a case chronic ostyeomyelitis

Dr. Om Parshuram Patil

Dept Of Orthopaedics

Under Guidance Of

Dr G.N.Pundkar

Prof and Head

17 year old male came to the casualtyn with Chief Complaints of

Pain in rt thigh since 1 month

Fever since 4 days

History of trauma to rt thigh and leg one and half month before, trivial in nature & due to fall

No h/o Chronics diseases, weight loss

Pain in rt thigh since one month which was insidious in onset , gradually progressive dull aching in nature ,with no aggravating factors, reduced in severity since last 4-5 days with associated fever since then

Fever was high grade , intermittent, not associated with chills and rigors

On examination

Local temp was raised than contralateral side in mid thigh region

Minimal swelling in rt thigh

Diffuse tenderness in mid thigh region

From hip to calf region

Could not be localised to a particular area

Investigation TLC : 21,600

Neutro : 80%

Lympho :15%

Mono :03%

Eosino :02%

Hb :12.3 gm %

ESR :20 mm

Sickling :negative

Blood Group: O negative

Usg Rt Thigh:

Evolving Abscess in rt thigh Deep muscle lateral side, with surrounding muscle myositis, with inflammatory changes in rt hip joint.

Started with Ceftriaxone and Linezolid for 7 days

Xray 21/11/14

Rt thigh AP /Lat

S/o : Periosteal reaction in mid third upper third junction of rt femur.. Suggesting

acute osteomyelitis ?

Ewings Sarcoma? With onion peel appearance

21/11/14

Pt was subjected biopsy through, latetral approach and window was made over the lateral cortex with multiple drilling holes

Minimal cheesy material was drained out from superficial part lateral cortex

Cortical bone and surrounding soft tissue sent for histopathology and culture

Started with Antibiotics Ceftriaxone with sulbactum, amikacin for three weeks

Patient was relieved of symptoms partially after procedure with reduced severity of pain and fever

Histopathology Of the tissue was suggestive of chronic osteomyelitis

29/11/14

HistopathologyChronic osteomyelitis, from infected femur s The irregular fragment of devitalized bone surrounded by dense fibrous tissue heavily infiltrated by plasma cells, lymphocytes, and only a few granulocytes.

Inflammatory Changes

Post operative Xray

Post op 3 weeks

8/12/14 TLC : 10200/cumm

Neutro : 60%

Lympho : 32%

Mono : 04%

Eosino : 04%

Hb : 12.0 gm %

ESR : 15 mm

17/12/14

TLC : 12900/cummNeutro : 59%Lympho : 37%Mono : 03%Eosino : 01%Hb : 12.3 gm %ESR : 12 mm

Parenteral antibiotics were stopped on 21 days and shifted to oral antibiotics .

But radiological picture of the patients rt femur was S/o

Increased periosteal reaction disseminated to lower part of femur

??? Onion peel appearance s/o ewings sarcoma

Further treatment Plan Saucerization and reaming of intramedullary cavity

with antibiotic impregnated nail for six weeks

Drain window in the distal part of femur laterally

Simultaneous repeat histopathological and culture studies from the site.

Chronic Osteomyelitis

Classification of COM

Anatomical classification

Classification of COM

Diagnosis COM

Based on

Clinical

laboratory and

imaging studies

Clinical evaluation COM

Skin and soft tissue integrity

Tenderness

Bone stability

Neurovascular status of limb

Presence of sinus

Laboratory COM

Erythrocyte sedimentation rate

C reactive protein

WBC count only elevated in 35%

Biopsy for histological and microbiological evaluation

Staphyloccocus species

Anaerobes and gram negative bacilli

Imaging studies in COM

Plain X rays

Cortical destruction

Periosteal reaction

Sequestra

Sinography

Sinography

Imaging -

Isotopic bone scanning more useful in acute than in chronic osteomyelitis

Gallium scans increased uptake in areas where leucocytes and bacteria accumulate. Normal scan excludes osteomyelitis

COM Imaging

CT Scan

Identifying sequestra

Definition of cortical bone and surrounding soft tissues

COM Imaging

MRI

Shows margins of bone and soft tissue oedema

Evaluate recurrence of infection after 1 year

Rim sign- well defined rim of high signal intensity surrounding the focus of active disease

Sinus tracks and cellulitis

Treatment of COM

Surgical treatment mainstay

Sequestrectomy

Resection of scarred and infected bone and soft tissue

Radical debridement

Resection margins >5mm

Surgical treatment of COM

Adequate debridement leaves a dead space that needs to be managed to avoid recurrence, or bony instability

Skin grafts,

Muscle and myocutaneous flaps

Free bone transfer

Papineau technique

Hyperbaric oxygen therapy

Vacuum dressing

Treatment of COM

Antibiotic duration is controversial

6 week is the traditional duration

1 week IV, 6 weeks of oral therapy

Antibiotic polymethyl methacrylate (PMMA) beads as a temporary filler of dead space

Biodegradable antibiotic delivery system

Resection or excision for COM

Resection of a segment of affected bone may be necessary to control infection

With techniques of bone and soft tissue transport, massive resections can be performed and reconstructed without significant disability.

Amputation for osteomyelitis

Amputation indications include

Arterial insufficiency

Major nerve paralysis

Non functional limb-stiffness, contracture

Malignant change

Prevalence of maliganacy arising from COM reported as 0.2 to 1.6% of cases.

Most are squamous cell carcinoma, also reticulum cell carcinoma,fibrosarcoma

Ewings Sarcoma

Epidemiology Incidence is 0.6 per million

Males > Females

65% in the 2nd decade of life

Rare in blacks and Asians

Clinical PresentationHistory:

Pain most commonly (90%)

Swelling (70%)

Fever (20%)

Pathological fracture

Weight loss, malaise

Clinical PresentationPhysical Exam and Labs

Local warmth, inflammation

Pleural effusions

Neurological signs if spinal involvement

ESR, LDH, anemia, leukocytosis

Radiology Site

Size

Effect on bone

Response of Bone

Matrix

Cortex

Soft tissue

Pathology Cell of origin is unknown

Previously a diagnosis of exclusion

Reciprocal translocation

Pathology Gross: soft, tan, gray tissue

Micro: nests of small round cells

No osteoid or chondroid production

Surface cell glycoprotein

PathologyDifferential Diagnosis

Lymphoma

Osteomyelitis

Osteosarcoma

Malignant Fibrous Histiocytoma

Metastatic neuroblastoma in toddlers

Staging and Prognosis Local and distal staging

Bone marrow aspirate

Pre-chemotherapy investigations

Biopsy

Staging and Prognosis Location

Tumor Size

Metastases at diagnosis

Response to chemotherapy

Treatment Multidisciplinary approach

Neoadjuvant chemotherapy, surgery

Don’t prolong interval between chemo

Radiation if indicated

Summary Rare but common

Main ddx is lymphoma and infection

Large soft tisse masses

Neoadjuvant chemo and surgery

75-80% disease free survival at 5 years

Thank you