OSTEOMYELITIS

Dr . Amit Dhawan
Lovely Professional University
OSTEOMYELITIS

INFLAMMATORY PROCESS
IN BONE & BONE MARROW
ACUTE & CHRONIC
 PATHOPHYSIOLOGY

Hematogenous Osteomyelitis

Contiguous-Focus Osteomyelitis

Peripheral Vascular Disease-associated

 PATHOPHYSIOLOGY
Microorganisms enter bone (Phagocytosis).

Phagocyte contains the infection

Release enzymes

Lyse bone
 PATHOPHYSIOLOGY
Bacteria escape host defenses by:

Adhering tightly to damage bone

Persisting in osteoblasts

Protective polysaccharide-rich biofilm

 PATHOPHYSIOLOGY
Pus spreads into vascular channels

Raising intraosseous pressure

Impairing blood flow

Chronic ischemic necrosis

Separation of large devascularized fragment

(Sequestra)

New bone formation

(involucrum)
 PATHOLOGY
Acute Infiltration of PMNs
Congested or thrombosed vessels

Chronic  Necrotic bone

Absence of living osteocyte
Mononuclear cells predominate
Granulation & fibrous tissue
Hematogenous
Osteomyelitis
HEMATOGENOUS OSTEPMYELITIS

Rapidly growing bone

Children:
Long bone, Femur, Tibia, Humerus

Older patients: Vertebral bone

HEMATOGENOUS OSTEOMYELITIS

Neonate & infant < 1 year old

Septic arthritis is common.

Growth deformities is common.

Soft tissue involvement is common.

 HEMATOGENOUS OSTEOMYELITIS
Children: 1 – 16 years old

Most frequent in the metaphysis of long bone.

Slugging blood flow through a

sinusoidal venous system.

Deficency of phagocytic cells.

Poor collateral circulation

Susceptibility of this region to trauma.

 HEMATOGENOUS OSTEOMYELITIS
Children: 1 – 16 years old

History of antecedent trauma in 30%

Involucrum

Sequestration

Associated septic arthritis

 HEMATOGENOUS OSTEOMYELITIS

Adult

Less common

Spread infection to joint space.

Vertebral Osteomyelitis is common> 50y

HEMATOGENOUS OSTEOMYELITIS

Special consideration
Sickle cell disease
Injection drug users (IDUs)
Hemodialysis
HIV/AIDS
Immunosuppression
Prosthetic orthopedic device
 HEMATOGENOUS OSTEOMYELITIS

Microbiologic features
Staphylococci  Aureus, Epidermidis
Streptococci  Group A & B
Haemophilus influenzae
Gram-negative enteric bacilli
Anaerobes
Polymicrobial
Mycobacterial
Fungi
 HEMATOGENOUS OSTEOMYELITIS

Clinical manifestation
Classic presentation: Sudden onset
Usually presentation: Slow, insidious

High fever, Night sweats

Fatigue, Anorexia, Weight loss
Restriction of movement
Local edema, Erythema, & Tenderrness
HEMATOGENOUS OSTEOMYELITIS

Differentials
Cellulitis
Gas gangrene
Neoplasm
Aseptic bone infection
Clenched fist
osteomyelitis
HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Lab study:
WBC  May be elevated, Usually normal

{C-Reactive Protein (CRP)

Erythrocyte Sedimentation Rate
(Usually is elevated at presentation
Falls with successful therapy)

Blood culture
( Acute osteomyelitis + ve > 50% )
HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Imaging
Radiology:
Normal
Soft tissue swelling
Periosteal elevation
Lytic change
Sclerotic changew
 HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Imaging
MRI:
Early detection
Superior to plan X ray & CT Scan &
radionuclide bone scan in slected
anatomic location.
Sensitivity 90 – 100%
 HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Imaging
Radionuclide bone scan:
A 3-phase bone scan ( Technetium 99m )

Positive as early as 24 h after

onset of symptoms.

False positive  Tumor, osteonecrosis

Artheritis, Cellulitis,
Abscess
 HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Imaging
CT – Scan:
Useful in evaluation of  Spinal, pelvic,
Sternum, Calcaneus

Provides exellent images of bone cortex

Is used for biopsy localization

Os + gaz in diabetic foot
Septic arthritis
Of
Right hip
 HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Ultrasonography
Simple & inexpensive

Demonstration anomaly 1 – 2 days after onset

Soft tissue abscess, Fluid collection, &

Periosteal elevation

It allows for aspiration

It doesn’t allow for evaluation of bone cortex.

 HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Neddle Aspiration or Open biopsy:
From: Soft tissue collection
Subperiosteal abscess
Intraosseos lesions

For: Smear
Culture
Pathology
 TREATMENT
Initial treatment shoud be aggressive.

Inadequate therapy  Chronic disease

Antibiotic use:
Parenteral
High doses
Good penetration in bone
Full course
Empiric therapy
Surgery
 TREATMENT
Empiric Initial Therapy
Neonate S.aureus PRP +
Infant<2 y G –ve bacilli Cefotaxime

Children S.aureus PRP +

H.Infenza Ceftriaxone

Adult S.aureus PRP or

1st ceph
 TREATMENT
Indication for Surgery

Diagnostic
Hip joint involvement
Neurologic complication
Poor or no response to IV therapy
Sequestration
 TREATMENT
Monitoring Therapeutic Response

1.Symptoms & Signs

2.ESR & CRP

3.Radiography

4.Serial Bone Scan?

 PROGNOSIS
Is related to:
Causative organisms

Duration of symptoms & sign

Patient age

Duration of antibiotic therapy

 COMPLICATION
Bone abscess
Bacteremia

Fracture
Loosing of the prosthetic implant

Overlying soft-tissue cellulitis

Draining soft-tissue tract
Post Osteomyelitis Treatment
 Septic Osteomyelitis

Post Osteomyelitis Scar

Post Osteomyelitis Deformity of the Forearm
CONTIGUOUS-FOCUS
OSTEOMYELITIS
Contiguous-focus Osteomyelitis

Clinical setting:

Postoperative infection

Contamination of bone

Contiguous soft tissue infection

Puncture wounds
Contiguous-focus Osteomyelitis

Microbiologic features
Staphylococci  Aureus, Epidermidis

Gram-negative bacteria

Anaerobic infection

Unusual organisms Clostridia, Nocardia

Contiguous-focus Osteomyelitis
Diagnosis
Leukocyte count
Blood culture (infrequently positive)

ESR & CRP

Radiologic evaluation

Technetium bone scan

Open bone biopsy

Culture of wound & draining sinuses??

Contiguous-focus Osteomyelitis
Treatment
Surgery is essential.

Antibiotics  Specific
Duration