This document provides an overview of osteomyelitis, including its history, causes, types, clinical presentation, diagnostic evaluation, treatment approaches, and adjunctive therapies. It discusses the typical bacteria involved, importance of biopsy for diagnosis, use of imaging studies like X-rays and MRIs, and treatment through a multimodal approach including antibiotics, surgical debridement, reconstruction, and optimization of patient comorbidities. Local antibiotic delivery methods like polymethylmethacrylate beads are also summarized.

1. Paulson Varghese
Post graduate student
Dept of Orthopedics
AIIMS, Bhubaneswar

2. 250 million
years
#spine
Permian
reptile
370 BC
Hippocrates
1773
Bromfield
‘Abscess In
medulla’
1831
Prof.Smith
‘Necrosis of
bone’
1844
Nelaton
‘osteomyelitis’

3. OSTEON MYELO ITIS

4. Duration
Acute
Sub acute
Chronic
Mechanism
Exogenous
Hematogenous
Host
response
Pyogenic
Non pyogenic

5. Involves metaphyses
Bacterial seeding
Inflammatory reaction
Local ishemic necrosis
Abscess formation

6. Staph aureus
• adults
• Children
Group B
streptococci
• infants
pseudomonas
• IV drug abusers
Fungal
• Long term iv
therapy
Salmonella
• Sickle cell hb
Eikenella
human bite
Kingella
Animal bite
Staph epidermidis
Surgical implants

7. History and
physical
examination
WBC
count-
ESR-CRP
Plain
radiographs
Tc-99
bone scan
+/-MRI
USG
FDG-PET
SPECT
Aspiration
For
Suspected
Abscess

8. Antibiotic is
effective
before
abscess
formation
Abscesses
require
surgical
removal
If such
removal is
effective
antibiotics
should
prevent their
re-formation
Surgery
should not
damage
further the
already
ischemic bone
and soft
tissue
Antibiotics
should be
continued
after surgery

9. SUBPERIOSTEAL ABSCESS
 CORTICAL DRILLING
INTRAMEDULLARY ABSCESS
 BONE WINDOW

10. More insidious
Less severe
Temperature mildly elevated
Mild to moderate pain
WBC count – normal
ESR elevated only in 50%
Blood culture usually negative

11. Differntialdiagnosis
Type I – LCH , Brodie’s abscess
Type II – Eosinophilic granuloma,
osteogenic sarcoma
Type III- Osteoid osteoma
Type IV- Ewings sarcoma
Type V – Chondroblastoma
Type VI- TB, osteogenic sarcoma

12. Localised form of subacute osteomyelitis in long bones of
lower extremity
Before physeal closure – metaphysis
Adults- metaphyseal epiphyseal area
Intermittent pain of long duration with local tenderness
Xray- lytic lesion with rim of sclerotic bone
Treatment- open biopsy with curettage

13. Infective, dead, sclerotic, relatively avascular peace of bone
covered by thickened periosteum, scarred muscle and
subcutaneous tissue.
Avascular envelope leaves systemic antibiotics ineffective
So eradication generally reqiers, aggressive surgical debridement +
dead space management+ effective antibiotic treatment

14.  PHYSIOLOGICAL
A-normal host
B-compromised
host
C- prohibitive
host
 ANATOMICA
L

15. Clinical, Laboratory And Imaging Studies
Gold Standard- Biopsy With C&S
ESR And CRP Elevated In Most.
WBC Elevated Only In 35%
Isotopes Scan More Useful In Acute Than Chronic
Normal Gallium Scan Excludes Presence Of Osteomyelitis
CT Useful In Identifying Sequestrum
IN C/C OSTEOMYELIYIS, T II MRI Shows RING SIGN

16. Multifactorial
approach
Antibiotic
suppression
Surgical
debridement
And
reconstruction
Optimisation
of host
morbities

17. Injection of
methylene blue
to identify the
sinus tract
Technique-
expose the
infected area
of bone and
excise all the
sinus tracts
Incise the
periosteum and
elevate
Cortical window
is created with
an osteotome
and drill

18. Remove
sequestra,
purulent
material and
necrotic
tissue
Until the
paprika sign
is achieved
Dead space
filled with
antibiotic
PMMA
beads
Non union-
bone
stabilized
with Ilizarov
fixator

19. Stage I
Debridement
Stabilisation
Application
Of VAC
Stage II
Bone
grafting
Apply VAC
Stage III
Wound
Coverage
With
Skin
Graft

20.  To deliver antibiotics locally in concentrations above MIC.
 AMINOGLYCOSIDES are most commonly employed antibiotics
 FQ, TETRACYCLINE & POLYMIXN B are not used in PMMA beads
Short term
10 days
Long term
80 days
Permanent

21.  Antibiotic laden PMMA intramedullary rods used in long bones
Thorough
debridement of
necrotic tissue and
bone
Irrigate the canal
with reamer irrigator
aspirator
( RIA)
Antibiotic cement
nail is made using
chest tube

22. Used when bony instability is not an issue and soft tissue coverage is adequate.
Contains osteoconductive and osteoinductive materials.
Carriers for delivery of antibiotics can be proteins, bone graft materials and
synthetic polymers.
Proteins- collagen, autologous blood clot, gelatin, thrombin.
Bone graft materials - Eg) Calcium sulphate and calcium phosphate mixed with
antibiotics.
Ideal biodegradable should have good biocompatibility, controllable degradation
and ability to release antibiotics without releasing acidic byproducts.

23.  Negative pressure wound therapy
 ADVANTAGE- allows change in local
antibiotic delivery based on culture
results
 DISADVANTAGE- frequent
occlusion and secondary
contamination

24.  Soft tissue transfer
 Ilizarov technique
 Adjunctive therapies- Hyperbaric O2 therapy
BMP
PRP
PEMF- pulsed electromagnetic field