Osteomyelitis.ppt how to intervention and

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Osteomyelitis
DR IMRAN JAVED.
ASSOCIATE PROFESSOR SURGERY.
FIJI NATIONAL UNIVERSITY.
SUVA, FIJI.

Osteomyelitis
• Severe infection of the
 Bone
 Bone marrow
 Surrounding soft tissue
• Caused by a variety of microorganisms ?
• Most common infecting microorganism ?

Etiology and Pathophysiology
• Antibiotics in conjunction with surgical
treatments have decreased mortality rate
and complications
• Infecting microorganisms can invade by
 Indirect entry
 Direct entry

Direct Entry
• Can occur at any age
• Open wound where microorganisms can
gain entry to body
• May also occur in presence of foreign
body
 Internal Fixation.

Direct Entry
• Sequestrum continues to be an infected
island of bone, surrounded by pus
• Difficult for blood-borne antibiotics or
white blood cells (WBCs) to reach
sequestrum
• Sequestrum can move out of bone and
into soft tissue

Direct Entry
• Once outside bone
 Sequestrum may
• Revascularize and then undergo removal by
normal immune process
• Be surgically removed through debridement of
necrotic bone
 If necrotic sequestrum is not resolved, it may
develop a sinus tract resulting in chronic,
purulent cutaneous drainage

Indirect Entry
• Frequently affects growing bone in boys
<12 years old ---Why???

 Most common sites of indirect entry
• Distal femur
• Proximal tibia
• Humerus
• Radius

Indirect Entry
• Adults with increased risk
 Vascular disorders
 Genitourinary and respiratory infections
 Spread infection from blood to bone
 Vascular-rich bone sites
• Pelvis
• Tibia
• Vertebrae

Development of Osteomyelitis
Fig 64-1

Clinical Manifestations
Acute Osteomyelitis
• Initial infection
 Infection of <1 month in duration
 Both systemic and local

Acute Osteomyelitis
• Systemic
 Pyrexia, Generalized weakness,
Dehydration, Bone pains etc.
• Local
 Constant bone pain that worsens with
activity
 Swelling, tenderness, warmth at infection site
 Restricted movement of affected part
 Later signs: drainage from sinus tracts

of Chronic Osteomyelitis
• Chronic – an infection that persists
for longer than 1 month
• Infection that has failed to respond
to initial course of antibiotic
therapy
• Systemic signs Less
evident.______
• Signs and Symptoms
 Constant bone pain
 Swelling
 Tenderness
 Warmth at site
 Continuous Drainage

Diagnostic Studies
• Bone or soft tissue biopsy
 Definitive way to determine causative
microorganism
• Patient’s blood and/or wound culture
 Frequently positive for presence of microorganism
• Lab Studies
 WBC
 Erythrocyte sedimentation rate (ESR)

Radiologic Studies
• Radiologic signs
 Usually do not appear until 10 days to weeks after
start of clinical symptoms
• Radionuclide bone scans
 Helpful in diagnosis and usually positive in areas of
infection
• Magnetic resonance imaging (MRI)
• Computed tomography (CT)
 Help identify extent of infection, including soft
tissue involvement

Collaborative Care
Acute Osteomyelitis
• Vigorous and prolonged intravenous (IV)
antibiotic therapy
 Treatment of choice for acute osteomyelitis
 As long bone ischemia has not occurred
 Cultures or bone biopsy should be done if
possible
• Delaying antibiotic treatment may require
surgical debridement and decompression

Collaborative Care
Acute Osteomyelitis
• Patients are often discharged to home care
or skilled nursing facility (SNF) with IV
antibiotics.

Collaborative Care
Acute Osteomyelitis
• Antibiotic therapy may be continued for
at home for _6 to 8 weeks or as long as
cultures are negative.
• Variety of antibiotics may be prescribed
 Penicillin, nafcillin (Nafcil)
 Neomycin, vancomycin
 Cephalexin (Keflex)
 Cefazolin (Ancef)

Collaborative Care
Chronic Osteomyelitis
• Adults with chronic osteomyelitis may be
prescribed oral therapy + fluoroquinolone
for 6 to 8 weeks instead of IV antibiotics
• Oral antibiotics may be given after acute
IV therapy to ensure resolution of
infection
• Monitoring patient’s response

Collaborative Care
• Surgical treatment for chronic
osteomyelitis
 Removal of poorly vascularized tissue and
dead bone
 Extended use of antibiotics
 Antibiotic-impregnated polymethyl
methacrylate bead chains may also be
implanted

Collaborative Care
• After debridement, wound may be closed
and a suction irrigation system inserted
• Intermittent or constant irrigation of
affected bone with antibiotics
• Protection on limb or surgical site with
casts or braces
• Negative pressure to draw wound together

Collaborative Care
• Hyperbaric oxygen therapy with 100%
oxygen as adjunct therapy
 Stimulate circulation and healing
• Orthopedic prosthetic devices, if source of
infection must be removed
• Muscle flaps, skin grafting provide wound
coverage over dead space (cavity) in bone

Collaborative Care
• Bone grafts may help restore blood flow
• Amputation may be indicated.

Collaborative Care
• Long-term and mostly rare complications
 Septicemia
 Septic arthritis
 Pathologic fractures
 Amyloidosis

Principles of Surgical Rx
• Antibiotic therapy.
• Drainage of Pus.
• Sequestrectomy & wound debridement.
• Removal of Prosthesis & Foreign Bodies.
• Bone grafts & Muscular flaps.
• External Fixator or POP with window.
• Amputation as Last resort.

Treatment of Impending Fracture.
• Assessing the risk.
• Treating the underlying disease.
• Stabilization of Bone by:
Early Internal Fixation if feasible like
metastasis to spine.
Fixation by External Fix or POP with
window if Osteomyelitis.
Bone cementing & Rehabilitation.

Osteomyelitis.ppt how to intervention and

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