Osteomyelitis

Osteomyelitis

 Infection of the bone

 acute or chronic
 based on the etiology
 type I - hematogenous osteomyelitis.
 Type II - associated with fracture union
 type III - without fracture union and
 type IV was postoperative or posttraumatic
osteomyelitis without a fracture.
Cierny Mader Classification

 A host has a healthy physiology and limb with little

systemic or local compromise
 B host is further divided into:
 with local compromise (B local),
 systemic compromise (B systemic),
 both (B systemic/local systemic compromise)
 which includes any immunocompromised
condition, poor nutrition, diabetes, old age,
multiple trauma, chronic hypoxia, vascular disease,
malignancy, or organ failure such as renal
insufficiency or liver failure).
Cierny Mader Classification

 Local compromise includes conditions such as

previous surgery or trauma, cellulitis, radiation
fibrosis, scarring from burns or trauma, local
manifestations of vascular disease, lymphedema,
or zone-of-injury issues.
 a new variable of compromise can be identified
in the trauma patient where systemic compromise
is because of multiple organ damage, and the
consequent systemic response to trauma and
local compromise is defined by the zone-of-injury
effects on local tissues
Cierny Mader Classification

 The C host is a patient in whom the morbidity of

treatment is greater than the morbidity of disease
because of multiple and severe comorbid
conditions that cannot be treated safely.
 In these patients, the risks of curative treatment
such as extensive surgery, as might be used with
free flaps, or prolonged
 reconstruction with bone transport would be
greater than that caused by the infective
condition itself.
 Type C hosts are often better treated with limited
nonablative surgery and suppression or, if
appropriate, by an amputation
Cierny Mader Classification

 Type I is a medullary or endosteal

infection without penetration
through cortex. This is the type of
infection that occurs after
intramedullary nailing
Cierny Mader Classification

 Type II is a superficial
osteomyelitis that involves only
the outer cortex and is frequently
contiguous with a pressure ulcer
or adjacent abscess
Cierny Mader Classification

 Type III is permeative in that

there is involvement of both
cortical and medullary bone,
but Importantly, there is no
loss of axial stability of the
bone.
Cierny Mader
Classification
 Type IV also
involves cortical
and medullary
bone but in a
segmental fashion
such that axial
stability is lost
Pathogenesis

 Inoculation
 Adhesion
 Formation of Biofilm
 Colonization
 Chronic Infection
Pathogenesis - Inoculation

 Biofilm bacteria exist in one of two states—the

planktonic state or the colonized state
 Planktonic state bacteria are free floating in the
blood stream and are isolated and relatively small
in quantity
 Planktonic bacteria are metabolically active and
reproductive
 If planktonic bacteria encounter a suitable inert
surface such as dead or necrotic tissue, foreign
bodies, or any avascular body part by either
direct contamination, contiguous spreading, or
hematogenous seeding, they can attach and
begin the process of colonization
Pathogenesis - Adhesion

 Juxtaposition of the bacteria with a surface or

biomaterial is accomplished by van der Waals
forces, which allow bacteria to develop
irreversible cross-links with the surface (adhesion–
receptor interaction).
 Adhesion is based on time-dependent specific
protein adhesion–receptor interactions, as well as
carbohydrate polymer synthesis in addition to
charge and physical forces
 This will usually not occur on viable tissue surfaces
Pathogenesis - Biofilm

 Following adhesion to a surface, bacteria begin

to create a mucopolysaccharide layer called
biofilm or slime.
 They then develop into colonies. These colonies
exhibit remarkably resilient behavior
Pathogenesis -
Colonization
 Bacterial colonies can undergo phenotypic
changes and appear to hibernate.
 Pseudoresistance
 it is theorized that bacteria within biofilms have a
decreased metabolic rate and undergo
phenotypic changes, active processes such as
cell membrane formation, which are targeted by
antibiotics, would be similarly decreased
 antibiotic concentrations of 1,500 times normal
may be required to penetrate both the biofilm
and the bacterial cell wall
 subsequent collection of inflammatory cells
brought in to wall off the bacteria via chemotaxis
manifests as purulence, which is a symptom of the
host’s attempt to isolate and destroy the infection
 Sequestrum – dead bone, dead bacteria
Pathogenesis – Chronic
Infection
 Involucrum – hallmark of chronicity;new bone
 if the infection grows and reaches the skin or an
internal epithelial surface, a sinus tract forms as a
route to dispel detritus
 Sinus tract – severe infection, and serves as route
to dispel detritus and prevent septicemia
Clinical Signs and
Symptoms
 A history of infection or intercurrent illness as well
as of remote surgery or trauma
 Normal signs of inflammation may be absent
 history of infection at another site, such as the
lungs, bladder, or skin in conjunction with a history
of trauma
 complain of pain in the affected area and feel
generally unwell
 reduced activity, malaise, anorexia, fever,
tachycardia, and listlessness may be present
 Local findings include swelling and warmth,
occasional erythema, tenderness to palpation,
drainage, and restricted range of motion in
adjacent joints
Laboratory Results

 Routine blood cultures are of little help unless

patients show manifestations of systemic disease,
but they may be positive in up to 50% to 75% of
cases where there is concomitant bacteremia or
septicemia
Laboratory Results

 CBC – elevated WBC

 ESR – nonspecific, normalizes after weeks
 CRP – normalizes, 5-7 days
Radiographic Imaging

 Radiologically detectable demineralization

may not be seen for at least 10 days after
the onset of acute osteomyelitis
 a periosteal reaction may be seen within 3
to 6 weeks if the infection spreads to the
cortex
 5% of radiographs were abnormal initially,
33% were abnormal by 1 week, and 90%
were abnormal by 4 weeks
Bone Scintigraphy

 bone scan, which uses tagged red cells;

 leukocyte scan, which uses tagged white cells;
 bone marrow scan, which investigates marrow cell activity
Bone Scan

Technetium-99m and Gallium-67

Metabolically active bone
 blood flow phase
 bone pooling phase - immediately post injection
represents the
 delayed uptake phase - image made at 3 hours when
there is decreased soft tissue activity
 Osteomyelitis presents as a region of increased blood
flow, and it should appear “hot” in all phases with focal
uptake in the third phase
Leukocyte Scan

 indium-111 or 99mTc-hexamethylpropyleneamine
oxime (99mTc-HMPAO)
 most common scan used in conjunction with a
standard bone scan
 do not show bony detail or distinguish
osteomyelitis from soft tissue infections.
 Labor intensive
Marrow Scan

 Sulfur colloid bone scanning

 marrow may be reactive in several conditions that
are not infected and is generally suppressed
when infection is present
Scintigraphic
Combination
 MRI

 provides better information for early

detection of osteomyelitis
 can detect osteomyelitis within three to
five days of disease onset
 Iimited by hardware
 Decreased signal in T1-weighted images
and appears bright in T2-weighted
 Computed Tomography
 remains unsurpassed in the imaging
of cortical bone
 useful in delineating the cortical
details in chronic osteomyelitis, such
as sequestra and foreign bodies
 useful in evaluating the adequacy
of cortical debridement in the
staged treatment of chronic
osteomyelitis
 useful in evaluating the adequacy
of cortical debridement in the
staged treatment of chronic
osteomyelitis
PET Scan

 hown to delineate various infective

and inflammatory disorders with a
high sensitivity.
 noninvasive
 PET scanning is especially accurate in
the central skeleton within active
bone marrow
Cultures and Biopsy

 Bone biopsy remains the preferred diagnostic

procedure in chronic osteomyelitis
 Multiple specimens should be obtained
 Non bone culture 52% false negatives and 36%
false positives
 88.7% of sinus tract isolates were identical to
operative specimens
 cultures of the sinus tract can be helpful, but they
should not be the sole guide for antibiotic
treatment
Cultures and Biopsy
Diagnostic Algorithm
Criteria

Clinical signs
 Exposed bone
 Persistent sinus tract
 Tissue necrosis overlying bone
 Chronic wound overlying surgical hardware
 Chronic wound overlying fracture

Laboratory evaluation
 Positive blood cultures
 Elevated C-reactive protein level
 Elevated erythrocyte sedimentation rate
Treatment
Treatment
Treatment
Antibiotic Treatment

 No consensus
 2 weeks – 6 weeks of IV antibiotics THEN
 6 weeks – 8 weeks of Oral Regimen
 as long as there are no signs of impending sepsis
or limb loss, it is worthwhile stopping antibiotic
treatment 1 to 2 weeks before surgical
intervention so that more precise and reliable
bacterial identification is possible.
 Begin an empirical course of antibiotics
intraoperatively after all the cultures have been
taken and continue until the culture results are
available
Surgical Management

 Debridement Saucerization and Sequestrectomy

 More than 5mm margin
 28% recurrence if less than 5mm
Debridement Principles

 limits of debridement have

classically been
determined by the
“paprika sign”
 Sinus tracts that are present
for longer than1 year
should be excised and sent
for pathologic
examinationto rule out an
occult carcinoma
 Efforts should be made to limit any periosteal
stripping that may further devitalize the bone
 When the medullary canal is infected,
intramedullary reaming is an effective method of
debridement that preserves cortical stability.
 In general, one should overream the medullary
canal by 2 mm
 Saucerization ideally should be oval in shape
 If more than 30% of cortex is removed,
stabilization is require
Depot Antibiotics

 Process of elution
 allows for high local concentrations of antibiotic
with little systemic absorption
 Antibiotic release is biphasic with most occurring
during the first few days to weeks after
implantation
 only the outer 1 cm or so of large-volume depots
will elute antibiotic
Depot Antibiotics

 1 and 2 g of vancomycin
 1.2 to 2.4 g of tobramycin per bag
 Gentamycin