Chronic osteomyelitis

Chronic Osteomyelitis presentation

1. CHRONIC OSTEOMYELITIS
Presenter:
Dr. BijayMehta
Moderator:
Dr. KshitizSapkota

2. Contents
⚫DEFINITION
⚫CAUSATIVE ORGANISMS
⚫PREDISPOSING FACTOR
⚫PATHOLOGY
⚫CLINICAL FEATURES
⚫CLASSIFICATION
⚫DIAGNOSIS
⚫TREATMENT
⚫COMPLICATIONS

3. OSTEOMYELITIS
⚫OSTEOMYELITIS-TERMCOINEDBYNELATON
⚫Therootwordsosteon(bone)andmyelo(marro)are
combinedwithitis(inflammation)todefineclinical
stateinwhichboneisinfectedwithmicroorganisms..

4. ⚫ISINFLAMMATION OFBONECAUSEDBYAN
INFECTINGORGANISM.
⚫ISUSUALLYDUETOSINGLEORGANISM BUT
POLYMICROBIALINFECTIONCANOCCUR
⚫Infectionmayinvolvenumerousregionsuchas
marrow,cortex,periosteumandsurroundingsoft
tissue
⚫CLASSIFIEDasACUTE,SUBACUTEandCHRONIC
dependingupondurationofsymptom.

5. CHRONIC OSTEOMYELITIS
⚫Used to be dreaded sequeleto acute hematogenous
osteomyelitis
⚫Now a days frequently follows open # or operation

6. Causative Organisms
Staphylococcus aureus
Escherichia coli
Streptococcus pyogens
Proteus mirabilis
Pseudomonas aeruginosa
Staphylococcus epidermidis –in presence of foreign
implant

7. Predisposing factors
⚫Acute hematogenous osteomyelitis if left untreated
⚫Local trauma such as open # or a prolonged bone
immobilization –commonest
⚫Very old or debilitated
⚫Substance abuse
⚫Malnutrition
⚫Diabetes ,skin infection ,malnutrition , lupus
erythematosus or any type of immune deficiency

8. PATHOLOGY
⚫Boneisdevitalizedindescreteareaaroundinfection
ordiffuselyaroundsurfaceofforeignbody
⚫Cavitycontainingpusandpiecesofdead
bone(sequestrum)aresurroundedbyvasculartissue,
andbeyondthatbyareaofsclerosis–theresultof
chronicreactivenewboneformation-whichmaytake
formofdestinctbonysheath(involucrum)
⚫Sequestrumactsameasforeignimplantforbacterial
adhesionensuringpersistenceofinfectiontill
removedordrainedthroughperforationin
involucrumandsinus

9. ⚫Skin may seal off for weeks or month giving
appearance of healing only to reopen again when
tissue tension rises
⚫HISTOLOGICAL PICTURE
Chronic inflammatory cell infiltration around
area of acellular bone or microscopic sequestra

10. CLINICAL FEATURES
⚫PAIN
⚫PYREXIA
⚫REDNESS AND TENDERNESS have recurred (flare)
⚫Tissue often thickened and puckered or folded
inward-in longstanding cases
⚫seropurulent discharge and excoriation of
surrounding skin
⚫Bone deformed or un-united in case of post traumatic
osteomyelitis

11. ⚫Hallmark of chronic osteomyelitis is infected dead
bone within a compromised soft tissue envelope.
⚫The infected foci within bone are surrounded by
sclerotic relatively avascular bone covered by
thickened periosteum and scarred muscle and
subcutaneous tissue

12. ⚫InChronicOM.secondaryinfectionarecommonand
sinustractculturedoesn'tcorrelatewithculture
obtainedbybonebiopsy.
⚫Eradicationgenerallyrequiresaggressivesurgical
debridementanddeadspacemanagementcombined
witheffectiveantibiotictreatment.
⚫limitedsurgicaldebridementcombinedwith
supressiveabandnutritionalsupportmaylimitthe
frequencyofsinusdrainageandpainindifficultcases.

13. CLASSIFICATION
⚫CIERNEY AND MADER developed classification
system based on physiological and anatomical criteria
to determine stage of infection

15. ⚫Anatomical and physiological classes are combined to
designate one of 12 clinical stage of chr. OM
⚫Classification system is helpful in determining if
treatment should be simple or complex ,curative or
palliative , limb sparing or ablative.

16. Jonesetal.Classificationofchronic
hematogenousosteomyelitisin
children
⚫BASED ON RADIOGRAPHIC APPEARANCE
TYPE A brodie abscess
TYPE B sequestrum involucrum
B1 localized cortical sequestrum
B2 sequestrum with normal or structural involucrum
B3 sequestrum with sclerotic involucrum
B4 sequestrum without sclerotic involucrum
TYPE C sclerotic
If proximal physis is damaged suffix P is added and if distal
physis is affected suffix D is added

17. DIAGNOSIS
⚫GOLDSTANDARD –BIOPSYSPECIMEN FOR
HISTOLOGICAL AND MICROBIOLOGICAL
EVALUATION
⚫IsBasedonCLINICAL,LABARATORY AND
IMAGINGSTUDIES.
⚫Physicalexaminationfocussedonintegrityofskin
andsofttissue,determineareaoftenderness,assess
bonestabilityandneurovascularstatusoflimb

18. ⚫Laboratory study are non specific and give no
indication of severity of infection.
⚫Esr and crp are elevated in most patients
⚫Wbc elevated in only 35%

19. Imaging studies
⚫Done to aid in confirmation of
diagnosis and to prepare for surgical
treatment
1.Plain radiograph –initial study
performed
sign of cortical destruction
and periostealreaction strongly
suggest dxof om
2.Plain tomography –useful in
detection of sequestra
3.Sinography–valuable adjunct to
surgical planning

20. 3.Isotopic bone scanning –more useful in acute OM
bcz they have negative plain film
⚫technetium 99 scan-shows increased uptake in
areas of increased blood flow
non specific
has high negative predictive value
⚫Gallium scan –increased uptake in area with
leucocyte or bacteria
normal gallium scan virtually excludes presence of
osteomyelitis so useful in follow up
⚫Indium 111 labelled leukocyte more specific and used
especially in differentiating chronic osteomyelitis
from neuropathic arthropathy in diabetic foot.

21. 4.CT -provides excellent definition of cortical bone
and useful in identifying sequestra
5.MRI –more useful for soft tissue evaluation than CT
provide fairly accurate extent of pathological
insult by showing margin of bone and soft
tissue edema.
rim sign-well defined rim of high signal intensity
surrounding the focus of active disease

22. 6. Biopsy with culture and sensitivity
⚫Establishing diagnosis
⚫Determining proper antibiotic regime
⚫Both soft tissue and bone specimen should be sent for
microbiological study

23. TREATMENT
⚫MULTIFACTORIAL APPROACH
1.ANTIBIOTIC SUPRESSION
2.SURGICAL DEBRIDEMENT AND
RECONSTRUCTION
3.CORRECT HOST MORBIDITIES
e.g. optimization of blood sugar ,smoking cessation,
treatment of liver or renal malfunction

24. Antibiotics
⚫Choice of antibiotics –depends on Culture/ sensitivity
⚫Antibiotics alone cannot cure chronic osteomyelitis
without surgical intervention
⚫Duration of antibiotics –6 weeks

25. ⚫Surgeryconsistsofsequestrectomyandresection
ofscarredandinfectedboneandsofttissue
⚫Forsofttissueanddeadspacemanagement
externalfixatorsaregenerallyused
⚫Reconstructionofboneandsofttissueshouldbe
undertakencombinedwithculturesensitive
antibiotics.
Surgical Treatment

26. Sequesterectomyand curettage
⚫Appropriate preparation done before surgery as it
may take more time to perform and more blood loss
than inexperienced surgeon anticipate
⚫Can inject methylene blue 24 hr before surgery into
sinus tract-easier to locate and excise
⚫

27. ⚫Allsequestra,purulentmaterialandscarredandnecrotictissue
areremoveduntilactivepunctatebleedingbone–paprikasignis
achieved
⚫Tissuesentforculture
⚫DeadspacecanbefilledwithantibioticPMMAbeads.
⚫Asofttissue,localmuscleflap,orafreetissuetransfercanbe
performedattimeofbeadremoval
⚫Ifboneunstable,stabilize,preferablywithilizarovtypeexternal
fixator
⚫Antibioticbefore,duringandafteroperation
⚫Woundissplinted

28. ⚫Bone and soft tissue defect eliminated by
1.Bone grafting with primary or secondary suture
2.Use of antibiotic PMMA beads as a temporary filler
of dead space before reconstruction
3.Local muscle flap and skin grafting with or without
bone grafting
4.Microvasculartransfer of muscle, myocutaneous,
osseous, and osteocutaneousflaps
5.Use of bone transport ( illizarovtechnique)
Management of Dead Space

29. Management of Dead Space

30. OPEN BONE GRAFTING
Papineau et al.
Used when free flaps or soft tissue transfer option are
limited
⚫OPERATION IS DIVIDED IN 3 STAGES
1.Debridement and stabilization
thoroughly debride and irrigate all sequestra and
necrotic bone
stabilize bone with external fixator and intramedullary
nail if needed
apply VAC
redebride and irrigate with VAC change every 48 to 96
hrs until healthy viable tissue bed

31. ⚫Cancellous bone harvested from iliac crest or
proximal tibia
2 . GRAFTING
⚫Bony defect packed
⚫Dressed with adaptic and VAC sponge
⚫vac changed every 72 to 96 hrs until healthy
appearing granulation tissue
⚫Local muscle pedicle graft can be used to enhance
blood supply to graft
3Wound coverage
apply skin graft or allow spontaneous epithelization

32. POLYMETHYLMETHACRYLATE ANTIBIOTICS
BEAD CHAIN
⚫Delivers antibiotics locally in concentration that exceeds
minimal inhibitory concentration
⚫Local concentration achieved are 200 times than systemic
antibiotic administration maintaining low serum and low
systemic toxicity
Aminoglycosides are commonly employed antibiotics
Other are Penicillin ,Cephalosporin and Clindamycin
Vancomycin elutes less effectively
Fluoroquinolones ,Tetracycline and Polymyxin are not
used

33. ⚫BONE CEMENT
has Gentamycin (500 mg /40 gm pack)
generally add 2 to 4 gm of Vancomycin with or
without Tobramycin 1.2 gm
add monomer
⚫Local antibiotic level last only 2 to 4 weeks after
placement ,foreign body that remains may be
colnized by glycocalyx forming bacteria

34. ANTIBIOTIC BEAD POUCH
Used if soft tissue coverage is impossible after initial
debridement
Also used to prevent infection in open #
⚫Thorough debridement of necrotic tissue and irrigation
using 9 lit saline solution containing bacitracin
⚫PMMA antibiotic bead prepared and rolling into small
spheres and placed on 18 to 20 gauge wire to form bead
chain
⚫PMMA antibiotic bead chain placed in bony defect.
⚫All wound extension closed with interrupted nylon suture

35. ⚫Skin edge is dried and benzoid solution applied
⚫Adhasive polyethylene wound film (opsite)applied to
cover wound
second layer larger opsite dressing over first dressing
to prevent leakage
⚫Bead pouch changed every 72 hrs with repeat
debridement and irrigation until wound healthy for
soft tissue coverage
⚫Limb is immobilized

36. INTRAMEDULLARY ANTIBIOTIC
CEMENT NAIL
⚫Reamer irrigator aspirator system followed by
placement of antibiotic impregnated cement nail plus
pathogenic specific systemic antibiotic is safe and
effective

37. ⚫Debrideallnecroticandnonviablesofttissueand
boneandpreparemedullarycavityusingreaming
technique
⚫Reamingssentforculturestudies
⚫Cementrodmouldedusingt-95chesttubeusing
desiredantibiotic,cementandmonomer.
⚫Oncepolimerizationiscompleteplastictuberemoved
andnailinsertedwithusualintramedullarynailing
technique
⚫Longleg,bentkneecastapplied
⚫Nonwtbearingfor6-8wk
⚫Cementnailreplacedwithregularintramedullarynail

38. BIODEGRADABLE ANTIBIOTIC
DELIVERY SYSTEM
⚫ADVANTAGE OVER PMMA
secondary procedure not required for implant
removal
better antibiotic release
better compatibility profile
⚫Used when bony instability is not an issue and soft
tissue coverage is adequate
⚫Some biodegradable substrates contain
osteoconductive and osteoinductive materials
⚫Biodegradable substance used as antibiotic delivery
system classified into 3 main categories

39. 1.Proteins –collagen ,gelatin, thrombin, and autologous
blood clot
2.Bone graft substitutes –calcium sulphate
3.Synthetic polymer –can be modified to release specified
drug quantities over specific amount of time
Properties of ideal biodegradable carrier
good biocompatibility
controllable degradation
ability to release any antibiotic at therapeutic level for
extended period of time

40. CLOSE SUCTION DRAIN
1.LAUTENBACH TECHNIQUEofclosedantibiotic
ingressandegressirrigationsystem
Allowschangeinantibioticdeliverybasedonculture
reports
Frequentocclusionofdeliverycatheteroccurswhichis
decreasedwithuseofstreptokinse
Alsoriskofprolongedhospitalizationandsecondary
contamination

41. Lautenbach drainage system

42. 2Negative pressure wound therapy (NPWT) or VAC
edema reduction
increase blood flow
increase granulation tissue
possibility of improved bacterial clearance
BUT
excessive bleeding can occur

43. SOFT TISSUE TRANSFER
⚫Ranges from localized muscle flap on a vascular pedicle to
microvascular free tissue transfer
⚫Transfer of vascularized muscle tissue improves blood
supply that is important in host defence mechanism and
for antibiotic delivery and osseous and soft tissue healing
⚫local muscle flap m/c used in chr OM of tibia
⚫Gastrocnemius muscle used for defect around proximal
third ,soleus around middle third
⚫microvascular free muscle transfer around distal third
⚫Adequate initial debridement is required

44. ILIZAROV TECHNIQUE
⚫Allows radical resection of infected bone
⚫Corticotomy is performed through normal bone
proximal and distal to area of disease
⚫Disadvantage
time required to achieve solid union
high incidence of complication
Use of distraction osteogenesis with ring fixation over
an intramedullary rod has been used for defect up to
13 cm

45. ADJUVANT THERAPY
⚫HYPERBARIC OXYGEN THERAPY
⚫GROWTH FACTOR
enhance osteogenesis
1.bone morphogenic protein
2.platelet rich plasma
⚫PHYSICAL ENERGY MODALITIES
1.pulsed electromagnetic fields
2.Ultrasound

46. AMPUTATION IN OSTEOMYELITIS
⚫Infrequently Performed
⚫INDICATIONS
⚫Malignancy
⚫Arterial insufficiency ,
⚫Major nerve paralysis,
⚫Joint contracture and stiffness that make a limb
non-functional
⚫In certain patients for multiple operations and
prolonged antibiotic therapy

47. COMPLICATIONS
⚫AcuteExacerbations-Mostcommon
⚫GrowthAbnormalities
⚫PathologicalFractures
⚫Deformities
⚫Amyloidosis
⚫MalignantTransformation-0.2to1.6%
mostaresquamouscellcarcinomafromsinustract
otherarereticulumcellcarcinoma,fibrosarcoma

48. REFERENCES:
⚫Campbell’s operative orthopaedics 13
th
edition
⚫Apley’s system of Orthopaedics and Trauma 10
th
edition
⚫Essential Orthopedics : Principles and Practice,
Manish Kumar Vashney

49. THANK YOU