OSTEOMYELITIS OSTEOMYELITIS Dr . Amit Dhawan Dr . Amit Dhawan Lovely Professional University Lovely Professional University
OSTEOMYELITISOSTEOMYELITIS
Dr . Amit DhawanDr . Amit DhawanLovely Professional UniversityLovely Professional University
OSTEOMYELITISOSTEOMYELITIS
INFLAMMATORY PROCESS INFLAMMATORY PROCESS IN BONE & BONE MARROWIN BONE & BONE MARROW
ACUTE & CHRONICACUTE & CHRONIC
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Hematogenous OsteomyelitisHematogenous Osteomyelitis
Contiguous-Focus OsteomyelitisContiguous-Focus Osteomyelitis
Peripheral Vascular Disease-associated Peripheral Vascular Disease-associated
PATHOPHYSIOLOGYPATHOPHYSIOLOGYMicroorganisms enter bone (Phagocytosis).Microorganisms enter bone (Phagocytosis).
Phagocyte contains the infectionPhagocyte contains the infection
Release enzymesRelease enzymes
Lyse bone Lyse bone
PATHOPHYSIOLOGYPATHOPHYSIOLOGYBacteria escape host defenses by:Bacteria escape host defenses by:
Adhering tightly to damage boneAdhering tightly to damage bone
Persisting in osteoblastsPersisting in osteoblasts
Protective polysaccharide-rich biofilmProtective polysaccharide-rich biofilm
PATHOPHYSIOLOGYPATHOPHYSIOLOGYPus spreads into vascular channelsPus spreads into vascular channels
Raising intraosseous pressureRaising intraosseous pressure
Impairing blood flowImpairing blood flow
Chronic ischemic necrosisChronic ischemic necrosis
Separation of large devascularized fragmentSeparation of large devascularized fragment
New bone formationNew bone formation (involucrum)(involucrum)
(Sequestra)(Sequestra)
PATHOLOGYPATHOLOGY
Acute Acute Infiltration of PMNsInfiltration of PMNs Congested or thrombosed vesselsCongested or thrombosed vessels
Chronic Chronic Necrotic bone Necrotic bone Absence of living osteocyteAbsence of living osteocyte Mononuclear cells predominateMononuclear cells predominate Granulation & fibrous tissueGranulation & fibrous tissue
HematogenoHematogenous us
OsteomyelitiOsteomyelitiss
HEMATOGENOUS OSTEPMYELITISHEMATOGENOUS OSTEPMYELITIS
Rapidly growing boneRapidly growing bone
Children: Children: Long bone, Femur, Tibia, HumerusLong bone, Femur, Tibia, Humerus
Older patients: Vertebral boneOlder patients: Vertebral bone
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Neonate & infant < 1 year oldNeonate & infant < 1 year old
Septic arthritis is common.Septic arthritis is common.
Growth deformities is common.Growth deformities is common.
Soft tissue involvement is common.Soft tissue involvement is common.
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISChildren: 1 – 16 years oldChildren: 1 – 16 years old
Most frequent in the metaphysis of long bone.Most frequent in the metaphysis of long bone.
Slugging blood flow through a Slugging blood flow through a sinusoidal venous system.sinusoidal venous system.
Deficency of phagocytic cells.Deficency of phagocytic cells.
Poor collateral circulationPoor collateral circulation
Susceptibility of this region to trauma. Susceptibility of this region to trauma.
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISChildren: 1 – 16 years oldChildren: 1 – 16 years old
History of antecedent trauma in 30%History of antecedent trauma in 30%
InvolucrumInvolucrum
SequestrationSequestration
Associated septic arthritisAssociated septic arthritis
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
AdultAdult
Less commonLess common
Spread infection to joint space.Spread infection to joint space.
Vertebral Osteomyelitis is common> 50yVertebral Osteomyelitis is common> 50y
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Special considerationSpecial considerationSickle cell diseaseSickle cell diseaseInjection drug users (IDUs)Injection drug users (IDUs)HemodialysisHemodialysisHIV/AIDSHIV/AIDSImmunosuppressionImmunosuppressionProsthetic orthopedic deviceProsthetic orthopedic device
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Microbiologic featuresMicrobiologic featuresStaphylococci Staphylococci Aureus, Epidermidis Aureus, EpidermidisStreptococci Streptococci Group A & B Group A & BHaemophilus influenzaeHaemophilus influenzaeGram-negative enteric bacilliGram-negative enteric bacilliAnaerobesAnaerobesPolymicrobialPolymicrobialMycobacterialMycobacterialFungiFungi
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Clinical manifestationClinical manifestationClassic presentation: Sudden onsetClassic presentation: Sudden onsetUsually presentation: Slow, insidiousUsually presentation: Slow, insidious
High fever, Night sweatsHigh fever, Night sweatsFatigue, Anorexia, Weight lossFatigue, Anorexia, Weight lossRestriction of movementRestriction of movementLocal edema, Erythema, & TenderrnessLocal edema, Erythema, & Tenderrness
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
DifferentialsDifferentialsCellulitisCellulitisGas gangreneGas gangreneNeoplasmNeoplasmAseptic bone infectionAseptic bone infection
Clenched fist Clenched fist osteomyelitisosteomyelitis
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-upDiagnosis & work-upLab study:Lab study:
WBC WBC May be elevated, Usually normal May be elevated, Usually normal
C-Reactive Protein (CRP)C-Reactive Protein (CRP) Erythrocyte Sedimentation RateErythrocyte Sedimentation Rate (Usually is elevated at presentation(Usually is elevated at presentation Falls with successful therapy)Falls with successful therapy)
Blood cultureBlood culture( Acute osteomyelitis + ve > 50% )( Acute osteomyelitis + ve > 50% )
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HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-upDiagnosis & work-upImagingImaging
Radiology:Radiology:NormalNormalSoft tissue swellingSoft tissue swellingPeriosteal elevationPeriosteal elevationLytic changeLytic changeSclerotic changewSclerotic changew
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-upDiagnosis & work-upImagingImaging
MRI:MRI:Early detectionEarly detectionSuperior to plan X ray & CT Scan &Superior to plan X ray & CT Scan & radionuclide bone scan in slected radionuclide bone scan in slected anatomic location.anatomic location.Sensitivity 90 – 100%Sensitivity 90 – 100%
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISDiagnosis & work-upDiagnosis & work-up
ImagingImagingRadionuclide bone scan:Radionuclide bone scan:A 3-phase bone scan ( Technetium 99m )A 3-phase bone scan ( Technetium 99m )
Positive as early as 24 h after Positive as early as 24 h after onset of symptoms.onset of symptoms.
False positive False positive Tumor, osteonecrosis Tumor, osteonecrosis Artheritis, Cellulitis, Artheritis, Cellulitis, AbscessAbscess
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISDiagnosis & work-upDiagnosis & work-up
ImagingImagingCT – Scan:CT – Scan:Useful in evaluation of Useful in evaluation of Spinal, pelvic, Spinal, pelvic, Sternum, CalcaneusSternum, Calcaneus
Provides exellent images of bone cortexProvides exellent images of bone cortex
Is used for biopsy localizationIs used for biopsy localization
Os + gaz in diabetic footOs + gaz in diabetic foot
Septic arthritisSeptic arthritisOfOf
Right hipRight hip
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISDiagnosis & work-upDiagnosis & work-up
UltrasonographyUltrasonographySimple & inexpensiveSimple & inexpensive
Demonstration anomaly 1 – 2 days after onsetDemonstration anomaly 1 – 2 days after onset
Soft tissue abscess, Fluid collection, &Soft tissue abscess, Fluid collection, & Periosteal elevationPeriosteal elevation
It allows for aspirationIt allows for aspiration
It doesn’t allow for evaluation of bone cortex. It doesn’t allow for evaluation of bone cortex.
HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISDiagnosis & work-upDiagnosis & work-up
Neddle Aspiration or Open biopsy:Neddle Aspiration or Open biopsy:From: Soft tissue collectionFrom: Soft tissue collection Subperiosteal abscessSubperiosteal abscess Intraosseos lesionsIntraosseos lesions
For: SmearFor: Smear CultureCulture PathologyPathology
TREATMENTTREATMENTInitial treatment shoud be aggressive.Initial treatment shoud be aggressive.
Inadequate therapy Inadequate therapy Chronic disease Chronic disease
Antibiotic use:Antibiotic use:
SurgerySurgery
ParenteralParenteralHigh dosesHigh dosesGood penetration in boneGood penetration in boneFull courseFull courseEmpiric therapyEmpiric therapy
TREATMENTTREATMENTEmpiric Initial TherapyEmpiric Initial Therapy
Neonate S.aureus PRP + Neonate S.aureus PRP + Infant<2 y G –ve bacilli CefotaximeInfant<2 y G –ve bacilli Cefotaxime
Children S.aureus PRP +Children S.aureus PRP + H.Infenza CeftriaxoneH.Infenza Ceftriaxone
Adult S.aureus PRP orAdult S.aureus PRP or 11stst ceph ceph
TREATMENTTREATMENTIndication for SurgeryIndication for Surgery
DiagnosticDiagnosticHip joint involvementHip joint involvementNeurologic complicationNeurologic complicationPoor or no response to IV Poor or no response to IV therapytherapySequestrationSequestration
TREATMENTTREATMENTMonitoring Therapeutic ResponseMonitoring Therapeutic Response
1.1.Symptoms & SignsSymptoms & Signs
2.2.ESR & CRPESR & CRP
3.3.RadiographyRadiography
4.4.Serial Bone Scan?Serial Bone Scan?
PROGNOSISPROGNOSISIs related to:Is related to:Causative organismsCausative organisms
Duration of symptoms & signDuration of symptoms & sign
Patient agePatient age
Duration of antibiotic therapyDuration of antibiotic therapy
COMPLICATIONCOMPLICATIONBone abscessBone abscessBacteremiaBacteremia
FractureFractureLoosing of the prosthetic implantLoosing of the prosthetic implant
Overlying soft-tissue cellulitisOverlying soft-tissue cellulitisDraining soft-tissue tractDraining soft-tissue tract
Post Osteomyelitis TreatmentPost Osteomyelitis Treatment
Septic OsteomyelitisSeptic Osteomyelitis
Post Osteomyelitis ScarPost Osteomyelitis Scar
Post Osteomyelitis Deformity of the ForearmPost Osteomyelitis Deformity of the Forearm
CONTIGUOUS-FOCUSCONTIGUOUS-FOCUSOSTEOMYELITISOSTEOMYELITIS
Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis
Clinical setting:Clinical setting:
Postoperative infectionPostoperative infection
Contamination of boneContamination of bone
Contiguous soft tissue infectionContiguous soft tissue infection
Puncture woundsPuncture wounds
Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis
Microbiologic featuresMicrobiologic features
Staphylococci Staphylococci Aureus, Epidermidis Aureus, Epidermidis
Gram-negative bacteriaGram-negative bacteria
Anaerobic infectionAnaerobic infection
Unusual organismsUnusual organisms Clostridia, Nocardia Clostridia, Nocardia
Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis
DiagnosisDiagnosisLeukocyte countLeukocyte countBlood culture (infrequently positive)Blood culture (infrequently positive)
ESR & CRPESR & CRPRadiologic evaluationRadiologic evaluation
Technetium bone scanTechnetium bone scanOpen bone biopsyOpen bone biopsy
Culture of wound & draining sinuses??Culture of wound & draining sinuses??
Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis
TreatmentTreatment
Surgery is essential.Surgery is essential.
Antibiotics Antibiotics Specific Specific Duration Duration