in depth discussion on osteomyelitis

1. DEPARTMENT OF SURGERY
Solwezi General hospital
TOPIC: OSTEOMYELITIS
PRESENTER: Dr.Chomachoma

2. Definition
Progressive infection or Inflammation of bone and bone
marrow.

3. Classification
➢ Acute hematogenous Osteomyelitis
➢ Post acute osteomyelitis
➢ Subacute osteomyelitis
➢ Chronic osteomyelitis

4. Risk Factors
➢ Immunosuppression
➢ Children
➢ Elderly
➢ Male

5. Commonest Anatomical sites
➢ Distal femur
➢ proximal Tibia
➢ Distal Tibia
➢ proximal Humerus

6. Causative organisms
➢ S.Aeurus 60-90%
➢ S. Pyogens (> 1year of age)
➢ H.Infleunzatype B(< 4yrs)
➢ Salmonella (SCD)

7. Pathophysiology
➢ Acute hematogenous comes from somewhere distant and spreads through blood to bone.
➢ There will be hx of trauma,absces,skin lesions, pharyngitis or UTI.If this is not treated can end up in
blood stream and thereby circulation.
➢ Osteomyelitis tend to occur in long bones( metaphysis).
➢ It is in the metaphysis that you will have hair pin arrangement of vessels. Hence blood supply slows
down incresing risk of infection.

8. Phases
➢ Inflammation 24-48hrs :- Stasis of blood flow causes vascular congestion and increases intraoseous
pressure leading to extreme pain.
➢ Suppuration 3-7days -Pus forms sipping down into the Volkmans canal and finds itself
insubperiosteal space to form sub periosteal abscess.
➢ NB: In young children, this infection can cross growth plate and end up in joints resulting in septic
arthritis.

9. 3.Necrosis
➢ Venous thrombosis cause increase in intraoseous pressure, vascular congestion plus stripping of
periosteum leading to cut in blood supply on bone leading to necrosis(sequestration formation)
➢ Involucrum Formation
➢ In the inner layer of periosteum, new bone begins to form as a reaction to dead bone,this is known as
Involucrum.

10. Resolution
➢ With proper intervention resolution can occur.
➢ Osteomyelitis can occur in multiple sites called Ostotic Osteomyelitis.

11. Acute Hematogenous Osteomyelitis
➢ Acute infection of bone and bone marrow and has a duration of 24-48hrs.Inflammation phase is
prominent here.
➢ This is a true orthopaedic emergency and is the most critical.

12. Clinical features
➢ Fingers tip Tenderness in metaphyseal area
➢ Fever,Pain ,pseudoparalysis,motion Tenderness, irrtablility ,failure to thrive.
➢ NB FEVER + BODY TENDERNESS =ACUTE HEMATOGENOUS OSTEOMYELITIS UNTIL PROVEN
OTHERWISE.

13. Investigations
Laboratory
➢ FBC/DC
➢ ESR
➢ CRP
➢ Blood culture
➢ Staphylococcal O titres
Radiological
➢ Plan Xray- normal upto day 10
➢ Technetium 99M bone scan is sensitive
before xray

14. Treatment
➢ Warrants emergency bone drilling and draining, this is MANDATORY. Remember to take a pus swab
foe mcs
➢ Give antibiotics upto 6weeks,starting with iv then switching to oral.
➢ Analgesia
➢ Splint affected limb

15. Complications
➢ Chronic osteomyelitis
➢ Anemia
➢ Septic Arthritis
➢ Growth disturbances

16. DDX
➢ Fracture
➢ Septic arthritis
➢ Sickle cell crisis
➢ Malaria
➢ heumatic fever

17. POST ACUTE HEMATOGENOUS
OSTEOMYELITIS
➢ Day 3-7,suppuration phase.
➢ Presentation is becoming more pronounced, local redness + warmth +edema
➢ Diagnosis: subsiding pain+ Fever
➢ Xray Maybe normal but sometimes soft tissue swelling and periosteal reaction Maybe noted.
➢ Management and Treatment is the same as in AHO.

18. Sub Acute Osteomyelitis
➢ Typically signs and symptoms are settling down.This is as a result of the organism becoming less
virulent due to body's defence mechanism.
➢ Investigations are similar to acute.
➢ On xray you may see a brodies abscess.

19. Brodies Abscess

22. Chronic osteomyelitis
➢ Complication of failure to manage AHO

23. Clinical features
➢ Chronic discharging sinuses
➢ Sequestrum
➢ Involucrum
➢ +/- pain ,fever,joint stiffness, joint effusion, fracture, limb deformities,pathologicaf fractures.

24. Classification
➢ Cierny Mader classification (Adults)
➢ Bert cure classification (Blantyre)- Children

25. Cierny Mader Classification
➢ Has two components; Anatomical and physiological.
1. Anatomical
a. Medullary- infection is confined to the medullary canal
b. Superficial- infection is confined to the cortex
c.Localised- infection in both both medullary canal and cotex but doesn't involve entire bone
d.Diffuse.

26. 2. PHYSIOLOGICAL COMPONENT
A.Host normal - Immunocompetent + good local vascularity.
B.Host compromised-Immunity compromised
C.Host prohibitive- delabitated that surgery is contraindicated

28. Bert Cure Classification

29. Investigations
➢ Radiological
➢ Plain Xray
➢ Sinogram
➢ Bone scan
➢ MRI (gold standard)
➢ Laboratory
➢ FBC/DC
➢ ESR
➢ CRP
➢ U&E Cr
➢ Pus swab
➢ Biopsy
➢ Anti staphylococcal A-titers

30. Treatment
➢ .Surgical debridement and bony stabilisation
➢ Control of dead space
➢ .Soft tissue cover
➢ Antibiotics

31. 1.Surgical debridment and bony stabilisation
➢ Wait for involucrum to sufficiency from around sequestration.(2/3rd of sequestrum)
➢ Once fully formed open the involucrum and do sequestrectomy,do curettage until ivory white then
open bone marrow end to release bone morphogenic proteins.
➢ Wash adequately and leave a drain.(24-478hrs)
➢ Stability of bone- external fixator,slpint,traction, fiber glass

32. 2.Control of dead space
➢ Vascularised bone graft transfers
➢ Tibialisation of the Fibula
➢ limb Lengthening via callotaxis

34. 3.Soft Tissue Cover
➢ 2° suturing
➢ flaps
➢ Skin grafting

35. 4.Antibiotics
➢ Two schools of thought
1.There is no need to give antibiotics as they cannot reach cause of the pyogenic membrane.
2. Despite the the pyogenic membrane give atleast for 6 weeks.
Antibiotic beads
Iv antibiotics
Pus swab sensitive antibiotics

36. Complications
➢ Pathological fractures
➢ Osteopenia/osteoporosis
➢ Limb shortening
➢ Fibrosis of adjacent soft tissue
➢ Neoplasm
➢ Amyloidosis
➢ Anemia
➢ Recurrence rate is very high

37. ➢ Septic arthritis
➢ Pyomyositis
➢ Delayed Union

38. REFRENCES
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