OSTEOMYELITIS
Moderator: Dr Collins
Presenter: Comfort Kaimbo
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outline
• Introduction
• Classification
• Acute hematogenous osteomyelitis
• Subacute osteomyelitis
• Chronic osteomyelitis
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Introduction
• Osteomyelitis (osteo- derived from the Greek word osteon, meaning bone,
myelo- meaning marrow, and -itis meaning inflammation)
• Thus Osteomyelitis is defined as an acute or chronic inflammatory process
of the bone and its structures secondary to infection with pyogenic
organisms.
• Infection mainly involves:
Marrow spaces
Haversian canals
Subperiosteal Spaces
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Classification of Osteomyelitis
Duration of infection
1. Acute ( <2/52)
2. Subacute (2-3/52 )
3. Chronic ( >3/52)
Mechanism of infection
4. Exogenous
5. Haematogenous
Type of host response to infection
• Pyogenic or non-pyogenic 4
Acute Haematogenous Osteomyelitis
Acute Haematogenous Osteomyelitis
Definition
• Acute infection/ inflammation of bone and bone marrow.
Introduction
• Almost commonly in Children
• Age distribution is bimodal: Children under 2 years &
Children between 8-12 years of age
• It is more common in males in all age groups affected.
Pathogens
• S. Aureus in 60-90% of cases
• Strep. Pyogenes (> 1 year)
• H. influenza b (Hib) makes up 20% of cases
under 4yrs
• Salmonella spp. in Sickle Cell Disease
Commonly isolated organisms
Infants (<1 y)
Adults (>16 y)
• Staphylococcus aureus
• S aureus
• Group B Streptococcus
• Coagulase-negative
• Escherichia coli
Staphylococcus species
• Gram-negative bacilli
Children (aged 1-16 y) (vert body infections)
• S aureus • P aeruginosa (iv drug
• Streptococcus pyogenes abusers)
• Haemophilus influenzae • Serratia marcescens
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Pathophysiology of AHO
• Caused by a bacteraemia, which is a common occurrence
in childhood.
• Bacteria blood borne from a primary focus (e.g. boil,
pharyngitis, infected skin lesion, UTI). However, In many
cases the exact cause of the disease cannot be identified
• Bacteriological seeding of bone generally is associated
with other factors such as localized trauma, chronic
illness, malnutrition, or an inadequate immune system
• Organisms usually settle in the metaphysis at the rapidly
growing end of a long bone.
• Hairpin arrangement of the capillaries slows down the
rate of blood flow promoting bacterial proliferation.
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Pathophysiology
1. inflammation
2.suppuration
3.necrosis
4. new bone formation
5.resoltion
Metaphysis of long bone is the most common site of
infection
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Clinical Features
History
• Antecedent or preceding trauma, skin lesion, UTI, RTI/Sore
throat, endocarditis or dental infection
• Limp
Children
• Pain,
• Malaise,
• Fever
Infants
• Failure to thrive
• Drowsiness
• Irritability
• Lethargy
• Refusal to use affected limb
Examination
• Limp or not weight bearing.
• ‘Fingertip’ tenderness on percussion of the metaphysis
near one of the large joints.
• Gentle manipulation tender
• Joint movement may be tender & restricted
(pseudoparalysis).
• Local redness, swelling, warmth and oedema are later
signs and signify the presence of pus.
Differential Diagnosis
• Fracture
• Acute Septic arthritis
• Sickle cell crisis
• Rheumatic fever
• Malaria
• Cellulitis
investigations
Bloods=>
1.WBC,ESR,CRP,ASOT ,Blood cultures(+50%
cases)
Image
• Plain xray
• Technetium 99m bone scan
• MRI
• CT scan
• Aspiration and biopsy 15
Investigations
• Radiograph reveals a lytic
lesion and periosteal
reaction of the posterior
cortex.
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Treatment
1. Antibiotics
• Cloxacillin 7.5mg/kg/day in divided doses I.V for 3-4 days
then orally for 3-6 weeks.
• < 4yrs Cefotaxime 100-200mg/kg/day in 2-4 divided doses
(to cover for H. influenzae).
• SCD= Chloramphenicol 50-100mg/kg/day in divided doses.
• Specific antibiotics introduced as soon as organisms are
identified on culture.
2. Analgesics
• Paracetamol 10 mg/kg TDS - QID
Treatment
3. Drainage
• Acute Osteomyelitis is a Surgical Emergency!
• Bone drilling to be done as soon as diagnosis is made.
• Culture of the exudate/ pus should be done to allow
identification of the organism.
4. Splintage
• Complete bed rest is essential.
• Splint could be used but should not conceal affected
area.
• Skin traction could be used for acute osteomyelitis of
the upper femur to prevent hip dislocation.
Complications
Seen in 5 % of cases and
5. Growth disturbance
include • If physis is damaged
1. Spread -Septic there may be
resultant shortening
arthritis, , septicaemia and or deformity.
metastatic osteomyelitis
to other bones. 6. Chronicity
• Treatment must be
2. Anaemia prompt and effective
3. Pathologic fracture
4. Recurrence ‘Too little too late’ =
• Rate in successfully Chronic osteomyelitis
treated osteomyelitis
= 4% / year 7. Mortality - rate is less
than 2 percent 19
Chronic Osteomyelitis
Chronic Osteomyelitis
• Classically is defined by the presence of either
sequestrum or involucrum as a result of an
infective process involving bone
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Pathophysiology of COM
• Periosteal elevation deprives the underlying cortical bone of
blood supply leading to necrotic bone (sequestrum)
• An outer layer of new bone is formed by the periosteum
(involucrum)
• Pus discharging through persistent sinus
– Pus from bone escapes through multiple hole in the
involucrum
• Chronic abscesses may become surrounded by sclerotic bone
and fibrous tissue leading to a Brodie's abscess
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Aetiology
• Untreated, Inadequately or Inappropriately treated
acute osteomyelitis
• Recurrent acute osteomyelitis
• Iatrogenic
• Penetrating trauma
• Open fractures
Risk factors of chronic osteomyelitis (COM)
---Immunosuppression e.g. HIV/AIDS
– Diabetes
– Sickle cell disease
– Tuberculosis
– Intravenous drug abuse
– Chronic steroid use
– Peripheral vascular disease
– Chronic joint disease
– Alcoholism
– Orthopaedic surgery e.g. Prosthetic
orthopaedic device 25
Clinical presentation
• Pain
• Swelling
• Discharging sinus
• Deformity
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Clinical presentation
• Shortening of limb
• Joint stiffness
• Pathological fracture
• Bone thickening
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CLASSIFIACTION OF COM
1.Cierny and Mader
• anatomical
• physiological criteria
2.Beit CURE Classification
of Childhood Haematogenous COM
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Anatomical/Classification of COM
Click to add text
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Beit CURE Classification of
Childhood Haematogenous COM
• Type A: Brodie’s abscess
• Type B: Sequestrum involucrum,
• B1-Localised cortical sequestrum
• B2-Sequestrum with normal /structural
involucrum (adequate involucrum to support
weight of limb against gravity)
• B3-Sequestrum with sclerotic involucrum
• B4-Sequestrum without structural
involucrum
Work up - Laboratory
• FBC: ↑ WBC in only 35% of patients
• ESR
• CRP (more reliable than ESR)
• Pus swab for M/C/S
• Anti-Staphylococcal antibody titres
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Work up- imaging
• plain xray
• CT scan:
• MRI
• Bone scan
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Sinography
• Evaluation of sinus tract before surgical
treatment
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Work up - Laboratory
•
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Differentials
• Sclerosing osteomyelitis of Garrḗ
• Chronic recurrent multifocal osteomyelitis
• TB osteomyelitis
– Previous h/o TB
– Watery discharge
– Sinus with undermined margin
• Ewing's sarcoma
– Primary malignant tumour of bone, usually arising as a
central tumour in long bone (r/o by biopsy)
• Soft tissue chronic infection (r/o on plain X-ray)
Hermann G, (2002), chronic recurrent multifocal sclerosis osteomyelitis in children
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Management of COM
• Multi-disciplinary approach
– Orthopaedic surgeon
– Infectious disease specialist
– Pathologist
– Physiotherapist
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Medical therapy
• To prevent spread of infection
• 6 weeks of IV antibiotics after surgical
debridement of COM
• Alternatively 1 week of IV antibiotics followed
by 6 weeks of oral therapy
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Surgical Management
• Sequestrectomy and Curretage
• Goal of surgery: eradication of infection by
achieving a viable and vascular environment
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After treatment •
• Limb is splinted prevent pathological fractures
• • Prolonged antibiotic therapy (6 weeks)
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Complications
• Pathological fracture
• Non-union of pathological fractures
• Shortening
• Angular Limb deformity
• Joint stiffness
• Muscle contracture
• Sinus track malignancy
• Amyloidosis
• DVT
• Malignant changes ( Squamous cell ca, Reticulum cell ca,
Fibrosarcoma)
Osteoporosis
References
1) Brinker M. R. and O’Connor D. P. (2012), in Review of Orthopaedics, 6th
edition, Saunders, Elsevier's.
2) Beit CURE classification of childhood chronic haematogenous
osteomyelitis, Wynn Jones H, Harrison JW, Bates J, Evans GA, Lubega N.
Radiologic classification of chronic haematogenous osteomyelitis in
children. J Pediatric Orthopaedic (2009);29:822-7.
3) Chronic Osteomyelitis in Children, David A. Spiegel, M.D. and John
Norgrove Penny, M.D., F.R.C.S.(C)
4) Chronic haematogenous osteomyelitis in Children, H. Wynn Jones H. W.
et al, from Beit Cure International Hospital, Blantyre, Malawi.
5) Gregory D. D, (2008), in Campbell’s Operative Orthopaedics, Volume 1,
11th edition, Mosby Elsevier.
6) Hermann G, (2002), chronic recurrent multifocal sclerosis osteomyelitis
in children
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