OSTEOMYELITIS

Vivien Tan
Lee Jan Ny
Denzel Chong
Jason Chong
Lee Shang Zhe
Contents
1. Classification
2. Routes & Causes
3. Risk factors
4. Clinical presentation
5. Phases
6. Investigations
7. Imaging
8. Management
Classification
1. Duration
- Acute
- Subacute
- Chronic
2. Mechanism of infection
- Hematogenous
- Exogenous
3. Anatomic involvement
4. Host type
Classification
Acute Chronic

Subacute
Cierny- Mader classification
Anatomic involvement

- Stage I: Medullary
- Stage II: Superficial
- Stage III:Localised
- Stage IV: Diffuse

Host type

- Type A: Normal
- Type B: BL- Locally compromised ,BS- systemic compromised
- Type C: Treatment is worse to the patient than infection
Risk factors
- Recent Trauma or surgery
- Immunocompromised patient
- Poor vascular supply
- Peripheral neuropathy
- Systemic condition such as DM or sickle cell
Routes of infection
1. Hematogenous
a. More common in young child - long bones
b. Adults - vertebrae
c. Monomicrobial
2. Exogenous
a. Contiguous
b. Direct inoculation
Hematogenous Osteomyelitis
Adults

- Elderly
- Immunocompromised
- IVDUs
- Indwelling central lines e.g. hemodialysis
- Sickle cell disease (Salmonella spp., S. Pneumoniae)

Pathogens

- S. Aureus
- Streptococci
- Gram negative Bacteria (E. Coli, Pseudomonas, Klebsiella spp. Proteus
Spp.
Hematogenous Osteomyelitis
Children

- Stap. Aureus
- Strep. Pyogenes
- Strep. Pneumoniae
- Haemophilus Influenzae Type B (before vaccination)

Neonates

- Staph. Aureus
- Group B Streptococci
- E Coli
Vertebral Osteomyelitis
● Mostly hematogenous
○ +/- epidural/paravertebral abscess
● Sources of hematogenous infection
○ GU tract
○ Infected IV sites (central, peripheral lines)
○ IVDU
○ Skin and soft tissue infection
○ Endocarditis
● Pathogens
○ As for hematogenous osteomyelitis)
○ M. TB (“Pott’s disease”)
○ Brucella spp. (endemic areas)
Exogenous Osteomyelitis
1. Contiguous
a. Adjacent prosthetic joint infection
b. Infected ulcers, e.g. Decubitus ulcer, diabetic foot infections
2. Direct inoculation
a. trauma , e.g. contaminated compound fracture
b. Surgery
Exogenous Osteomyelitis
● S. Aureus (Including MRSA)
● Streptococci (Beta-hemolytic streptococci, enterococci)
● Gram Negative Bacteria
● Anaerobes
● Fungi
● Can be polymicrobial
Clinical presentation
Children - long bones of arms and legs mostly

Adults - feet, spine and hips mostly

Acute osteomyelitis - (more inflammatory)
Symptoms - gradual/sudden onset

- Pain in a specific bone

- Overlying redness
- Fever
- Weakness
- Enlarged LN
Chronic osteomyelitis (generally secondary to open fracture, soft tissue infection, bacteremia)
Physical exam
vital signs - fever, tachycardia, and hypotension suggest
sepsis

inspection:

- erythema, tenderness, and edema are commonly seen

- draining sinus tract - more common in chronic
osteomyelitis
- if able to probe bone through sinus chronic osteomyelitis
is present
Physical exam - continued
motion

- limp and/or pain inhibition with weight-bearing or motion

may be present
- assess the joints above and below the area of concern

neurovascular - assessment of vascular insufficiency locally

or systemically
Draining sinus tract
phases
● Acute osteomyelitis
○ Collection of pus
becomes surrounded by
granulation tissue and
reactive bone, forming
an intraosseous
abscess (Brodie’s
Abscess)
○ Subsequent increased
in intramedullary
pressure leading to
elevation of the
periosteum
○ Leading to rupture of
the cortex, creating a
defect known as
cloaca, which drains
from the bone to
surrounding tissues
● Chronic Osteomyelitis
○ Disruption of
intraosseous and
periosteal supply
leads to formation of
necrotic bone
fragments, known as
sequestrum
○ A reactive new shell
of bones forms around
the sequestrum known
as an involucrum
○ A sinus tract, which
drains pus from bone
to the skin surface,
may be present in both
acute or chronic
phase.
Investigations
INITIAL :

Non-specific
- WCC
- ESR
- CRP

To guide antibiotic treatment:

Blood cultures (before antibiotics)
Bone cultures

MONITORING DURING TX
- FBC and serum chemistries weekly
- ESR/CRP at beginning and end of parenteral antibiotics and when switching to oral
antibiotics
Imaging - plain radiographs
❏ soft tissue swelling
❏ Osteopenia
❏ cortical loss
❏ Loss of trabecular bone architecture
❏ bony destruction
❏ periosteal reaction

**May not be apparent for first 2 weeks

Normal (left) Bony destruction (right)
Periosteal reaction

- 1st metatarsal
bone
 Sequestrum
“Necrotic bone”
Involucrum

- Reactive
new bone
formation
Brodie’s abscess

- Rare
- Most common
organism S. Aureus
- Usually metaphyses
Management of acute osteomyelitis

1. Supportive treatment for pain & hydration

2. Splintage of the affected part
3. Appropriate antimicrobial therapy
4. Surgical drainage
Antimicrobial therapy
- Blood and aspiration fluid C+S
- Duration
● In the presence of residual infected bone (at least 6
weeks from last debridement
● In the absence of residual infected bone ~5 days
● In the presence of soft tissue infection but no residual
infected bone ~14 days
● Also to monitor CRP, ESR and WBC at regular intervals
Management of subacute osteomyelitis
- Immobilization
- Antibiotics (flucloxaillin & fusicid acid)
● IV for 5 days
● Orally for another 6 weeks
- Open biopsy if diagnosis is in doubt
- Curettage if x-ray shows that there is no healing afer
conservative management
Management of Chronic Osteomyelitis
Antibiotics

- To suppress the infection & prevent spread to healthy

bone
- To control acute flares
- Fusidic acid, clindamycin & cephalosporins may be used
- Given 4 - 6 weeks before considering operative management
Operation (waiting policy)
Till there’s clear indication of radical surgery

- Constitutional symptoms
- Failure of adequate antibiotic treatment
- Evidence of sequestrum/ dead bone
- Intractable wound and/ or an infected ununited fracture

* presence of foreign implant will further increase the need

for operation
Irrigation & debridement
● Soft tissue
- All devitalized & necrotic tissue should be removed
- Extensive debridement : to eradicate infection
● Bone work
- Sequestrum must be removed or infection is likely to
recur
- Debride bone until punctate bleeding is seen: “paprika
sign”
● Hardware removal
- Any non-essential hardware should be removed
Dead space management
goal is to replace dead bone and scar tissue with
vascularized tissue

1. vascularized bone grafts

2. local tissue flaps or free flaps
3. antibiotic-impregnated acrylic beads (PMMA) - laid in
cavity and left for 2 - 3 weeks and then replaced with
cancellous bone grafts
4. vacuum-assisted closure
vacuum - assisted closure
- improve wound healing and dead space closure in multiple
ways
- remove interstitial fluids
- eliminate superficial purulence or slime
- allow arterioles to dilate, which allows granulation
tissue to proliferate
- decrease in capillary afterload to promote inflow of
blood
- mechanical force on wound edges draws them in
instrumentation
- bony stability is required for successful eradication of
infection
- external fixation preferred to internal fixation

surgical fixation techniques

- antibiotic-impregnated acrylic (PMMA) Intramedullary nail

- Ilizarov technique
- intramedullary nail with or without external fixation
- Masquelet technique
- in situ reconstruction
Amputation
indications

chronic infection with pervasive wound or bone damage that

is unable to be salvaged
References
- Uptodate
https://www-uptodate-com.proxy.library.rcsi.ie/contents/osteomyelitis-in-adults-clinical-manifestations-and-diagnosis?search=os
teomyelitis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
https://www-uptodate-com.proxy.library.rcsi.ie/contents/osteomyelitis-in-adults-treatment?search=osteomyelitis&source=search
_result&selectedTitle=1~150&usage_type=default&display_rank=1
- Orthobullets
https://www.orthobullets.com/trauma/1057/osteomyelitis--adult
- The imaging of osteomyelitis
- http://qims.amegroups.com/article/view/9839/10918