Surgical aspects of osteomyleitis. .pptx

Surgical aspects of osteomyleitis

1. Osteomyelitis DR. BALAKH SHER ZAMAN MBBS(KE), FCPS, FACS(USA), MRCS(London), MRCS( Glasg ) Assistant Professor Surgery KEMU/Mayo Hospital, Lahore

2. Learning points Definition Classification Acute osteomyelitis Chronic osteomyelitis

3. definition Osteomyelitis is the inflammation of bone or bone marrow

4. classification Classification based on duration: Acute : infection that hasn’t progressed to bone death Subacute : Less virulent Chronic : infection associated with bone death

5. Classification based on route of spread 1- Hematogenous 2- Direct

6. types Hematogenous osteomyelitis: Bacterial seeding from blood Common in children Most common site: Metaphysis at growing end of long bones in children Vertebrae in adults

7. 2.    Direct inoculation osteomyelitis: Complication of open fracture or surgical procedure Tend to involve multiple organisms, but mainly  S.Aureas

8. Remember Sequestrum : Macroscopic piece of dead tissue Involucrum : New bone around area of osteomyelitis due to periosteal reaction

9. Acute osteomyelitis Primarily a disease of childhood Often follows bout of respiratory or skin infection Causes In children : 90% by staph Aureus   In adults : rare organisms, HIV immunosuppressant therapy, indwelling prosthetics, IV drug abuse

10. Presentation Pain, tenderness, pyrexia, systemic toxicity

11. pathology 1. Inflammation: Earliest change Increase intraosseous pressure causes pain 2. Suppuration: Pus at medulla >>>> surface>>sub periosteal abscess>>spread along shaft>> burst into soft tissue May extend to epiphysis in neonates and children May extend to intervertebral discs in adults

12. 3.Necrosis/sequestrum: Causes: increased intraosseous pressure, vascular stasis, infected thrombus, periosteal stripping which increasingly compromise blood supply 4.New bone formation: involucrum 5.Resolution: Bone will heal if infection is controlled and intraosseous pressure is released

13. Investigations 1.Lab investigations: CBC: Leukocytosis Raised CRP and ESR Blood culture Culture and sensitivity

14. Investigations 2.Radiological studies X-ray MRI Radionuclide bone scan CT scan US

15. X-ray Changes not visible for first 10-14 days

16. MRI Investigation of choice Shows edema of marrow and collection of pus MRI showing osteomyelitis of tibia

17. CT scan Shows bone erosion and fluid collection

18. Treatment Resuscitation and rest Antibiotics : IV antibiotics should be given for 2 weeks followed by 4-6 weeks of oral antibiotics

19. treatment Splintage of affected limb : to prevent soft tissue contracture Radiology guided aspiration of pus Cortex drilling at 2-3 sites: for decompression (send pus obtained for culture and sensitivity)

20. Chronic osteomyelitis When infection >6 Months Causative organisms: Staph aureus Anaerobes Gram negative bacilli M . tuberculosis

21. Risk factors Smoking Malnutrition Immunosuppressants Diabetes Steroids IV drug abuse

22. presentation Pain, chronic infection, sinus formation

23. Cierny and Mader staging for Chronic osteomyelitis

24. Stage 1 Medullary osteomyeltitis: infection confined to the  intramedullary  bone surfaces Stage 2 Superficial osteomyelitis: true contiguous infection (bone surface undergoes  necrosis  at the base of a  soft tissue  wound) Stage 3 Localized osteomyelitis: full-thickness, cortical sequestration Stage 4 Diffuse osteomyelitis: through-and-through process requiring intercalary reconstruction of bone

25. Management Management depends upon stage Medullary: Excision of dead bone and resulting defect may be filled with antibiotic loaded cement beads or absorbable pallets. Superficial: It requires complete excision and local or free muscle flap. Localised : Radical excision is required with cancellous bone graft. Difuse : In difuse stage resection must be segmental and stabilisation with an external fixator is required.

26. After surgery Antibiotics should be advised for 6-12 weeks