Comprehensive guide on osteomyelitis and septic arthritis. Pathogenesis, subtypes, clinical features, treatment principles and options and sequlae.

1. Osteomyelitis and Septic arthritis
prepared by: Alazar (OSR-2)
moderator : Dr. Birhanu Ayana
(Consultant pediatric orthopedic surgeon)
May, 2022

2. Outline
Part 1: Osteomyelitis
• definition
• history & epidemiology
• pathogenesis
• classical & modern concepts
• classifications
• AOM
• subacute OM
• COM
• treament principles
• prongs of Rx in COM
• complications
• special forms of OM
Part 2: Septic Arthritis
• routes of spread
• risk factors
• pathophysiology
• classification
• clinical features, labs & imaging
• ddx
• treatment principles
• sequelae in ped hips

3. Osteomyelitis

4. Definition & History
 primary infection of the BM --> subsequent infection of the
cortex & periosteum “Nelaton, 1844”
 fractured spine of dimetrodon Pemian reptile, 291-250 million
yrs ago

5. Epidemiology & Pathogenesis
 incidence
• acute hematogenous OM decreasing
• due to direct inocultion /contiguous focus increasing
Older theories
 Hobo’s
• metaphysis: “poor phagocytic activity”
 Trueta, 1968
• sluggish flow through “hair-pin bends”
• 3 clinical stages
• 3 types of OM

6.  stage 1 “boil” in the bone
• severe constant pain & tenderness; absent
inflammatory ssx
 stage 2
• pus in medulla & subperiosteal space;
systemic ssx appear
 stage 3
• inflammation spreads to STs
challenged recently by findings of pus
w/n 48hrs beneath the periosteum
his view of no/late inv’t of diaphysis
also not supported

7. infantile childhood adults
transphyseal blood supply physis & epiphysis spared often due to contiguous spread
diaphysis rarely involved diaphysis is at greater risk
(endosteal thrombosis)
long bone inv’t in hematogenous
rare
thin & weak bone
• give way to pus under
pressure
no extensive devascularization &
large sequesterum
metaphyseal cortex is thicker
extensive devascularization & large
sequestrum (“cylinderical
sequestrum”)
infected bone resorbed leaving
behind a cavity
high regenerating potency of
periosteum --> large involucrum
growth disturbance rare whole bone inv’t & chronic OM
common
joint inv’t if
• metaphysis is intracapsular
• iatrogenic seeding while
drainage

8.  Starr from Toronto
• progression & course of abscess
 Wilenski concept
• site of bone inv’t depends on occlusion at
particular site by septic embolus
 Morrisey & Haynes
• concept of “trauma as focalizing influence”
• delicate metaphyseal circ --> hematoma formation

9. Modern concept & understanding
A. Alteration of homeostasis of the body
• close interaction of host factors, bacteriological factors & env’t
B. terminal metaphyseal vessels
 open ended (NOT looped/“hair-pin bends”)
• chondrotropic bacteria adhere to cartilage cells at junction
b/n metaphy and physis “homing of bacteria”
 sluggish flow not important
C. centripetal concept of developing infection
 lodging in periosteal circulation --> subperiosteal abscess -->
involve the cortical circ --> thrombosis of nutrient aa --> dev’t
of characteristic AOM

10.  biofilms are permanent
source of virulent pathogens
insensitive to immune system
& progressively resistant to
Abx
 rush to surface --> thrive --> review mechanisms for inc proliferation (quorum
sensing) --> grow into mushrooms & columns --> interval shedding of “planktonic
form” --> host immunity “confused” mounts a common inflammatory rxn
• ineffective (Th2 humeral response against pseudomonas)
• self damaging & misdirected (Th1 & Th17 cell mediated response against S. Aureus) --> further
tissue damage and inc adhesion

11. Classification
 13 d/t classification systems (Hotchen et al.)
• most important variables
• bone inv’t
• antimicrobial resistance patterns
• need for ST coverage
• host status

12. traditional
classfication
acute, subacute, chronic  time of onset
 manner of clinical presentation
 response to Rx
depending on duration of ssx
• arbitrary (<2 weeks, 2 wks-3 mo; >3 smo)
• identification of sequestrum on xray 4-6wks
Meier acute, acute with x-ray changes, chronic localized, chronic systemic
Lew & Waldvogel hematogenous/endogenous
, contiguous/exogenous,
vascular insufficiency,
chronic
by cause not useful for guiding Rx
or determining Px
based on host
response
pyogenic or nonpyogenic
Cierny & Mader based on host factors & anatomic criteria
Trueta neonatal, infantile, early
child hood, late childhood,
adolescent
based on age & dev’t helpful in identifying
causative organism &
clinical manifestation

13. PTO (post-traumatic OM)
Kelly hematogenous, # healing w/ OM, # nonunion w/ OM, no # OM
Gordon et al. • type A: tibia defect & nonunion; no segmental loss
• type B: tibia defect >3 cm; fibula intact
• type C: tibia defect >3 cm; involving both tibia & fibula
Mayet al. • type 1: tibia & fibula intact and load bearing stable
• type 2: fibula intact; tibia continuous but need bone graft
• type 3: fibula intact; tibia defect <= 6cm
• type 4: fibula intact; tibia defect > 6cm
• type 5: tibia defect > 6 cm; fibula #
Schmidt et al. • classified by 8 items
• source of infection
• anatomical region, stability
• FB
• infection range
• activity of infection
• microorganism,
comorbidity
• good for clinical classification of
PTO
• complex; limits its use in clinic

14. CCHOM
Lauschke based on onset
• early acute: <= 3 days
• late acute: 4-5 days
• chronic: >=6 days
peds doesnt recognise more
extensive dz
progression (not
applicable to majority
of CCHOM seen in
clinical practice)
Beit CURE
classification
comments on both
sequestrum & involucrum
• useful tool in
planning
designed in countries where readily available
CT & MRI are not there
Solagberu’s pre-invasion to compound
chronic
based on
progressionof dz
subjectivity of grading
makes reproducibility
difficult

15. Cierny-Mader classification
 University of Texas Medical Branch
(UTMB) clinical staging system
• for adult OM (Cierny et al.)
• part of affected bone, physiological status &
risk factors affecting immunity, metabolism &
vascularity
• doesn’t recognize chronic form of bone
infection
(but best suited for classifying chronic OM)
 helps in determining if Rx
should be
• simple Vs complex
• curative Vs palliative
• limb sparing Vs
ablative

16.  draw back
• relatively subjective
• reliant on clinical judgement,
interpretation of radiology & asst
of host status
• created to classify OM in adults
• less transferable to peds
• most children are normal hosts
with localized OM (3A) -->
limited application

17. Beit CURE classification
Type A Brodie’s abscess
Type B Sequestrum
involucrum
B1: localized cortical sequestrum
B2: sequestrum with structural
normal involucrum
B3: sequestrum with sclerotic
involucrum
B4: sequestrum w/o structural
involucrum
Type C sclerotic
physeal damage indicated by the addition of “P”: proximal or “D”:
distal
 Jones et al.
 solely for use in CCHOM
 explicit use of plain
radiograph
 has been assessed for intra-
& inter-observability
 comments on both
sequestrum & involucrum
• useful tool in planning

19. Acute hematogenous OM
• most common type & usu seen in peds
• metaphyses of rapidly growing long bones
• bimodal age destribution in peds
• < 2yrs & between 8-12yrs
• much less common after physis are closed
• in adults, often seen in immunocompromised host
• predilcation for vertebral bodies

21.  in peds: clinical diagnosis
• localized bone pain & fever
• presumed OM till proven otherwise
(upto 40% peds afebrile on admission)
• pain & local tenderness are common findings
• other typical ssx (refusal to bear weight, malaise, limited ROM, redness,
warmth, swelling)
 in infants, elderly or immunocompromised
• ssx minimal

22.  in adults: high index of suspicion
• hx open #
• nonhealing ulcers
• contiguous sites of infection
• predisposing factors
• C/f
• tenderness to deep palpation
• thrust tenderness (vertebral OM)
• painful ROM

23. Diagnostic criteria

24.  TC/DC
• WBC normal in >50%; elevated in only 35%
 ESR (90%) & CRP (98%)
• elevated & sensitive; non-specific
• ESR peaks 3-5 days; normalizes by 3wks
• CRP rises w/n 6hrs, peaks in 2 days; normalizes by 7-10 days
 Blood culture
• +ve in 50% of AOM in peds; commonly -ve in adults
• despite low yield always obtain prior to Abx (if +ve, repeat q48hrs until clear)
 Bone aspirate/contiguously infected joint aspirate culture
• identification of causative only ~50-60%

25. X-rays
 1cm & 30-50% dec in mineral
content for noticable change
 limited role in AOM
 48-72hrs: muscle swelling &
blurring of ST planes

26.  periosteal thickening, lytic
lesions, endosteal scalloping,
osteopenia, loss of trabecular
structure
• 5-7 days in children; 10-14
days in adults

27. USG
• detect concurent SA & differentiates from SA,
pyomyositis, ST abscess, cellulitis & malignant bone
tumors
• earliest sign (w/n 48hrs): deep ST swelling
• thin layer of subperiosteal fluid, subperiosteal abscess
& perosteal rxn (hypoechoic & anechoic shadow)
• doppler: detect hyperemia around periosteum &
surrounding ST abscess
• Labbe et al.: dx accuracy 64% on admission; 84% on
2nd day
MRI
• sn: 98%, sp: 75%
• show early inflammatory changes in BM &
ST
• changes in marrow evident w/n 3-5 days
• short tau-inversion sequence & T1 spin
echo
• highest sensitivity & specificity
• marrow change as early as 1-2 days
• detects intraosseous & subperiosteal
abscesses

28.  T-99 bone scan
• can confirm dx 24-48hrs after onset in 90-95%
• negative scan rules out dx
• role in multifocal dz/nonlocalized esp. in infant/toddler where
sedation is unwanted
• gallium & 111-labeled leukocyte scans inc specificity
• use has dec with inc use of MRI

29. Chronic OM
 >6 wks; devitalized bone
 usu persistence of AOM
incomplete Rx, trauma, implant related, open #
 may develop de novo
• infection with chronic persisting type of microbes, OM ass with DM
foot/vascular dz
 r/f for polymicrobial OM: advanced age, GA type 3 injuries, need for
blood transfusions & multiple debrima

30.  sequestrum: hallmark
• 10 days histopathologically
• seen on xray by 3 weeks
• 2-3 month for sequestrum to separate
from parent bone
 involurum
• rough inner & smooth outer surface
• physiologically seen in infants
 Cloacae

31. Sequestrum
shape consistency color
pencil like or cylinderical/tubular:
infants
coke like: TB black:
• amputation stump
• long exposure of necrotic
bone to air
• fungal infection
• actinomycosis
ring: ex-fix pins, schanz screws,
ilizarov wires
feathery: syphilis
conical/annular: amputation
stumps
sand like (coarse): TB in
metaphysis green - pseudomonal OM
trapezoid & irregular: adolescents sand like (fine): viral OM
coralliform: perthes
flake like: TB
button sequestrum: calvarium

33.  intermittent acute
exacerbations for years
• w/c responds to rest & Abx
ssx: nonspecific
pain
• Walenkamp phenomena (gradually inc bcm
unbearable & suddenly relaxes w/ opening
up of sinus & pus discharge)
tenderness on deep palpation
irregulary thickened
muscle atrophy
 characteristic ones
• adherent sinus tract with
discharging pus/bone pieces
• nonhealing wound exposing
surgical hardware
• nonhealing wound/ulcer
overlying exposed bone

34.  labs
• WC: elevated in only 35%
• ESR & CRP: elevated in most pts
 X-ray
• periosteal reaction , involucrum formation, sinus tracts, ST fistulas,
sequestrum formation, cortical destruction
 CT
• superior in demonstrating
• sequestrum, cloacae, involucrum or intraosseous gas
• beam hardening effect in presence of implants (losing resolution)
• nature & magnitude of bone defect

35.  Sinography
• valuable adjunct to surgical planning
 MRI
• extent of inv’t & activity of dz
• sequestrum & ossified periosteal shell: low intensity on all sequences
• surrounding granulation tissue & pus: high signal on T2 & STIR
• “rim sign”: well-defined rim of high signal intensity surrounding focus
of active dz

36.  nuclear imaging/3-phase bone scintigraphy
• as early as 48hrs; high sensitivity; low specificity; inc uptake in all 3 phases
• gallium: intense uptake in infection, aseptic inflammatory conditions & malignancy
• Indium-111: improv in specificity
• FDG-PET: highest accuracy for confirming/excluding; vertebral lesions better
evaluated
 Bone biopsy
• >5 neutrophils/HPF (specificity 93-97%)
• useful before proceeding with reconstruction/during repeated debrima
• high -ve yield of culture from “biofilm” infections
• even with sonication/subcultures

37. Subacute hematogenous OM
 less common than AHO; incidence increasing
 inc host resistance & dec virulence of bacteria
or
administration of Abx before onset of ssx
 onset insidious & as a rule no systemic features of infection

38.  remitting pain
• mild to moderate
• prominent after activity
• night pains (relief from ASA)
 localized tenderness & swelling (may even be absent)
 peds: metaphysis > diaphysis (equal distribution in adults)
• metaphyseal equivalents: pelvis, vertebrae, calcaneum, clavicle & talus
• multifocal rarely
• ddx: Ewing’s, Largerhans, osteosarcoma, chondroblastoma, ABC, GCT, PVNS,
NOF, chondromyxoid fibroma, osteoid osteoma, intracortical hemangioma

39.  Robert et al. (modified Gledhill
classification)
• 6 types (morphology, location &
bone rxn)

40.  labs: often not helpful
• WBC normal; ESR inc in 50% only
• blood cultures -ve
 xray
• nonsensitive & non-specific
• characteristic lesion: lytic cavity surrounded by sclerosis
• Serpentine sign of Letts
 MRI
• better characterization & differentiation of spinal lesions
• Penumbra sign: Brodie’s abscess
 Tissue dx (FNAC/trephine bx)
• must for documentation & diagnosis
• yield is +ve only 60%

41. Principles of treatment in AOM
• until 1920’s, surgical Rx was the only Rx for OM
(ubi pus ibi evacua)
• currently, Abx is the basis for Rx of AOM
• Nade principles (pertaining to Abx use) for managment of AOM
• Abx is effective before pus/abscess formation (<48hrs)
• Abx can’t sterilize avascular tissue/abscess
• Abx prevent reformation of pus once evacuated
• Evacuation of pus restores periosteum & blood flow
• Abx should be continued following surgery

42.  surgical indications in AOM
• abscess formation (strongest indication)
• concomitant septic arthritis
• some recommend in proximal femur OM (even absent SA)
• persistence w/o improv after 48hrs of Abx Rx
• slow progression as clinically deemed after 72hrs of Abx Rx
• multifocal OM with pus formation esp. in an ill, moribund child
• delayed presentation >7-10 days
• bone more/less dead & immediate pus evacuation should be done to preserve as
much bone

43. Abx
• 1st line
• b-lactams (1st gen cephalosporins)
• efficacy against MSSA, K.kingae, Strep. pyogens, Strep. pneumo
• clindamycin
• concern for MRSA & allergic to B-lactams
• inactive against K.kingae
• vancomycin
• pt clinical status, regional resistance patterns
• comparatively less effective against MSSA
• gm negative coverage
• neonates, HAI

45.  historically, long course IV
• to prevent compx or relapses
• randomized, controlled,
multicenter trial in UK
• 1054 patients
• Rxed for complex bone &
joint infections
• sequential IV/PO
noninferior to entirely IV
with fewer IV related compx
& lower financial costs

46.  initial 5-7 days: IV
• normal temp, improved c/f, resolving CRP
• minimum of 3 days
 3-4 wks: PO
 total duration arbitrary
• cont Rx for 4wks
• revascularization of bone takes that much time
• <3 wk Rx associated with higher rates of relapse/recurrence
• depends on extent of infection & clinical and lab responses

47.  supportive Rx
• immobilization/comfortable positioning, hydration, electrolyte replacement,
protein rich diet & adeq analgesia
 frequent serial examinations
• daily clinical condition and limb girth
• CRP q2-3 days
 clinical improvement occurs w/n 24-48hrs
• fever settles w/n 2-3 days
• erythema & swelling settle & range and rhytm of mov’t recover
 by 1 wk
• WBC decline
• ESR reduce by minimum of 20%
• CRP reduce by 50%

48. Principles of treatment in SOM
 controversial
• prolonged IV Abx in peds (Hamdy & Colleagues)
• surgical Rx in adults
• agressive looking lession: Bx & curette --> Abx
• simple abscess: No Bx. IV Abx*48hrs --> 6wk PO Abx
 surgical indications
• poor response to Abx
• doubtful lesions that appear as potential threats
• impending joint inv’t
• subperosteal pus/synovitis

49. Principles of treatment in COM
 based on oncologic approach
• radical surgical eradication of affected bone & ST
+ reconstruction for stable limb function
• systemic & local Abx and adjuvant therapy to eradicate infection
• retain limb function
 immunocompromised host
• might not survive extensive surgical stress required to eradicate
• limited surgical debrima + suppresive Abx + nutritional support
• goal: limit the freq of sinus drainage & pain

51. timing the intervention
prerequisites for surgery in symptomatic pt
 acute phase should subside (no fever)
 D/C Abx 1 week before
 sequestrum should have separated from parent bone
 involucrum strong enough for supporting the bone w/o need of
supportive fixation
• seen in 3/4 cortices on 2 perpendicular views; minimum of 70% circumferential
on CT
• may take 2-8 mo to form
 salvagable limb
• use Klemm’s triad for assessing
 pt willing for multiple operations
• on average # of op required is 4

52. 5 Rx prongs
 bone & ST debridement w/ removal of infected & necrotic tissue and
drainage (wound toileting)
 removal of metal implants, hardware & FB
 stabilization of the bone throughout
 local Abx therapy
 dead space mgm’t
• reconstruction of the ST
• reconstruction of the osseous defect

53. 1. Tissue debridment ‘’excision of focus’’
 aid in identification of nonviable tissue
& sequesterum
• methylene blue: stains viable gray; nonviable
blue
• sulfous blue: color all tissue green; devitalized
remains uncolored
• intra-op lased doppler: cumbersome & not very
accurate
 sinus tract excised, infected granulation
tissue curetted out
 sequestrae inspected for completeness
& not fractured while removal
 if bone window needs to be created for
removing sequestrum
• oval fashion; 10-15% more length than
measured length of sequestrum
 progressive nibbling of involucrum &
bone till punctate bleeding bone
 saucerization
• burred to have smooth borders that aren’t
undermined; akin to “wide resection”
margin of 5mm recommended

54.  sclerotic bony blocks in the
medullary cavity should be opened
 ST debridment
• all grossly visible necrotic tissue &
slough excised
 thorough irrigation
 splint limb till wound heals
• prevents pathological #
 NWB ROM excercises
 Abx continued
 repeated q48 hrs till samples taken
from wound return normal/local
conditions of wound looks healthy

55. 2. Bone Stabilization
 Ex-fix
• cumbersome to pt for prolonged duration
• possibility of pin site infection
 slab/cast
• often inadequate
• has to be changed frequently

56. 3. Local Abx Rx
advantages of local Abx over
systemic?
advantages of biodegradable over
nonbiodegradable?

57. PMMA (antibiotic loaded bone cement)
 current gold standard
 high compression strength
• good structural strength; an advantage in membrane induced technique
 Abx elution approaches 75% @ 30days
• maintaing >100*MIC & approaching/exceeding MBEC conc
 implantation short Vs intermediate to long term
• short term: removed within 10 days (bead pouch technique)
• intermediate term: removed by 2-3wks
• long term: kept for 3wks & pulled daily at a rate of 1 bead/day that extends to 2-
3wks
• for upto 80 days

58.  considerations for use of Abx in cement?
 Abx in order of preference?

59.  Bead-pouch technique
• beadson circlage wire
• covered with adhesive sheet (2 layers)
• “closed bead-hematoma-Abx env’t”
• dressing & bead pouch change repeated q48-72hrs
• depending on fluid accumulation
• debride till healthy granulating bed
• when satisfactory, ST coverage planned
*** suction drainage: ineffective & counterproductive

60.  IM Abx cement nail
• recent alternative to external
fixation
• removal of standard nail --> I&D
of IM canal (RIA) --> Abx PMMA
nail + systemic Abx
• NWB in cast for 6-8wks
• exchanged with standard nail
after clearance of infection

61. biodegradable systems
 useful when instability is not an issue & ST coverage is adequate
• bone graft & bone substitutes
• protein-based materials (natural polymers)
• synthetic polymers
• miscellaneous material
 elution
• for water soluble agents depends on SA of carrier & initial conc
• for insoluble agents depends on porosity of the matrix

62.  closed suction drains
• modified Lautenbach method (success rates of ~85% reported)
• adv
• allows change in local Abx delivery based on culture results
• aids in gradual dec in the size of ST dead space
• disadv
• frequent occlusions (steptokinase solves this)
• prolonged hospitalization required
• risk of secondary contamination

63. 4. Dead space (cavity) mgmt
Dead space managment
leave to heal of its own
(not preferred)
secondary intention
mobilize local tissue
(usu done)
mm flaps (myoplasty)
myocutaneous flaps
osteomyocutaneous flaps
microvascular
reconstruction
mm flap
osteomyofasciocutaneous
flaps
using foreign material
(mainly bone cement)
biodegradable
non-biodegradable
Autogenous cancellous
bone graft

64. A. Reconstruction of the osseous defect
 Autogenous cancellous bone grafts
prerequisite
• critical defect of 6-7cm
• optimal vascular situation in ST & bone
• optimal contact b/n cancellous graft & living cancellous bone
• infection-free bone bed in defect

65.  Rhinelander-Papineau technique
• open bone grafting of vascularized bone bed defect
3 stages
1st stage (debrima & stabilization)
 debrima repeated till deemed healthy
 wound packed with Abx soaked dressings/bead-pouch
technique
 nailing (original recommendation)/Ex-fix (commonly used)
• Rhinelander used POP cast
 delay 2nd stage till healthy granulation is obtained

66. 2nd stage (cancellous autografting)
 cancellous iliac bone graft
• pack tightly concentrically to SC level
 ends of bones petalled (inc SA of contact)
 pack with Abx-soaked dressings
• changing after 4-5 days (when graft stabilize &
incorporate)
• freq dressings till granulation tissue engulfs the
grafts & surrounding skin covers them
 VAC (Archdeacon & Messerschmitt)
• hasten healing & remove serous discharge
 in b/n edges refreshed if epithelium dig
into grafts
3rd stage (skin closure)
 for large wound defects (>3-4cm)
• prolonged time for spontaneous
epithelization
 providing wound coverage
• skin grafts, mm pedicle flaps or free
microvascular flaps
 In mini-papineau
• after bone grafting --> local mm
pedicle flap
• incorporation is faster
• skin coverage provided early

67. Reconstruction of segmental bone defects
 Wiese defined CSD
• loss of length of segmental bone that exceeds the diameter of affected
bone by a factor of 2 to 2.5 (Wiese & Pape, 2010)
 open bone grafting
• small-moderated bone defects (up to 3cm) in peds

70. timing of 2nd procedure

71.  bone stabilized by Ex-fix/IMN
• internal fixators (locked plates): for smaller bones of forearm & hand
 spacer removed after 8 wks
 bone formation & union in ~ 8-9 months
adv
 prevention of encroachment by adjacent ST into bone defects
 stable placement of graft in place
 prevention of resorption of graft/local production of osteoinductive
substances
• maintain graft volume & helps in augmenting bone formation

72.  animal studies
• membrane have histologic
characteristics & local factors
(VEGF, TGFB-1, BMP-2) that
facilitate bone healing

73.  24 adult crossbred ewes (mean age of 5.6 +/- 0.4 yrs; mean wt 55
+/- 5 kg)
 allocated into 3 groups (empty ctrl, 100% allograft, 67%
allograft/33% autograft)
• For ctrl group, ST closed over an empty defect
• For graft material groups, defect was filled w/ PMMA prior to closure
 4 wks after surgery, sheeps of gr 2&3, reanesthesized and sample
taken from fibrous capsular tissue surrounding PMMA for
histological and immunohistochemical evaluation
 Patterns of expression including distribution & intensity of staining
summarized

74.  retrospective series
 single center experiece of 21 pts w/ infected nonunion/underlying
OM
 20/21 went to solid union at mean time of 5.6mo (range 2-10mo)
• average time to healing of 1.21mo/cm of defect
 success rate of 95.23%

75.  prospective study, case series
 19 pts (12 posttraumatic OM, 4 infected nonunion, 3 COM)
 most had large bone defects & multiple previous surgical
intervenions
• 4.1 previous operations (range, 2-11 failures)
 most had >1 debrima before graft application
 overall success (union) rate reported to be 85.71% (18 in 21
cases)

76. Callus-distraction & distraction histiogenesis
(Ilizarov method)
 many different techniques
• Monorail (Wagner type)
• lengthening over IMN (rail-road lengthening)
• Unilateral Ex-fix & hybrid fixators
• Three dimensional fixators (for multi-plane deformity correction)
• Ring fixators (classic Ilizarov technique)

77.  considered today gold
standard
• esp if defect >4cm but <15cm
 DO with ring fixation over an IMN:
reported for defects upto 13cm
• the combined method improved ex-fix
period & consolidation index
• the earlier removal of ex-fix: inc pt
comfort, dec compx rate & convinient &
rapid rehab
 DO with monolateral Ex-fix: defects ranging
from 6-18.5cm
• union 34/35 with no reinfection
• average length of fixator wear 17mo

78. adv
 bone formation in distraction zone is autogenic & healthier
 single low risk surgical procedure
 deformity correction can be simultaneously done
 resultant increase in vascularity improves surrounding ST & ctrls
infection
 early weight bearing can be allowed
disadv
 time required to achieve solid union
 high incidence of associated compx
 impact on patient’s mental health

79.  problem analyzing data from
literature
• infected & noninfected cases often
presented together making clear
discrimination & analysis difficult
 evaluated use of Ilizarov in Rx of infected nonunions
of tibia & femur
 the only review exclusively dealing w/ infected cases
 24 studies, 590 patients (mean age 22.7 yrs)
 many had multiple procedures in the past (average of
3.64)
 mean bone defect of 6.7 cm (femur: 8.05 cm; tibia: 6.54
cm)
 mean f/u: 3 yrs
 overall union rate 97.26%
 overall time with the fixation: 10.69mo
 low compx and adverse effects

80. IBT Vs MT

81. Microvascular graft osteosynthesis
“vascularized grafts”
 defects > 6 cm
• reconstruction up to 26 cm reported
adv
 good healing (due to vascularity & simultaneous cortical support)
 previously failed cases tried w/ cancellous grafts
 can be used in pts w/ poor ST envelop
 maintain mass, architecture & strength
 with endurance of load undergo remodelling & hypertrophy

82.  vascularized fibula (commonly)
 vascularized rib, scapula or ilium grafts
disadv
 needs skill & expertise in microvascular surgery
• otherwise success rate is low
 arteriogram should be done before fibula harvest
• peroneal arteria magna (5%) --> peroneal aa is the dominant aa of foot -->
harvesting leads to severe ischemia of foot

83. Huntington’s procedure
(ipsilateral fibula transfer, tibialization of fibula)
 Rx posttraumatic tibial defects, OM produced defects and congenital
deformities
 original procedure 2 steps (now done in 1)
• 1st: distal part of fibula osteotomized & inserted into medullary canal of
tibia/fixed to the surface
• 2nd: done at 2-4mo; proximal portion of fibula cut and approximated to tibia
surface
 bone union around ~ 6 mo
• till then protection by slab or Ex-fix

84. adv
 less expertise than free
microvascular fibula transfer
 bone remodels w/ weight
bearing & hypertrophies
 union & bone uptake more
certain than avascular fibula
graft
 union bypasses stage of
creeping substitution

85. B. Reconstruction of the ST defect
 planning of cover done during initial surgical planning
• carried out when infection undergoes remission (usu after 6-8 days)
 ST coverage options depend on the ff criteria (Heppert et al.)
• type of osteosynthesis
• site & size of ST defect
• local vascular status
• pt compliance
 spectrum of Rx
• localized muscle flap --> microvascular free-tissue transfer
 success rate of 66-100% reported

86. NPWT
• VAC system (Kinetic Concepts,
Inc., San Antonio, TX)
• PICO (Smith & Nephew,
Mepmphis TN)
• canister-less, single-use device
• Avelle (ConvaTec, Oklahoma
City, OK)
efficacy in Rx of
 complex wounds well reported
(helpful in prevention of OM)
 little information in Rx of OM

87.  continous/intermittent application of sub-atm pressure to
wound
• reduce edema
• enhance granulation tissue
• maintain a moist & viable env’t
 increased mechano-transduction
• inc collagen organization
• inc expression of FGF-2 & VEGF
• contracture of the wound & inc angiogenesis

88. Amputation
 reserved for
• unrelenting & multiply failed cases where no possibility of reconstruction
or
• reconstructed limb will fare worse than prosthetic fitted amputated limb
 other indications
• OM associated with
• malignant change
• aa insufficiency
• major nn paralysis
• joint contractures & stiffness that make a limb nonfunctional
 should be fully logically supported & only prescribed when all options
have been exhausted

89. Adjuvant Rx
Hyperbaric oxygen
 elevated atm pressure (2-2.5 atm)
 90-120 mins
 beneficial physiologic effects
• osteoblasts & osteoclasts inhibited by oxygen deficient envt partially reversed
• synergistic effect w/ Abx on infection ctrl
• stimulating angiogenesis
• suppressing anaerobic organisms
 not evidenced based; no destinct benefit of therapy

90. Compx of OM
AOM
 COM
 SA, AVN
 growth disturbance
 septicemia & multisys inv’t
 DVT & PE
 ADR
• neutropenia, rash, hepatitis,...
COM
 recurrence & relapses; residual stage
 LLD, pathological #, infected
nonunion
 implant failure
 SA, septicemia
 DVT
 joint stiffness, ST contractures
 ST abscess formation & cellulitis
 amyloidosis
 SCC of the sinus tract (0.2-1.6%)

91. Some special forms of OM
Sclerosing OM of Garre
 thickening of bone cortex in irregular fashion
• w/o suppuration, sequesteration, sinus formation
 chronic low grade infective pathology
• no organism have been isolated
 peds & young adults
 pain with activity or @ night; Ssx of inflammation absent

92. xray
 inc bone density
 complete obliteration of medullary cavity
 marked cortical thickening
 lamellated periosteal rxn
Rx
 course of Abx
 in few, decompression of meduallary canal
• in extreme unusual cases, surgical removal of a segment of bone + recon

93. Brodie’s abscess
 most common subtype of subacute OM
• nonorthopedic literature refer this as chronic form of OM
 Sir Benjamin Brodie (St George Hospital, London, U.K), 1832
• dark colored pus surrounded by whiter & harder dense bone
• inner surface of the cavity appeared highly vascular
 typically in peds & boys
 metaphysis in peds; metaphy-epiphy area in adults
 rarely cross physis/physeal scar
 intermittent pain of long duration + local tenderness

94. xray
 lytic oval lesion (oriented along the long axis)
 surrounded by thick dense rim of reactive sclerosis
 pathognomonic feature: lucent tortuous channel (“serpentine sign”)
• extending toward physis
MRI best characterizes pathology
 “target sign” Marti-Bonmati et al.
• central 2 rings & peripheral halo
 “penumbra sign”
• 4 sections
• central core (abscess cavity): low intensity on T1 & high on T2 & STIR
• 1st layer (grannulation tissue): isointense
• 2nd layer (reactive new bone formation): hypointense on all sequence
• outermost layer: peripheral halo of low intensity on T1
• ddx: benign cystic lesions, chondrosarcoma, eosinophilic granuloma,
intraosseous ganglion

95. Neonatal OM
2 forms
 severely ill with septicemia
• B-hemolytic streptococci & S. Aureus
• common source is umblical cord
 mildly affected
• fever usu absent
• pseudoparalysis & local ssx of inflammation
Rx
• standard
• should be followed for angular deformities

96. CNO/CRMO
 subacute & chronic features
 etiology unknown
• cultures -ve; autoimmune (genetic); imbalance b/n pro- & anti-inflammatory cytokine
 peds (peak age 10 yrs); F>M
xray
• osteolytic & sclerotic with minimal/no subperiosteal bone formation; bilaterally symmetric
• spine, tibia, femur, clavicle
• dx of exclusion
• Abx are of no use
• an episode subsides by 6wks; continue to recur over 2yrs
• little or no sequelae & self limiting

97. Septic Arthritis

98.  large joints more commonly
• esp. knee & hip (60%)
 monoarticular is the rule
• polyarticular in <20%
 usu hematogenous
 most frequently in adults but most serious
sequelae in peds
 transepiphyseal vessels
• patent in peds <18 mo; open up again near
puberty
• septic arthritis from AOM more common in
infants & adults
• less common in older children

99. r/f (systematic review by Mathews et al.)
 joint rendered structurally abnormal (underlying
inflammatory/degenerative arthritis)
 prosthetic joint
 IVDU, alcoholism
 DM
 prev intra-articular steroid injections
 cutaneous ulcers
Male sex
age <5
concomitant infections
inc susceptibility to infections

100. poor px
 delayed presentation & suboptimal mgmt
• longer than 5 days
 underlying RA
 presence of OM
 elderly, multiple comorbidities
 prostethic joints

101. pathophysiology
why the prediliction for joints?
 collagen receptors on S.aureus adhere to synovial cartilaginous junctions
 lack of limiting basement membrane
 synovial fibroblasts inhibit phagocytosis
delayed/inadequate Rx
 fibrinous adhesions/fibrous ankylosis
 articular erosion by pannus (chondrolysis)
 destruction of stabilizing ligaments

102. culprits
 macophages, PMN, synovial cells release (the host inflamm response)
• cytokines (IL-1b, IL-6 & TNF-a), immunoglobulin G, lysosomal enzymes (MMPs)
 bacterial endotoxins & direct baterial invasion of synovium
 inc intra-articular pressure
experimental model in rabbit knees (after S.aureus injection)
 PG subunit loss
• 30% at 48 hrs
• 50% at 5 days
• 80% at 3 wks
• collagen degradation starts by 3 wks

103. Bacterial arthritis
 commonly monoarticular
• polyarticular: 5-8% peds & 10-19% adult
 gonococcal or nongonococcal
 type of organism
• depend on age, immune status, habits, pre-existing arthropathy

104. Gonococcal arthritis
 most common cause of acute monoarthritis in sexually active
young adults
 2 forms
• disseminated gonococcal infection
• fever, chills, vesiculopustular skin lesions, tenosynovitis &
polyarthragia
• blood culture +ve; synovial culture -ve
• purulent arthritis
• knee, wrist & ankle
• synovial culture +ve
• acute onset of pain & swelling

105.  nongonococcal
• Gm +ve: 80%
< 3mo 3mo-5yr 6-10 yr >10 yr
Bacteria GBS S. aureus S. aureus S.aureus
Gm- ve bacilli K. kingae N. gonorrhea
MRSA S. pneumo,
GABHS
candida H.inf
(unvaccinated)

106. ill-appearing child
+ atraumatic limitation of mobility
+ joint irritability
other c/f
 fever (absent in elderly)
 inability to bear weight/limp
 malaise, poor appetite, irritability, progressive reluctance to use affected limb
 warmth & tenderness of affected joint
 joint effusion
 limited active & passive ROM

107.  SA Vs OM
• presence of irritable joint w/c is provoked by gentle passive motion
• joint motion doesn’t substantially provoke ssx in OM
 SA Vs transient synovitis (hip)
Kocher & colleagues
• fever > 38.5 (best predictor)
• hx of NWB
• ESR > 40 mm/h
• WBC > 12k
• CRP > 20 mg/L (added by Caird et al., 2006)
Luhmann
• only 59% probability when all 4 +
• fever, WBC, prev health care visit: only 71%
• advised for adjunct USG & arthrocentesis
Predictive probability
Kocher Caird
0 predictors 0.2% 16.9%
1 predictors 3% 36.7%
2 predictors 40% 62.4%
3 predictors 93.1% 82.6%
4 predictors 99.6% 93.1%
5 predictors N/A 97.5%

108.  WBC, ESR & CRP: +ve
 Blood culture +ve: 50% cases
 Synovial fluid aspiration: most valuable test
• fluid analysis
• cloudy/turbid
• CRP > 10.5 mg/dl
• WBC > 50k
• PMN %: >90%
• Gm staining: +ve in only 50%
• Culture positivity ranges 30-70%
• joint fluid may inhibit growth of certain bacteria

109.  Xray
• nonspecific
• joint space widening, periarticular osteopenia, enlargement of ST shadows,
displacement of fat pads
• joint space narrowing
• periosteal rxn appear late (3-4wks)
• not as prominent as in OM
 U/S
• non-echo free effusion with synovial thickening
• differentiates from bursitis & cellulitis by plane of collection
 MRI
• no better advantage over clinical judgement
• TB arthritis in axial locations

110. Principles in mgm’t
 adeq drainage + resection of infected tissue
 Abx
• uncomplicated SA: duration ~ 3wks
• guided by normalization of ESR
 resting the joint in stable position
• joint mobilization & weight bearing encouraged early (based on pain
tolerance)
 low dose IV corticosteroid

112.  123 peds
 low dose IV dexa + Abx Vs Abx alone

113. SA of hip in peds
Poor prognostic factors (Choi et al.)
 < 22wks of age
 prematurity
 ssx > 4 days
disability after acute septic arthritis
 pain: incongruous articulae surfaces/pathologic dislocation
 stiffness: partial/complete ankylosis
 deformity: abnormal angulation or shortening
 instability: destruction of prox femur/pathologic dislocation
SA of infancy “Tom-Smith’s arthritis”
 affection of hip joint in peds (not only restricted to infants)

114. Neonatal period & infancy
 Most common in this group
 Classic ssx not seen (fever, chills, rigor,
prostration)
 High index of suspicion
• Refusal to feed & cyanosis during feeding
• Abdominal distention
• Presence of focus of infection
• Edema of LE/buttock
• Crying on handling
• Not able to use lower limb actively
• Abnormal position of femur
(flexion & abduction)
Children
 Unwell
 Febrile
 Intense pain
 Restriction of all hip joint movt (esp.
rotation)
 Tenderness over Scarpa’s triangle

115.  If pus aspirated, hip joint promptly drained
Anterior approach
• Avoid damage to vascular supply
• Reduce chance of post-op dislocation
 Immobilization until infection is controlled

116. Compx of acute septic arthritis of hip
Pathological dislocation
 Prompt aggressive treatment
 ST contracture haven’t formed
• Reduction at time of drainage
 If damaged head
• Heavy skeletal traction to bring head to acetabulum
• then reduce by abduction & gentle rotation
 Immobilized in spica till stable or fibrous/bony ankylosis

117.  Complete resorption of the head
• May be replaced by new bone of vascularity is restored
 Pelvic abscess
 Persistent infection
• Characterized by excessive scarring & draining sinuses
 Ankylosis of hip
 OM of proximal femur
 Myositis ossificans
 Contractures & deformities
 Coxa breva/magna

118. Post septic hip sequelae in peds
 residual deformity
• Dx not established early &
proper Rx not instituted
• severe infection
 myriad presentation
• great mimicker
 needs in-depth Hx, detailed
clinical & radiological
assessment
Pain
Limp
LLD
Stiffness
Sinus

119. Classification systems
Hunka (1982)
Based on observation of pts that he treated
Type 1: absent/minimal head change
Type 2: Deformity of head
• A: intact physis; B: premature fusion
 Type 3: Pseudoarthrosis of neck
 Type 4: Complete destruction of
prox femoral epiphysis
• A: stable neck segment; B: unstable neck segment
 Type 5: Complete destruction to the IT line + dislocation

120. Choi et al. (1990)
 modification of Hunka
 detailed description of the anatomical alteration of the
proximal femur
 Type 1
• 1A: normal xray; 1B: AVN
 Type 2 (invt of epi, phy, metaphy)
• 2A: Coxa breva; 2B: Coxa vara/valga
 Type 3 (only femoral neck)
• 3A: Coxa vara/valga +/- excessive version
• 3B: pseudoarthrosis of neck
 Type 4 (loss of femur head & neck)
• 4A: Segment of neck preserved
• 4B: No neck remnant

121. Johari (2002)
 uniqueness: classified dislocations where CFE is present
 Group 1: loss of CFE/neck, metaphy spike; stable
 Group 2: loss of CFE & neck; unstable
 Group 3A: CFE present; dislocation; unstable
 Group 3B: CFE present; subluxation; unstable
 Group 4: articular incongruity; AVN; coxa magna; physeal
disturbance (coxa breva, vara, valga & trochanteric
overgrowth); stable
 Group 5: Pseudoarthrosis of neck; stable/unstable

122. Forlin & Milani (2008)
 simpler, more reliabe & useful for prognosis & Rx selection
 based on instability & destruction of femur head
 Grade 1: head/neck wn acetabulum
• A: head (total/part) present
• B: absent
 Grade 2: Hip dislocated
• A: head present
• B: absent

123. Principles & algorithms of reconstructive
procedures
aim
 hip stability & conc reduction of hip
 correction of LLD
 preservation of articular cartilage
remnants & reorientation of the axis
of normal physiologic load
 adequate containment of femoral
head
 correction of other deformities
Rx options
 patient’s ssx & needs
 extent of inv’t
 affordability
 active or quiescent
 age of patient
 degree of residual deformity

124. Management algorithm according to Choi
 type 1: observation
 type 2: mechanical issues &
containment (subluxation)
addressed
 type 3: derotation; + grafting
for 3B
 type 4A
<6 yr: Open reduction + modified
Harmon operation/ distal transfer of GT
(if fail salvage done)
>6 yr: treated as 4B
 type 4B
<6 yr: GT arthroplasty + fem varus
osteotomy + acetabuloplasty (if fail
salvage done)
> 6yr or all salvage cases: Ilizarovs hip
reconstruction osteotomy

125. Active infection
 debride/redebride & IV/oral Abx
 resection arthroplasty
Surgical options based on age
 childhood
• open reduction +/- femoral shortening +/- pelvic osteotomy
• epiphysiodesis
• GT arthroplasty (Colonna procedure) (4B; <6yr); modified Harmon procedure (4A; < 6yr)
• GT growth arrest
 adolescent
• corrective osteotomy
• ST release
• arthrodesis
• schanz osteotomy, lengthening procedures, neck lengthening (absolute/relative)
 adult
• Schanz osteotomy, PSO w/ limb lengthening
• THR, arthrodesis

126. Symptomatic approach
 painful joint degeneration:
• PSO, THR, resection, arthrodesis
 abductor insufficiency
• GT growth arrest, GT transfer
(RNL/ANL), PSO, arthrodesis
 LLD
• ST release, epiphysiodesis,
lengthening, PSO w/
lengthening
 instability
• open reduction, GT arthroplasty,
PSO, arthrodesis, THR, pelvic
osteotomy
 loss of motion
• ST release
 malpositioned extremity
• realignment osteotomy, THR
 non-union
• bone grafting, valgus osteotomy

127. references
 Campbell’s Operative Orthopaedics, 14th ed.
 Tachdjian’s Pediatric Orthopaedics, 6th ed.
 Essential Orthopedics principles & practice
 Textbook of Orthopedics & Trauma (Kulkarni), 3rd ed.
 Rockwood & Green’s Fractures in Adults, 8th ed.
 Global Orthopedics
 Fundmentals of Orthopedics
 Conceptual Orthopedics
 Amboss

128. 1. Darville, Toni, and Richard F Jacobs. “Management of acute hematogenous osteomyelitis in children.” The
Pediatric infectious disease journal vol. 23,3 (2004): 255-7
2. Giannoudis, Peter V et al. “Masquelet technique for the treatment of bone defects: tips-tricks and future
directions.” Injury vol. 42,6 (2011): 591-8
3. Masquelet, A C et al. “Reconstruction des os longs par membrane induite et autogreffe spongieuse”
[Reconstruction of the long bones by the induced membrane and spongy autograft]. Annales de chirurgie
plastique et esthetique vol. 45,3 (2000): 346-53. French.
4. Henrich, D et al. “Establishment and characterization of the Masquelet induced membrane technique in a rat
femur critical-sized defect model.” Journal of tissue engineering and regenerative medicine vol. 10,10 (2016):
E382-E396
5. Giannoudis PV, Harwood PJ, Tosounidis T, et al. Restoration of long bone defects treated with the induced
membrane technique: protocol and outcomes. Injury. 2016;47 (suppl 6):S53–S61

129. 6. Cho JW, Kim J, Cho WT, et al. Circumferential bone grafting around an absorbable gelatin sponge core reduced the amount of grafted bone in
the induced membrane technique for critical-size defects of long bones. Injury. 2017;48:2292–2305
7. Stevenson AJ, Jones HW, Chokotho LC, Beckles VL, Harrison WJ. The Beit CURE Classification of Childhood Chronic Haematogenous
Osteomyelitis--a guide to treatment. J Orthop Surg Res. 2015;10:144. Published 2015 Sep 17
8. Yin, Peng et al. “A Systematic Review and Meta-Analysis of Ilizarov Methods in the Treatment of Infected Nonunion of Tibia and Femur.” PloS
one vol. 10,11 e0141973. 3 Nov. 2015
9. Bari MM, Islam S, Shetu NH, Rouf AHMA, Rahman M (2016) Distraction Osteogenesis by Ilizarov Technique for Infected Gap Non-Union of
the Femur. MOJ Orthop Rheumatol 6(2): 00212
10. Kocaoglu, Mehmet et al. “Reconstruction of segmental bone defects due to chronic osteomyelitis with use of an external fixator and an
intramedullary nail.” The Journal of bone and joint surgery. American volume vol. 88,10 (2006): 2137-45
11. Odio, Carla M et al. “Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in
children.” The Pediatric infectious disease journal vol. 22,10 (2003): 883-8
12. Reinehr, T et al. “Chronic osteomyelitis in childhood: is surgery always indicated?.” Infection vol. 28,5 (2000): 282-6

130. 13. Cierny, George 3rd et al. “A clinical staging system for adult osteomyelitis.” Clinical orthopaedics and related research ,414 (2003):
7-24
14. Tong, Kai et al. “Masquelet technique versus Ilizarov bone transport for reconstruction of lower extremity bone defects following
posttraumatic osteomyelitis.” Injury vol. 48,7 (2017): 1616-1622
15. Koryllou, Aikaterini et al. “Chronic Nonbacterial Osteomyelitis in Children.” Children (Basel, Switzerland) vol. 8,7 551. 25 Jun. 2021
16. Gornitzky, Alex L et al. “Diagnosis and Management of Osteomyelitis in Children: A Critical Analysis Review.” JBJS reviews vol. 8,6
(2020): e1900202
17. Dartnell, J et al. “Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature.” The Journal
of bone and joint surgery. British volume vol. 94,5 (2012): 584-95
18. Montgomery, Corey O et al. “Treatment of subperiosteal abscesses in children: is drainage of the intramedullary canal required?.”
Journal of pediatric orthopedics. Part B vol. 26,6 (2017): 497-500
19. Arshad, Zaki et al. “Management of chronic osteomyelitis of the femur and tibia: a scoping review.” EFORT open reviews vol. 6,9
704-715. 14 Sep. 2021

131. 20. Wassif, Reem Khaled et al. “Recent advances in the local antibiotics delivery systems for management of osteomyelitis.” Drug delivery vol.
28,1 (2021): 2392-2414
21. Yang, Jian et al. “Current opinions on the mechanism, classification, imaging diagnosis and treatment of post-traumatic osteomyelitis.”
Chinese journal of traumatology = Zhonghua chuang shang za zhi vol. 24,6 (2021): 320-327
22. Lipsky, Benjamin A, and İlker Uçkay. “Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update.” Medicina (Kaunas,
Lithuania) vol. 57,4 339. 1 Apr. 2021
23. Maamari, Julian et al. “Diagnosis of vertebral osteomyelitis.” Journal of bone and joint infection vol. 7,1 23-32. 27 Jan. 2022
24. Kocher, M S et al. “Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical
prediction algorithm.” The Journal of bone and joint surgery. American volume vol. 81,12 (1999): 1662-70
25. Caird, Michelle S et al. “Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study.” The
Journal of bone and joint surgery. American volume vol. 88,6 (2006): 1251-7
26. Gilbert, DN; Chambers, HF. "Sanford Guide to Antimicrobial Therapy." 2020

132. Thank you