acute osteomyelitis - dr. (prof.) anil arora | best knee ... acute osteomyelitis ( bone... · acute...
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Acute Osteomyelitis:Pathogenesis, Early Identification and
Prevention of Complications
Dr. (Prof.) Anil Arora
MS (Ortho) DNB (Ortho) Dip Sirot (USA)
FAPOA (Korea), FIGOF (Germany), FJOA (Japan)
Commonwealth Fellow Joint Replacement
(Royal National Orthopaedic Hospital, London, UK)
Senior Knee and Hip Replacement Surgeon
Associate Director
Department of Orthopaedics and Joint Replacement
Max Superspeciality Hospital, Patparganj, Delhi (India)
E-mail : [email protected]
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Pathogenesis
Infection Starts in Metaphysis
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☻☻☻☻☻☻ BACTERIA (Hematogenous Inoculum)
Localise in metaphysis (Developing Metaphyseal Vessels Hair pin Bends >> Sluggish Circulation: Gaps in endothelium : Poor Phagocytosis in Metaphysis)
Bacteria pass out of vessels
Adhere to Type 1 collagen
Inflammatory response in “Inexpansile Rigid Compartment”• Increased pressure in bone
• Decrease blood flow
Death of BonePus and Necrotic Tissue
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HIP joint most commonly affected
(Physes are intra –articular)
Other joints-Radial Neck /Distal
Fibula /Proximal humerus.
JOINT INVOLVEMENT in Children younger then 2 years Blood Vessels cross the physeal area !!!!
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Bacteriology
• Infants Streptococcus B
Staphylococcus
E. coli
• Children Staphylococcus aureus
Streptococcus pyogenous
Hemophilus influenzae
• Adult Staphylococcus epidermidis
Staphylococcus aureus
Pseudomonas aeruginosa
E. coli
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Early Diagnosis is Mandatory
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History and Physical Examination
• High index of suspicion >> (Refusal)
• Fever is not always a consistent finding in INFANTS
• Classical triad– Pain and Tenderness (Most Common)
– Fever
– Swelling
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Lab Diagnosis
• WBC increased in only 30-50% !!!
• Left Shift in 65%
• ESR increased 91%…24-36hrs, peak 3 to 5 days
• CRP increased 97%…4-6 hrs, peaks in 2 days
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• Blood Culture
– Positive in 30-60%
– Decreased with antibiotic
– Multiple cultures no significant increase in
yield
– 48 hours to get most organisms
Lab Diagnosis
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Soft Tissue
– Swelling, obscured soft tissue
planes, haziness
Osseous (7-10 days).
– Demineralization < Hyperemia
– Lysis (when > 40% resorbed)
– Periosteal reaction
– Sclerosis (late)
Radiographs >> -ve Early case
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Bone Scan
• Mostly used – 99M Tc
• Positive within 24 to 48 hours
• Sensitivity 90 to 95%
• If negative rules out the diagnosis
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MRI
• Sensitivity 98-100%, Specificity 98%
• Show early inflammatory changes in bone marrow and soft tissue.
• Detect Subperiosteal, Intraosseous pus and provide anatomic detail.(Soft tissue extension)
• Also helpful, when acute osteomyelitis does not respond to antibiotic therapy and localized abscess is suspected.
• Excellent for pelvis and Spine (Modic, RCNA, 1986)– Sensitvity 96%, Specificity 92%, Accuracy 94%
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T1T2
MRI
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Aspiration Biopsy
• Very Useful, false negative in only 10-15%
• Area of maximum swelling and tenderness,
usually long bone metaphysis
• Subperiosteal space should be aspirated, if no
material, obtain marrow aspirate.
• Grams Stain, Culture, HPE
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Complications
Infection
– Growth plate injury
– Recurrence
– Chronic
osteomylelitis
– Pathologic fracture
Antibiotics
– Diarrhea
– Thrombocytopenia
– Neutropenia
– Rash
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Prevention of Complications
Do Not Delay Diagnosis & Treatment
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Treatment
General
– Hospitalization
– Hydration
– Electrolyte Balance
– Analgesia
– Immobilization (Rest to the affected part)
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Antibiotics
• Early to PREVENT COMPLICATIONS
• Cephalosporins ….. 1st drug of choice.
• Change as per culture
• Initially IV >>> then oral combinations
• 4 to 6 week depending on response
• Follow WBC / ESR/ CRP (CRP better then ESR )
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Surgical Drainage
Indications?
• Demonstrable Pus
• Associated septic arthritis
• Failure of clinical response to
antibiotics over 2-3 days
Procedure?•Decompress abscess cavity•Remove infected devitalized bone•Surgery to improve local environment
Drilling? For intraosseous abscess
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Treatment
• Four principles
– Identify organism (ultimate purpose)
– Select correct antibiotics
– Deliver the antibiotic to organism
– Stop the tissue destruction
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What is Osteomyelitis?
• Inflammation of the bone cause by infecting organism.
• Infection may limited to single portion of bone or may involve marrow, cortex, periosteumand surrounding soft tissue.
• Ususally Hematogenous- Children
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Pathophysiology
Poorly defined!
– Hematogenousspread
– Direct inoculation
– Local invasion
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Evaluation of Acute Osteomyelitis
• History and Physical Examination
• Laboratory Tests: White blood cell count, ESR, CRP
• Plain Radiographs
• Technetium-99m Bone scan
• MRI
• Aspiration of Suspected Abscess
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Radiographs
Early – Usually negative
Bony Changes – Delayed (7-10 days)
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Differential Diagnosis
• Acute Septic Arthritis
• Acute monoarticularrheumatoid arthritis
• Sickle cell crisis
• Cellulitis
• Ewing’s Sarcoma