osteomyelitis
TRANSCRIPT
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DR. GAJANAN PANDIT
OSTEOMYELITIS
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DEFINITION
Osteomyelitis is defined as an inflammation of the bone caused by an infecting organism.
The infection may be limited to a single portion of the bone or may involve numerous regions such as the marrow, cortex, periosteum, and the surrounding soft tissue.
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CLASSIFICATION
Classification of osteomyelitis is based on numerous criteria, such as
Based on duration of symptoms.Based on mechanism of infection.Based on the host response to disease.
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CLASSIFICATION
Based on duration of symptoms.
AcuteSubacuteChronic
The time limits defining these classes are arbitrary.
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CLASSIFICATION
Based on mechanism of infection.
ExogenousHematogenous
Exogenous osteomyelitis is caused by open fractures, surgery (iatrogenic), or contiguous spread from infected local tissue.
The hematogenous form results from bacteremia.
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CLASSIFICATION
Based on the host response to disease.
PyogenicNonpyogenic
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Bacterial Associations
Hematogenous osteomyelitis is most commonly caused by S. aureus.
In the past, Haemophilus influenzae type B (HiB) was a common organism in children, but the advent of HiB vaccine has made it a rare cause.
Causes of osteomyelitis due to direct inoculation, such as into an open fracture, will be influenced by the environment in which the injury occurred. For example, injuries occurring in water may lead to infection with Aeromonas or Plesiomonas.
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Bacterial Associations
Nail puncture wounds of the foot, particularly through a tennis shoe, are associated with infection with Pseudomonas aeruginosa
Underlying medical conditions of the host also influence the expected microbiology. Intravenous drug users may have P. aeruginosa and other gram-negative bacilli as causes of their osteomyelitis
Patients with sickle cell disease are prone to the development of Salmonella osteomyelitis.
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Bacterial Associations
Osteomyelitis caused by fungal infections is more likely to be seen in immunocompromised hosts.
Diabetic foot infections leading to osteomyelitis often are polymicrobial, often involving anaerobes and gram-positive and gram-negative aerobic bacilli.
Patients infected with the human immunodeficiency virus (HIV) are at risk for a variety of unusual infections, including atypical mycobacteria.
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ACUTE HEMATOGENOUS OSTEOMYELITIS
This is the most common type of bone infection and usually is seen in children.
It is more common in males in all age groups.It is caused by a bacteremia which is common
occurrence in children.Bacteriological seeding of bone is generally
associated with other factors such as localized trauma, chronic illness, malnutrition, or an inadequate immune system.
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ACUTE HEMATOGENOUS OSTEOMYELITIS
In children, the infection generally involves the metaphysis of rapidly growing bone.
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CAUSES FOR MORE INCIDENCE OF METAPHYSEAL OSTEOMYELITIS
1. Hair pin bend vessels in metaphysis.
2. Increased vascularity to metaphysis causing pooling of blood. It has been aptly called ‘a lake of blood’.
3. Immature cells of metaphysis due to high turnover.
4. Relative lack of phagocytosis.04/13/23
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CAUSES FOR MORE INCIDENCE OF METAPHYSEAL OSTEOMYELITIS
5. Presence of degenerating cartilage cells which act as a good culture media.
6. Presence of end arteries in metaphysis.
7. More prone to trauma.
8. Presence of single endothelial lining in metaphyseal arteries.
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Pathogenesis
Introduction of bacteria.Infective embolus enters the nutrient artery.Trapped in small calibre vessels.Active hyperemia.Exudate and debris.Increased pressure in bone.Exudate travels along the paths of least
resistence.Subperiosteal abscess.Sequestrum.
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DIAGNOSIS
A diagnosis of acute osteomyelitis should be considered an emergency.
The presenting signs and symptoms may vary with the severity of the infection.
Symptoms include fever and chills, general malaise, irritability, pain, and swelling.
With lower extremity involvement, there is either a limp or an inability to bear weight.
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DIAGNOSIS
An infant with upper extremity involvement may exhibit pseudoparalysis; older children and adults with upper extremity involvement complain of pain on movement or use of the extremity.
It is important to localize the point of maximum tenderness, which is usually warm and swollen. In children it is generally in the metaphyseal region.
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DIAGNOSIS
It is also important to evaluate the adjoining joint for evidence of septic arthritis, which can occur as an extension of the adjoining osteomyelitis.
Osteomyelitis involving the neck of the femur, talus, and humeral head often leads to sepsis of the joint
because these foci are located within the joint capsule.
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DIAGNOSIS
Once the point of maximum tenderness is localized, aspirate the area, and send the pus or fluid obtained for Gram stain, culture, and sensitivity studies.
If tuberculosis or a fungal infection is suspected, obtain an acid-fast stain and tuberculosis and fungal cultures.
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DIAGNOSIS
When a joint effusion is present or joint involvement is suspected, aspirate the joint and confirm with an arthrogram.
The arthrogram helps document the location of the aspiration and is useful for positive as well as for negative aspirations, since it may also identify joint capsule rupture.
Aspiration of the hip joint under ultrasound guidance is very helpful in children and adults.
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DIAGNOSIS
The white blood cell count is generally elevated, depending on the severity of the infection, with an increase in immature or band cells.
The erythrocyte sedimentation rate and the C-reactive protein are usually elevated.
Obtain blood cultures in all cases of acute hematogenous osteomyelitis and in chronic osteomyelitis exacerbated by fever and bacteremia.
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DIAGNOSIS
Roentgenograms taken early in the disease process generally show soft-tissue swelling. Bony changes are not present until 7–10 days after the onset of infection.
Radionuclide bone scanning using radioactive-labeled isotopes, such as technetium-99m and, more specifically, gallium citrate-67 and indium-111-labeled white blood cells, is helpful in localizing the area of involvement and in helping diagnose the condition.
Aspiration is used for the diagnosis, especially when there is no drainage or sinuses, and in some cases bone biopsy may be necessary.
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DIAGNOSIS
Magnetic resonance imaging (MRI) has added a new dimension to the diagnosis, localization, and characterization of the extent of infection.
T1- and T2-weighted images are the initial screening techniques for diagnosing osteomyelitis.
The MR finding in osteomyelitis on T1-weighted image sequences is a low signal intensity due to a dark marrow signal and an increased signal intensity due to a bright marrow signal on the T2-weighted image sequences. MRI has decreased the need for bone scanning and provides more useful information.
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DIAGNOSIS
Sinograms are done whenever there is a sinus tract or open draining area from which the depth and extent of the infection can be determined.
Abscessograms are done whenever an abscess is present and frank pus is aspirated. The abscessogram will help outline the extent of the abscess cavity.
MRI, computed tomographic scanning, and radiographic tomogram are all useful tools in evaluating osteomyelitis.
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Radiographic Pathogenesis
The earliest signs of bone infection are soft-tissue edema and loss of fascial planes. (seen within 24 to 48 hours of the onset of infection)
The earliest changes in the bone are evidence of a destructive lytic lesion. (seen within 7 to 10 days after the onset of infection), and a positive radionuclide bone scan.
Within 2 to 6 weeks, there is progressive destruction of cortical and medullary bone, an increased endosteal sclerosis indicating reactive new bone formation, and a periosteal reaction.
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Radiographic Pathogenesis
In 6 to 8 weeks, sequestra indicating areas of necrotic bone usually become apparent; they are surrounded by a dense involucrum, representing a sheath of periosteal new bone.
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DIFFERENTIAL DIAGNOSIS
Acute Rheumatism:onset- gradual, pain- less acute, articular,
swelling confined to joint, affects more than one joint at the same time and is ‘flitting’ in nature.
Erysipelas:Less pain and general toxemia.
Haemophilia:Bleeding diathesis should be looked for.
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DIFFERENTIAL DIAGNOSIS
Cellulitis:No intense pain and general malaise is less.
Acute Pyogenic Arthritis:Features related to joint.
Ewing’s tumour or Osteosarcoma:Much less intense general illness.
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PRINCIPLES OF TREATMENT OF ACUTE OSTEOMYELITIS (Proposed by
NADE)
1. An appropriate antibiotic is effective before pus formation.
2. Antibiotics do not sterilize avascular tissues or abscesses, and such areas require surgical drainage.
3. If such removal is effective, antibiotics should prevent their reformation, and primary wound closure should be safe.
4. Surgery should not damage further already ischemic bone and soft tissue; and
5. Antibiotics should be continued after surgery.
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INDICATIONS FOR SURGERY IN ACUTE HEMATOGENOUS OSTEOMYELITIS
1. Presence of an abscess requiring drainage.
2. Failure of the patient to improve despite appropriate intravenous antibiotics.
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Subacute Hematogenous Osteomyelitis
More insidous onset.Lacks severity of symptoms.Diagnosis usually delayed.Temperature is only mildly elevated.Mild to moderate pain.Usually positive radiographs and bone scan.Often confused with malignancy.
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Subacute Hematogenous Osteomyelitis
The indolent course is related toIncreased host resistence.Decreased bacterial virulence.Administration of antibiotics before onset of
symptoms.
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Subacute Hematogenous Osteomyelitis
Classification:Gledhill and modified
by Roberts et. al.Type ICentral metaphyseal
lesion.DD: Langerhans’ cell
histiocytosis, Brodie abscess.
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Subacute Hematogenous Osteomyelitis
Classification:Gledhill and modified
by Roberts et. al.Type IIEccentric
metaphyseal lesion with cortical erosion.
DD: Eosinophilic granuloma, osteogenic sarcoma.
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Subacute Hematogenous Osteomyelitis
Classification:Gledhill and modified
by Roberts et. al.Type IIIDiaphyseal cortical
lesion.DD: Osteiod osteoma
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Subacute Hematogenous Osteomyelitis
Classification:Gledhill and modified
by Roberts et. al.Type IV:Diaphyseal lesion
with periosteal new bone formation, but without bony lesion.
DD: Ewings sarcoma.
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Subacute Hematogenous Osteomyelitis
Classification:Gledhill and modified
by Roberts et. al.Type V:Primary subacute
epiphyseal osteomyelitis
DD: Chondroblastoma.
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Subacute Hematogenous Osteomyelitis
Classification:Gledhill and modified
by Roberts et. al.Type VI:Subacute
osteomyelitis crossing physis to involve metaphysis and epiphysis.
DD: Tuberculosis, osteogenic sarcoma
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Subacute Hematogenous Osteomyelitis
Diagnosis must be established by an open biopsy and culture.
Treatment consists of biopsy and curretage followed by treatment with appropriate antibiotics.
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Brodie Abscess
Localized form of subacute osteomyelitis.Involves long bones of lower extremity.C/f: intermittent pain of long duration, local
tenderness.X-rays:- lytic lesion with a rim of sclerotic
bone.T/t: open biopsy with curettage.
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CHRONIC OSTEOMYELITIS
The hallmark of chronic osteomyelitis is infected dead bone within a compromised soft-tissue envelope.
The infected foci within the bone is surrounded by sclerotic, relatively avascular bone covered by a thickened periosteum and scarred muscle and subcutaneous tissue.
This avascular envelope of scar issue leaves systemic antibiotics essentially ineffective.
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CHRONIC OSTEOMYELITIS
CLASSIFICATION:
Cierny and Mader classification based on
Physiological criteria and,Anatomical criteria
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CHRONIC OSTEOMYELITIS
Physiological criteria: are divided into 3 classes based on three types of host:
Class A hosts have a normal response to infection and surgery.
Class B hosts are compromised and have deficient wound healing capabilities.
Class C hosts, the results of treatment are potentially more damaging than the present condition.
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CHRONIC OSTEOMYELITIS
Anatomical criteria:
Type I: Medullary
Is characterised by endosteal disease.
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CHRONIC OSTEOMYELITIS
Anatomical criteria:
Type II: Superficial
Limited to surface of the bone.
Infection is secondary to a coverage defect.
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CHRONIC OSTEOMYELITIS
Anatomical criteria:
Type III: Localized
Stable, well demarcated lesion characterised by full thickness cortical sequestration and cavitation.
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CHRONIC OSTEOMYELITIS
Anatomical criteria:
Type IV: Diffuse
Lesion creates mechanical instability, either at presentation or after appropriate treatment.
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Radiographic Findings
Early stages- Moth – eaten appearance.Elevation of periosteum with subperiosteal
laminations of new bone.Sharply delineated areas of dense bone with
surrounding decalcification.Gradually, necrotic dense area is sorrounded
by white ring of involucrum.
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Sclerosing Osteomyelitis of Garre
Chronic form of disease in which the bone is thickened and distended.
Abscesses and sequestra are absent.Intermittent pain of moderate intensity and
usually long duration.Swelling and tenderness.X-ray: expanded bone with generalized
sclerosis.T/t: Fenestration of sclerotic bone and
antibiotics.
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CHRONIC OSTEOMYELITIS
TREATMENT:Surgery for chronic osteomyelitis consists of
sequestrectomy and resection of scarred and infected bone and soft tissue.
The goal of surgery is eradication of the infection by achieving a viable and vascular environment.
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SEQUESTRECTOMY AND CURETTAGE
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SEQUESTRECTOMY AND CURETTAGE
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SEQUESTRECTOMY AND CURETTAGE
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SEQUESTRECTOMY AND CURETTAGE
AFTERTREATMENT:
Protection of limbAntibioticsManagement of dead space.
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METHODS OF DEAD SPACE MANAGEMENT
PAPINEAU CANCELLOUS GRAFT
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METHODS OF DEAD SPACE MANAGEMENT
LOCAL CLOSURE
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METHODS OF DEAD SPACE MANAGEMENT
MYOPLASTY
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METHODS OF DEAD SPACE MANAGEMENT
FREE BONE TRANSFER
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METHODS OF DEAD SPACE MANAGEMENT
USE OF BONE TRANSPORT
ILIZAROV TECHNIQUE
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OPEN BONE GRAFTING
Papineau et. al. described an open bone grafting technique for the treatment of chronic osteomyelitis.
Based on following principles:1.Granulation tissue markedly resists infection.2.Autogenous cancellous bone grafts are rapidly
revascularized and are resistant to infection.3.The infected area is completely excised.4.Adequate drainage is provided.5.Adequate immobilization is provided and6.Antibiotics are used for prolonged periods.
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Papineau technique
The surgery is divided into three stages:
1.DEBRIDEMENT2.CANCELLOUS AUTOGRAFTING:- posterior
iliac crest, 3 to 4 cm long.3.SKIN CLOSURE
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Papineau technique
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Polymethylmethacrylate Antibiotic Bead Chains
Commonly used.RationaleBead pouch technique when primary closure
not possible.Aminoglycosides most commonly employed.Short term(10 days), long term(80 days) or
permanent implantation.Rationale for removal.Technique.
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Biodegradable Antibiotic Delivery System
Advantage over PMMA:- no second procedure, osteoinductive and osteoconductive property.
E.g. of carriers: BMP+ cancellous bone, Demineralised bone matrix(DBM) + CaSo4, CaPO4, Hydroxyappetite.
Problem with calcium based carriers.
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Other modalities
Soft tissue transfer.Ilizarov technique.Hyperbaric Oxygen Transfer.
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Complications
Growth disturbances.Pathological fracture.Muscle contractures.Secondary septicemia.Epithelioma.Joint stiffness.Amyloidosis.
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SURGICAL CONSIDERATIONS
TOURNIQUETSApply a tourniquet whenever possible except in
patients with sickle cell disease or significant peripheral vascular disease.
The tourniquet improves hemostasis and thus facilitates identification of the infection process.
In acute cases with swelling, cellulitis, or abscess formation, elevate the extremity for several minutes before inflating the tourniquet.
In chronic osteomyelitis without significant cellulitis or abscess formation, use an elastic bandage to extravasate the extremity before inflating the tourniquet
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SURGICAL CONSIDERATIONS
DEBRIDEMENTThorough debridement of all sequestra and
necrotic and desiccated bone is essential. Do not remove viable infected bone, so as not to
create large bony defects. It is not necessary to debride viable infected bone.
Clinically dried out, exposed, desiccated bone is darker than normal and should be debrided. Necrotic bone that has not been exposed may appear at surgery more yellowish than viable bone, which is whitish. The main finding is that viable bone bleeds, whereas necrotic bone does not.
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SURGICAL CONSIDERATIONS
DEBRIDEMENTUse of an osteotome to superficially shave the
outer cortex of the questionable bone results in small areas of punctate bleeding.
Some bone that may have been exposed to air may be viable; in these cases, the exposed outer cortex should be debrided with an osteotome down to good bleeding bone.
Evacuate all pus and abscess, and remove all necrotic and infected soft tissue.
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SURGICAL CONSIDERATIONS
IRRIGATIONUse copious amounts of irrigating fluid, which
cleanses the area of purulent exudate, loose soft tissue, and bony fragments, and decreases the bacterial count.
Recommended:- 2 L of antibiotic solution containing 50,000 units of bacitracin and 1 million units of polymyxin per liter as the final irrigating solution.
Other antibiotics can be used for topical irrigation as well.
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SURGICAL CONSIDERATIONS
WOUND MANAGEMENTThe decision to leave a wound open or to close it requires
careful judgment. In the majority of acute infections, and in all cases in which there is associated abscess formation with cellulitis and swelling, the wound should be left open.
In some cases of early postoperative infection, the wound may be closed over drainage tubes, as long as the wound is thoroughly clean and the infection is not anaerobic.
In cases of chronic osteomyelitis in which there is no significant cellulitis or abscess formation and in which the wound has been adequately debrided and converted to a clean wound, the wound may be closed over drainage tubes.
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SURGICAL CONSIDERATIONS
WOUND MANAGEMENTIn some cases in which bone or metal will be
exposed if the wound is left open, a partial closure over the bone or metal may be desirable, as long as an adequate pathway has been provided for drainage. When there is any doubt, it is safest to leave the wound open.
If the wound is closed, the wound site must be examined daily for any signs of infection; if such signs appear, the wound must be opened.
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SURGICAL CONSIDERATIONS
WOUND MANAGEMENTMany wounds heal nicely by secondary intention. In the
case of large wounds or when delayed closure is preferable, do not attempt closure until two criteria are met.
First, the wound should appear clinically healthy, with clean granulating tissue and without any purulent exudate or necrotic tissue. If infected necrotic tissues are present, redebride the wound until it appears healthy.
Second, once the clinical appearance of the wound is clean, take quantitative tissue cultures and do Gram stains. Wounds with either a positive Gram stain or quantitative tissue cultures with a bacterial count greater than 10-5 organisms should never be closed. (A positive Gram stain implies a bacterial count of greater than 10-5 organisms.)
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SURGICAL CONSIDERATIONS
WOUND MANAGEMENTThese wounds should be considered infected and
reassessed for further surgical debridement and the appropriateness of the systemic antibiotic therapy.
In secondary closure of wounds, it is important to redebride the wound at the time of closure and to do en bloc resection of the granulating tissue for several reasons.
First, although the bacterial count is low, these tissues should still be considered contaminated; debridement will further reduce the bacterial count and thereby diminish the chance of infection.
Second, debridement allows for cleaner, healthier tissue to be approximated by wound closure or covered by muscle transfer.
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SURGICAL CONSIDERATIONS
DRAINS When the wounds are closed, Silastic or polyethylene drains
may be used. Remove the suction drain in 48–72 hours. The drain allows
the removal of all hematoma and tissue fluid, and the collapse of the potential dead space. The drains should be removed under sterile conditions and the tip cut off and sent for culture and sensitivity tests.
The drain tends to attract whatever bacteria are present because it is a foreign body and because tissue fluids are removed through it.
In general, a positive culture of the drain tip is a bad prognostic sign: It means that bacteria remain behind.
Monitor the clinical course and wound site closely; if any clinical signs of wound infection reappear, it may be necessary to consider redebridement and reassessment of antibiotic therapy.
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SURGICAL CONSIDERATIONS
WOUND PACKINGThe purpose of leaving a wound open is to allow drainage. Make certain, therefore, when packing wounds with gauze
or other materials, that packing does not obstruct drainage. If it does, the purulent exudate will be retained in the wound, possibly causing tissue breakdown and necrosis with secondary cellulitis or even abscess formation.
It is best to put wicks perpendicular to the open wound to allow free drainage. Wicks can be either povidone-iodine (Betadine)-soaked gauze, plain gauze, or fine-mesh gauze. The size varies with the size of the wound. The ends of the wicks should always protrude through the skin edges to allow easy access and removal and to prevent retention.
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PRINCIPLES OF TREATMENT OF INFECTED UNUNITED FRACTURES AND
NONUNIONS
The principles of treatment are infection control, stabilization of the fracture, soft-tissue coverage, and bone graft of ununited fractures and large bone defects.
Infection control includes irrigation and debridement, culture and sensitivities, and antibiotic therapy. In chronic osteomyelitis, obtain aerobic, anaerobic, and fungal cultures. Recent studies have advocated taking of multiple deep cultures from purulent material, soft tissue, and bone
Stabilization of the ununited fracture or nonunion is essential. Soft-tissue coverage may require the use of local muscle flaps and free vascularized muscle flaps for soft-tissue defects or an inadequate soft-tissue envelope after control of the osteomyelitis.
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PRINCIPLES OF TREATMENT OF INFECTED UNUNITED FRACTURES AND
NONUNIONS
Local muscle flaps and free vascularized muscle transfers also help by bringing in a new blood supply, which is important in host defense mechanisms, antibiotic delivery, and osseous and soft-tissue healing. For the tibia, use the gastrocnemius muscle for proximal-third defects, the soleus for middle-third, and for the distal-third, free vascularized muscle transfers.
For local muscle transfers, it is important to assess the muscle preoperatively and not to transfer damaged muscle. Also avoid using crushed or badly damaged muscle, as flap necrosis or flap complications may result. In these cases, use free vascularized tissue transfer. Do preoperative angiograms on patients whose vascular status has been altered from any cause.
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