Case Report

CASE REPORTCHRONIC OSTEOMYELITIS OF THE RIGHT

FOOT

Presented by:Annisa Trie Anna [C11108280]

Advisor:dr. Erick

dr. Harianto

Supervisor:dr. Henry Yurianto, M. Phil., Ph.D,SpOT.

Orthopaedic and Traumatology DepartmentMedical Faculty of Hasanuddin University

Makassar, 2012

Patient Identity

Name : R Age / Sex : 49 years old/ male Admission : July 23th, 2012 Registration :555 978 Status : JAMKESMAS

HISTORY TAKING

Chief complain : Swelling and pain at the right foot

Anamnesis : Suffered since 4 years ago and become heavy 4 months before admitted to the hospital. Intermittent pain, especially felt pain on exertion and reduced at rest. On the right foot also contained small lumps that if injured out the pus and blood. Initially, in 2008 approximately 2 weeks after tumor surgery on the right foot, swelling and redness. Patients admitted often do not wear footwear when working in the fields. History of intermittent fever (-), history of family with the same disease (-), history of prior treatment (-).

General status

Moderate illness/ concious BP : 120/80 mmHg Pulse : 80x/m, regular RR : 20x /m, regular T : 36.50 C (axillar)

Local statusRight Foot RegionI : wound and scar at dorsal aspect,

Swelling (+), deformity (-), sinus(+).P : Tenderness (+), warm compared to

surrounding.ROM : Active and passive motion ankle

joint within normal limits. Active extend of big toe (+) and extend other toes (-)

NVD :Good sensitivity, Dorsalis pedis and tibialis posterior artery palpable, CRT < 2“.

CLINICAL PICTURE

Radiology findings

Laboratorium Findings (20th July 2012 )

WBC : 13,66 x 103 /uL RBC : 4,29 x 106 /uL HGB : 11,6 g/dL HCT : 373,3% PLT : 312x 103 /uL CT : 7’ 30” BT : 2’ 00” GDS : 91 mg/dl ESR : 40/78 mm HBSAg : negatif

Culture and sensitivity test – Samples : Blood – Result : no growth of

bacteria Evaluation of cytology (FNA)

– Results: Chronic granulomatous inflammation causa specific process could not be ascertained - suppurative inflammation

– Suggestion: FNA repeated after treatment

Resume

A male 49 years old with pain and swelling on the right foot. Suffered since 4 years ago and become heavy 4 months before admitted to the hospital. On the right foot also contained small lumps that if injured out the pus and blood. Initially, swelling and redness.. History of tumor surgery before 4 years ago (+). History of intermittent fever (-), history of family with the same disease (-), history of prior treatment (-).

On physical examination of the left leg : wound and scar at dorsal aspect, Swelling (+), sinus (+), tenderness (+), warm compared to surrounding. ROM, active and passive motion ankle joint within normal limits. Active extend of big toe (+) and extend other toes (-). NVD are within normal limit.

Laboratory finding : increased of ESR. Radiography : characterized by thick, irregular, sclerotic bone interspersed with radiolucencies, an elevated periosteum, and chronic draining sinuses, periosteal new bone, and soft tissue swelling.

Evaluation of cytology (FNA) :Chronic granulomatous inflammation causa specific process could not be ascertained - suppurative inflammation

Diagnosis

CHRONIC OSTEOMYELITIS OF THE RIGHT FOOT

Management

Medicamentosa: Analgetic Antibiotic

Surgery : Debridement and Guttering

DISCUSSION

Definition

Osteomyelitis inflammation of the bone caused by an infecting organism.

The infection may be limited to a single portion of the bone or may involve numerous regions, such as the marrow, cortex, periosteum, and the surrounding soft tissue

Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed.

Port D’ entry

Contagenous

Hematogenous Direct

infection

CLASSIFICATION Based on onset

Acute SubacuteChronic

Mechanism of infectionExogenous

Direct infection Contagenous

Hematogenous

Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed

Chronic Osteomyelitis

This used to be dreade sequel to acute hematogenous osteomyelitis

Now days, it more frequently follows an open fracture or operation.

Usual organisms are staphylococcus aureus, Escherichia coli, Streptococcus pyogens, Proteus and Pseudomonas.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Pathology Bone is destroyed or devitalized in a discrete

area at the focus of infection.

Cavities containing pus and pieces of dead bone (sequestra) are surrounded by vascular tissue, and beyond that by areas of sclerosis the result of chronic reactive new bone formation.

Sequestra, foreign implants act as substrates for bacterial adhesion, ensuring the persistence of infection and sinus drainage.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Cierny and Mader staging system of chronic osteomyelitis based on

anatomical

I Medullary Endosteal disease

II Superficial Cortical surface infected because of coverage defect

III Localized Cortical sequestrum that can be excised without compromising stability

IV Diffuse Features of I, II, and III plus mechanical instability before or after débridement

Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed

Staging System based on phisiological class

A host Normal Immunocompetent with good local vascularity

B host Compromised Local (L) or systemic (S) factors that compromise immunity or healing

C host Prohibitive Minimal disability, prohibitive morbidity anticipated, or poor prognosis for cure

Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed

DIAGNOSIS

BIOPSY “Gold

Standart”

IMAGING

LABORATORY

CLINICAL

Sign & symtomps The patient presents because pain, pyrexia,

redness and tenderness have recurred (a 'flare'), or with a discharging sinus.

In long-standing cases the tissues are thickened and often puckered or folded in where a scar or sinus is attached to the underlying bone.

There may be a sero-purulent discharge and excoriation of the surrounding skin.

In post-traumatic osteomyelitis the bone may be deformed or non-united.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Laboratory ESR and white blood cell count may be

increased

Organisms cultured from discharging sinuses should be tested repeatedly for antibiotic sensitivity.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Imaging

X-ray examinationBone resorption with

thickening and sclerosis of surrounding bone,

loss of trabeculation, area osteoporosis,

periosteal thickening, sequestra, or the bone crudely thickened and misshapen.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Radioisotope scintigraphySensitive but not specific. Using 99m Tc-HDP for showing increased activity of perfusion and bone phase and 67 Ga-Citrate or In-labelled leucocytes for showing hidden foci of infection

CT and MRIShow the extent of bone destruction and reactive edema, hidden abscess and sequestra.

Management Antibiotics Operation :

Thorough debridement of necrotic tissue and bone

Stabilization of boneDead space managementSoft tissue coverageLimb reconstruction

CHAPTER 19, chronic osteomyelitis Bruce D. Browner, M.D., F.A.C.S.Ed Pesanti, M.D., F.A.C.P.

Complication

A pathologic fracture may develop if the bone is excessively loaded before healing and remodeling.

Joint stiffness Malignent changes in epidermis

(epidermioid carcinoma)

Robert B. Salter, Textbook of disorders and injuries of the musculoskeletal system. Third edition

THANK YOU