Chronic osteomyelitis is a severe, persistent infection of bone resulting from various causes, including trauma and postoperative complications. It is characterized by necrotic bone, purulent material, and an avascular envelope that renders systemic antibiotics largely ineffective. Diagnosis involves clinical examination and imaging studies, while treatment often requires surgical intervention followed by a course of intravenous antibiotics.

1. Chronic osteomyelitis
Presented by
Dr. Karrar Kareem Al-Jubory
Orthopedic surgeon
FICMS, CABMS (ORTHO)

2. Introduction
Severe,persistent and
incapacitating infection
of bone and bone
marrow.
• Sequele to acute
haematogenous
osteomyelitis

3. Introduction
Definition:
An inflammation of the bone
caused by an infecting
organism.
The infection may be limited
to a single portion of the bone
or may involve the marrow,
cortex, periosteum, and the
surrounding soft tissue.

4. Classification
Duration of symptoms
(acute, subacute, and
chronic)
Mechanism of infection
exogenous or
hematogenous.
Based on the host response to
the disease.
pyogenic or nonpyogenic

5. When the duration of
osteomyelitis is more than
3weeks, its called
ch. osteomyelitis.
Causes-
1.Trauma causing open
fractures.
2.Post operative.
3.Osteomyelitis with chronic
etiology- - TB - Brodie’s
abscess. - Fungal osteomyelitis

6. Chronic osteomyelitis is
difficult to eradicate
completely.
Systemic symptoms may
subside, but one or more foci
in the bone may contain
purulent material, infected
granulation tissue, or a
sequestrum

8. Pathology
Necrosis >> stage of new bone
formation >> involucrum. >>
with sequestrum inside, with a
persistent discharging sinus.
>> pus from bone escapes
through multiple hole in
involucrum

9. The hallmark of chronic
osteomyelitis is infected dead
bone within a compromised
soft-tissue envelope.
The infected foci within the
bone are surrounded by
sclerotic, relatively avascular
bone covered by a thickened
periosteum and scarred muscle
and subcutaneous tissue.
This avascular envelope of
scar tissue leaves systemic
antibiotics essentially
ineffective.
Secondary infections are
common, and sinus track
cultures usually do not
correlate with cultures obtained
at bone biopsy.
Multiple organisms may grow
from cultures taken from sinus
tracks and from open biopsy
specimens of surrounding soft
tissue and bone.

11. Clinically
Pain, swelling.
Discharging sinus.
Bone thickening.
Deformity.
Joint stiffness.
Shortening of limb,
Pathological fracture.
Sinus track
malignancy.

12. Cierny and Mader Staging System
I Medullary >> Endosteal disease
II Superficial >> Cortical surface
infected because of coverage defect
III Localized >> Cortical sequestrum
that can be excised without
compromising stability
IV Diffuse >> Features of I, II, and
III plus mechanical instability before
or after débridementl sequestrum

13. Differential diagnosis and diagnosis
1.TB osteomyelitis- watery
discharge. - previous h/o TB,
sinus with undermined margin
with blue colour.
2. Ewing's sarcoma- A primary
malignant tumor of bone,
usually arising as a central
tumor in long bone. (biopsy)
3. Soft tissue chronic infection.
(X-ray)
Diagnosis :
Clinical, Laboratory, and
Imaging studies.
The “gold standard” is to
obtain a biopsy specimen for
histological and
microbiological evaluation of
the infected bone

14. Diagnosis
Clinical examination - Integrity of the skin and soft tissue -areas
of tenderness -assess bone stability - neurovascular status of the
limb.
Laboratory investigations Blood counts ESR CRP

15. Imaging studies
Plain radiographs
Cortical destruction
Periosteal reaction
Sequestrum deformity
Sclerotic bone

16. Sinography
CT Scan >> Cortical bone and
surrounding soft tissues and is
especially useful in identifying
sequestra.

17. MRI
The extent of the pathological
insult by showing the margins
of bone and soft-tissue edema.
Well-defined rim of high signal
intensity surrounding the focus
of active disease seen
(rim sign)

18. Treatment
Supportive treatment .
Antibiotics – to prevent
spread.
Surgery – sequestretomy +
saucerization [cannot be
eradicated without surgical
intervention]
Sinus tracks can be injected
with methylene blue 24 hours
before surgery to make them
easier to locate and excise.

19. After Treatment
6-week course of intravenous
antibiotics is given after
surgical débridement
The limb is splinted until the
wound has healed, and then it
is protected to prevent
pathological fracture

20. Methods described to eliminate dead
space
(1) Bone grafting with primary or secondary closure
(2) Antibiotic polymethyl methacrylate (PMMA) beads as a
temporary filler of the dead space before reconstruction
(3) Local muscle flaps and skin grafting with or without bone
grafting
(4) Microvascular transfer of muscle, myocutaneous, osseous,
and osteocutaneous flaps
(5) The use of bone transport (Ilizarov technique).

22. Complications
Joint stiffness.
Shortening.
Muscle contracture.
Pathological fracture.
Sinus track malignancy (sq. cell CA).
Amyloidosis.

23. THANK YOU