Osteomyelitis

Fanny Indarto
SMF Ilmu Bedah UKRIDA

Definition
An infection of the bone, a rare but serious
condition.

WebMD

Classification
Acute, subacute, chronic
Exogen, hematogen
Pyogenic, non pyogenic

Classification
Acute osteomyelitis is usually considered to
occur within the first 6 weeks following
inoculation
Chronic osteomyelitis being greater than 6
weeks.

Essential of Orthopedic Surgery, 2010

Infection pathway
Exogenous or hematogenous pathways.
Exogenous delivery involves direct inoculation
of the bone from either trauma, surgery, or a
contiguous focus of infection.
Hematogenous delivery is via the vascular
system into either osseous or synovial tissue
producing a localized focus of infection.

Risks for Osteomyelitis

Diabetes (most cases of osteomyelitis stem from
diabetes)
Sickle cell disease
HIV or AIDS
Rheumatoid arthritis
Intravenous drug use
Alcoholism
Long-term use of steroids
Bone surgery, including hip and knee replacements,
also increase the chance for infection to invade a bone.

Osteomyelitis
Children
Acute
Arm, leg bone
Easier to treat

Adult
Either acute or chronic
Pelvic, vertebrae. Diabetic
feet
Persist, recure despite
treatment

 Pyogenic organisms elicit a rapidly progressive

course of pain, swelling, abscess formation,
and aggressive bone destruction. A grampositive staphylococci is a classic example.
In contrast, less aggressive nonpyogenic
organisms invoke a more insidious
granulomatous reaction, classically seen with
acid-fast bacilli.

Symptoms of Osteomyelitis
The symptoms for acute and chronic
osteomyelitis are very similar and include:
Fever, irritability, fatigue
Nausea
Tenderness and swelling around the affected bone
Lost range of motion
Osteomyelitis in the vertebrae makes itself known
through severe back pain, especially at night.

Osteomyelitis
The infection may be limited to a single
portion of the bone or may involve numerous
regions
The infection generally is due to a single
organism, but polymicrobial infections can
occur, especially in the diabetic foot.

Pathophysiology
Cortical bone : increased local pressure which accompanies
inflammations infarction of the marrow fat
coagulative necrosis initially and then is replaced by a
myxofibrous stroma.
Cancellous trabeculae also are infarcted by the collapse of
the vessels and also undergo necrosis.
These necrotic segments of bone often are not resorbed
and are termed sequestrae. These will calcify and remain
centrally located, and they appear radiologically as very
dense areas within the lytic portion of the process.
Reactive, viable bone often will form around a sequestrum;
this bone is called an involucrum.

Essential of Orthopedic Surgery, 2007

Campbell's, 2007

Biofilm Pathophysiology
Once implanted, the prosthesis is
progressively coated by a glycoprotein layer,
which favours the superficial adhesion of
bacteria.
These are, themselves, coated with a biofilm
composed of polysaccharides (glycocalyx)
which protects them from the hosts immunity
system and from antibiotics
Infection & Local Treatment in Orthopedic
Surgery, 2007

Acute hematogenous osteomyelitis

Hematogenous spread of bacteria to the bone is
a common event.
It is seen most frequently in children, likely due
to the vascular anatomy at the epiphyseal
growth plate, although it is also commonly seen
in patients after illnesses involving bacteremias.
Bacteriological seeding of bone generally is
associated with other factors such as localized
trauma, chronic illness, malnutrition, or an
inadequate immune system. In many cases, the
exact cause of the disease cannot be identified.

 After the physes are closed, acute hematogenous

osteomyelitis is much less common.
Hematogenous seeding of bone in adults usually
is seen in a compromised host.
Although it can occur anywhere and in any part
of the bone, generally the vertebral bodies are
affected. In these patients, abscesses spread
slowly, and large sequestra rarely form.
If localized destruction of cortical bone occurs,
pathological fracture can result

Etiology
Staphylococcus aureus is the most common infecting
organism found in older children and adults with
osteomyelitis.
Gram-negative bacteria have been found to cause an
increasing number of vertebral body infections in adults.
Pseudomonas is the most common infecting organism
found in intravenous drug abusers with osteomyelitis.
Fungal osteomyelitis is seen increasingly in chronically ill
patients receiving long-term intravenous therapy or
parenteral nutrition.
Salmonella osteomyelitis has long been associated with SS
or SC hemoglobinopathies

 Bone infections in children are almost all due to

Staphylococcus aureus
Infections of the bone can occur to a wide
variety of organisms, ranging from gram-positive
and gram-negative bacteria to microbacteria and
even fungi.
Immunocompromised patients (particularly those
on immunosuppressive medications,
corticosteroids, or suffering from HIV infection)
can present with bone infections caused by very
unusual pathogens.

Campbell's, 2007

 In patients with acute osteomyelitis, the

radiologic features do not appear until 1 to 14
days after the onset of symptoms

Biopsy
when a bone infection is suspected, biopsy for
culture is nearly always necessary.
Indeed, bony changes caused by bone
infection quite often mimic the appearance of
tumor.

 Nade proposed five principles for the treatment of

acute hematogenous osteomyelitis :
(1) an appropriate antibiotic is effective before pus
formation;
(2) antibiotics do not sterilize avascular tissues or
abscesses, and such areas require surgical removal;
(3) if such removal is effective, antibiotics should
prevent their reformation, and primary wound
closure should be safe;
(4) surgery should not damage further already
ischemic bone and soft tissue;
(5) antibiotics should be continued after surgery.
Campbell's, 2007

 Antibiotic treatment for severe bone

infections generally is not nearly as successful
as antibiotic treatment for most soft tissue
infections. Thus, prolonged IV therapy often is
indicated (6 weeks or more), and most severe
bone infections also are dbrided surgically

 Chronic osteomyelitis may lead to a fistula or

chronically draining sinus. This is a commonly
seen problem in diabetic patients, but may
arise in any incompletely treated
osteomyelitis.

Granulomatous Osteomyelitis
chronic inflammatory process with central giant
cells and macrophages with a peripheral cuff of
lymphocytes and plasma cells.
Plain radiographs generally are notable for
ossification and calcification with variable
degrees of lucency.
The histology demonstrates granuloma formation
that is identical to that seen in other locations.
The most common granulomatous condition in
the skeletal system is due to tuberculosis

Surgical Treatment
three main facets:
(1) extensive debridement,
(2) vascular soft tissue coverage,
(3) bone stabilization.

Essential of Orthopedic Surgery, 2007

 Principles of treatment for adult osteomyelitis

apply with one important exception; namely, the
retention of implants for fixation of the fracture.
In patients who present with an infection
surrounding an intramedullary nail or plate, the
wound should be aggressively debrided and the
implant maintained if fracture stability is being
achieved.
Loose implants should be removed and either
replaced or substituted by another implant type
Essential of Orthopedic Surgery