Chronic osteomyelitis, an infective condition of bone and marrow, management is most for the condition.

1. Chronic Osteomyelitis

2. Introduction
• In pre antibiotic era mortality and morbidity following
osteomyelitis was very high.
• Antimicrobials drugs have changed the course of
osteomyelitis but in developing and under developed
countries, where health care facilities are inadequate,
osteomyelitis remains a problem.

3. Reasons for such a situation
• Failure to suspect correct diagnosis
• Failure to perform the simple clinical investigations which
can confirm the suspicion
• Failure to initiate properly planned therapeutic program
• Failure to continue treatment till the disease is eliminated

4. • Hallmark of chronic osteomyelitis: infected dead bone within
a compromised soft tissue envelope.
• The infected foci within the bone- surrounded by sclerotic
relatively avascular bone covered by a thickened periosteum
and scarred muscle and subcutaneous tissue.

5. Predisposing factors
• Incomplete treatment of acute OM(most common)
• Trauma
• Implant related infection
• A hematogenous type of OM
• Compound fractures
• Infection with chronic persisting type of microbes(M.
tuberculosis, Treponema species, etc)
• Osteomyelitis associated with diabetic foot, vascular disease,
etc.

6. Pathology
• Bone destruction or devitalization (discrete or diffuse)
• Formation of cavities containing pus and pieces of dead
bone(sequestrum)
• Surrounded by vascular tissue, and beyond that by areas of
sclerosis(involucrum)

7. • Sequestrum- a piece of
dead bone,
surrounded by infected
granulation tissue.
• Appears pale; smooth
inner surface, and
rough outer surfact

8. • When sequestrum is complete, it lies in the free cavity and is
less attacked by granulation tissue and is absorbed more
slowly
• Meanwhile, the surrounding living bone attempts to wall off
the infection by forming a thick, dense wall, the involucrum
• An involucrum usually has multiple openings, the cloacae,
through which exudate, bone debris, and sequestra find exit
and pass through sinus tracts to the surface

9. • Constant destruction of neighboring soft tissue leads to thin
skin which is easily traumatized, skin epithelium grows
inwards to line the sinus tract.

10. Bacteriology
• Staphyloccus aureus, most common infecting organisms
• Other organisms are- group A streptococci, pseudomonas
aeruginos, proteus, e. coli, staphylococcus epidermidis
• Hemophilus influenza- culprit in children below 2 years of
age
• Bacteroids
• Salmonella in patients suffering from sickle cell anemia

11. Classification

12. Jones et al.
A Brodie abscess
B Sequestrum involucrum
B1 Localized cortical sequestrum
B2 Sequestrum with structural involucrum
B3 Sequestrum with sclerotic involuvrum
B4 Sequestrum without structural structural
involucrum
C Sclerotic

13. Clinical Picture
• During the period of inactivity no symptoms are present
• Pain, pyrexia, redness and tenderness, discharging sinus
• A break in the skin causes ulceration that is slow to heal
• Muscles are scarred and cause contractures of the adjacent
joints.

14. Clinical Picture (contd.)
• Pain is aching type and usually worsens in the night
• The overlying soft tissue becomes swollen, edematous,
warm, reddened and tender.
• As the infection progresses a sinus is formed and is drained
indefinitely
• Spontaneous closure of the sinus and subsidence of infection
often occur following explusion of a large fragment.

15. • Recurrent flare ups occur indefinitely over period of months
and years. A sinus may drain continuously
• Recurrent toxemia over a long period will cause amyloidosis
• In post traumatic osteomyelitis the bone may be deformed
or un-united

16. Diagnosis
• The diagnosis is based on
clinical,
Laboratory and
Imaging studies
• The GOLD STANDARD is to obtain a biopsy specimen for
histological and microbiological evaluation of the infected
bone.

17. Clinical
Physical examination should be focused on
• Integrity of skin and soft tissue
• Determination of area of tenderness
• Assessment of bone stability
• Evaluation of neurovascular status of the limb

18. Laboratory
• Lab studies generally are nonspecific
and give no indication for severity of
the infection
• ESR and CRP are elevated in most
patients.
• But WBC is elevated in only 35%.

19. Imaging
• Multiple imaging techniques are
available to evaluate chronic
osteomyelitis, however no technique can
absolutely confirm or exclude presence
of osteomyelitis,
• Imaging should be done to confirm the
diagnosis and prepare for surgery
• Initial plain radiographs to be performed
it yields valuable info.
• Signs of cortical destruction and
periosteal reaction strongly suggest the
diagnosis of osteomyelitis.

20. • X ray examination –bone
resorption (patchy loss of density or
frank excavation around the
implant), thickening and sclerosis of
the surrounding bone.
• Sinography can be performed if a
sinus track is present and can be
valuable adjunct to surgical
planning

21. • Isotope bone scanning – more useful in acute osteomyelitis
than chronic osteomyelitis.
• CT scans – provides excellent definition of cortical bone and
fair evaluation of the surrounding soft tissues and is
especially useful in identifying sequestra.
• MRI – provides a fairly accurate measure of pathological
insult to bone and soft tissue, so it is superior to CT in soft
tissue evaluation
• MRI may reveal a well defined rim of high signal intensity
surrounding the focus of active disease (RIM SIGN)

22. Treatment
• Requires a multi faceted approach
• In addition to antibiotic and surgical debridement and
reconstruction
• 1st objective – removal of dead bones (sequestrum)
• 2nd objective – find a method of obliterating any dead space
left after debridement.
• 3rd objective – obtain soft tissue coverage of exposed bone
which is a part of the objective of obliterating dead space.

23. Antibiotics
• Chronic infection is seldom eradicated by antibiotics alone.
• Bactericidal drugs important
a. To suppress the infection and prevent its spread to
healthy bone and
b. To control acute flares.
• The choice depends on microbiological studies, but the drug
must be capable of penetrating sclerotic bone and should be
non toxic with long term use.

24. Surgery
• In spite of somewhat clear objectives, the actual decision
making process is not always easy or clear cut.
• The real test of a surgeon’s judgement lies not only in
deciding when to operate, but also how to avoid
meddlesome surgery
• Total eradication of all areas of potentially infected bone is
hardly possible.

25. Indications
• Chronic hematogenous infections – intrusive symptoms,
failure of adequate antibiotic treatment, and /or clear
evidence of sequestrum or dead bone
• Post traumatic infections – intractable wound and /or
infected ununited fracture
• Post operative infection – evidence of bone erosion.
• Presence of foreign implant

26. • Surgery for osteomyelitis consists of sequestrectomy and
resection of scarred and infected bone and soft tissue.
• Ring external fixators are generally used for soft tissue and
dead space management after radical debridement.
• The GOAL of surgery is to eradicate infection by achieving a
viable and vascular environment.
• Extensive debridement creates a large dead space – this is
treated with antibiotic polymethyl meth acrylate (PMMA)
beads that fills the dead space and prevents recurrences.

28. • The duration of post operative antibiotics is controversial
• Traditionally, a 6 week of intravenous antibiotics is
prescribed after surgical debridement.

29. Sequestrectomy and curettage for chronic
osteomyelitis
• Sequestrectomy – removal of the sequestrum
• If within medullary cavity – a window is made in
the overlying involucrum and the sequestrum is
removed.
• One must wait for adequate involucrum
formation before performing sequestrectomy.
• Sinus tracks can be injected with methylene blue
24 hours before surgery to make them easier to
locate and excise.

31. Open bone grafting
• Described by Papineau et al.
• Procedure relies on the formation of healthy granulation
tissue in a bed of bone graft that will become rapidly
vascularized.
• The granulation tissue resists infection and is allowed to
adequately drain.
• Used when free flaps or soft tissue transfer options are
limited because of anatomic location.

32. Divided into 3 stages
1. Debridement and stabilization
2. Cancellous autografting
3. Skin closure

33. Polymethylmethacrylate antibiotic bead
chains
• Commonly used
• Rationale – to deliver levels of
antibiotics locally in concentrations
that exceed the minimal inhibitory
concentrations
• Studies shown that the local
concentrations achieved are 200 times
more than intravenous.
• Short term(10 days), long term(80
days), permanent implantation of
PMMA beads is possible.

34. Intramedullary antibiotic cement nail
• Safe and efficacious in the treatment of osteomyelitis of long
bones
• Treatment protocol included removal of the standard
intramedullary nail>debridement and irrigation>intravenous
antibiotic administration.
• After clearance of infection ,antibiotic nail removed and
standard IMILN implanted

35. Biodegradable antibiotic delivery system
• Offers significant advantage over PMMA – a
second procedure is not required to remove
the implant.
• Useful when bone instability is not an issue
and soft tissue coverage is adequate.
• Variety of bioabsorbable substrates(calcium
sulfate or calcium phosphate) that can be
mixed with antibiotics(vancomycin and
tobramycin)
Kluin et al: ideal
biodegradable carrier
• Good biocompatibility
• Controllable
degradation
• Ability to release any
Abx at therapeutic
levels
• Without releasing
acidic byproducts

36. Closed suction drains
• Success rates of approx. 85% have
been reported for the modified
Lautenbach method of close
suction antibiotic ingress and
egress irrigation system
• More recent wound closure
technique is negative pressure
wound therapy(NPWT).

37. Soft tissue transfer
• Mainly done to fill dead space which is left behind after
extensive debridement.
• Transfer of vascularized muscle tissue improves the local
biologic environment by bringing in a blood
supply(antibiotics delivery and osseous and soft tissue
healing).
• Success rate reported ranges from 66% to 100%

38. Ilizarov technique
• This technique allows radical resection of the infected bone.
• A corticotomy is performed through the normal bone
proximal and distal to the area of the disease
• Disadvantage – long time to achieve solid union and high
chances of infections.
• Treatment of segmental defects of upto 13 cm can be
achieved

39. Adjunctive therapies
• Hyperbaric oxygen is not reliably effective but is used as
more traditional methods of treatment.
• Bone morphogenic proteins (BMPs) and even Platelet Rich
Plasmas (PRPs) have been advocated as it has the ability to
accelerate or enhance osteogenesis.

40. Adjunctive therapies
• Hyperbaric oxygen is not reliably effective but is used as
more traditional methods of treatment.
• Bone morphogenic proteins (BMPs) and even platelet rich
plasmas (PRPs) have been advocated as it has the ability to
accelerate or enhance osteogenesis

41. Complications
• Acute exacerbation of infections
• Growth abnormalities:
shortening –if growth plate is damaged
lengthening –because of increased vascularity of growth
plate
• Pathologic fracture
• Joint stiffneess

42. • Sinus tract infection
• Muscle contracture
• Epithelioma
• Amyloidosis