled white blood cell scan
•Bone or soft tissue biopsy
•Magnetic resonance imaging (MRI)
•Blood studies- leukocytosis and an elevated ESR.
•Wound and blood culture

11. Chronic osteomyelitis
•X-ray- Large, irregular cavities, raised
periosteum, sequestra, or dense bone
formations.
•Bone scan
•ESR and WBC count
•Anaemia
•Blood culture

12. PREVENTION
•Elective orthopaedic surgery should be postponed if the
patient has a current infection (e.g. urinary tract infection,
sore throat).
•During surgery, careful attention is paid to the surgical
environment.
•Prophylactic antibiotics, administered to achieve adequate
tissue levels at the time of surgery and for 24 hours after
surgery, are helpful.
•Urinary catheters and drains are removed as soon as possible
to decrease the incidence of hematogenous spread of
infection.

13. •Aseptic postoperative wound care reduces the
incidence of superficial infections and
osteomyelitis.
•Prompt management of soft tissue infections
reduces extension of infection to the bone or
hematogenous spread.
•When patients who have had joint replacement
surgery undergo extensive dental procedures or
other invasive procedures (e.g., cystoscopy),
prophylactic antibiotics are recommended before
the procedure.

14. MEDICAL MANAGEMENT
The initial goal of therapy is to control and halt the infective
process. General supportive measures (e.g., hydration, diet high in
vitamins and protein, correction of anaemia) are instituted. The
area affected with osteomyelitis is immobilised to decrease
discomfort and to prevent pathologic fracture of the weakened
bone.
• Pharmacologic therapy-
Because there is decreased penetration by medications, antibiotic
therapy is longer term than with other infections; typically it
continues for 3 to 6 weeks. After the infection appears to be
controlled, the antibiotic may be administered orally.

15. SURGICAL MANAGEMENT
•Surgical debridement- The infected
bone is surgically exposed, the
purulent and necrotic material is
removed, and the area is irrigated
with sterile saline solution.

16. •Sequestrectomy- removal of enough involucrum to
enable the surgeon to remove the sequestrum.

17. WHEN TO DO A SEQUESTRECTOMY??

18. •Saucerization- sufficient bone is
removed to convert a deep cavity
into a shallow saucer.
•A closed suction irrigation system
may be used to remove debris.
•Wound irrigation using sterile
physiologic saline solution may be
performed for a week.
•The wound is either closed tightly
to obliterate the dead space or
packed and closed later by
granulation or possibly by grafting.

19. •The debrided cavity may be packed with cancellous bone graft to
stimulate healing.
•With a large defect, the cavity may be filled with a vascularized bone
transfer or muscle flap (in which a muscle is moved from an adjacent
area with intact blood supply).
•These microsurgery techniques enhance the blood supply. The
improved blood supply facilitates bone healing and eradication of the
infection.
•These surgical procedures may be staged over time to ensure
healing.
•Because surgical debridement weakens the bone, internal fixation or
external supportive devices may be needed to stabilize or support the
bone to prevent pathologic fracture.

20. COMPLICATIONS
•Septicaemia
•Septic arthritis
•Pathologic
fractures
•Amyloidosis

21. NURSING MANAGEMENT
Nursing assessment
•Assess the sign and symptoms- localized pain, edema, erythema, fever,
etc or recurrent drainage of an infected sinus with associated pain,
edema and low-grade fever.
•Assess for risk factors- older age, diabetes, long term corticosteroid
therapy and a history of previous injury, infection, or orthopaedic
surgery.
•Assess the gait as it may be altered as the patient avoids pressure and
movement of the area.
•In acute hematogenous osteomyelitis, the patient exhibits generalized
weakness due to the systemic reaction to the infection.
•Assess for inflamed, markedly edematous, warm area that is tender,
purulent drainage, elevated temperature, etc.

22. NURSING DIAGNOSIS
•Acute pain related to inflammation and
edema.
•Impaired physical mobility related to pain,
use of immobilization devices, and weight-
bearing limitations.
•Infection related to bone abscess formation.
•Deficient knowledge related to the
treatment regimen.

23. RESEARCH ARTICLES
•Chronic Osteomyelitis - Bacterial Flora, Antibiotic Sensitivity and Treatment
Challenges
A single surgeon, prospective cohort study on 30 consecutive patients with clinically
and radiologically diagnosed chronic osteomyelitis presented to a hospital was done.
The objectives of the study were to determine bacterial flora and antibiotic
sensitivity, and to evaluate the outcome of an aggressive surgical approach to chronic
osteomyelitis. Demographic, clinical, radiological features, treatment protocol,
microbiologic results of culture and sensitivity were recorded. The main treatment
outcome measures were clinical signs of eradication of infection. Microbiologic
results showed that Gram-negative and mixed flora accounts for more than half of
chronic osteomyelitis cases while Staphylococcus aureus was a dominating single
pathogen (39%). The study presented the high rate of MRSA strains is alarming and
calls for updating of the antibiotic therapy guidelines in the country. Good results in
treatment of chronic osteomyelitis can be achieved by a single-stage protocol
including radical debridement combined with systemic and topical antibiotic.

24. •The Relationship Between Osteomyelitis Complication and Drug-
Resistant Infection Risk in Diabetic Foot Ulcer: A Meta-analysis
A meta-analysis was done to find out the relationship between
Osteomyelitis complication and drug-resistant infection risk in diabetic
foot ulcer. Searches of MEDLINE and ISI databases were performed for the
studies. Odds ratios (ORs) for drug-resistant infection incidence were
calculated for diabetic foot ulcer patients with or without osteomyelitis
complications. Eleven studies (12 cohorts) with 1526 patients were
included in this study. Significant publication bias was found. The meta-
regression showed that drug-resistant incidence and published year were
not related with the OR changes. In conclusion, this meta-analysis
indicates that osteomyelitis complications are related with drug-resistant
infection risk in diabetic foot ulcer. The study suggests bone culture–based
narrow-spectrum antibiotic therapy for osteomyelitis for prevention drug-
resistant infection in diabetic foot ulcer.

25. SUMMARY AND CONCLUSION
•As discussed throughout the presentation, learning about
osteomyelitis and its management will help nurses to care for
patients of osteomyelitis.
•Nurses can do assessment of patients with osteomyelitis,
observe the sign and symptoms, provide the necessary
nursing care, prevent complications and support the patient
psychologically.
•Nurses can also counsel the patients and their family for
various options available in treatment for osteomyelitis.

26. REFERENCES
1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical
Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no.1147-
1150.
2.Lewis. Medical Surgical Nursing Assessment and Management of clinical
problems.2015. New Delhi. Elsevier. 2nd Edition. Volume II. Pg. no.1600-1603.
3.OMICS International. Osteomyelitis. Available from
https://www.omicsonline.org/india/osteomyelitis-peer-reviewed-pdf-ppt-articles/
[cited 9 nov 2019]
4.PubMed. Chronic Osteomyelitis - Bacterial Flora, Antibiotic Sensitivity and Treatment
Challenges. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5925860/
[cited 10 nov 2019]
5.PubMed. The Relationship Between Osteomyelitis Complication and Drug-Resistant
Infection Risk in Diabetic Foot Ulcer: A Meta-analysis. Available from
https://journals.sagepub.com/doi/abs/10.1177/1534734617728642 [cited 10 nov
2019]