DR ALIHUSSEIN I KASSAMMNAZI MMOJA HOSPITAL
INTERN DOCTOR
ACUTE AND CHRONIC OSTEOMYELITIS
3 May 2023Dr Alihussein Kassam
DEFINITION
Inflammation of the bone caused by an infecting organism
3 May 2023Dr Alihussein Kassam
Introduction The key to successful management
is early diagnosis and appropriate surgical and antimicrobial treatment.
A multi disciplinary approach is required, involving an orthopaedic surgeon, an infectious disease specialist, and a plastic surgeon in complex cases with significant soft tissue loss.
3 May 2023Dr Alihussein Kassam
Classification 1) The duration - acute, subacute and
chronic
2) Mechanism of infection – exogenous or hematogenous
3) The type of host response to the infection- pyogenic or non pyogenic
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisBimodal distribution- younger than 2
years, and 8-12 years
3 May 2023Dr Alihussein Kassam
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitis microbial patternStaphylococcus aureus most common
in older children and adultsGram negative bacteria- increasing
trend- vertebralPseudomonas most common in
intravenous drug abusersSalmonella in sicke cellFungal infections in chronically ill
patients on long term intravenous therapy.
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitismicrobial patternInfants- staph aureus most common but
group B streptococcus and gram negative coliforms
Prematures staph aureus andgram negative organisms
Hemophilus influenzae primarily in children 6 months to 4 years old, incidence decreased dramatically by immunizations
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisdiagnosisHistory and physical examination
Fever and malaisePain and local tendernessSweliingCompartment syndrome in children
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisdiagnosisLaboratory tests
White blood cell countErythrocyte sedimentation rateC-reactive protein
checked very 2- 3 days post treatment initiation
Aspiration for suspected abscess
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisdiagnosis
Plain radiographs
Technetium-99m bone scan +/- MRI
3 May 2023Dr Alihussein Kassam
Radiographs Soft tissue swelling
Periosteal reaction
Bony destruction (10-12 days)
3 May 2023Dr Alihussein Kassam
Bone scan
Can confirm diagnosis
24-48 hrs after onset
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisTreatmentSurgery and antibiotic treatment are
complementary, in some cases antibiotics alone may cure the disease.
Choice of antibiotics is based on the highest bacteriocidal activity, the least toxicity and the lowest cost
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisTreatmentNade’s 5 principles of treatment
1. An appropriate antibiotic is effective before pus formation
2. Antibiotics do not sterilize avascular tissues or abscesses and such areas require surgical removal
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisTreatment- nades principles
3. If such removal is effective, antibiotics should prevent their reformation and primary wound closure should be safe
4. Surgery should not damage already ischaemic bone and soft tissue
5. Antibiotics should be continued after surgery
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisTreatment
The two main indications for surgery in acute hematogenous osteomyelitis are:1. The presence of an abscess
requiring drainage2. Failure of the patient to improve
despite appropriate intravenous antibiotic treatment
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisTreatment- surgeryThe objective of surgery is to drain any
abscess cavity and remove all non viable or necrotic tissue
Subperiosteal abscess in an infant-several small holes drilled through the cortex into the medullary canal
If intramedullary pus is found, a small window of bone is removed
Skin is closed loosely over drains and the limb splinted
3 May 2023Dr Alihussein Kassam
Acute hematogenous osteomyelitisTreatment
Generally a 6 week course of intravenous antibiotics is given
Orthopedic and infectious disease followup is continued for at least 1 year
3 May 2023Dr Alihussein Kassam
CHRONIC OSTEOMYELITISHallmark is infected dead bone within
a compromised soft tissue envelope
The infected foci within the bone are surrounded by sclerotic, relatively avascular bone covered by a thickened periosteum and scarred muscle and subcutaneous tissue
3 May 2023Dr Alihussein Kassam
Classification of COM
3 May 2023Dr Alihussein Kassam
Anatomical classification
3 May 2023Dr Alihussein Kassam
Classification of COM
3 May 2023Dr Alihussein Kassam
Diagnosis COM
Based on Clinical laboratory and imaging studies
3 May 2023Dr Alihussein Kassam
Clinical evaluation COM
Skin and soft tissue integrityTenderness Bone stabilityNeurovascular status of limbPresence of sinus
3 May 2023Dr Alihussein Kassam
Laboratory COM Erythrocyte sedimentation rateC reactive proteinWBC count only elevated in 35%Biopsy for histological and
microbiological evaluationStaphyloccocus speciesAnaerobes and gram negative bacilli
3 May 2023Dr Alihussein Kassam
Imaging studies in COMPlain X rays
Cortical destructionPeriosteal reactionSequestra Sinography
3 May 2023Dr Alihussein Kassam
Sinography
3 May 2023Dr Alihussein Kassam
COM Imaging
CT ScanIdentifying sequestraDefinition of cortical bone and surrounding soft tissues
3 May 2023Dr Alihussein Kassam
COM ImagingMRI
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 cellulitis3 May 2023Dr Alihussein Kassam
Treatment of COMSurgical treatment mainstay
SequestrectomyResection of scarred and infected bone and debridement
3 May 2023Dr Alihussein Kassam
Surgical treatment of COMAdequate debridement leaves a dead
space that needs to be managed to avoid recurrence, or bony instabilitySkin grafts,Muscle and myocutaneous flapsFree bone transferPapineau techniqueHyperbaric oxygen therapyVacuum dressing
3 May 2023Dr Alihussein Kassam
Treatment of COMAntibiotic duration is controversial
6 week is the traditional duration1 week IV, 6 weeks of oral therapyAntibiotic polymethyl methacrylate
(PMMA) beads as a temporary filler of dead space
Biodegradable antibiotic delivery system
3 May 2023Dr Alihussein Kassam
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.
3 May 2023Dr Alihussein Kassam
Resection or excision for COM
3 May 2023Dr Alihussein Kassam
Amputation for osteomyelitisAmputation indications include
Arterial insufficiencyMajor nerve paralysisNon functional limb-stiffness,
contractureMalignant 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
3 May 2023Dr Alihussein Kassam
References Canale Terry and Beaty James (2007) Campbell’s
Operative Orthopaedics, Philadelphia, Mosby Ben Mbonye-Girasi (1981) Mode of Presentation and
End results of Management of Haematogenous Osteomyelitis at the Orthopaedic Unit Kenyatta National Hospital over a Five Year Period. Nairobi : unpublished masters in medicine project, School of Medicine, University of Nairobi
Issac K Ngetich (2002) A Study of Haematogenous Osteomyelitis in Children in Kenyatta National Hospital Kenya. Nairobi : unpublished masters in medicine project, School of Medicine, University of Nairobi
Lewis R P, Sutter V L and Finegold S M (1978) Bone Infections Involving Anaerobic Bacteria. Baltimore pub med PMID 207946
3 May 2023Dr Alihussein Kassam