OSTEOMYELITISOSTEOMYELITIS

M.RASOOLINEJAD, MDM.RASOOLINEJAD, MDDEPATMENT OF INFECTIOUS DISEASEDEPATMENT OF INFECTIOUS DISEASETEHRAN UNIVERSITY OF MEDICAL SCIENCE TEHRAN UNIVERSITY OF MEDICAL SCIENCE

OSTEOMYELITISOSTEOMYELITIS

INFLAMMATORY PROCESS INFLAMMATORY PROCESS IN BONE & BONE MARROWIN BONE & BONE MARROW

ACUTE & CHRONICACUTE & CHRONIC

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Hematogenous OsteomyelitisHematogenous Osteomyelitis

Contiguous-Focus OsteomyelitisContiguous-Focus Osteomyelitis

Peripheral Vascular Disease-associated Peripheral Vascular Disease-associated

PATHOPHYSIOLOGYPATHOPHYSIOLOGYMicroorganisms enter bone (Phagocytosis).Microorganisms enter bone (Phagocytosis).

Phagocyte contains the infectionPhagocyte contains the infection

Release enzymesRelease enzymes

Lyse bone Lyse bone

PATHOPHYSIOLOGYPATHOPHYSIOLOGYBacteria escape host defenses by:Bacteria escape host defenses by:

Adhering tightly to damage boneAdhering tightly to damage bone

Persisting in osteoblastsPersisting in osteoblasts

Protective polysaccharide-rich biofilmProtective polysaccharide-rich biofilm

PATHOPHYSIOLOGYPATHOPHYSIOLOGYPus spreads into vascular channelsPus spreads into vascular channels

Raising intraosseous pressureRaising intraosseous pressure

Impairing blood flowImpairing blood flow

Chronic ischemic necrosisChronic ischemic necrosis

Separation of large devascularized fragmentSeparation of large devascularized fragment

New bone formationNew bone formation (involucrum)(involucrum)

(Sequestra)(Sequestra)

PATHOLOGYPATHOLOGY

Acute Acute Infiltration of PMNsInfiltration of PMNs Congested or thrombosed vesselsCongested or thrombosed vessels

Chronic Chronic Necrotic bone Necrotic bone Absence of living osteocyteAbsence of living osteocyte Mononuclear cells predominateMononuclear cells predominate Granulation & fibrous tissueGranulation & fibrous tissue

HematogenoHematogenous us

OsteomyelitiOsteomyelitiss

HEMATOGENOUS OSTEPMYELITISHEMATOGENOUS OSTEPMYELITIS

Rapidly growing boneRapidly growing bone

Children: Children: Long bone, Femur, Tibia, HumerusLong bone, Femur, Tibia, Humerus

Older patients: Vertebral boneOlder patients: Vertebral bone

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

Neonate & infant < 1 year oldNeonate & infant < 1 year old

Septic arthritis is common.Septic arthritis is common.

Growth deformities is common.Growth deformities is common.

Soft tissue involvement is common.Soft tissue involvement is common.

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISChildren: 1 – 16 years oldChildren: 1 – 16 years old

Most frequent in the metaphysis of long bone.Most frequent in the metaphysis of long bone.

Slugging blood flow through a Slugging blood flow through a sinusoidal venous system.sinusoidal venous system.

Deficency of phagocytic cells.Deficency of phagocytic cells.

Poor collateral circulationPoor collateral circulation

Susceptibility of this region to trauma. Susceptibility of this region to trauma.

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISChildren: 1 – 16 years oldChildren: 1 – 16 years old

History of antecedent trauma in 30%History of antecedent trauma in 30%

InvolucrumInvolucrum

SequestrationSequestration

Associated septic arthritisAssociated septic arthritis

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

AdultAdult

Less commonLess common

Spread infection to joint space.Spread infection to joint space.

Vertebral Osteomyelitis is common> 50yVertebral Osteomyelitis is common> 50y

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

Special considerationSpecial considerationSickle cell diseaseSickle cell diseaseInjection drug users (IDUs)Injection drug users (IDUs)HemodialysisHemodialysisHIV/AIDSHIV/AIDSImmunosuppressionImmunosuppressionProsthetic orthopedic deviceProsthetic orthopedic device

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

Microbiologic featuresMicrobiologic featuresStaphylococci Staphylococci Aureus, Epidermidis Aureus, EpidermidisStreptococci Streptococci Group A & B Group A & BHaemophilus influenzaeHaemophilus influenzaeGram-negative enteric bacilliGram-negative enteric bacilliAnaerobesAnaerobesPolymicrobialPolymicrobialMycobacterialMycobacterialFungiFungi

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

Clinical manifestationClinical manifestationClassic presentation: Sudden onsetClassic presentation: Sudden onsetUsually presentation: Slow, insidiousUsually presentation: Slow, insidious

High fever, Night sweatsHigh fever, Night sweatsFatigue, Anorexia, Weight lossFatigue, Anorexia, Weight lossRestriction of movementRestriction of movementLocal edema, Erythema, & TenderrnessLocal edema, Erythema, & Tenderrness

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

DifferentialsDifferentialsCellulitisCellulitisGas gangreneGas gangreneNeoplasmNeoplasmAseptic bone infectionAseptic bone infection

Clenched fist Clenched fist osteomyelitisosteomyelitis

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-upDiagnosis & work-upLab study:Lab study:

WBC WBC May be elevated, Usually normal May be elevated, Usually normal

C-Reactive Protein (CRP)C-Reactive Protein (CRP) Erythrocyte Sedimentation RateErythrocyte Sedimentation Rate (Usually is elevated at presentation(Usually is elevated at presentation Falls with successful therapy)Falls with successful therapy)

Blood cultureBlood culture( Acute osteomyelitis + ve > 50% )( Acute osteomyelitis + ve > 50% )

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HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-upDiagnosis & work-upImagingImaging

Radiology:Radiology:NormalNormalSoft tissue swellingSoft tissue swellingPeriosteal elevationPeriosteal elevationLytic changeLytic changeSclerotic changewSclerotic changew

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-upDiagnosis & work-upImagingImaging

MRI:MRI:Early detectionEarly detectionSuperior to plan X ray & CT Scan &Superior to plan X ray & CT Scan & radionuclide bone scan in slected radionuclide bone scan in slected anatomic location.anatomic location.Sensitivity 90 – 100%Sensitivity 90 – 100%

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISDiagnosis & work-upDiagnosis & work-up

ImagingImagingRadionuclide bone scan:Radionuclide bone scan:A 3-phase bone scan ( Technetium 99m )A 3-phase bone scan ( Technetium 99m )

Positive as early as 24 h after Positive as early as 24 h after onset of symptoms.onset of symptoms.

False positive False positive Tumor, osteonecrosis Tumor, osteonecrosis Artheritis, Cellulitis, Artheritis, Cellulitis, AbscessAbscess

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISDiagnosis & work-upDiagnosis & work-up

ImagingImagingCT – Scan:CT – Scan:Useful in evaluation of Useful in evaluation of Spinal, pelvic, Spinal, pelvic, Sternum, CalcaneusSternum, Calcaneus

Provides exellent images of bone cortexProvides exellent images of bone cortex

Is used for biopsy localizationIs used for biopsy localization

Os + gaz in diabetic footOs + gaz in diabetic foot

Septic arthritisSeptic arthritisOfOf

Right hipRight hip

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISDiagnosis & work-upDiagnosis & work-up

UltrasonographyUltrasonographySimple & inexpensiveSimple & inexpensive

Demonstration anomaly 1 – 2 days after onsetDemonstration anomaly 1 – 2 days after onset

Soft tissue abscess, Fluid collection, &Soft tissue abscess, Fluid collection, & Periosteal elevationPeriosteal elevation

It allows for aspirationIt allows for aspiration

It doesn’t allow for evaluation of bone cortex. It doesn’t allow for evaluation of bone cortex.

HEMATOGENOUS OSTEOMYELITISHEMATOGENOUS OSTEOMYELITISDiagnosis & work-upDiagnosis & work-up

Neddle Aspiration or Open biopsy:Neddle Aspiration or Open biopsy:From: Soft tissue collectionFrom: Soft tissue collection Subperiosteal abscessSubperiosteal abscess Intraosseos lesionsIntraosseos lesions

For: SmearFor: Smear CultureCulture PathologyPathology

TREATMENTTREATMENTInitial treatment shoud be aggressive.Initial treatment shoud be aggressive.

Inadequate therapy Inadequate therapy Chronic disease Chronic disease

Antibiotic use:Antibiotic use:

SurgerySurgery

ParenteralParenteralHigh dosesHigh dosesGood penetration in boneGood penetration in boneFull courseFull courseEmpiric therapyEmpiric therapy

TREATMENTTREATMENTEmpiric Initial TherapyEmpiric Initial Therapy

Neonate S.aureus PRP + Neonate S.aureus PRP + Infant<2 y G –ve bacilli CefotaximeInfant<2 y G –ve bacilli Cefotaxime

Children S.aureus PRP +Children S.aureus PRP + H.Infenza CeftriaxoneH.Infenza Ceftriaxone

Adult S.aureus PRP orAdult S.aureus PRP or 11stst ceph ceph

TREATMENTTREATMENTIndication for SurgeryIndication for Surgery

DiagnosticDiagnosticHip joint involvementHip joint involvementNeurologic complicationNeurologic complicationPoor or no response to IV Poor or no response to IV therapytherapySequestrationSequestration

TREATMENTTREATMENTMonitoring Therapeutic ResponseMonitoring Therapeutic Response

1.1.Symptoms & SignsSymptoms & Signs

2.2.ESR & CRPESR & CRP

3.3.RadiographyRadiography

4.4.Serial Bone Scan?Serial Bone Scan?

PROGNOSISPROGNOSISIs related to:Is related to:Causative organismsCausative organisms

Duration of symptoms & signDuration of symptoms & sign

Patient agePatient age

Duration of antibiotic therapyDuration of antibiotic therapy

COMPLICATIONCOMPLICATIONBone abscessBone abscessBacteremiaBacteremia

FractureFractureLoosing of the prosthetic implantLoosing of the prosthetic implant

Overlying soft-tissue cellulitisOverlying soft-tissue cellulitisDraining soft-tissue tractDraining soft-tissue tract

Post Osteomyelitis TreatmentPost Osteomyelitis Treatment

Septic OsteomyelitisSeptic Osteomyelitis

Post Osteomyelitis ScarPost Osteomyelitis Scar

Post Osteomyelitis Deformity of the ForearmPost Osteomyelitis Deformity of the Forearm

CONTIGUOUS-FOCUSCONTIGUOUS-FOCUSOSTEOMYELITISOSTEOMYELITIS

Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis

Clinical setting:Clinical setting:

Postoperative infectionPostoperative infection

Contamination of boneContamination of bone

Contiguous soft tissue infectionContiguous soft tissue infection

Puncture woundsPuncture wounds

Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis

Microbiologic featuresMicrobiologic features

Staphylococci Staphylococci Aureus, Epidermidis Aureus, Epidermidis

Gram-negative bacteriaGram-negative bacteria

Anaerobic infectionAnaerobic infection

Unusual organismsUnusual organisms Clostridia, Nocardia Clostridia, Nocardia

Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis

DiagnosisDiagnosisLeukocyte countLeukocyte countBlood culture (infrequently positive)Blood culture (infrequently positive)

ESR & CRPESR & CRPRadiologic evaluationRadiologic evaluation

Technetium bone scanTechnetium bone scanOpen bone biopsyOpen bone biopsy

Culture of wound & draining sinuses??Culture of wound & draining sinuses??

Contiguous-focus OsteomyelitisContiguous-focus Osteomyelitis

TreatmentTreatment

Surgery is essential.Surgery is essential.

Antibiotics Antibiotics Specific Specific Duration Duration