THIRD SECTION.

Bone and joint infections Osteomyelitis

DEFINITION AND CONCEPT

Corresponds to bone infection, considered as a body, which extends process all the tissues that comprise it.

Thus, the infection involves a greater or lesser degree mieloreticular tissue content in the medullary canal, the Haversian canals (Haversitis), the bone tissue proper, in either flake or compact cancellous bone in the cortical (osteitis), engagement the periosteum (periostitis), vessels and nerves.

Translating clinical, radiologic, pathologic, prognostic and therapeutic, is determined by the intensity of alteration and damage to the tissues involved. Are these facts, varying from one case to another, that determine the different characters that can occur with the pictures of the disease.

Other terms that speak of bone inflammation and need to be clarified:

Osteitis: is an infection that involves specifically to bone tissue itself, for example: the dense bone that forms the compact cortical diaphysis of the long bone or flat. Commitment mieloreticular component is low or nil. Myelitis or medulitis: is the mieloreticular tissue infection. There is still a major bone involvement itself. It is the initial stage and transient incipient osteomyelitis. Periostitis: is the inflammation of the periosteum. This membrane surrounding the bone has the great ability to respond against various insults, including infection, trauma, tumors. Thus, in response to trauma, the periosteum can react and produce what we call a traumatic periostitis. Periosteal reaction is also seen in response to an aggressive tumor eg Ewing sarcoma or produced by stimulation of an underlying infection. Each of these designations may show successive stages in the same condition, but at different times.

ETIOLOGY

Clinical experience shows that approximately 90% of cases are caused by Staphylococcus aureus, however, theoretically, any germ can be cause bone infection. In recent years, we are seeing a progressive increase in bone infections by germs that used to have a very small display, such as Salmonella typhimurium, the Koch bacillus, osteomyelitis Gram (-), various strains of streptococci.

In order of frequency, we find:

Staphylococcus aureus. Streptococcus. Gram negative. Hemophilus influenzae. Salmonella Tiphis. Pneumococcus. Koch bacillus. Fungi. Parasites. Although Staphylococcus aureus is still the causative pathogen most frequently isolated, it is necessary to add that the Gram negative have been increasing in frequency as a cause of bone infection. Especially we see in patients with immune disorders, elderly, with frequent urinary tract infections, or chronic osteomyelitis where infections occur on or selected seeds by prolonged use of broad spectrum antibiotics, patients still often multiple surgeries, which increases the chances of reinfection.

Pathogenesis

The germ can reach the bone in two ways: hematogenous or direct.

In the first case we speak of hematogenous osteomyelitis, when the seed reaches the bone carried by the bloodstream (bacteremia). The germ of an infectious preexisting (pyoderma, furuncle, anthrax, pharyngitis, pneumonitis), enters the bloodstream (bacteremia) and then settles in the bone. It is located in the metaphysis of choice, which produce a slowing of blood flow and allow the nesting of the germ. Concomitantly no vascular compromise of varying magnitude, but always implies a serious risk of bone tissue irrigation. The result is bone necrosis (kidnapping). Therefore, hematogenous osteomyelitis in the avascular bone necrosis concept is inherent to the concept of osteomyelitis.

The extent of bone necrosis reaches all parts of the tissue supplied by the compromised vascular system. If the blood vessel caliber happens to be important as a feeding artery or one of its branches, may compromise bone necrosis most or all of the shaft of the bone (mass kidnapping).

The high incidence of skin infections in children, makes this age group have more osteomyelitis than other age groups. The clinical picture in children occurs acutely, so what we label the diagnosis of "acute hematogenous osteomyelitis of the child", referring to the clinical pathway and bone infection. Often there is the front door of the infection.

In osteomyelitis by direct route, the seed reaches the bone through a wound that becomes infected (sharp, blunt, sharp, projectile, surgery, fracture, etc..).

The pathological process is essentially identical, but instead is local limits characters focused osteomyelitis.

Clinical forms of osteomyelitis

The bone infection manifested by two clinical forms:

-Acute osteomyelitis

For their clinical features and pathogenetic evolution, is identified with the box hematogenous osteomyelitis of children and adolescents, it, considering that almost all acute osteomyelitis with his picture so characteristic occurs in childhood and especially in adolescence. They are exceptional acute forms of osteomyelitis in adults.

Moreover, the clinical concept of the picture, they are associated with staphylococcal etiology whereas almost 90%, has that etiology. Thus, acute osteomyelitis box suggests the clinician three facts:

Sick teen patient Hematogenously Germ-hemolytic Staphylococcus aureus Acute osteomyelitis who do not recognize these three facts are exceptional.

Pathogeny

Infection of a septic focus preexisting skin (pyoderma, furuncle, anthrax, etc..) Of the airways (streptococcal) pharyngitis, pneumonitis and infections of other etiologies (TBC).

Often the focus is gone and skin is not when acute osteomyelitis is diagnosed.

Pathology

When the route is haematogenous bone focus in the vast majority of cases, is the metaphyses of long bones. The bones are mainly engaged Femur (lower metaphysis), tibia (upper metaphysis), humerus (upper metaphysis).

This corresponds to the most active metaphysis growing skeleton. The process follows a sequence that allows the clinic analogarlo:

In the metaphysis, and the seed is placed into the tissue and ducts mieloreticular Havers (myelitis or medulitis and haversitis). Hyperemia and edema is generated in an area within a walled space inextensible (bone). Compression of blood vessels, vascular collapse, corresponding territory ischemia extensive or small, irrigated by collapsed vessels. Bone necrosis (kidnapping). Progressive bone destruction. Evolution of the process

Since the primary focus of infection progresses, if not treated properly, can compromise other areas:

Break into the medullary canal, and it engages the entire bone. Breaking the barrier of the growth plate (rare) or via the lymphatic undertakes next joint (septic osteoarthritis). Break into the bloodstream, sometimes massively generating septicopioemia sepsis or acute. Gradually approaches to the cortical bone, the drill, becoming an abscess superistico with severe pain and focal signs of acute infection. Then break the barrier periosteal cell invades and finally makes its way through the skin evacuating pus outwards (fistula). The latter is the most common form of evolution. Other anatomical and clinical facts

Abscess intra Bone carved into the bone cavity, pus-filled, usually septic.

Sequestration: bone segment devoid of movement (necrotic) isolated bone inside or on its surface.

Involucre: cavity within the bone that holds inside the kidnapping.

Foramina: drilling of bone segments, which emptied the abscess from inside the BC or the kidnapping.

Commitment should be considered, sometimes very intense, the cellular integument of skin covering the bone osteomyelitic. They are especially manifest in bone (tibia) skin covered with little cell. The commitment comes in the wake of chronic osteomyelitis.

Applies to skin and cell biological deficient anatomical features: thin and fragile skin, attached to the underlying bone, cellular nonexistent, poorly vascularized, pigmented, with a low potential for scarring. It is a strong deterrent, when planning a surgical action through it.

Important epidemiological facts

Age: 10 to 20 years Sex: male preferably. Probably it influences the frequency of skeletal trauma (direct or indirect) of the teenager boy. With high frequency, is associated with socio-economic-cultural impacts: poverty, environmental or personal dirt, cold and humidity, chronic malnutrition, frequent injuries, skin diseases unrecognized or untreated, lack of medical culture, difficult access to medical care timely and effective. Symptoms

The initiation of the picture is very typical characteristics:

Initiation acute or sub-acute, rapidly progressive. With characters of an infectious state, generally disturbing. Fever, malaise, headache, weakness. In an initial period may not be revealing the focal signology. The patient can, in principle, not revealing pain in relation to a particular segment esqulitico.

Then the picture evolves very revealing signs: fever in needles, tachycardia, headache, dehydration, progressive malaise, pain and local temperature increase on a certain segment skeletal (bone metaphysis).

When it is detected, it is sure sign that the process is at an advanced stage in its evolution. Probably already happened rupture of cortical bone, periosteal abscess sub-or even more, subcutaneous abscess. In a step immediately following the fistula occur outwardly.

In this stage, the diagnosis should be considered late and the disease is advanced.

Diagnostic Process

The diagnostic process steps are:

Anamnesis very complete and thorough Complete physical examination, including all skeletal segments. Almost certainly, in the case of acute osteomyelitis that has just begun, will be found in the focus bone pain, usually metaphyseal. He did not find it, does not rule out the existence of suspected box. A new control in a few hours later, safely detect it. At the slightest suspicion that it is initiating an outbreak of acute osteomyelitis: Immediate hospitalization. Laboratory tests: blood count, sedimentation. Radiographic study. Bone scintigraphy. The radiographic signs are late in appearing. Maybe if the box takes several days duration, metaphyseal area is slightly softened. Obvious radiographic signs of bone destruction, the diagnosis is certain, but late.

The bone scintigraphy gives telltale signs very early and very significant.

It is thus a useful diagnostic test, although nonspecific.

A clinical picture, as noted, with a positive bone scintigraphy, almost forced to accept the diagnosis of acute osteomyelitis and determines the therapeutic indication.

Differential Diagnosis

And the clinical picture pointed towards an infectious state, with referring to an inflammatory reaction skeletal segment, there are at least two possible clinical misdiagnosis.

Acute arthritis: not always easy to determine exactly, at an early stage, if the inflammatory process is part of a focus osteomyelitic metaphyseal or acute arthritis. Joint pain, functional impotence early acute inflammatory signs typical of joint and joint effusion, semiological elements which are, in most cases, allow to differentiate one from the other box.

There are rare cases in which, as neighborhood inflammatory reaction, a neighboring joint osteomyelitic focus, react with proper signs, which make it difficult differential diagnosis.

Ewing sarcoma: clinical facts: age, location of the process, pain, inflammatory signs, high sedimentation, added to the radiological picture, bears a similarity that inexplicably make frequent diagnostic confusion. The fact cases of Ewing sarcomas infected, make the problem even more disturbing differential diagnosis. In light of this, it is mandatory hostolgico study of all cases of acute osteomyelitis be tapped. Personal experience is very illustrative.

Treatment

It is surgical and urgent.

General anesthesia. Addressing compromised bone segment. Window opening in the cortex. Curettage osteomyelitic focus, with removal of pus, compromised bone (bone grit). Osteoclisis drainage probe dropwise a solution of broad-spectrum antibiotic.

Plaster splinting. Broad spectrum antibiotic: gentamicin, cloxacillin. Is changed according to the sensitivity of the organism identified. Hydration parenterally. Maintain the prescribed treatment until the clinical picture, sedimentation, fever, indicating a definite break of the infection.

This may occur between 10 to 20 days.

The antibiotic is maintained for 1 to 2 months.

The possibility that the acute ostemielitis well treated, manages to be stopped before the bone lesion is established and passed to a chronic phase, depends on two factors: very early diagnosis and immediate surgical treatment with the support of appropriate antibiotic treatment and maintained .

If it was in a phase in which the bone lesion or abscess already fistulized and radiograph shows osteolytic lesions, the diagnosis is delayed and no treatment achieved improvement "ad integrum" osteomyelitic process. The future is passing the infection to the chronic stage (chronic osteomyelitis).

Estimated to be so serious this evolution to chronicity, it would be justified to surgery clinical suspicion reasonably supported. Although bone lesion is not evident or purulent material, must be upheld as a proper proceeding, means that it was before the process is triggered. Expecting clinical and radiographic signs are already evident in deciding the operation safely determine that the action was delayed, and chronicity is inevitable. -Chronic Osteomyelitis Corresponds to chronic infection of the bone. It is usually a sequel or sequel of acute osteomyelitis osteomyelitis caused by direct route (fractures, infected bone surgery).

Acute osteomyelitis low virulence that go unnoticed, where consultation has been delayed and the resolution of the process is spontaneous or treatment is delayed or inadequate, can lead to chronic osteomyelitis.

The Presentation of acute osteomyelitis can improve, but the disease can persist in bone intra subclinical and asymptomatic, becoming a chronic osteomyelitis. Table osteomyelitic remains latent and is impossible to predict when it will flare up, nor the frequency or magnitude of future crises. It may take years without clinical manifestations, and repeated exacerbations may have brief periods of time, manifesting clinically as mild or violently, with emergence of new abscesses, fistulas or chronic fistulas constantly oozing.

There are factors that can reagudizar chronic osteomyelitis: direct trauma, bruises, fractures, bone surgery local poor nutrition, alcoholism, anergizantes diseases, diabetes, persistent cold and wet. Sometimes the table reagudiza unexplained.

Clinical

Typically, medical history reveals a history of acute osteomyelitis occurred years ago, or that has evolved with one or more exacerbations, fistulas scarred former or current draining fistulas, with a segment of atrophic pigmented skin, poorly vascularized, attached to the bone, fragile, easily becomes ulcerated, fact to keep in mind when you need surgery.

Factors known to potentially reagudizadores of chronic osteomyelitis are:

Direct trauma. Mal chronic nutritional status. Persistent cold and wet. Alcoholism-diabetes. Immuno-depressant treatment. However, the crisis of exacerbation can occur without the presence of any of the triggering factors identified.

Symptoms

While the process remains inactive ostemieltico is asymptomatic. The reactivity is manifested by:

Focal pain, spontaneous and evoked. Edema. Local temperature increase. Redness of the skin of the zone. The magnitude of symptoms varies in intensity and speed of its evolution, according to the magnitude of the development process, virulence and aggressiveness of the germ, immune status, etc.. If the process continues to evolve, we have:

Clear signs of cellulite. Subcutaneous abscess. Fistula and emptying of the abscess. It adds fever, malaise, weakness, leukocytosis, elevated sedimentation.

Radiological examination

There are obvious alterations of bone remodeling and as a body, manifested by dense necrotic areas, osteolytic areas of variable length, thickening of the bone diameter, cortical thickening, periosteal reaction or hyperplastic, intra-bone cavity (abscess), isolated bone segments (abduction) and deformation of the shape of the bone (Figures 1 and 2).

Figure 1. chronic osteomyelitis Extensive alteration of bone structure. Images osteolytic areas alternate with osteosclerticas, infiltrating, breaking the cortex. Some kidnappings are observed within osteolytic areas.

Figure 2. Chronic osteomyelitis of the tibia All lower tibia metaphysis is compromised by an osteolytic process, infiltrating, the cortex is destroyed. Shadows of intra and extra bone kidnappings. Note that the process, very aggressive, stops at the growth plate.

From the radiological point of view, there are two features of chronic osteomyelitis predominantly dependent phenomena mentioned above:

Sclerosing osteomyelitis of Garre Brodie's abscess: an image shows osteolytic metaphyseal, rounded, central, clinically inactive, can be painful (reason for consultation). Contains purulent-looking fluid may be sterile (culture-negative). Prognosis

Chronic osteomyelitis should be considered, in general, as a disease with no cure.

A acute, usually follow phases of exacerbations spaced in time, it is not possible to predict their frequency and intensity.

Local commitment, bone and soft tissue, adds a slow engagement, gradual and progressive overall, especially in those forms prone to frequent and intense exacerbations, with drainage and long-held fistulas: anemia, malaise, depression, obsessive behavior for fear of further exacerbations, generalized amyloidosis are clinical manifestations of the disease itself. These patients usually fragile, prone to infection, with high surgical risk (myocardial amyloidosis cardiac arrest).

Treatment

The type of treatment will depend on the magnitude of the inflammatory process.

If the flare is mild, which is most common, general measures are indicated as absolute rest, tests to assess bone involvement (Rx), general and inflammatory process. CBC, sedimentation, culture and antibiotic sensitivity testing with antistaphylococcal or as long-held (2-3 months).

Severe exacerbations may also be treated conservatively, as the process usually fades and enters the inactive phase it had before.

We should not rush to operate these patients, since the prognosis will not improve, no operation will be able to definitively eradicate the disease and can worsen the situation. The wound can not heal, appearing necrosis and ulceration of the skin, due to the poor quality of the bone osteomyelitic integuments. If there is an indication for surgery should be performed on surgical approach integuments uncommitted.

Surgical treatment should be given with caution, due to the aforementioned circumstances.

We proceed to surgery in the following cases:

Osteomyelitis reagudizadas, hyperacute, with large osteolytic phenomenon, phlegmon or abscess of soft tissue. Fistulizadas reagudizadas Osteomyelitis with bone sequestration presence or intraosseous abscesses maintaining fistula and chronic suppuration. Osteomyelitis with local infectious process and maintained rebel unresponsive to conservative treatment. The surgical procedures performed on chronic osteomyelitis have been mixed. Basically consists of:

Bone channel in order to remove the tissue osteomyelitic, intraosseous drain abscesses, delete abduction, bone cavities clean purulent material and fungal tissue, etc. Try this cavity carved in order to fill it and try to prevent new reactivations, for which it has been used many methods, all of which in varying degrees have successes and failures. Is filled with: Cancellous bone, which has proven to be a good technique (Papineau technique), with the cavity filled with spongy bone in contact with the environment and secondary closure. With skin, placenta, omentum (rarely used today). With iodoform gauze.

Another technique used is not sufficiently fill, close the skin and leave two probes (afferent and efferent) dropwise washing with serum and antibiotics (osteoclisis). Using pellets intracanalicular antibiotics (Gentamicin beads), which seems to be a good procedure. But do not forget that any procedure will be able to eradicate the disease and, despite all efforts, it is likely that there will be one or more future exacerbations. Do not ever promise cure osteomyelitis with the operation envisaged.

These patients suffering from chronic osteomyelitis, tend to live years of his life hospitalized with multiple exacerbations, fistula and chronic suppuration, making in extreme cases, get to raise, either by bone problem (large area of bone destruction) or at the request of the patient, the need for amputation.

Another serious complication that can occur is osteomyelitic bone fracture, which because it is an altered and infected bone, has high potential to evolve with nonunion or delayed union.