This document discusses chronic osteomyelitis, including its causes, types, clinical features, investigations, staging, treatment, and differential diagnosis. Chronic osteomyelitis is caused by bacteria such as Staphylococcus aureus entering bone through breaks in the skin or surgery. It is characterized by destruction of bone tissue, formation of cavities containing pus and dead bone, and chronic inflammation. Diagnosis involves imaging like x-rays and biopsy. Treatment consists of long-term antibiotics, surgery to remove infected tissue, and management of any underlying risks or complications.

1. CHRONIC OSTEOMYELITIS
NUR AINA BINTI AB KADIR

2. CONTENTS
Pathology
Intro-
duction
Investigation
Treatment
Clinical
features
Staging

3. INTRODUCTION
 Chronic pyogenic osteomyelitis
 Incidence is decline
 Other causes: tuberculosis, fungal infections
Types Chronic osteomyelitis
secondary to acute
osteomyelitis
Garre’s osteomyelitis
Brodie’s abscess

4. CHRONIC OSTEOMYELITIS
 Open fracture/operation
 Staphylococcus aureus
 Escherichia coli
 Streptococcus pyogenes
 Proteus mirabilis
 Pseudomonas aeruginosa
 Staphylococcus epidermidis (foreign implants )

5. PREDISPOSING FACTORS
 COMMONEST: local trauma eg: open fracture/
prolonged bone operation, foreign implant
 Host defences:
 Scar formation
 Dead bone
 Blood vessel
 Bacteria covered in a protein-polysaccharides
slime (glycocalyx)

6. PREDISPOSING FACTORS
 Delayed and inadequate treatment
 Patient’s condition:
 Very old/debilitated
 Suffering from substance abuse
 Diabetes
 Peripheral vascular disease

7. PATHOLOGY
 Bone is destroyed or devitalized
 Cavities containing pus and pieces of dead
bone (sequestra)
 the result of chronic reactive new bone
formation – which may take the form of a
distinct bony sheath (involucrum).
 Sequestra act as substrates for bacterial
adhesion
 A sinus may seal off for weeks/ even months
healing

9. CLINICAL FEATURES
 Pain,Pyrexia,Redness,Tenderness
 Discharging sinus
 Longstanding cases the tissues are thickened
and puckered or folded inwards where a scar
or sinus adheres to the underlying bone.
 Seropurulent discharge and excoriation of the
surrounding skin.
 Post-traumatic osteomyelitis: the bone may
be deformed or ununited

10. IMAGING
X- ray
Radio
Isotope
scintigraphy
CT scan MRI

11. IMAGING
 X-ray examination: bone resorption patchy
loss of density/frank excavation around an
implant & thickening & sclerosis of the
surrounding bone
 Crudely thickened & mishappentumour
 Sinogram: help

13. IMAGING
 Radioisotope
scintigraphy
 Sensitive,not
specific.
 99mTc-HDP scans:
increased activity
 67Ga-citrate or
111In-labelled
leucocytes: specific
for osteomyelitis
hidden foci of
infection.
 CT and MRI  the
extent of bone
destruction and
reactive oedema,
hidden abscesses
sequestra.

14. Technetium
Indium

15. INVESTIGATIONS
 Elevated CSR,ESR and WBC levels.
 Cultures of organisms- antibiotic sensitivity-
deep tissue
 Molecular technique- amplication of bacterial
DNA/RNA fragments(PCR), by gel
electrophoresis

16. STAGING-ADULT
LESION TYPE
STAGE 1 MEDULLARY
STAGE 2 SUPERFICIAL
STAGE 3 LOCALIZED
STAGE 4 DIFFUSE
TYPE A NORMAL
TYPE B COMPROMISED BY LOCAL/SYSTEMIC CONDITION
TYPE C SEVERELY COMPROMISED BY LOCAL AND SYSTEMIC
CONDITIONS
CATEGORY INTERPRETATION
Stage 1 or 2, Type A Least serious
Stage 1,2,3, Type B Have chance of recover
Type C Poor prognosis
Stage 4 Long term palliative care

17. TREATMENT
Antibiotic
Local
treatment
Operation

18. ANTIBIOTIC
 To suppress the infection, prevent its spread to
healthy bone
 Control acute flares
 Choices:
 Microbiological studies
 Capable of penetration
 Non toxic for long-term use

19. ANTIBIOTIC
 Fusidic acid, clindamycin, cephalosporins
 Meticillin-resistant Stapyhlococcus aureus
infection (MRSA): vancomycin and teicoplanin
 4-6 weeks –serum antibiotic concentration
measurement
 Surgical clearance failed continue for
another 4w
 Continuous collaboration with a microbiologist.

20. LOCAL TREATMENT
 Simple dressing
 Colostomy paste
 Acute abscess urgent incision & drainage

21. OPERATION
 INDICATIONS
 chronic haematogenous infection
 intrusive symptoms
 failure of adequate antibiotic treatment
 evidence of a sequestrum
 post-traumatic and postoperative infections
 intractable wound and/or an infected ununited
fracture
 Presence of foreign implant

22.  Debridement
 Dealing with the ‘dead space’
 Soft tissue cover
 After care

23. Dealing with the ‘dead space’
 Porous antibiotic-impregnated beads can be
laid in the cavityleft for 2/3 weeksreplaced
with cancellous bone grafts.
 Papineau technique: the entire cavity is
packed with small cancellous chips mixed with
an antibiotic and a fibrin sealantarea is
covered by adjacent muscle & the skin wound
is sutured without tension

24. Dealing with the ‘dead space’
 Radical excision of all avascular and infected
tissue followed by closed irrigation and suction
drainage of the bed using double-lumen tubes
and an appropriate antibiotic solution in high
concentration.
 The spaces is gradually filled by vascular
granulation tissue
 Tubes is removedculture negative
 Refractory caseexcise the infected and/or
devitalized segment of bone completely and
then close the gap by the Ilizarov method

25. DIFFERENTIAL DIAGNOSIS
Tubercular
osteomyelitis
• Thin& watery discharge
• Often multifocal
Soft tissue
infection
• Absence of thickening of underlying bone
• Absence of sinus fixed to the bone
Ewing’s
sarcoma
• Sudden onset of pain & swelling
• Biopsy

26. GARRE’S SCLEROSING
OSTEOMYELITIS

27. GARRE’S SCLEROSING
OTEOMYELITIS
 Rare form of non-suppurative osteomyelitis
 Marked sclerosis, cortical thickening
 No abscess, diffuse enlargement of the bone
at the affected site
 Adolescent and young adult
 Long history of aching and slight swelling over
the bone
 Recurrent attack of acute pain with malaise
and slight fever

28. X-RAY
 increased bone density and cortical thickening
 some cases the marrow cavity is completelly
obliterated.
 There is no abscess cavity.
 Diaphysis and mandible

29. DIAGNOSIS
 If a small segment of bone is
involvedosteoid osteoma.
 If there is marked periosteal layering of new
boneEwing’s sarcoma.
 Biopsy: low-grade inflammatory lesion with
reactive bone formation
 Micro-organism culture: staphylococal
infection

30. TREATMENT
 Operation:
 the abnormal area is excised and the exposed
surface thoroughly curetted.
 Bone grafts, bone transport or free bone
transfer may be needed.

31. Also know as SUBACUTE
HAEMATOGENOUS OSTEOMYELITIS
BRODIE’S ABSCESS

32. PATHOLOGY
 well-defined cavity in cancellous bone –
usually in the tibial metaphysis – containing
glairy seropurulent fluid (rarely pus).
 The cavity is lined by granulation tissue
containing a mixture of acute and chronic
inflammatory cells.
 The surrounding bone trabeculae are often
thickened.
 The lesion sometimes encroaches on and
erodes the bony cortex.

33. CLINICAL FEATURES
 child or adolescent
 had pain near one of the larger joints for
several weeks or even months.
 Limp,slight swelling, muscle wasting and local
tenderness.
 The temperature is usually normal and there
 is little to suggest an infection.
 The WBC count and blood cultures usually
show no abnormality but the ESR is
sometimes elevated

34. IMAGING
 lesion is a circumscribed,
 round or oval radiolucent ‘cavity’ 1–2 cm in
diameter.
 tibial or femoral metaphysis, but it may occur in
the epiphysis or in one of the cuboidal bones (e.g.
the calcaneum).
 Sometimes the ‘cavity’ is surrounded by a halo of
sclerosis extending into the diaphysis.
 Metaphyseal lesions cause little or no periosteal
reaction; diaphyseal lesions may be associated
with periosteal new bone formation and marked
cortical thickening.
 If the cortex malignant tumour.

35. DIAGNOSIS
 Clinical and x ray appearances may resembles
osteoid osteoma,cystic tuberculosis,
eosinophilic granuloma
 Biopsy
 If fluid is encountered: bacteriological culture

36. TREATMENT
 Conservative
 Immobilization
 Antibiotic (flucloxacillin & fusidic acid)
 IV for 4-5 days
 Oral 6 weeks
 Diagnosis in doubt: open biopsy + curettage
 Curettage: x-ray shows no healing after
conservative treatment

37.  Apley’s System of Orthopaedics and Fracture
,11th edition, page 36-41
 Essential orthopaedics by Maheshwari
 http://reference.medscape.com/features/slides
how/osteomyelitis#page=7
 http://radiopaedia.org/articles/osteomyelitis
REFERENCES