Management Of ChronicOsteomyelitis
Definition.
DerivefromGreekword:
Osteo : meansBone
Myelo : meansMarrow
itis : means inflammation
Simplymeans infection of bone or bonemarrow.
CLASSIFICATION
Séveral system of classification have been described .
A). On the basis of duration.
Acute :
within 7 to 14 days.
Sub acute : withinweeks to months
chronic :
more than 3 months.
B) On the basis of mode .
i) Haematogenous
ii) non-haematogenous---Arising from contiguous infection
C)
On the basis of host response.
pyogenic
non pyogenic
D). Cierny-Mader system.
osteomyelitis is by anatomic extent of the infection and by the
pathologic status of host.
1: Anatomic extent of infection.
a) medullary only (acute haematogenous)
b) superficial cortex(contiguous spread).
c) localized (cortex and medullary, mechanical stable)
d) diffuse (cortical and medullary, mechanical unstable)
2) Host,sphsiological status.
a)healthy
b)compromised due to systemic factors
c)compromised due to local factors
d) compromised due to local and systemic factors.
3. Treatment worse than the disease, where the treatments that would be
necessary to cure the disease are worse than living with the disease itself.
PATHOGESNESIS
Once bone is infected, leukocytes enter the infected area and in their
attempt to engulf the infectious organism, releases enzyme that lyses
the bone. Pus is formed, that spread and involve the endosteal blood
vessels, resulting the interruption of cortical blood supply, leading to
devitilization of bone, this dead bone is known as sequestrum.
Then pus perforate the cortex, sub periosteal abscess is formed,
periostium form the new bone, known as involucrum. Later on
pusdischared through the sinus.
Formation of sequestrum form the basis of chronic infection.
Causative organism.
new born up to 4 months:
Staph.Aureus. enterobacter.
4 months to 4 years.
Staph.Aureus. H.Influenza
4 years to adult.
Staph.Aureus. Sreptococcus A
ETIOLOGY.
The disease may result from the following.
a) Inadequate treatment of acute osteomyelitis.
b)trauma.
c)Iatrogenic causes, like after internal fixation of fracture.
d)open fractures.
Clinical Features.
Recurrent attacks of pain, fever ,redness,
Pus from discharge sinus.
May have infected non-union.
Laboratory test.
E.S.R. And CRP may be elevated during acute attacks.
Pus cultures. For the diagnosis of causative organism.
X-Rays
Bone resorption with surrounding sclerosis and thicking.
May have periosteal reaction, involucrumor sequestrum.
Bone deformity may be present.
Biopsy./ Aspiration.
 Preferred diagnostic procedure .
 Sinus tract culture for diagnosis of infecting organism.
Bone Scan.
 Tc99 bone scan. Shows increased activity in both the blood
pool and bone phases.
 Wbc-labelled indium or gallium scan are more sensitive.
 MRI / CT scan.
shows extent of bone destruction and hidden abscesses,
sequestrum.
TREATMENT.
5 steps.
a) appropriate antibiotic
b)
adequate debridement
c)
skeletal stabilization
d)
adequate soft tissue coverage
e)
consider delayed bone graft
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Antibiotic therapy.
Infection seldom eradicated by antibiotic alone.
Important to stop spread of infection to healthy bone.
Control acute flares.
Duration of antibiotic remains controversial.
standard recommendation for treating chronic osteomyelitis is 6
weeks of parentral antibiotic therapy.
Oral antibiotic are available that achieve adequate level in bone.
Oral and parenteral therapies achieve similar cure rates.
Antibiotic therapy(cont).
Combination of B-lactam antibiotic, aminoglycoside.
addition of adjunctive RIFAMPACIN to other antibiotics may improve
cure rate.
Orally active antibacterial agents:
Fluoroquinolones(ciprofloxacin.Levofloxacin)
Lenzolid , Sulfamethoxazole-Trimethoprim,
Beta-lactamase inhibitors(salbactum, Calvulanic acid).
 optimal duration of therapy for chronic osteomyelitis remains
uncertain. There is no evidence that antibiotic therapy for more than
4-6 weeks improves outcome.
Surgical treatment
1) Debridement.
Remove all dead and infected material, cut back to healthy bone.
Saucerization of cortex and curettage of medullary content to
bleeding bone.
Irrigation with normal saline.
Stabilization of bone ,if required, often with external fixator.
2) Dead space management.
Soft tissue and bony reconstruction (closure of dead space)
i) local muscle flap.
ii) freecancellous bone graft.
Iii) antibiotic beads : deliver high concentration of antibiotic at site, act
as spacer.
3) Distraction osteogenesis.
bone transport to fill the large defect.
4) Cancellous bone graft to fill the bone gap.
5). Amputation.
if persistent infection, large bone defect, bone instability, type C host.
Brodies abscess
 Localized form of chronic osteomyelitis, most often in long bones
in lower limb in young adult.
 Caused by low virulence organism.
Location
a) metaphysis in children
b) metaphysis-epiphyhsis
Clinical presentation
 intermittent pain and local tenderness.
Treatment
 local curettage and bone graft, if needed.
Sclerosing osteomyelitis of Garre
 Described by Garre in 1893
 mainly affects young adult and children.
 Average age 16 years.
Pathology.
 no necrosis, no purulent discharge.
 new bone deposition
 non-specific chronic inflammation with new bone formation and
areas of necrosis.
Clinical presentation.
 insidious onset, local pain and local tenderness
Labs.
 Raised ESR
X-Rays
 Scelerosis with cystic areas on x-rays.
Treatment
 treatment predictably helpful
 Fenestration and curettage provide temporary relief.
 No Prolong antibiotic therapy does not affect natural history.
COMPLICATIONS
i)
Ii)
Iii)
iv)
v)
vi)
vii)
Pathological fracture
Constant sinus
Eczematous skin reaction
Neoplastic change in sinus
Epidermoid carcinoma
Amyloidosis
Malignant bone transformation to sarcoma
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