This document provides information on chronic osteomyelitis, including types, pathology, diagnosis, and treatment. It notes that chronic osteomyelitis is usually caused by delayed or inadequate treatment of acute osteomyelitis, which allows spread of infection and bone death. Key features include sequestra (dead bone), involucrum (dense bone overlying sequestra), sinus tracts, and irregular thickened bone visible on x-ray. Treatment involves surgery to remove dead bone and tissue along with antibiotics to eliminate infection. Complications can include exacerbations, growth abnormalities, fractures, or rarely malignant changes in long-standing cases.

1. BY:-
SRAVANTHI
BPT III
YEAR.
CARE
INSTITUTE
OF
MEDICAL
SCIENCES.

2. INTRODUCTION:-
 The term chronic osteomyelitis is
used for chronic pyogenic
osteomyelitis.
INCIDENCE:-
 Occurs less in developed countries and
more in developing countries.
ETIOLOGY:-
 Tuberculosis , fungal infections etc.

3. TYPES:-
 3 types:-

4. PATHOLOGY:-
 Acute osteomyelitis commonly leads to
chronic osteomyelitis because of any one
or more of the following reasons:-
a)Delayed and inadequate
treatment:-
 It’s the commonest cause for the
persistence of osteomyelitis.
 Delay causes spread of pus within the
medullary cavity and subperiosteally.

5.  This results in death of a part of a bone
(sequestrum formation).
 Destruction of cancellous bone leads to
formation of cavities within the bone.
 Such non-collapsing bone cavities and
sequestra are responsible for persistent
infection.
b) Type and virulence of organism:-
 Despite early , adequate treatment of acute
osteomyelitis, the body defense mechanism
may not be able to control the damaging
influence of a highly virulent organism, and
the infection persists.

6. c)Reduced host resistance:-
 Malnutrition compromises the body's
defense mechanisms, thus letting the
infection persist.
 When the infection persists because
of above reasons, the host bone
responds by generating more and
more subperiosteal new bone.
 This results in a thickening of the
bone.

7.  The subperiosteal bone is deposited in a
very irregular fashion so that the
osteomyelitic bone has irregular surface.
 The continues discharge of pus results in
the formation of a sinus.
 With time , the wall of the sinus gets
fibrosed and the sinus becomes fixed to
the bone
 With the time, the wall of the sinus gets
fibrosed and sinus becomes fixed to the
bone.

8.  SEQUESTRUM:-
-It’s a piece of dead bone
surrounded by infected granulation tissue trying
to eat the sequestrum away.
-It appears pale and has
smooth inner and rough outer surface because
the latter is being constantly eroded by the
surrounding granulation tissue.
 INVOLUCRUM:-
-It’s a dense sclerotic bone overlying a
sequestrum .
-There may be some holes in
the involucrum for pus to drain out.
-These holes are called
cloacae.
-The bony cavities are lined
by infected granulation tissue.

10. DIAGNOSIS:-
 The diagnosis is suspected clinically.
 Its confirmed radio logically by its
characteristic features.
 Disease begins in childhood.
 Lower end of Femur is commonest site.
PRESENTING COMPLAINTS:-
 Chronic discharging is the commonest
presenting
symptom.
 Often sinus heal for short periods, only to
reappear with each acute exacerbation.

11.  The quality of discharge varies from sero -
purulent to thick pus.
 There may be a history of small bone
fragments from the sinus.
 Pain - minimal but may become aggravated
during acutecondition.
 Generalized symptoms of infection such as
fever etc are present during acute condition.

12. EXAMINATION:-
 Chronic discharging sinus:-
-sinus is fixed to underlying bone.
-There may be sprouting granulation
tissue at its opening, indicating a sequestrum
within the bone.
-The sequestrum may be visible at
the mouth of the sinus itself.
-The sinus may be surrounded by
healed puckered scars, indicating previous healed
sinuses.

13.  Thickened irregular bone:-
- This can be
appreciated on comparing the girth of
the affected bone with that of the
bone on the normal side
 Tenderness on deep palpation:-
-Usually mild
 Adjacent joint:-
-Stiff, either due
to excessive soft tissue scarring
around the joint or because of
associated arthritis of the joint.

14.  INVESTIGATIONS:-
(i) RADIOLOGICAL
EXAMINATION:-
The features seen in chronic osteomyelitis
are:-
 thickening and irregularity of the cortices.
 Patchy sclerosis giving rise to honey
combed appearance.
 Bone cavity:- This is seen as an area of
rarefaction surrounded by sclerosis.

15.  Sequestrum:-this appears denser than the
surrounding normal bone because the
decalcification which occurs in normal bone does
not o occur here
 The granulation tissue surrounding the
sequestrum gives rise to a radiolucent zone
around it.
 A sequestrum may be visible in soft tissues.
 Involucrum and cloacae may be visible.
(II) BLOOD:-
 A blood examination is usually of no help.
 ESR – mildly elevated
 Total blood counts are increased during acute
exacerbation only.

16. (III)PUS:-
 Pus culture may grow the causative organism,
 This is useful for the control of the acute stage or
may help in selecting the pre-operative antibiotics
as and when operation is performed.
 DIFFERENTIAL DIAGNOSIS:-
 A history of bone piece from a sinus is used for
diagnosis of chronic osteomyelitis.
other differential diagnosis are:-
1.) Tuberculosis Osteomyelitis:-
 The discharge is often thin and watery .
 A tubercular sinus may show its characteristic
featured like undetermined margins and bluish
surrounding skin.

17.  Tubercular osteomyelitis is often multi focal .
 The patient may be suffering from or may have
suffered from pulmonary tuberculosis.
2) Soft-tissue infection:-
 A long standing soft tissue infection with a long standing
discharging sinus may mimic osteomyelitis.
 The absence of any radiological changes in the bone would
help in diagnosis.
3) Ewing’s sarcoma:-
 A child with this disease presents with a rather sudden
onset of pain and swelling mostly in the diaphysis.
 Radiological appearance often resembles that of
osteomyelitis
 A biopsy will settle the diagnosis.

18. TREATMENT:-
o Principles of treatment:-
o Its treatment primarily is surgery.
o Antibiotics are useful only during acute exacerbations and during the
post-operative period
o Aims:-
(i) The removal of dead bone.
(ii)The elimination of dead space.
(iii)The removal of infected granulation tissue and
sinuses.
o Operative measures:-
1. Sequestrectomy:-
 Removal of sequestrum.
 If it lies within the medullary cavity , a window is made
in the overlying involucrum and sequestrum removed.
 One must wait for adequate involucrum formation before
performing Sequestrectomy.

19. 2.Saucerization:-
 A bone cavity is a non – collapsing cavity so that
there is always some pent up pus inside it.
 This is responsible for the persistence of an
infection.
 In saucerization , the cavity is converted into a
saucer by removing its wall.
This allows free drainage of the infected material.

20. 3.Curettage:-
 The wall of the cavity lined by infected
granulation tissue is curetted until the underlying
normal looking bone is seen.
 The cavity is sometimes filled with gentamycin
impregnated beads to fill up the dead space.
4.Excision of an infected bone:-
 In a case where the affected bone can be excised
en-bloc without compromising the functions of the
limb, it is a good method e.g., osteomyelitis of a
part of the fibula.
 With the availability of ilizarov’s technique, an
aggressive approach i.e, excising the infected
bone segment and building up the gap by
transporting a segment of the bone from adjacent
part shows good results.

21. 5.Amputation:-
 It may very rarely be preferred in a case
with a long standing discharging sinus
especially if the sinus undergoes a
malignant change.
 In most cases, a combination of these
procedures is required.
 After surgery the wound is closed over a
continuous suction irrigation system.
 This system has an inlet tube going to the
medullary cavity and an outlet tube
bringing the irrigation fluid out.

22.  A slow suction is applied to the outlet
tube.
 The irrigation fluid consists of antibiotics
and a detergent.
 The medullary canal is irrigated in this
way for 4-7 days

23. COMPLICATIONS:-
1.An acute exacerbation or flare up of the
infection occurs commonly.
 It subsides with a a period of rest, and
antibiotics-either broad spectrum or based on
a pus culture and sensitivity report.
2. Growth abnormalities:
 The osteomyelitis may cause growth
disturbance at the adjacent growth plate by:-
 shortening when the growth plate is damaged.
 lengthening because of the increased
vascularity of the growth plate due to the
nearby osteomyelitis.

24.  Deformities may appear if a part of the growth
plate is damaged and the remaining keeps
growing.
3) A pathological fracture may occur through a
weakened area of the bone. Treatment is by
conservative methods.
4)A joint stiffness may occur because of
scarring of the soft tissues or a secondary
infection of the joint.
5)Sinus tract malignancy is a rare complication.
It occurs many years after the onset of
osteomyelitis. It is usually a squamous cell
carcinoma. The patient may need amputation.
6)Amyloidosis as with all other long standing
suppuratios, this is a late complication of
osteomyelitis.

25.  PROGNOSIS:-
 To cure bone infection is very difficult.
 Operative intervention may be useful if there is an
obvious factor responsible for persistence of the
infection. E.g.., sequestrum, cavity etc.
GARRE’S OSTEOMYELITIS:-
 This is a sclerosing non suppurative chronic
osteomyelitis.
 It may begin with acute local pain, pyrexia and
swelling.
 The pyrexia and pain subside but the fusiform
osseous enlargement persists.
 There is tenderness on deep palpation.
 There is no discharging sinus.
 The shafts of the femur or tibia are most
commonly affected.

26.  The importance of Garre's osteomyelitis lies
in differentiating it from bone tumors , which
commonly present with similar features e.g..,
Ewing’s tumor or osteosarcoma.
 Treatment is guarded.
 Acute symptoms subside with rest and broad
spectrum antibiotics.
 Sometimes making a gutter or holes in the
bone bring relief in pain.
BRODIE’S ABSCESS:-
 It’s a special type of osteomyelitis in which
the body defense mechanism have been able
to contain the infection so as to create a
chronic bone abscess containing pus or jelly
like granulation tissue surrounded by a zone
of sclerosis.

27.  Clinical features:-
 The patient is usually between 11-20 years
of age.
 The common sites are the upper end of the
tibia and lower end of femur.
 It is usually located at the metaphysis.
 A deep boring pain is the predominant
symptom .
 It may become worse at night.
 In some instances it becomes worse on
walking and is relieved by rest.
 Occasionally, there may be a transient
effusion in the adjacent joint during
exacerbation of the symptoms.
 An examination may reveal tenderness and
thickening of bone.

28.  Radiological features:-
 The radiological picture is diagnostic.
 It shows a circular or oval lucent area
surrounded by a zone of sclerosis.
 The rest of the bone is normal.
 Treatment is by operation.
 Surgical evacuation and curettage is
performed under antibiotic over.
 If the cavity is large, it is packed with
cancellous bone chips.

29. SALMONELLA OSTEOMYELITIS:-
 This occurs during the convalescent phase
after an attack of typhoid fever.
 It is sub acute type of osteomyelitis,
usually occurring in the ulna, tibia or
vertebra.
 Often, multiple bones are affected
sometimes bilaterally symmetrical.
 The predominant radiological feature is a
diaphysial sclerosis.
 The disease occurs more commonly in
children with sickle cell anemia.