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  • Fig. 9.  Sixteen-year-old male patient with history of six weeks of pain in the right knee with fever consistent with Brodie abscess. T1 weighted image of the knee (A) demonstrates the double line effect, a focal area of low signal with alternating bands of high and low signal. Axial T2 weighted image of the proximal tibia at the same level (B) demonstrates a region of high-intensity surrounded by alternating bands of low signal and high signal.
  • Fifteen-year-old male with knee pain and acute osteomyelitis. Coronal weighted image of the knee demonstrates low signal in the proximal epiphysis extending through the growth plate into the metaphysis of the tibia.
  • Osteomyelitis

    1. 1. Osteomyelitis SMS3053 Dr.Mohanad R. Alwan
    2. 2. What is osteomyelitis? Osteomyelitis is a progressive infection of bone or bone marrow, and Surrounding soft tissue usually caused by pyogenic bacteria. (most common in staphylococcus aureus)  It can be usefully subclassified on the basis of the causative organism, the route, duration and anatomic location of the infection. Infection is more common in the long bones and vertebras, but it can affect any bone in the body.
    3. 3. How Common Is Osteomyelitis? Chronic osteomyelitis occurs in about 2 in 10,000 adults. Children have the acute form of the disease more often than adults do, at a rate of about 1 in 5,000
    4. 4. Development of Osteomyelitis
    5. 5. Osteomyelitis is infection in the bones. Often, the original site of infection is elsewhere in the body, and spreads to the bone by the blood. Bacteria or fungus may sometimes be responsible for osteomyelitis.
    6. 6. Classification of Osteomyelitis Pathogenesis Hematogenous (most common cause in kids) • In children: tubular bones • In adults: spine, pelvis and small bones Spread from adjacent soft tissue infection • Ex: ulcers, diabetic foot ulcers Direct inoculation • Ex: Trauma or surgery Chronicity Acute Subacute Chronic Progression to subacute or chronic disease depends on timing of dx and tx, comorbid conditions, immune status etc.
    7. 7. Acute Osteo Sub-Acute Osteo Chronic Osteo Begins with marrow edema, cellular infiltration and vascular engorgement May progress to necrosis and abscess formation Spread within the intramedullary cavity  extension through cortex by Havers and Volkman’s canals  subperiosteal space  periosteum  soft tissues Rupture of joint space  septic arthritis  Occurs in abnormal bone or after inadequate antibiotics Localized pyogenic process Commonly appears as a well-defined osteolytic metaphyseal lesion (Brodie’s abscess) with a sclerotic margin that fades peripherally (fuzzy sclerotic margin) S. aureus is most common pathogen  Occurs after inadequate tx or in pts with altered immunity Distinguishing feature is necrotic bone surrounded by granulation tissue Interruption of blood supply  necrosis  devitalized bone fragments (sequestra) A thick sheath of new periosteal bone can develop around the sequestra (involucrum) Fistula tract formation Sharp interface between normal and diseased marrow
    8. 8. Subacute MRI Findings Brodie’s abscess  (intraosseous abscess, internal wall covered by granulation tissue) 16 y/o with Brodie’s abscess. T1 weighted image of the knee (A) demonstrates the double line effect, a focal area of low signal with alternating bands of high and low signal. Axial T2 weighted image of the proximal tibia at the same level (B) demonstrates a region of high-intensity surrounded by alternating bands of low signal and high signal. Subacute osteo is often confused with tumor (osteosarcoma, Ewing)
    9. 9. Osteomyelitis Classification of osteomyelitis 1. Haematogenous (Children and aged people). 2. Inoculation osteomyelitis (Bacteria from tissues nearby) i.e. (from open wounds, operations or open fractures). 3. Direct or contiguous osteomyelitis is caused by direct contact of the tissue and bacteria during trauma or surgery.
    10. 10. Haematogenous Osteo.
    11. 11. Most common sites of indirect entry in children Distal femur Proximal tibia Humerus Radius Most common sites of indirect entry in adults are Vascular-rich bone sites Pelvis Tibia Vertebrae
    12. 12. Pathophysiology of Osteomyelitis Generally, microorganisms may infect bone through one or more of three basic methods: 1. Via the bloodstream. 2. Penetrating (trauma). 3. Internal fixation of fractures.
    13. 13. PATHOPHYSIOLOGYPATHOPHYSIOLOGY Microorganisms enter bone (Phagocytosis). Phagocyte contains the infection Release enzymes Lyse bone
    14. 14. PATHOPHYSIOLOGYPATHOPHYSIOLOGY Bacteria escape host defenses by: Adhering tightly to damage bone Persisting in osteoblasts Protective polysaccharide-rich biofilm
    15. 15. PATHOPHYSIOLOGYPATHOPHYSIOLOGY Pus spreads into vascular channels Raising intraosseous pressure Impairing blood flow Chronic ischemic necrosis Separation of large devascularized fragment New bone formation (involucrum) Often, the body will try to create new bone around the area of necrosis. (Sequestra)(Sequestra)
    16. 16. Pathophysiology of Osteomyelitis In infants, the infection can spread to the joint and cause arthritis. tibia, femur, humerus, vertebra, the maxilla, are susceptible to osteomyelitis because of the particulars of their blood supply. Many infections are caused by Staphylococcus aureus, a member of the normal flora found on the skin and mucous membranes.
    17. 17. Pathophysiology (Smeltzer, Bare, Hinkle, & Chever, 2008)
    18. 18. Osteomyelitis
    19. 19. PATHOLOGYPATHOLOGY AcuteAcute Infiltration of PMNsInfiltration of PMNs Congested or thrombosed vesselsCongested or thrombosed vessels ChronicChronic  Necrotic boneNecrotic bone Absence of living osteocyteAbsence of living osteocyte Mononuclear cells predominateMononuclear cells predominate Granulation & fibrous tissueGranulation & fibrous tissue
    20. 20. Osteomyelitis-gross & microscopy
    21. 21. Involucrum (new bone)
    22. 22. Jose R. Jimenez MD, UTHCT 28
    23. 23. Risk factors Osteomyelitis does not occur more commonly in a particular race or gender. However, some people are more at risk for developing the disease, including: People with diabetes Patients receiving hemodialysis People with weakened immune systems People with sickle cell disease Intravenous drug abusers The elderly Chronic steroid use
    24. 24. Immunosuppression,  And chronic joint disease. In addition, the presence of a prosthetic orthopedic device is an independent risk factor, as is any recent orthopedic surgery or open fracture.
    25. 25. Etiology and Pathophysiology ORGANISM POSSIBLE PROBLEM Staphylococcus aureus Pressure ulcer, penetrating wound, open fracture, orthopedic surgery, vascular insufficiency disorder Staphylococcus epidermidis Indwelling prosthetic device Streptococcus viridans Abscessed tooth, gingival disease Escherichia coli Urinary tract infection Mycobacterium tuberculosis Tuberculosis Neisseria gonorrhoeae Gonorrhea Pseudomonas sp. Puncture wounds, intravenous drugs Salmonella sp. Sickle cell disease Fungi, mycobacteria Immunocompromised host
    26. 26. Osteomyelitis Infants Children Streptococcus B Staphylococcus E. coli Staphylococcus aureus Streptococcus pyogenous Hemophilus influenzae
    27. 27. Osteomyelitis Adult Staphylococcus epidermidis Staphylococcus aureus Pseudomonas aeruginosa E. coli
    28. 28. Hematogenous osteomyelitis Most common in children, especially premature infants and babies born with complications. Hip joint destroyed by osteomyelitis
    29. 29. HEMATOGENOUS OSTEPMYELITISHEMATOGENOUS OSTEPMYELITIS Rapidly growing bone Children: Long bone, Femur, Tibia, Humerus Older patients: Vertebral bone
    30. 30. HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS Neonate & infant < 1 year oldNeonate & infant < 1 year old Septic arthritis is common.Septic arthritis is common. Growth deformities is common.Growth deformities is common. Soft tissue involvement is common.Soft tissue involvement is common.
    31. 31. HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS Children: 1 – 16 years oldChildren: 1 – 16 years old Most frequent in the metaphysis of long bone. History of antecedent trauma in 30% Involucrum •Part of periosteum that continues to have a blood supply forms new bone called involucrum Sequestration  Devitalized bone separates from living bone Associated septic arthritis
    32. 32. Once outside bone Sequestrum may Revascularize and then undergo removal by normal immune process Be surgically removed through debridement of necrotic bone If necrotic sequestrum is not resolved, it may develop a sinus tract resulting in chronic, purulent cutaneous drainage
    33. 33. HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS AdultAdult Less commonLess common Spread infection to joint space.Spread infection to joint space. Vertebral Osteomyelitis is common> 50yVertebral Osteomyelitis is common> 50y
    34. 34. Clenched fistClenched fist osteomyelitisosteomyelitis
    35. 35. Clinical Manifestations Acute Osteomyelitis Initial infection Infection of <1 month in duration Both systemic and local Systemic Fever, night sweats, chills, restlessness, nausea, Fatigue, Anorexia
    36. 36. Clinical Manifestations Acute Osteomyelitis Local Constant bone pain that worsens with activity Swelling, tenderness, warmth at infection site Restricted movement of affected part Later signs: drainage from sinus tracts
    37. 37. Failure to thrive Drowsy Irritable Metaphyseal tenderness Decrease ROM (range of motion)
    38. 38. Clinical Manifestations Chronic Osteomyelitis Bone infection lasting longer than a month Infection that has failed to respond to initial course of antibiotic therapy Systemic signs may be diminished Local signs of infection more common Constant bone pain Swelling, tenderness, warmth at infection site
    39. 39. Acute Osteomyelitis Differential Diagnosis Cellulitis Acute septic arthritis Acute rheumatism Sickle cell crisis Gaucher’s disease
    40. 40. Osteomyelitis Diagnosis Complete medical history Physical examination Full body examination and local tenderness.
    41. 41. Lab C-Reactive Protein Elevated WBC count Erythrocyte sedimentation rate (ESR)
    42. 42. Diagnostic Methods Bone or soft tissue biopsy Definitive way to determine causative microorganism Patient’s blood and/or wound culture Frequently positive for presence of microorganism Elevated WBC count Erythrocyte sedimentation rate (ESR)
    43. 43. Diagnostic Methods Radiologic signs Usually do not appear until 10 days to weeks after start of clinical symptoms Radionuclide bone scans Helpful in diagnosis and usually positive in areas of infection Magnetic resonance imaging (MRI) Computed tomography (CT) Help identify extent of infection, including soft tissue involvement
    44. 44. Osteomyelitis Ultrasound Fast diagnosis Possible punction Abscess
    45. 45. MRI of Acute Osteomyelitis 15 y/o with knee pain and acute osteomyelitis. Coronal image shows low signal intensity in the proximal epiphysis extending through the growth plate into the metaphysis of the tibia.
    46. 46. Osteomyelitis Bone scan Positive reply within 2-3 days. Non-specific – other changes with increased bone metabolism can give the same signs.  Bad resolution – no details are shown
    47. 47. Osteomyelitis MRI Early diagnosis – better than bone scan. Good because it shows soft tissue changes Abscess
    48. 48. Osteomyelitis Bacteriologic diagnosis Blood culture. Local culture.  Needle biopsy.
    49. 49. Complications Septicemia/ Bacteremia Metastatic infection Septic arthritis Altered bone growth Chronic osteomyelitis
    50. 50. COMPLICATIONCOMPLICATION Bone abscess Fracture Loosing of the prosthetic implant Overlying soft-tissue cellulitis Draining soft-tissue tract
    51. 51. Spondylitis (Vertebral osteomyelitis) Back pain in elderly people. Fever. Engages two vertebras and disc in between Caused by (Staph aureus).
    52. 52. Treatment Primarily non-operative. Surgery to improve local environment by remove infected bone and soft tissue. Decompressing abscess cavity. Facilitate antibiotic delivery.
    53. 53. TREATMENTTREATMENT Indication for SurgeryIndication for Surgery Hip joint involvement Neurologic complication Poor or no response to IV therapy Sequestration
    54. 54. Treatment Antibiotic therapy Bacteriologic diagnosis. Specific general antibiotic treatment. Local antibiotics.
    55. 55. Antibiotic therapy Early treatment important (after culture) Intravenous broad-spectrum Anti biotic until pain relief and clinical improvement (1-2 w). Oral antibiotics followed, often combination.
    56. 56. • Extensive debridement was carried out. Debris and dead bone were removed, and antibiotic cement beads were placed. • In this case, as in all cases of suppurative osteomyelitis, surgical debridement is primary, and antiobiotic treatment is supporitive.
    57. 57. Antibiotic therapy Antibiotics changed after culture and clinical course Staph aureus Streptococcus Penicillin G Follow CRP, ESR and leukocytes. Duration of Ab treatment at least 4 - 6 w after normalized CRP Cloxacillin, Rifampicin
    58. 58. b
    59. 59. PROGNOSISPROGNOSIS Is related to:Is related to: Causative organismsCausative organisms Duration of symptoms & signDuration of symptoms & sign Patient agePatient age Duration of antibiotic therapyDuration of antibiotic therapy
    61. 61. Osteomyelitis In adults, osteomyelitis is usually a sub acute or chronic infection that develops secondary to an open injury to bone and surrounding soft tissue.
    62. 62. Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis Clinical setting:Clinical setting: Postoperative infectionPostoperative infection Contamination of boneContamination of bone Contiguous soft tissue infectionContiguous soft tissue infection Puncture woundsPuncture wounds
    63. 63. Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis Microbiologic featuresMicrobiologic features StaphylococciStaphylococci  Aureus, EpidermidisAureus, Epidermidis Gram-negative bacteriaGram-negative bacteria Anaerobic infectionAnaerobic infection Unusual organismsUnusual organisms Clostridia, NocardiaClostridia, Nocardia
    64. 64. Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis DiagnosisDiagnosis Leukocyte countLeukocyte count Blood culture (infrequently positive)Blood culture (infrequently positive) ESR & CRPESR & CRP Radiologic evaluationRadiologic evaluation Technetium bone scanTechnetium bone scan Open bone biopsyOpen bone biopsy Culture of woundCulture of wound
    65. 65. Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis TreatmentTreatment Surgery is essential.Surgery is essential. AntibioticsAntibiotics
    66. 66. The End