OSTEOMYELITIS

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OSTEOMYELITIS
M.RASOOLINEJAD, MD DEPATMENT OF INFECTIOUS
DISEASE TEHRAN UNIVERSITY OF MEDICAL SCIENCE
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OSTEOMYELITIS
INFLAMMATORY PROCESS IN BONE BONE
MARROW ACUTE CHRONIC
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PATHOPHYSIOLOGY

• Hematogenous Osteomyelitis
• Contiguous-Focus Osteomyelitis
• Peripheral Vascular Disease-associated

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PATHOPHYSIOLOGY
Microorganisms enter bone (Phagocytosis). Phag
ocyte contains the infection Release
enzymes Lyse bone
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PATHOPHYSIOLOGY

• Bacteria escape host defenses by
• Adhering tightly to damage bone
• Persisting in osteoblasts
• Protective polysaccharide-rich biofilm

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PATHOPHYSIOLOGY
Pus spreads into vascular channels Raising
intraosseous pressure Impairing blood
flow Chronic ischemic necrosis Separation
of large devascularized fragment New bone
formation (involucrum)
(Sequestra)
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PATHOLOGY
Acute ?Infiltration of PMNs
Congested or thrombosed vessels Chronic ?
Necrotic bone Absence of
living osteocyte Mononuclear
cells predominate Granulation
fibrous tissue
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Hematogenous Osteomyelitis
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HEMATOGENOUS OSTEPMYELITIS

• Rapidly growing bone
• Children
• Long bone, Femur, Tibia, Humerus
• Older patients Vertebral bone

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HEMATOGENOUS OSTEOMYELITIS

• Neonate infant lt 1 year old
• Septic arthritis is common.
• Growth deformities is common.
• Soft tissue involvement is common.

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HEMATOGENOUS OSTEOMYELITIS

• Children 1 16 years old
• Most frequent in the metaphysis of long bone.
• Slugging blood flow through a
• sinusoidal
  venous system.
• Deficency of phagocytic cells.
• Poor collateral circulation
• Susceptibility of this region to trauma.

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HEMATOGENOUS OSTEOMYELITIS

• Children 1 16 years old
• History of antecedent trauma in 30
• Involucrum
• Sequestration
• Associated septic arthritis

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HEMATOGENOUS OSTEOMYELITIS

• Adult
• Less common
• Spread infection to joint space.
• Vertebral Osteomyelitis is commongt 50y

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HEMATOGENOUS OSTEOMYELITIS

• Special consideration
• Sickle cell disease
• Injection drug users (IDUs)
• Hemodialysis
• HIV/AIDS
• Immunosuppression
• Prosthetic orthopedic device

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HEMATOGENOUS OSTEOMYELITIS

• Microbiologic features
• Staphylococci ? Aureus, Epidermidis
• Streptococci ? Group A B
• Haemophilus influenzae
• Gram-negative enteric bacilli
• Anaerobes
• Polymicrobial
• Mycobacterial
• Fungi

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HEMATOGENOUS OSTEOMYELITIS

• Clinical manifestation
• Classic presentation Sudden onset
• Usually presentation Slow, insidious
• High fever, Night sweats
• Fatigue, Anorexia, Weight loss
• Restriction of movement
• Local edema, Erythema, Tenderrness

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HEMATOGENOUS OSTEOMYELITIS

• Differentials
• Cellulitis
• Gas gangrene
• Neoplasm
• Aseptic bone infection

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Clenched fist osteomyelitis
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HEMATOGENOUS OSTEOMYELITIS

• Diagnosis work-up
• Lab study
• WBC ? May be elevated, Usually normal
• C-Reactive Protein (CRP)
• Erythrocyte Sedimentation Rate
• (Usually is elevated at presentation
• Falls with successful therapy)
• Blood culture
• ( Acute osteomyelitis ve gt 50 )

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HEMATOGENOUS OSTEOMYELITIS

• Diagnosis work-up
• Imaging
• Radiology
• Normal
• Soft tissue swelling
• Periosteal elevation
• Lytic change
• Sclerotic changew

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HEMATOGENOUS OSTEOMYELITIS

• Diagnosis work-up
• Imaging
• MRI
• Early detection
• Superior to plan X ray CT Scan
• radionuclide bone scan in slected
• anatomic location.
• Sensitivity 90 100

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HEMATOGENOUS OSTEOMYELITIS

• Diagnosis work-up
• Imaging
• Radionuclide bone scan
• A 3-phase bone scan ( Technetium 99m )
• Positive as early as 24 h after
• onset of
  symptoms.
• False positive ? Tumor, osteonecrosis
• Artheritis,
  Cellulitis,
• Abscess

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HEMATOGENOUS OSTEOMYELITIS

• Diagnosis work-up
• Imaging
• CT Scan
• Useful in evaluation of ? Spinal, pelvic,
• Sternum, Calcaneus
• Provides exellent images of bone cortex
• Is used for biopsy localization

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Os gaz in diabetic foot
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Septic arthritis Of Right hip
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HEMATOGENOUS OSTEOMYELITIS

• Diagnosis work-up
• Ultrasonography
• Simple inexpensive
• Demonstration anomaly 1 2 days after onset
• Soft tissue abscess, Fluid collection,
• 
  Periosteal elevation
• It allows for aspiration
• It doesnt allow for evaluation of bone
  cortex.

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HEMATOGENOUS OSTEOMYELITIS

• Diagnosis work-up
• Neddle Aspiration or Open biopsy
• From Soft tissue collection
• Subperiosteal abscess
• Intraosseos lesions
• For Smear
• Culture
• Pathology

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TREATMENT

• Initial treatment shoud be aggressive.
• Inadequate therapy ? Chronic disease
• Antibiotic use
• Surgery

• Parenteral
• High doses
• Good penetration in bone
• Full course
• Empiric therapy

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TREATMENT
Empiric Initial Therapy
Neonate S.aureus PRP
Infantlt2 y G ve bacilli
Cefotaxime Children
S.aureus PRP
H.Infenza Ceftriaxone Adult
S.aureus PRP or

1st ceph
Appropriate dose duration of Ab
Cure without surgery
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TREATMENT
Indication for Surgery

• Diagnostic
• Hip joint involvement
• Neurologic complication
• Poor or no response to IV therapy
• Sequestration

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TREATMENT
Monitoring Therapeutic Response

• Symptoms Signs
• ESR CRP
• Radiography
• Serial Bone Scan?

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PROGNOSIS

• Is related to
• Causative organisms
• Duration of symptoms sign
• Patient age
• Duration of antibiotic therapy

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COMPLICATION

• Bone abscess
• Bacteremia
• Fracture
• Loosing of the prosthetic implant
• Overlying soft-tissue cellulitis
• Draining soft-tissue tract

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Post Osteomyelitis Treatment
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Septic Osteomyelitis
Post Osteomyelitis Scar
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Post Osteomyelitis Deformity of the Forearm
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CONTIGUOUS-FOCUS OSTEOMYELITIS
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Contiguous-focus Osteomyelitis

• Clinical setting
• Postoperative infection
• Contamination of bone
• Contiguous soft tissue infection
• Puncture wounds

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Contiguous-focus Osteomyelitis

• Microbiologic features

• Staphylococci ? Aureus, Epidermidis
• Gram-negative bacteria
• Anaerobic infection
• Unusual organisms? Clostridia, Nocardia

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Contiguous-focus Osteomyelitis

• Diagnosis

• Leukocyte count
• Blood culture (infrequently positive)
• ESR CRP
• Radiologic evaluation
• Technetium bone scan
• Open bone biopsy
• Culture of wound draining sinuses??

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Contiguous-focus Osteomyelitis

• Treatment

• Surgery is essential.
• Antibiotics ? Specific
• Duration

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