I. Chronic osteomyelitis is an inflammation of bone caused by infection that remains debilitating, especially in developing countries, despite antibiotics. II. It has multiple presentations and causes, can lead to complications like sequestrum and involucrum formation, and is diagnosed through history, exams, imaging and microbiology. III. Treatment involves antibiotics, extensive surgical debridement of devitalized tissue, management of dead space, and sometimes reconstruction or amputation in severe cases.

1. Chronic
osteomyelitis
Dr. Mohamed Jukaku
www.mjortho.com

2. Introduction
• Osteomyelitis- Inflammation of bone caused by infecting organism
• Mortality & morbidity high in pre-antibiotic era
• Antibiotics have changed prevalence & outcome considerably
• Yet osteomyelitis remains to be a debilitating disease especially in
developing countries.

3. Etiopathogenesis
No age restriction, childhood more common
Developing countries: Malnourishment, poor sanitation, improper
antibiotic use
Neglected/Improperly treated injuries
Late presentation to healthcare facilities

4. Pathophysiology
• Structure of bone & immune system of host
• Nature & character of Invading organism
• Role of antibiotics

5. Chronic Osteomyelitis
Failure of early diagnosis &
improper treatment of early
infection
De Novo
-Low virulence
organisms/subclinical cases

6. Spread of infection
Joint infection
If infected region is intracapsular/blood vessels traverse the physis, as in
neonates
(Trueta 1959; Ogden 1979)

7. Sequestrum ||Involucrum
Large subperiosteal abscess may elevate periosteum from shaft
Occlusion of nutrient vessels
Death of bone
Sequestrum formation

8. Stripped periosteum
(provided with its own blood supply from muscle attachments)
Lays down new bone in a shell- Involucrum
Around the old shaft- Sequestrum

9. I: From sequestrum, area of devascularised dead bone, progression of intramedullary infection towards an intracapsular location can lead to septic arthritis; progression
of infection towards a subperiosteal location can lead to periosteal elevation. II: New bone formation as result of massive periosteal elevation. III: Extension of
sequestrum & necrotic material through cortical bone creates a fistula & ultimately breaks through skin
-Jauregui, LE and Senour, CL. in: LE Jauregui (Ed.) Diagnosis & management of bone infections. Marcel Dekker, New York; 1995: 37–108

12. Whole shaft of femur is
sequestrated with
surrounding abscess

14. Anatomical classification of adult
osteomyelitis
A, Type I, intramedullary osteomyelitis;
nidus is endosteal.
B, Type II, superficial osteomyelitis;
limited to bone surface.
C, Type III, localized osteomyelitis, full
thickness of cortex is involved.
D, Type IV, diffuse osteomyelitis; entire
circumference of the bone is
involved.
(Redrawn from Parsons B, Strauss E: Surgical
management of chronic osteomyelitis, Am J Surg
188[Suppl]:57S, 2004.)

15. Diagnosis
• Based on:
1. History
2. Physical Examination
3. Radiographs
4. Operative findings
5. Histopath & microbiology

16. 3 Variations of Presentation
1. Active infection with swelling & continuous discharge from sinus/es
2. Controlled infection with frequent flare ups, f/o subacute infection
& sinuses with purulent discharge reappear
3. Sinus with discharge from time to time. Patients worried about
recurrent discharge, otherwise patient in good health, no other
local symptoms/signs present

17. Culture from discharge
• Staphylococcus aureus
• Escherichia coli
• Streptococcus pyogenes
• Proteus
• Pseudomonas
• Secondary contaminants

18. INVESTIGATIONS
• Hb – Anaemia work up
• Total & differential counts
• ESR & Crp
• Blood proteins to assess degree of anemia & depletion of body
proteins in cases with copious purulent discharge.

19. RADIOGRAPHIC APPEARANCE
• Xrays
-Plain films show soft-tissue swelling, narrowing /widening of joint
spaces, bone destruction & periosteal reaction
-Bone destruction, apparent on plain films after 10–21 days of infection
*Gold RH, Hawkins RA, Katz RD. Bacterial osteomyelitis: findings on plain radiography, CT, MR, & scintigraphy. AJRAm J Roentgenol
1991; 157: 365–70.
*Kaim AH, Gross T, von Schulthess GK. Imaging of chronic posttraumatic osteomyelitis. Eur Radiol 2002; 12: 1193–202.
*Santiago Restrepo C, Gimenez CR, McCarthy K. Imaging of osteomyelitis & musculoskeletal soft tissue infections: current concepts.
Rheum Dis Clin North Am 2003; 29: 89–109.

21. Chronic osteomyelitis of humerus
with sequestrum
-Therapeutic Aspects of Chronic Bone Infections & Management
Challenges; Charles Diémé et al, Open Journal of Orthopedics
Vol.4 No.2(2014),

23. -Value of sinogram in case of extensive resection
& debridement of osteomyelitis who developed a
sinus.
-2-3yrs after surgery, sinogram reveals area which
harbored latent infection which flared up.
Sinogram

25. • Radionuclide imaging, CT scans or MRI becomes necessary to localize
site of active infection, necrotic bone & to assess involvement of the
surrounding soft tissues.

26. RADIONUCLIDE STUDIES
Technetium polyphosphate ‘Tc’ scan
• Demonstrates ↑ isotope accumulation in areas of more blood flow &
reactive new bone formation (Jones et al. 1976)
• In cases with impaired blood supply to infected area negative ‘Tc’
scans is seen (Russin and Staab 1976)

27. Gallium scan
• Shows ↑ isotope uptake in areas concentrating PMN leukocytes,
macrophages, & malignant tumors
• Gallium citrate scan doesn’t show bone detail well
• May be difficult to distinguish between bone & soft tissue
inflammation.

28. Indium-labeled leukocyte
• Scans positive in approximately 40% of patients with acute
osteomyelitis
• Positive in 60 per cent of patients with septic arthritis
• Chronic osteomyelitis may show negative indium-labeled leukocyte
scans.

29. Technetium 99m bone
scan
• Diffusely ↑ multifocal radiotracer uptake in
Rt femur shaft & Lt prox. humerus
• After 13 months of treatment, ↓ in radiotracer uptake,
associated with healing state of osteomyelitis

30. TREATMENT
G e n e r a l P r i n c i p l e s
• Rest, balanced high protein diet & hematinics
• Broad range parenteral bacteriolytic antibiotics started empirically
after taking blood & culture samples till reported
• Attempts made to take sample depth of sinus when present
• If positive- acts as rough guide to antimicrobial drugs
• However, culture from sinus material misleading

31. • In polymicrobial infection with sinus, more than one antibacterial
agent to be used
• Repeated cultures need to be obtained to detect bacterial flora with
altered sensitivity tests, appropriate change in therapy then becomes
necessary

32. Surgical treatment
3 Principles
1. Removal of all devitalized bone & tissue
2. Obliteration of dead space
3. Soft tissue coverage

33. Sequestrectomy & Curettage
• Requires considerable time to
perform & more blood loss than
one can anticipate.
• Sinus tracks injected with
methylene blue 24 hrs pre
surgery to make them easier to
locate & excise

34. • Excise sinus tracks
• Oval cortical window at appropriate site with osteotome.
• Remove sequestra, purulent material, and scarred necrotic tissue
• Medullary canal opened in both directions to allow blood vessels to
grow into cavity.
• Debride until “paprika sign” (active punctate bleeding bone) achieved

35. Antibiotics in Chr. Osteomyelitis
• Used only as adjuvants to local treatment & not for eradicating
infection
• Local treatment  Debridement
• Removal of all sequestra, deep scar tissues in depth of bone &
surrounding soft tissues, intracortical abscess, etc.
• So as to leave area of clean, well vascularized bone & soft tissue cover
at end of debridement

36. Dead Space Management
1. Bone grafting with primary/secondary closure
2. Antibiotic PMMA beads as a temporary filler of the dead space
before reconstruction
3. Local muscle flaps & skin grafting with or without bone grafting
4. Microvascular transfer of muscle, myocutaneous, osseous, &
osteocutaneous flaps
5. Bone transport (Ilizarov technique).

38. OPEN BONE GRAFTING
• Papineau et al. described an open bone grafting technique for the
treatment of chronic osteomyelitis
• Procedure relies on formation of granulation tissue in a bed of bone
graft that will become rapidly vascularized
• Granulation tissue resists infection

39. • The surgery is divided into 3 stages
(1) Debridement & stabilization
(2) Cancellous autografting
(3) Skin closure
• Culture-specific intravenous antibiotics should be continued beyond
the last surgical procedure.

40. VAC - Vacuum-assisted closure
• Archdeacon & Messerschmitt described a modification of Papineau
technique using vacuum-assisted closure (VAC)
• VAC has been used extensively in the acute trauma setting & is useful
for decreasing edema & for closure of dead space
• VAC also stimulates the formation of granulation tissue

46. Local antibiotic delivery
• Polymethylmethacrylate Antibiotic Bead Chains (PMMA)
• Intramedullary antibiotic cement nail
Biodegradable substances used as antibiotic delivery systems classified into:
(1) Proteins
(2) Bone graft materials/substitutes
(3) Synthetic polymers

47. Genta-PMMA beads inserted in a TKR
post debridement (retained prosthesis).
Beads placed in suprapatellar bursa &
removed after 2 weeks.

49. (1) Proteins: Collagen, gelatin, thrombin, & autologous blood clot, they
provide a scaffolding that can be used to contain an antibiotic
(2) Bone graft: Calcium sulfate
(3) Synthetic polymers: Can be modified to release specified drug
quantities over specified time. Polylactide, Poly(D,L)-lactide-
coglycolide beads impregnated with vancomycin.

51. CLOSED SUCTION DRAINS
• Success rates of 85% have been reported for modified
Lautenbach method of closed suction- irrigation system

52. Complications
• Acute exacerbations
• Growth abnormalities: Shortening (Growth plate damage)
Lengthening (↑vascularity of growth plate)
• Deformities
• Pathological fracture
• Joint stiffness
• Sinus Malignancy
• Muscle contracture
• Amyloidosis

53. Growth arrest
• If Infection located in vicinity of growth plate, damage may occur
• May be localized to part of physis
• Location & area of damage determines whether growth arrest occurs
• Limb length discrepancy/angular deformities may develop
• Frequency of growth plate damage following osteomyelitis estimated
to be around 3% in children & higher in neonates

54. Surgical Management Physeal Involvement
• Physeal bar resection
• Limb lengthening
• Angular correction
• Epiphyseodesis

55. SA orthop. j. vol.9 n.2 Centurion Jan. 2010,
Orthopaedic implications of physeal arrest
following meningococcal septicaemia, J-P du
Plessis

57. PATHOLOGICAL FRACTURE
• Because the involucrum is sometimes insufficient/a result of
becoming dense & brittle
• All treatment necessary to combat infection carried out,
• Bone fragments realigned & immobilized
• External fixation/cast immobilization is preferred
• If bone loss is significant, defect filled with autogenous bone graft,
vascularized osseous graft, or bone transport using Ilizarov technique

58. ILIZAROV TECHNIQUE
• Helpful in the treatment of chronic osteomyelitis & infected nonunions.
• Allows radical resection of the infected bone.
• Corticotomy is performed through normal bone proximal & distal to area of
disease.
• The bone is transported until union is achieved.
• Disadvantage: time required & high incidence of associated complications.
• Use of distraction osteogenesis with ring fixation over an intramedullary
rod has been used for the treatment of segmental defects of up to 13 cm.

60. Malignancy
• Malignancy arising from chronic osteomyelitis: -0.2%-1.6%
• Most of these are SCC arising from sinus track, reticulum cell
carcinoma, fibrosarcoma, & others have been reported.
• Treatment: Complete tumour resection  Limb Salvage/Amputation

61. AMPUTATION FOR OSTEOMYELITIS
• Performed infrequently for osteomyelitis
• In certain cases, may be preferable to multiple surgeries & prolonged
antibiotic therapy.
• Arterial insufficiency, major nerve paralysis, or joint contractures &
stiffness that make a limb nonfunctional are indications for
amputation

62. www.mjortho.com
@mjorthopedics
References
• Campbell’s operative orthopaedics, twelfth edition, Vol 1, Part VII, Chapter 21, Osteomyelitis
• Textbook of Orthopedics & Trauma, GS Kulkarni, Pyogenic Hematogenous Osteomyelitis: Acute & Chronic, SC Goel
• Paediatric Orthopaedics, Benjamin Joseph, Section 8, Infections
• Lancet 2004; 364: 369–79, Osteomyelitis, Daniel P Lew, Francis A Waldvogel
• Open Journal of Orthopedics, 2014, 4, 21-26, Therapeutic Aspects of Chronic Bone Infections & Management Challenges, Charles
Diémé
• SA orthop. j. vol.9 n.2 Centurion Jan. 2010, Orthopaedic implications of physeal arrest following meningococcal septicaemia, J-P du
Plessis