osteomyelitis

Moderator: Dr peeyush Moderator: Dr peeyush sharmasharma

Presenter: Dr Pramod mahender

osteomyelitisosteomyelitis

Nelaton (1834):coined osteomyelitisNelaton (1834):coined osteomyelitis

osteon:boneosteon:bone

myelo:marrowmyelo:marrow

OsteomyelitisOsteomyelitis

Acute:Acute: <2weeks<2weeks Early acute Early acute Late acute(4-Late acute(4-5days)5days)

Subacute:Subacute: 2weeks—2weeks—3months 3months

Less virulent – more Less virulent – more immuneimmune

Chronic:Chronic: >3months>3months

Organisms Commonly Isolated in Organisms Commonly Isolated in Osteomyelitis Based on Patient Osteomyelitis Based on Patient

Age Age Infants (<1 year) Infants (<1 year)

Group B streptococci Group B streptococci Staphylococcus aureus Staphylococcus aureus

Escherichia coli Escherichia coli

Children (1 to 16 Children (1 to 16 years) years) S. aureus S. aureus Streptococcus Streptococcus pyogenes pyogenes Haemophilus Haemophilus influenzae influenzae

Adults (>16 years) Adults (>16 years) Staphylococcus Staphylococcus epidermidis epidermidis S. aureus S. aureus Pseudomonas Pseudomonas aeruginosa aeruginosa Serratia Serratia marcescens marcescens E. coliE. coli

Risk factorsRisk factors

Trauma (orthopaedic surgery or open fracture) Trauma (orthopaedic surgery or open fracture) Prosthetic orthopaedic device Prosthetic orthopaedic device Diabetes Diabetes Peripheral vascular disease Peripheral vascular disease Chronic joint disease Chronic joint disease Alcoholism Alcoholism Intravenous drug abuse Intravenous drug abuse Chronic steroid use Chronic steroid use Immunosuppression Immunosuppression Tuberculosis7 Tuberculosis7 HIV and AIDS HIV and AIDS Sickle cell disease Sickle cell disease Presence of catheter-related blood stream infection4 Presence of catheter-related blood stream infection4

osteomyelitis

General factorsGeneral factors

AnaemiaAnaemia DebilityDebility InfectionInfection Poor nutritionPoor nutrition Poor immune statusPoor immune status

Local factorLocal factor Hair pin bend vesselsHair pin bend vessels Metaphyseal Metaphyseal

haemorrhagehaemorrhage Defective PhagocytosisDefective Phagocytosis Rapid groth at Rapid groth at

metaphysismetaphysis Trabeculae of Trabeculae of

degenerating cartilagedegenerating cartilage VasospasmVasospasm AnoxiaAnoxia

pathophysiologypathophysiology

Primary &secondary spongiosa

Limit reticuloendothelial cells

Immature cell,anoxia

Hairpin bend(metaphyseal arteries)

Sluggish circulation

infection

Clinical featureClinical feature

Early AcuteEarly Acute •Febrile illnessFebrile illness

•Limping to walkLimping to walk•Avoidance of using the extremityAvoidance of using the extremity

Late AcuteLate Acute (Infant;premature neonates)(Infant;premature neonates)• SwellingSwelling• painpain

Sub acute Sub acute

VagueVagueCannot pinpoint onsetCannot pinpoint onsetFever/swelling-mildFever/swelling-mild

ChornicChornic Spurulent drainageSpurulent drainage

lablab COMPLETE BLOOD COUNT COMPLETE BLOOD COUNT CULTURE (24-48hrs later)CULTURE (24-48hrs later)- 1-JOINT FLUID 2-BLOOD 3-DEEP BONE BIOPSY1-JOINT FLUID 2-BLOOD 3-DEEP BONE BIOPSY- LEUKERGYLEUKERGY- ESRESR- C REACTIVE PROTIENC REACTIVE PROTIEN- LEUCOCYTE COUNTLEUCOCYTE COUNT- X RAY-LAGS 2wks BEHINDX RAY-LAGS 2wks BEHIND- RADIONUCLEOTIDE SCAN- Disadvantage-fracture RADIONUCLEOTIDE SCAN- Disadvantage-fracture

healing,osteomyelitis,tumourhealing,osteomyelitis,tumour- C T SCAN- NECROTIC PORTIONC T SCAN- NECROTIC PORTION- TECHNETIUM 99 BONE SCAN(85% PPV)-when diag unclear-TECHNETIUM 99 BONE SCAN(85% PPV)-when diag unclear-

clavicle,pelvis,fibulaclavicle,pelvis,fibula- SPECTSPECT- INDIUM/GALLIUM SCANINDIUM/GALLIUM SCAN- USG-SUBPERIOSTEAL ABSCESSUSG-SUBPERIOSTEAL ABSCESS- MRI- BESTMRI- BEST

MORREY AND PETERSON”S MORREY AND PETERSON”S CRITERIACRITERIA

DEFINITION- THE PATHOGEN IS ISOLATED DEFINITION- THE PATHOGEN IS ISOLATED FROM BONE OR ADJACENT SOFT TISSUE FROM BONE OR ADJACENT SOFT TISSUE AS THERE IS HISTOLOGIC EVIDENCE OF AS THERE IS HISTOLOGIC EVIDENCE OF OSTEOMYELITISOSTEOMYELITIS

PROBABLE- A BLOOD CULTURE IS POSITIVE PROBABLE- A BLOOD CULTURE IS POSITIVE IN SETTING OF CLINICAL AND IN SETTING OF CLINICAL AND RADIOLOGICAL FEATURES OF RADIOLOGICAL FEATURES OF OSTEOMYELITISOSTEOMYELITIS

LIKELY- TYPICAL CLINICAL FINDING AND LIKELY- TYPICAL CLINICAL FINDING AND DEFINITE RADIOGRAFFIC EVIDENCE OF DEFINITE RADIOGRAFFIC EVIDENCE OF OSTEOMYELITIS ARE PRESENT AND OSTEOMYELITIS ARE PRESENT AND RESPONSE TO ANTIBIOTIC THERAPYRESPONSE TO ANTIBIOTIC THERAPY

Peltola and vahvanen’s criteriaPeltola and vahvanen’s criteria

-Pus on aspiration -Pus on aspiration -Positive bacterial culture from bone -Positive bacterial culture from bone or blood or blood -Presence of classic signs and -Presence of classic signs and symptoms of acute osteomyelitis symptoms of acute osteomyelitis -Radiographic changes typical of -Radiographic changes typical of osteomyelitis osteomyelitis *--*--Two of the listed findings must be present for establishment Two of the listed findings must be present for establishment

of the diagnosisof the diagnosis. .

Plain-film radiograph Plain-film radiograph showing osteomyelitis showing osteomyelitis of the second of the second metacarpal (arrow).metacarpal (arrow).

Periosteal elevation,Periosteal elevation, cortical disruption cortical disruption

and and medullary medullary

involvement are involvement are present. present.

WALDVOGEL 1970WALDVOGEL 1970

1.1. HEMATOGENOUS HEMATOGENOUS

2.2. CONTIGEUOUS FOCUSCONTIGEUOUS FOCUS

3.3. OSTEOMYELITIS WITH VASCULAR OSTEOMYELITIS WITH VASCULAR INSUFFICIENCYINSUFFICIENCY

WEILAND 1984WEILAND 1984

TYPE TYPE 1 –1 – -OPEN EXPOSED BONE WITHOUT OSSEOUS INFECTION -OPEN EXPOSED BONE WITHOUT OSSEOUS INFECTION

BUT SOFT TISSUE INFECTIONBUT SOFT TISSUE INFECTION TYPE TYPE 22 – – CIRCUMFERENTIALCORTICAL+ENDOSTEAL INFECTIONCIRCUMFERENTIALCORTICAL+ENDOSTEAL INFECTION INCREASE SCLEROTIC THICKENING OF CORTEXINCREASE SCLEROTIC THICKENING OF CORTEX INCREASE DENSITYINCREASE DENSITY AREAS OF BONY RESORPTION+SEQUESTRUMAREAS OF BONY RESORPTION+SEQUESTRUM TYPE 3 –TYPE 3 – CORTICAL+ENDOSTEAL INFECTION+A SEGMENTAL BONE CORTICAL+ENDOSTEAL INFECTION+A SEGMENTAL BONE

DEFECTDEFECT

GORDON’S 1988GORDON’S 1988

TYPE A – NONUNION WITHOUT TYPE A – NONUNION WITHOUT SEGMENTAL LOSSSEGMENTAL LOSS

TYPE B - >3cm SEGMENTAL LOSS TYPE B - >3cm SEGMENTAL LOSS WITH INTACT FIBULAWITH INTACT FIBULA

TYPE C - >3cm SEGMENTAL LOSS TYPE C - >3cm SEGMENTAL LOSS WITHOUT INTACT FIBULAWITHOUT INTACT FIBULA

GER’S 1982GER’S 1982

1.1. SIMPLE SINUSSIMPLE SINUS

2.2. CHRONIC SUPERFICIALCHRONIC SUPERFICIAL

3.3. MULTIPLE SINUSESMULTIPLE SINUSES

4.4. MULTIPLE SKIN-LINED SINUSESMULTIPLE SKIN-LINED SINUSES

KELLY’S 1984KELLY’S 1984

1.1. HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

2.2. OSTEOMYELITIS WITH FRACTURE OSTEOMYELITIS WITH FRACTURE UNIONUNION

3.3. OSTEOMYELITIS WITH FRACTURE OSTEOMYELITIS WITH FRACTURE NONUNIONNONUNION

4.4. POST OPERATIVE OSTEOMYELITIS POST OPERATIVE OSTEOMYELITIS WITHOUT FRACTUREWITHOUT FRACTURE

MAY’S 1989MAY’S 1989

TYPE 1- WITHSTAND FUNCTIONAL LOAD – TYPE 1- WITHSTAND FUNCTIONAL LOAD – 6-12weeks6-12weeks

TYPE 2- INTACT TIBIA NEEDED GRAFT- 3-TYPE 2- INTACT TIBIA NEEDED GRAFT- 3-6months6months

TYPE 3- DEFECT < 6cm, INTACT FIBULA – TYPE 3- DEFECT < 6cm, INTACT FIBULA – 6-12months6-12months

TYPE 4- > 6cm,INTACT FIBULA – 12-TYPE 4- > 6cm,INTACT FIBULA – 12-18months18months

TYPE 5- > 6cm- UNUSABLE FIBULA- > TYPE 5- > 6cm- UNUSABLE FIBULA- > 18months18months

TABLE 1TABLE 1 Waldvogel Classification System Waldvogel Classification System

for Osteomyelitis for Osteomyelitis

Hematogenous osteomyelitis Hematogenous osteomyelitis Osteomyelitis secondary to Osteomyelitis secondary to

contiguous focus of infectioncontiguous focus of infection No generalized vascular disease No generalized vascular disease Generalized vascular disease Generalized vascular disease Chronic osteomyelitis (necrotic Chronic osteomyelitis (necrotic

bone)bone)

The Penny classification of chronic The Penny classification of chronic osteomyelitis in children includes both osteomyelitis in children includes both

diaphyseal and metaphyseal typesdiaphyseal and metaphyseal types.. DiaphysealDiaphyseal osteomyelitis may be broken down into osteomyelitis may be broken down into

the following types:the following types: type I (typical, A),type I (typical, A), type II (atrophic, B),type II (atrophic, B), type III (sclerotic, C),type III (sclerotic, C), type IV (cortical, D), typetype IV (cortical, D), type V (multiple walled-off abscesses, E), andV (multiple walled-off abscesses, E), and type VI (multiple microabscesses, F). type VI (multiple microabscesses, F).

metaphyseal osteomyelitis is shown in G.metaphyseal osteomyelitis is shown in G.

DE CIERNY-MADERDE CIERNY-MADER

12 STAGES12 STAGES DISEASE PROCESS – REGARDLESS DISEASE PROCESS – REGARDLESS

OF – 1-ETIOLOGY OF – 1-ETIOLOGY

2-REGIONALITY 2-REGIONALITY

3-CHRONICITY3-CHRONICITY DYNAMICDYNAMIC

The Cierny-MaderThe Cierny-MaderStaging SystemStaging System

AnatomicAnatomicType DescriptionType Description Stage 1 Medullary osteomyelitisStage 1 Medullary osteomyelitis Stage 2 Superficial osteomyelitisStage 2 Superficial osteomyelitis Stage 3 Localized osteomyelitisStage 3 Localized osteomyelitis Stage 4 Diffuse osteomyelitisStage 4 Diffuse osteomyelitis PhysiologicPhysiologic ClassClass A host Normal hostA host Normal host B- host Systemic compromise (Bs)B- host Systemic compromise (Bs) Local compromise (Bl)Local compromise (Bl) Systemic and local compromise (Bls)Systemic and local compromise (Bls) C host Treatment worse that the diseaC host Treatment worse that the disea

Systemic or LocalSystemic or LocalFactors That Affect Metabolism, LocalFactors That Affect Metabolism, LocalVascularity, and Immune SurveillanceVascularity, and Immune Surveillance

Local (Bl)Local (Bl) ArteritisArteritis Chronic lymphedemaChronic lymphedema Extensive scarringExtensive scarring Major vessel Major vessel

compromisecompromise NeuropathyNeuropathy Radiation fibrosisRadiation fibrosis Small vessel diseaseSmall vessel disease Tobacco abuseTobacco abuse 2 packs/day)2 packs/day) Venous stasisVenous stasis

• Systemic (Bs)Systemic (Bs) Chronic hypoxiaChronic hypoxia Diabetes mellitusDiabetes mellitus Extremes of ageExtremes of age Immune diseaseImmune disease Immunosuppression orImmunosuppression or immune deficiencyimmune deficiency MalignancyMalignancy MalnutritionMalnutrition Renal and/or hepaticRenal and/or hepatic failurefailure

Nade’s principlesNade’s principles

Antibiotic is effective before pus formsAntibiotic is effective before pus forms Antibiotic cannot sterilise avacular tissueAntibiotic cannot sterilise avacular tissue Antibiotic prevents reformation of pus Antibiotic prevents reformation of pus

once removedonce removed Pus removal restores periosteum---- Pus removal restores periosteum----

restores blood flowrestores blood flow Antibiotic should be continued after Antibiotic should be continued after

surgerysurgery

Nade’s indications for surgeryNade’s indications for surgery

1.1. Abscess formationAbscess formation

2.2. Severely ill & moribund childSeverely ill & moribund child

3.3. Failure to respond to IV antibiotics Failure to respond to IV antibiotics for >48 hrsfor >48 hrs

managementmanagement Antibiotic:Antibiotic:stage1---- 2week iv stage1---- 2week iv change to oralchange to oral

(avoid quinolones) (avoid quinolones)

stage 2 – 2wk+stage 2 – 2wk+

superficial debridementsuperficial debridement

stage3& 4 -4-6wk iv stage3& 4 -4-6wk iv

(from last major deb) (from last major deb)

Surgical mxSurgical mx

Debridement surgery is fondation of Debridement surgery is fondation of osteomyelitis treatmentosteomyelitis treatment

External fixator prior/duringExternal fixator prior/during Complete wound closure;whereverComplete wound closure;wherever Sution irrigation(not recommended)Sution irrigation(not recommended) Secondary intention-discouragedSecondary intention-discouraged Local flap+/- cancellous boneLocal flap+/- cancellous bone Illizarov external fixation-9mthIllizarov external fixation-9mth

Antibiotic impregnated Acrylic beadsAntibiotic impregnated Acrylic beads removed in 2-4 wksremoved in 2-4 wks Replased with cancellous boneReplased with cancellous bone -vanco/tobra/genta -vanco/tobra/genta -degrada beads-degrada beads -implantable pump-implantable pumpInfected pseudorthosis .>3cms vascu.b Infected pseudorthosis .>3cms vascu.b

transfer transfer

Cierney maderCierney maderStage1Stage1 ChildrenChildren

AdultAdult

:NO hardware-:NO hardware-NosurgeryNosurgery

Intramedulary Intramedulary reaming+/- bone reaming+/- bone grafting +/- brace/castgrafting +/- brace/cast

Stage2Stage2 Bone Bone exposedexposed

Soft tissue coverageSoft tissue coverage

After debridementAfter debridement

Cierney maderCierney maderStage3Stage3 SequesterSequester

ed ed

+above+above

DeberidmentDeberidment

Reconstruction of bone Reconstruction of bone

&soft tissue&soft tissue

Stage4Stage4 instabilityinstability Structural stabilityStructural stability

Obliterating Obliterating debridement gapsdebridement gaps

-bone graft-bone graft

-Illizarov-Illizarov

- free flaps - free flaps

-vascular bone-vascular bone

Osteomyelitis and hivOsteomyelitis and hiv• Uncommon (.5%-2%)Uncommon (.5%-2%)• Mortality(20%)Mortality(20%)• S.aureus(mc)S.aureus(mc) m.tuberculosis (not common)m.tuberculosis (not common) Atypical –macAtypical –mac BortonellaBortonella cmvcmv fungifungi• DD -kaposi’s sarcomaDD -kaposi’s sarcoma -avn-avn -lymphoma-lymphoma

Musculoskeletal &hivMusculoskeletal &hiv

ArthritisArthritis MyositisMyositis OsteomyelitisOsteomyelitis

SpondylarthropathySpondylarthropathy reiter’sreiter’s psoriaticpsoriatic Acute symmetric polyarthritisAcute symmetric polyarthritis Hiv asso ArthritisHiv asso Arthritis Painful articular synPainful articular syn Septic arthritisSeptic arthritis Myositis—Myositis— AZtAZt hiv related polymyositishiv related polymyositis

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