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Osteomyelitis
Osteomyelitis is an inflammation of the bone often caused by infection, manifesting in various forms depending on its cause, with common pathogens being Staphylococcus aureus. Risk factors include diabetes, immunosuppression, and surgical interventions, with symptoms ranging from bone pain to fever. Diagnosis may involve imaging and microbiologic tests, while treatment typically necessitates surgical debridement alongside antibiotic therapy for effective management.
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Osteomyelitis
- 2. OSTEOMYELITIS DR M. TAHIRKARIM PGR ORTHOPAEDIC SURGERY UNIT-I JHL
- 3. OUTCOMES ๏ต Epidemiology ๏ต Riskfactors ๏ต Pathophysiology ๏ต Clinical features ๏ต Diagnosis ๏ต Management ๏ต Complications
- 4. OSTEOMYELITIS ๏ต Osteomyelitis isthe inflammation or swelling of bone that is usually the result of infection ๏ต It may be localized or may spread through the bone to involve the marrow, cortex, periosteum, and soft tissue around the bone.
- 5. EPIDEMIOLOGY ๏ต Bimodal agedistribution ๏ต Under 20 ๏ต Over 50 ๏ต Pediatrics: ๏ต boys>girls ๏ต Usually no identifiable risk factors ๏ต Adults: ๏ต Usually have risk factors ๏ต Incidence of infection increases with increase in grade of compounding (Guistilo Anderson): 2% for type I and II, approx.10-50% for type III
- 6. HOW DO YOUGET OSTEOMYELITIS 1.Exogenous 2. Contiguous focus 3. Haematogenous spread โข Most common โข Direct inoculation of bone after trauma, surgery, insertion of hardware โข Can occur at any age and with any bone โข Second most common โข Related to diseases such as Diabetes mellitus, peripheral vascular disease โข Almost always begins with a soft tissue infection that spreads to bone โข Least common โข Seeded from other source โข Seen most commonly in adolescent children (metaphysis of long bones) and elderly (vertebrae) โข Occurs in metaphysis โข Examples: IV drug abusers, sickle cell disease
- 7. RISK FACTORS ๏ต Diabetesmellitus ๏ต Sickle cell disease ๏ต AIDS ๏ต Alcoholism ๏ต IV drug abuse ๏ต Chronic corticosteroid use ๏ต Preexisting joint disease ๏ต Other immunosuppressed states ๏ต Postsurgical patientsโespecially those with prosthetic devices
- 8. Organisms isolated inBacterial Osteomyelitis Organisms Comments Staphylococcus aureus Most common in all types Coagulase-negative staphylococci Propionibacterium species Foreign body associated infection Enterobacteriaceae species Pseudomonas aeruginosa Nosocomial infections and punctured wounds Streptococci or anaerobic bacteria With bites/fist injuries with other person, diabetic foot lesions, decubitus ulcers Salmonella species Sickle cell disease
- 9. OTHER PATHOGENS ๏ต Virusesand fungi may also be involved ๏ต Gram negative bacteria (in elderly patients) ๏ต Mycobacterium (in immunosuppressed, alcoholic, IV drug abusers or residents of endemic areas) ๏ต MRSA, MRSE, and VRE have emerged as a significant microbiologic problem in the past decade ๏ต Polymicrobial (36 to 50%) more likely in diabetic foot osteomyelitis, posttraumatic osteomyelitis and chronic osteomyelitis
- 10. Based on durationand type of symptoms Acute <2 weeks Subacute 2-6 weeks Chronic >6 weeks, Involves relapses
- 11. PRESENTATION SYMPTOMS ๏ต Bone pain ๏ตFever (High grade in case of blood infection) ๏ต Systemic complaints (general discomfort, fatigue, malaise) ๏ต Difficulty bearing weight or walking (in lower limbs) ๏ต Stiff back (in vertebral involvement) ๏ต Discharging sinus (in chronic osteomyelitis) SIGNS ๏ต Swelling, redness on inspection ๏ต Severe tenderness, warmth on palpation ๏ต Difficulty in moving joints around the affected area
- 12. SUBACUTE OSTEOMYELITIS ๏ต Moreinsidious onset and lack of severity of symptoms ๏ต Diagnosis typically is delayed for more than 2 weeks ๏ต Pathogen is identified only 60% of the time ๏ต S. aureus and S. epidermis are usually involved ๏ต The diagnosis is often established by an open biopsy or culture
- 13. CHRONIC OSTEOMYELITIS ๏ต Sequestrum,Involucrum, abscess or sinus (cloaca) is present ๏ต Sinus usually has a purulent or seropurulent discharge ๏ต May remain dormant for months or years with acute or subacute flares. ๏ต X-ray shows signs of bone destruction ๏ต Tuberculosis, Fungal infection and Brodieโs abscess usually leads to chronic osteomyelitis ๏ต Muscle wasting contractures, atrophy may occur
- 14. CHRONIC OSTEOMYELITIS ๏ต Sequestrumis the necrotic bone embedded in the pus/infected granulation tissue ๏ต Involucrum is the new bone laid down by the periosteum that surrounds the sequestra. ๏ต Cloaca is the opening in the involucrum through which pus & sequestra make their way out
- 15. CHRONIC OSTEOMYELITIS ๏ต Brodieโsabscess: ๏ต Sequela of subacute or chronic osteomyelitis ๏ต Bone abscess containing pus or jelly like granulation tissue surrounded by a zone of sclerosis ๏ต 11-20yrs, metaphyseal area, usually upper tibia or lower femur. ๏ต Deep pain, worst at night, relieved by rest. ๏ต On radiograph, circular or oval lucency surrounded by zone of sclerosis
- 16. Bacteria invades bone andproliferate Alerts macrophages that release enzymes Bone breakdown, local destruction Acute Immune system eventually destroys all bacteria Resolution, osteoblasts and osteoclasts repair the damage Chronic Bone becomes necrotic due to impaired blood flow and separates (Sequestrum) Osteoblasts form new bone around sequestrum (Involucrum) Pathophysiology
- 17. Cierny-Mader Classification System Anatomicaltype I Medullary osteomyelitis II Superficial osteomyelitis III Localized osteomyelitis IV Diffuse osteomyelitis Physiological class A Good immune system B Compromised locally(BL) or systemically (BS) C Requires suppressive or no treatment, minimal disability, treatment worse than disease, not a surgical candidate
- 18. DIAGNOSIS ๏ต WBC ๏ต Neithersensitive nor specific ๏ต Usually elevated with leftward shift ๏ต Values commonly range from normal to 15,000/mm3 ๏ต ESR ๏ต Usually elevated ๏ต Very sensitivity but very nonspecific ๏ต Can be used to follow treatment ๏ต CRP ๏ต yet another nonspecific marker of inflammation ๏ต Elevated earlier than ESR
- 19. DIAGNOSIS ๏ต Plain films: ๏ตLow sensitivity early in the disease ๏ต 3-5 days: may detect soft tissue edema ๏ต 7-10 days: >66% still have normal x-rays ๏ต By 28 days, >90% of plain films will be positive ๏ต By the time there is X-ray evidence of bone destruction(30- 50% reduction of bone density), the patient has entered he chronic phase of the disease ๏ต Characteristic finding: lytic lesions of cortical bone destruction ๏ต Advanced disease: lytic lesions are surrounded by dense, sclerotic bone, and sequestrum may be noted
- 20. Blue arrow: Areaof bone destruction on the great toe. Mottled appearance and irregularities at the edge of the bone. Red arrow: Notice the normal bone of first metatarsal
- 21. Plain film radiograph showingosteomyelitis of second metacarpal. Periosteal elevation, cortical disruption and medullary involvement are present
- 22.
- 23. DIAGNOSIS ๏ต Ultrasound ๏ต Cannot directly access bone marrow abnormalities present in osteomyelitis ๏ต Can document osteomyelitis indirectly by identifying periosseous soft tissue abnormalities ๏ต Allows for ultrasound guided aspiration ๏ต The very first sonographic sign is edematous swelling of the deep soft tissues
- 24. DIAGNOSIS ๏ต Bone Scan: ๏ตMore useful early on than plain radiographs ๏ต Can detect osteomyelitis within 48 to 72 hours of disease onset ๏ต Sensitivity 90% with technetium-99 scan ๏ต False positive rate is high (trauma, surgery, tumors, soft tissue infection)
- 25. DIAGNOSIS ๏ต In 111-labeled leucocyte scan ๏ต Can distinguish infected bone from bone that has increased turnover from other reasons ๏ต Usually reserved for equivocal or normal bone scans in patients where osteomyelitis is still a consideration
- 26. Bone scan showingaccumulation of tracer in right ankle.
- 27. DIAGNOSIS ๏ต CT ๏ต Usedfor infection in bones that are difficult to visualize on plain radiographs and bone scans: sternum, vertebrae, pelvic bones, and calcaneus ๏ต Appears as rarefaction or lucent areas, on the CT scan images ๏ต Gas may also be visible in bony abscess cavities ๏ต Limitation: disease must be present for > 1 week
- 28. Left femoral headfluffiness and distortion due to acute osteomyelitis (arrow)
- 29. DIAGNOSIS ๏ต MRI ๏ต Highlysensitive and specific (>90%) ๏ต Good for early detection and surgical localization ๏ต Useful in differentiating bone and soft tissue infection ๏ต Limitation: A metallic implant in the region may produce focal artifacts and can cause a safety hazard.
- 30. MRI showing osteomyelitisof 5th metatarsal (A) and L4-5 vertebral bodies and intervertebral disc (B)
- 31. DIAGNOSIS ๏ต Microbiologic Diagnosis: ๏ตNeedle aspiration or surgical specimen is best ๏ต Swab of draining wound or sinus is not adequate ๏ต Blood cultures in untreated patients are positive ~50% of the time
- 33. Differential Diagnosis ๏ต Tumor: ๏ตOsteoid osteoma, chondroblastoma, Ewingโs sarcoma, metastases, lymphoma ๏ต Trauma ๏ต Myositis ossificans ๏ต Erythema nodosum ๏ต Cellulitis ๏ต Eosinophilic granuloma
- 34. Treatment ๏ต Goals oftreatment ๏ต Complete removal of necrotic bone and affected soft tissue ๏ต Control of infection and elimination of dead space (after removal of dead bone) ๏ต Pain management
- 35. Treatment ๏ต Surgery andAntibiotics are complimentary to each other. ๏ต General measures include IV fluids, proper analgesia and comfortable positioning of the limb ๏ต Patient should be treated with appropriate antimicrobial therapy for 4-6 weeks, dating from the initiation of therapy or last major surgical debridement
- 36. Indications of Surgery ๏ตThe presence of abscess requiring drainage ๏ต Failure of clinical improvement despite appropriate intravenous antibiotics (Occult abscesses must be sought) Surgery may range from minor debridement to amputation of infected bone.
- 37. Sequestrectomy: ๏ต Well formedinvolucrum surrounding the discretely visible sequestrum (at least 2/3rd diameter of bone) and symptomatic patient with pus discharge or chronic disabling pain are pre- requisites of sequestrectomy. ๏ต It is critical to preserve Involucrum to minimize the risk of fracture, deformity & segment loss. ๏ต Preferable to wait 3-6 months before performing sequestrectomy
- 38. Management of deadspace ๏ต Adequate debridement may leave a large bone defect, termed as dead space. ๏ต The goal is to replace dead bone and scar tissue with durable vascularized tissue. ๏ต Free vascularized bone graft, local tissue flaps or free flaps, cancellous bone grafts or open cancellous grafts can be used accordingly for this purpose. ๏ต Antibiotic beads may be used to sterilize and temporarily maintain a dead space, usually removed within 2-4 weeks and replaced with a cancellous bone graft.
- 40. After Surgery: ๏ต Skinis closed over drains ๏ต Limb is splinted ๏ต Once wound is healed, protected weight bearing is begun ๏ต Limb protected for a few weeks to prevent pathological fracture ๏ต Patient is followed for one year
- 41. Nadeโs Principles 1. Antibioticsare effective before pus forms. 2. Antibiotics can not sterilize avascular tissue or abscess 3. Antibiotics prevent reformation of pus once removed, therefore primary closure should be safe 4. Pus removal restores periosteum, restores blood flow 5. Antibiotics should be continued after surgery
- 42. SPECIAL CONSIDERATIONS ๏ต Infectionof an orthopaedic prosthesis may need to be removed along with the infected tissue around it. ๏ต If the patient is diabetic, needs to have well controlled. ๏ต If the patient has some vascular disease, surgery to improve blood flow may also be needed. ๏ต In patients with vertebral osteomyelitis, there is risk of paralysis and epidural abscess. ๏ต Patients with sickle cell disease have increased risk of developing osteomyelitis due to salmonella.
- 43. COMPLICATIONS ๏ต Acute exacerbations- most common ๏ต Septicemia ๏ต Growth abnormalities ๏ต Deformities ๏ต Pathological Fractures ๏ต Joint stiffness ๏ต Thrombophlebitis ๏ต Amyloidosis ๏ต Malignancy(0.25%) โ sq. cell carcinoma, fibrosarcoma, reticulum cell carcinoma ๏ต Septic arthritis