1- Osteomyelitis-Salah orthopedic ppt.ppt

orthopedic revision on infection disease of the bone

1. ميحرلا نمحرلا للها مسب
Bone Infections
By
Dr: Salah Youssef El Khateeb.
MD Orth. Surgery
Al Azhar University.

2. Intended Learning Outcomes 
(
ILOs)
•RELEVANT ANATOMY
•DESCRIPTION OF ETIOLOGY , PATHOLOGY , PATHOPHYSIOLOGY
•THE CLINICAL PRESENTATION OF OSTEOMYELITIS
•OUTLINE OF MANAGEMENT ( INVESTIGATIONS AND TREATMENT)
•DIFFERENTIAL DIAGNOSIS
•COMPLICATIONS

3. Definition
What is osteomyelitis?
It is an infection of the of the bone or bone marrow which
leads to a subsequent Inflammatory process.
Osteomyelitis (Osteo- bone, Myelo- Marrow, and –itis –
inflammation).

4. Pathogenesis
Where Does it Come From?
1.Hematogenous
2.Non Hematogenous Osteomyelitis
a. Direct contact of the tissue and bacteria as a result of an
Open Fracture or Trauma. Tend to involve multiple organisms.
b. Contiguous soft tissue infection {rare}.

5. Types of Osteomyelitis
Acute hematogenous Osteomyelitis.
Subacute
Chronic.

6. Acute Osteomyelitis
Causative Organisms:
Staphylococcus aureus (Mainly)
Streptococcus pyogens or pneumonia. (Less)
H. Influenza (Young Children)
Salmonella (Sickle-Cell)

7. Pathology of Acute Osteomyelitis
Being blood borne, the site in bone which becomes the target is
usually the metaphysis, being the area of maximum blood supply.
Occasionally, a bone abscess may develop in the sub periosteal
region especially in adult.

8. Pathology

9. Pathology

10. Pathology
Necrosis.
•Begin to see signs within one week.
New-bone formation.
•Bone thickens to form an involucrum enclosing the infected tissue.
•Perforation may occur converted acute into chronic osteomyelitis.

11. Clinical Features
Must have high index of suspicion
History: preceding skin Lesion or sore Throat.
Pain
Fever and Malaise.
Neonate malaise, no interest in feeding, listless, often no or low
fever.
Signs
Point tenderness over a metastasis.
Restricted Joint Movement.
Adjacent joint may swell with effusion.
Redness, Edema, Warmth (Signify Pus).

12. Clinical Picture
•Clinical Picture

13. Infection: Acute osteomyelitis
•C.P:

14. Investigations
•Lab studies
•Radiological studies

15. Lab Investigations
CBC: Leukocytosis.
The CRP level usually is elevated (nonspecific but more useful than ESR).
ESR usually is elevated (90%) nonspecific.
Blood culture results are positive in only 50% of patients with
hematogenous osteomyelitis.
Aspiration of the pus from the sub periosteal abscess and culture, and
test sensitivity for antibiotics

16. Investigation
Laboratory findings
- Leucocytosis ↑ ESR ↑ CRP
- Blood culture (50% +ve)
- Bone aspiration (90% +ve)
Conventional x-ray:
- Soft tissue edema (0-4 days)
- Rarefaction & destruction(4-8 days)
- Periosteal reaction (> 8 days)
Other imaging modalities :
- Tomography, C.TS., MR1
- Radio nuclide scan, U.S.

17. X - Ray

18. Imaging
First sign is soft-tissue edema at 3-5 days after infection.
First 10 days X-Rays Show No Abnormality.
By the end of the 2
nd
Week signs of rarefaction of Metaphysis and
New Bone Formation.
With Healing there is Sclerosis and thickening of Cortex.
Involucrum and sequestrum in late persistent osteomyelitis.

19. Radiological Studies
X-Ray
Plain-film radiograph showing osteomyelitis of the second
metacarpal (arrow) and tibia.
Periosteal elevation, cortical disruption and medullary
involvement are present.

20. The above X-ray of the
right ankle of a 10-year-
old boy shows lucency in
the tibial metaphysis
secondary to acute
hematogenous
osteomyelitis (AHO).
The above X-ray of the
left ankle of a 10-year-
old boy shows lucency
in the tibial metaphysis
secondary to acute
hematogenous
osteomyelitis (AHO).
X-ray of an AHO lesion
extending into the
growth plate.

21. Radiological Studies
•MRI
Early detection and surgical localization of osteomyelitis.
Sensitivity ranges from 90-100%.
•Bone scanning
A 3-phase bone scan with technetium 99m is probably the initial
imaging modality of choice.
Show increase activity but it is a non specific sign of inflammation.

22. This MRI sagittal section shows the same AHO lesions with the right
lesion extending into the growth plate.

23. Bone scans, both anterior (A) and lateral (B), showing the
accumulation of radioactive tracer at the right ankle
(arrow).
This focal accumulation is characteristic of osteomyelitis.

24. Radiological Studies
CT scan
Spinal vertebral lesions, complex anatomy: pelvis, sternum, and
Calcaneus.
Ultrasound
May demonstrate changes as early as 1-2 days after onset of
symptoms.
Abnormalities include soft tissue abscess or fluid collection and
periosteal elevation.
Ultrasonography allows for ultrasound-guided aspiration.
It does not allow for evaluation of bone cortex.

25. Treatment

26. Treatment Principles
•To avoid permanent damage ---- early treatment necessary.
•General: Antibiotics.
•Local
Drainage of the pus {culture}.
Drilling (medulla).
Surgical eradication of pus and necrotic tissue{debridement}.

•Immobilization of the limb: back slab.

•Supportive measures
- Analgesics - antipyretics {Relief pain}.
-Infusion.

27. Treatment Principles
Antibiotic choices
Duration: Start with I.V antibiotics for 1-2 weeks then oral for 3-6
weeks.
Take cultures to detect the organism and its sensitivity pattern.
Start empirical treatment before the results came back, then modify
it according to the results.
Older children and adults (staph infection): fluloxacillin and fusidic
acid.
Children younger than 4 year-old or those with gram negative
organisms: 3
rd
generation cephalosporins.
MRSA: Vancomycin.

28. Complications of AOM
•Chronicity: the most common complication.
•Joint affection: how?
•Physeal damage {Growth disturbance- angular deformity}.
•Pathological fracture.

29. Subacute Osteomyelitis
Results from a less virulent Microorganism, or a patient with
an elevated resistance.
Occurs Mostly at the Distal Femur or Proximal Tibia
X-Ray:
Brodie’s Abcess:
Small and Oval in shape.
It is surrounded by sclerotic bone.
May be mistaken for Ostieoid Osteoma

30. Subacute Osteomyelitis
An image depicting subacute osteomyelitis

31. Chronic osteomyelitis
Chronic osteomyelitis continues to be a major challenge to
the orthopaedic surgeon.
Staphylococcus aureus is the most common organism
isolated from osteomyelitic foci.
Chronic osteomyelitis can be favorably treated by using a
good surgical debridement of the affected bony and soft
tissues, obliteration of bone cavities and intraoperative and
postoperative antibiotic.

32. Chronic Osteomyelitis

33. Chronic Osteomyelitis

34. Complications of Chronic Osteomyelitis
1.Intermittent flare.
2.Joint affection.
3.Growth disturbance.
4.Deformity.
5.Pathological fracture.
6.Malignant changes {epithelioma}.
7.Amyloidosis.
8.Social and psychological.

35. Post Operative Infections
Not Uncommon.
Predisposed by:
1.Debility
2.Chronic disease
3.Previous Infection
4.Tight Dressing
5.Corticosteroid Treatment
6.Long Surgery
7.Hematoma
8.Foreign Material Implants

36. Post Operative Infections
•Prophylaxis is the KEY in prevention.
•Treated According to Infection.

37. Conclusions
•Osteomyelitis still forms a major problem for both surgeon
and patient.
•Hematogenous osteomyelitis is a disease of the growing
age, more common in males, the tibia and femur are the
common bones affected.
•Staphylococcus aureus is the most common organism
isolated from osteomyelitic foci.

38. Conclusions
•High suspicion
•Early intervention
•Obtain deep cultures
•Aggressive debridement
•Appropriate antibiotic
•Early coverage {in cases of open fr}

39. Questions to Be Answered?
What is osteomyelitis?
Describe the clinical classification of acute hematogenous
osteomyelitis?
Describe the pathogenesis of acute hematogenous osteomyelitis?
What are the most common pathogens isolated from AOM?
What are the clinical finding in AOM?
What diagnostic tests are useful in AOM?
Describe an imaging approach for the diagnosis of AOM?
What is a sequestrum?
What is the involucrum?
What are the complications of acute osteomyelitis?
What are the Complications of Chronic Osteomyelitis?

40. Thank You for Your Attention