Dr. Om Parshuram Patil Dept Of Orthopaedics Under Guidance Of Dr G.N.Pundkar Prof and Head
Dr. Om Parshuram Patil
Dept Of Orthopaedics
Under Guidance Of
Dr G.N.Pundkar
Prof and Head
17 year old male came to the casualtyn with Chief Complaints of
Pain in rt thigh since 1 month
Fever since 4 days
History of trauma to rt thigh and leg one and half month before, trivial in nature & due to fall
No h/o Chronics diseases, weight loss
Pain in rt thigh since one month which was insidious in onset , gradually progressive dull aching in nature ,with no aggravating factors, reduced in severity since last 4-5 days with associated fever since then
Fever was high grade , intermittent, not associated with chills and rigors
On examination
Local temp was raised than contralateral side in mid thigh region
Minimal swelling in rt thigh
Diffuse tenderness in mid thigh region
From hip to calf region
Could not be localised to a particular area
Investigation TLC : 21,600
Neutro : 80%
Lympho :15%
Mono :03%
Eosino :02%
Hb :12.3 gm %
ESR :20 mm
Sickling :negative
Blood Group: O negative
Usg Rt Thigh:
Evolving Abscess in rt thigh Deep muscle lateral side, with surrounding muscle myositis, with inflammatory changes in rt hip joint.
Started with Ceftriaxone and Linezolid for 7 days
Xray 21/11/14
Rt thigh AP /Lat
S/o : Periosteal reaction in mid third upper third junction of rt femur.. Suggesting
acute osteomyelitis ?
Ewings Sarcoma? With onion peel appearance
21/11/14
Pt was subjected biopsy through, latetral approach and window was made over the lateral cortex with multiple drilling holes
Minimal cheesy material was drained out from superficial part lateral cortex
Cortical bone and surrounding soft tissue sent for histopathology and culture
Started with Antibiotics Ceftriaxone with sulbactum, amikacin for three weeks
Patient was relieved of symptoms partially after procedure with reduced severity of pain and fever
Histopathology Of the tissue was suggestive of chronic osteomyelitis
29/11/14
HistopathologyChronic osteomyelitis, from infected femur s The irregular fragment of devitalized bone surrounded by dense fibrous tissue heavily infiltrated by plasma cells, lymphocytes, and only a few granulocytes.
Inflammatory Changes
Post operative Xray
Post op 3 weeks
8/12/14 TLC : 10200/cumm
Neutro : 60%
Lympho : 32%
Mono : 04%
Eosino : 04%
Hb : 12.0 gm %
ESR : 15 mm
17/12/14
TLC : 12900/cummNeutro : 59%Lympho : 37%Mono : 03%Eosino : 01%Hb : 12.3 gm %ESR : 12 mm
Parenteral antibiotics were stopped on 21 days and shifted to oral antibiotics .
But radiological picture of the patients rt femur was S/o
Increased periosteal reaction disseminated to lower part of femur
??? Onion peel appearance s/o ewings sarcoma
Further treatment Plan Saucerization and reaming of intramedullary cavity
with antibiotic impregnated nail for six weeks
Drain window in the distal part of femur laterally
Simultaneous repeat histopathological and culture studies from the site.
Chronic Osteomyelitis
Classification of COM
Anatomical classification
Classification of COM
Diagnosis COM
Based on
Clinical
laboratory and
imaging studies
Clinical evaluation COM
Skin and soft tissue integrity
Tenderness
Bone stability
Neurovascular status of limb
Presence of sinus
Laboratory COM
Erythrocyte sedimentation rate
C reactive protein
WBC count only elevated in 35%
Biopsy for histological and microbiological evaluation
Staphyloccocus species
Anaerobes and gram negative bacilli
Imaging studies in COM
Plain X rays
Cortical destruction
Periosteal reaction
Sequestra
Sinography
Sinography
Imaging -
Isotopic bone scanning more useful in acute than in chronic osteomyelitis
Gallium scans increased uptake in areas where leucocytes and bacteria accumulate. Normal scan excludes osteomyelitis
COM Imaging
CT Scan
Identifying sequestra
Definition of cortical bone and surrounding soft tissues
COM Imaging
MRI
Shows margins of bone and soft tissue oedema
Evaluate recurrence of infection after 1 year
Rim sign- well defined rim of high signal intensity surrounding the focus of active disease
Sinus tracks and cellulitis
Treatment of COM
Surgical treatment mainstay
Sequestrectomy
Resection of scarred and infected bone and soft tissue
Radical debridement
Resection margins >5mm
Surgical treatment of COM
Adequate debridement leaves a dead space that needs to be managed to avoid recurrence, or bony instability
Skin grafts,
Muscle and myocutaneous flaps
Free bone transfer
Papineau technique
Hyperbaric oxygen therapy
Vacuum dressing
Treatment of COM
Antibiotic duration is controversial
6 week is the traditional duration
1 week IV, 6 weeks of oral therapy
Antibiotic polymethyl methacrylate (PMMA) beads as a temporary filler of dead space
Biodegradable antibiotic delivery system
Resection or excision for COM
Resection of a segment of affected bone may be necessary to control infection
With techniques of bone and soft tissue transport, massive resections can be performed and reconstructed without significant disability.
Amputation for osteomyelitis
Amputation indications include
Arterial insufficiency
Major nerve paralysis
Non functional limb-stiffness, contracture
Malignant change
Prevalence of maliganacy arising from COM reported as 0.2 to 1.6% of cases.
Most are squamous cell carcinoma, also reticulum cell carcinoma,fibrosarcoma
Ewings Sarcoma
Epidemiology Incidence is 0.6 per million
Males > Females
65% in the 2nd decade of life
Rare in blacks and Asians
Clinical PresentationHistory:
Pain most commonly (90%)
Swelling (70%)
Fever (20%)
Pathological fracture
Weight loss, malaise
Clinical PresentationPhysical Exam and Labs
Local warmth, inflammation
Pleural effusions
Neurological signs if spinal involvement
ESR, LDH, anemia, leukocytosis
Radiology Site
Size
Effect on bone
Response of Bone
Matrix
Cortex
Soft tissue
Pathology Cell of origin is unknown
Previously a diagnosis of exclusion
Reciprocal translocation
Pathology Gross: soft, tan, gray tissue
Micro: nests of small round cells
No osteoid or chondroid production
Surface cell glycoprotein
PathologyDifferential Diagnosis
Lymphoma
Osteomyelitis
Osteosarcoma
Malignant Fibrous Histiocytoma
Metastatic neuroblastoma in toddlers
Staging and Prognosis Local and distal staging
Bone marrow aspirate
Pre-chemotherapy investigations
Biopsy
Staging and Prognosis Location
Tumor Size
Metastases at diagnosis
Response to chemotherapy
Treatment Multidisciplinary approach
Neoadjuvant chemotherapy, surgery
Don’t prolong interval between chemo
Radiation if indicated
Summary Rare but common
Main ddx is lymphoma and infection
Large soft tisse masses
Neoadjuvant chemo and surgery
75-80% disease free survival at 5 years
Thank you