Looking at the treatment approach and pathophysiology of 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
• 1.Inflammation 24-48hrs :- Stasis of blood flow
causes vascular congestion and increases
intraoseous pressure leading to extreme pain.
• 2.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)
• 4. 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
• Rheumatic 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
• 1.Cierny Mader classification (Adults)
• 2.Bert cure classification (Blantyre)- Children

25. Cierny Mader Classification
• Has two components; Anatomical and
physiological.
• Anatomical
• 1.Medullary- infection is confined to the medullary
canal
• 2. Superficial- infection is confined to the cortex
• 3.Localised- infection in both both medullary canal
and cotex but doesn't involve entire bone.

26. 4.Difuse
• Covers enter diameter of bone and there is
compromise in stability of bone.
• 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
• 1.Surgical debridement and bony stabilisation
• 2.Control of dead space
• 3.Soft tissue cover
• 4.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
• 1. Osteomyelitis: diagnosis and treatment. Bury
DC, Rogers TS, Dickman MM.
https://pubmed.ncbi.nlm.nih.gov/34652112/ Am
Fam Physician. 2021;104:395–402. [PubMed]
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• 2. Progress in diagnosis and treatment of post-
traumatic osteomyelitis [Article in Chinese]
Tang B, Zhu W.
https://pubmed.ncbi.nlm.nih.gov/34911865/.
Zhong Nan Da Xue Xue Bao Yi Xue Ban.
2021;46:1290–1297. [PubMed] [Google
Scholar]