HEMATOGENOUS OSTEOMYELITIS WITH VASCULAR

CONTIGUOUS-FOCUS OSTEOMYELITIS
OSTEOMYELITIS INSUFFICIENCY
Osteomyelitis is inflammation of the The most commonly isolated organism is S This is seen predominantly in patients with diabetes
bone and bone marrow generally caused aureus. At the same time, local soft-tissue and peripheral vascular disease and is localized
by a bacterial infection. The most vascularity may be compromised, leading to almost exclusively to lower extremities.
common form in childhood is acute interference with healing. Compared with Neuropathy, Ischemiaand biomechanical
hematogenous osteomyelitis (AHO), hematogenous infection, posttraumatic infection dysfunction lead to foot ulcers. Infection is seen as a
which is infection of the bone of less begins outside the bony cortex and works its way consequence of ulcer, which progressively burrows
than two weeks duration spread in toward the medullary canal. Low-grade fever, its way into small bones of the feet. Multiple
hematogenously. drainage, and pain may be present. Loss of bone organisms are usually isolated although S. aureus
stability, necrosis, and soft-tissue damage may and S. agalactiae still predominate. Patients may
Description lead to a greater risk of recurrence.   present with non-healing foot ulcer; cellulitis see
photos or deep abscess see photos. Fever and
systemic toxicity are often absent unless there is
severe limb threatening infection with gangrene and
fasciitis. Pain may be absent in patients with severe
neuropathy. Osteomyelitis should be suspected
when bone is exposed before or after debridement or
probing the ulcer with a stainless-steel probe, bone
is encountered. Resection of the infected bone is
almost always necessary for a favorable outcome.
Etiology Acute hematogenous osteomyelitis Polymicrobial: S. aureus, coagulase-negative Frequently, patients with vascular disease develop
typically arises in the metaphysis of staphylococci, Streptococcus spp., Enterococcus osteomyelitis in their toes and fingers, and there is
long tubular bones, with approximately spp., gram-negative bacilli, anaerobic usually an adjacent area of infection, such as
twothirds of all cases involving the Clostridium spp., Bacillus spp., cellulitis or dermal ulcers. Importantly, infections in
femur, tibia or humerus. While a variety Stenotrophomonas maltophilia, Nocardia spp., these patients are almost always polymicrobial and
of bacterial pathogens may be involved, atypical mycobacteria, Aspergillus spp., often include staphylococcus and streptococcus or
Staphylococcus aureus is the pre- Rhizopus spp., Mucor spp. S. aureus, coagulase the combination of staphylococcus, streptococcus,
eminent pathogen and is responsible for negative staphylococcus, Propionibacterium spp. and Enterobacteriaceae. Enterococci and anaerobic
70– 90% of acute hematogenous Pasteurella multocida, Eikenella corrodens P. organisms also can be involved.
osteomyelitis infections in children. aeruginosa Actinomyces spp. Enterobacteriaceae,
Other etiological agents, in no particular P. aeruginosa, Candida spp.
order, include Streptococcus pyogenes,
Streptococcus pneumoniae, Group B
streptococci, coagulasenegative
staphylococci, Kingella kingae, enteric
 Gram-negative bacilli and anaerobic
bacteria.
 Prematurity, umbilical or other Hip fractures and open fractures Diabetes mellitus, peripheral vascular disease, and
central venous catheter or venous pressure sores
cutdown, respiratory distress
syndrome, and perinatal asphyxia

Risk Factors  Infection (pharyngitis,cellulitis, and

respiratory infections), trauma, and
sickle cell disease

 Diabetes mellitus, blunt trauma to

spine, and urinary tract infection
 Less than 1 year Older than 50 Older than 50

Age  1 – 20

 Older than 50
 Long bones and joints Femur, tibia, and mandible Feet and toes

Site(s)  Long bones(femur, tibia, and

Involved humerus)

 Vertebrae
Clinical Acute osteomyelitis In osteomyelitis due to a contiguous focus of In patients who develop osteomyelitis in the setting
Feature  Onset:usually gradual, over several infection without vascular insufficiency, patients of vascular insufficiency, infection occurs most
days often present with: often in the small bones of the feet. These patients
 Chief complaint:pain at the site of • Pain may experience minimal pain because of
infection, possibly related to • Fever neuropathy. Physical exam frequently reveals
movement • Purulent drainage from a traumatic or evidence of neuropathy and compromised vascular
 Possible localized findings:point surgical wound. supply (e.g. diminished pulses, poor capillary refill).
tenderness, swelling, redness, The contiguous site of infection is typically a
warmth neuropathic ulcer, though it can be a paronychia,
 Possible systemic cellulitis, or puncture wound.
findings:malaise, fever, chills
 Common localization of
 hematogenous osteomyelitis
o Infants: long bone metaphysis,
joints
o Children:long bone metaphysis
(joint infection is very rare)
o Adults:vertebral involvement is
most common
Chronic osteomyelitis
 Onset
Usually following a prior episode of
osteomyelitis
May last for months
 Chief complaint:recurrent pain
 Possible findings
Swelling, redness
Local sinus tract formation, perhaps
draining pus
Examples A.)Osteomyelitis of the distal right Is seen most often after trauma or surgery, and is Is seen almost exclusively in the lower extremities,
tibia. (A) Massive involucrum exposing caused by bacteria which gain access to bone by most commonly as a diabetic foot infection.
sequestrum (arrow) in a large opening. direct inoculation (for example, a contaminated A.) Necrotic Toe
(B) Porous involucrum with multiple compound fracture) or extension to bone from
cloacal openings (arrows). (HM P618) adjacent contaminated soft tissue (for example, a - Moderate to sever diabetic foot infection with
prosthetic joint contaminated at the time of gangrene of the great toe
B.) Osteomyelitis of the left tibia implantation).
following slight injury of 18-months - Osteomyelitis demonstrated clinically and
duration. Notice the massive A.) 65-year-old female with sternal osteomyelitis radiographically.
hypervascular involucrum exposing following a CABG. Photo is taken at bedside B.) Mild diabetic foot infection associated with
large sequestra in large cloacal openings following extensive sternal debridement. Pseudomonas.
and periostosis of the fibula. Definitive closure with a muscle flap had yet to
(Adolescent, WM HS44.6 from 1851.) be performed. C.) Severe diabetic foot infection.
B.) 46-year-old cirrhotic with chronic
C.) Osteomyelitis of distal right femur. osteomyelitis secondary to an open tibial
(A) Anterior view, showing smooth fracture. Pt subsequently developed a
total sequestrum with involucrum above complicated skin and soft tissue infection with a
and below the living bone. (B) Posterior draining sinus tract. Cultures were positive for E.
view, showing destruction of the coli and MRSA.46-year-old cirrhotic with
 metaphysis and proximal diaphysis;
notice the jagged border of the
sequestrum at the junction with the
living bone. (About 10 years of age,
WM HS 44.5 from 1841.)
o Children with acute bone pain and
systemic signs of sepsis should be
considered to have acute
hematogenous Osteomyelitis until
proved otherwise.
o  Diagnosis may be established if
a patient fulfills two of the
following criteria:
o 1. Bone aspiration yield pus
Diagnostics o 2. Bacterial culture of bone or blood
positive
o 3. Presence of the classical s/s of
acute osteomyelitis
o 4. Radiographic changes typical for
osteomyelitis.
Prognosis Acute osteomyelitis
Quick, full recovery is common in
children receiving appropriate
antimicrobial treatment →> 95% of
cases resolve completely. [10]
Acute osteomyelitis in adults often
transforms into chronic osteomyelitis.
chronic osteomyelitis secondary to an open tibial
fracture. Pt subsequently developed a
complicated skin and soft tissue infection with a
draining sinus tract. Cultures were positive for E.
coli and MRSA.
C.) Prosthetic devices
D.) Internal fixation devices
E.) Antibiotic beads inserted into an area of
osteomyelitis.
X-ray
Early stages
•(< 2 weeks of symptoms onset): typically, no
pathological findings
Later stages:
bone destruction, sequestrum
formation, periosteal reactions
MRI
•Shows signs of inflammation ≤ 5 days after
onset of infection
With aggressive early treatment, the prognosis of
acute osteomyelitis is good. However, there is a
possibility that the infection could recur years
after successful treatment if there is new trauma
to the same area or if host immunity is
compromised. In adults, the recurrence rate of
chronic osteomyelitis is about 30% at 12 months,
Magnetic resonance imaging and bone scintigraphy
•Has improved diagnostic accuracy and the ability
to characterize the infection.
Plain radiography
•Useful initial investigation to identify alternative
diagnoses and potential complications
- Direct sampling of the wound
- For culture and antimicrobial sensitivity is
essential to target treatment.
- Free vascularized bone can be used to
reconstruct large skeletal defects greater than 6
cm or bone defects of smaller size that failed to
heal with nonvascularized bone grafting. The
length, cortical strength, and anatomic
configuration of the free vascular fibular graft
make it an ideal bone graft to bridge extremity
defects, and it can be transferred with skin,
fascia, and muscle to fill soft tissue defects in
the recipient site.
With treatment, the outcome for acute osteomyelitis
is often good.The outlook is worse for those with
long-term (chronic) osteomyelitis. Symptoms may
come and go for years, even with surgery.
Amputation may be needed, especially in people
with diabetes or poor blood circulation.
Chronic osteomyelitis but in cases involving P. aeruginosa, the The outlook for people with an infection of a
Difficult to cure recurrence rate may be as high as 50%. Cases prosthesis depends partly on:
Often requires repeated surgical and involving prosthetic devices are more difficult to
antibiotic treatment (over years to treat, causing increased morbidity due to the o The person's health
decades) need for more surgical procedures and extended o The type of infection
In patients with diabetes antibiotic courses required for treatment. Various o Whether the infected prosthesis can be safely
or vascular insufficiency, the measures used to prevent postoperative removed
probability of complete resolution is infections include good preoperative preparation
particularly low. where possible and use of surgical rooms with
laminar airflow. Recommended also is the use of
prophylactic preoperative antibiotic treatment
administered parenterally 30 minutes before skin
incision with first-generation (cefazolin) or
second-generation cephalosporins (cefuroxime).
All these measures have been shown to decrease
the rate of postoperative infections to 0.5% to
2%, thereby improving patient outcomes.
Musculoskeletal Infections
Osteomyelitis
Osteomyelitis is an infection of the bone that results in inflammation, necrosis, and formation of new bone. Osteomyelitis is classified
as:
• Hematogenous osteomyelitis (i.e., due to bloodborne spread of infection)
• Contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury
(e.g., gunshot wound)
• Osteomyelitis with vascular insufficiency, seen most commonly among patients with diabetes and peripheral vascular disease, most
commonly affecting the feet (Grossman & Porth, 2014) Patients who are at high risk for osteomyelitis include older adults and those
who are poorly nourished or obese. Other patients at risk include those with impaired immune systems, those with chronic illnesses
(e.g., diabetes, theumatoid arthritis), those receiving long-term corticosteroid therapy or immunosuppressive agents, and those who
use IV drugs (Lalani, 2016)
Postoperative surgical wound infections typically occur within 30 days after surgery. They are classified as incisional (superficial,
located above the deep fascia layer) or deep (involving tissue beneath the deep fascia). If an implant has been used, deep postoperative
infections may occur within a year. Osteomyelitis may become chronic and may affect the patient's quality of life. Pathophysiology
More than 50% of bone infections are caused by Staphylococcus aureus and increasingly of the variety that is methicillin resistant
(i.e., methicillin-resistant Staphylococcus aureus (MRSA)) (Kaplan, 2014). Surgical site ink markers have been linked to infections by
cross contamination between preoperative patients who use their markers; therefore these items are now considered one patient or
onestir use items (Driessche, 2012). Other pathogens include the Gram-positive organisms streptococci and enterococci, fol. lowed by
Gram-negative bacteria, including pseudomonas (Kaplan, 2014), The initial response to infection is inflammation, includeded
vascularity, and edema. After 2 or 3 days, thrombosis of the local blood vessels occurs, resulting in ischemia with bor necrosis. The
infection extends into the medullary cavity: under the periosteum and may spread into adjacent soft tissit and joints. Unless the
infective process is treated promorly, a bone abscess forins. The resulting abscess cavity contain sequestrum (i.e., dead bone tissue),
which does not easil. liquefy and drain. Therefore, the cavity cannot collapse and heal, as it does in soft tissue abscesses. New bone
growth, the involucrum, forms and surrounds the sequestrum. Although healing appears to take place, a chronically infected seques
trum remains and produces recurring abscesses throughout the patient's life. This is referred to as chronic osteomyelitis.

Clinical Manifestations
When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical and laboratory manifestations of sepsis
(e.g., chills, high fever, rapid pulse, general malaise). The systemic symptoms at first may overshadow the local signs. As the infection
extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and
extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the
collecting purulent material (i.e., pus). When osteomyelitis occurs from spread of adjacent infection or from direct contamination,
there are no manifestations of sepsis. The surface area that lies over the infected bone is swollen, warm, painful, and tender to touch.
The patient with chronic osteomyelitis presents with a nonhealing ulcer that overlies the infected bone with a connecting sinus that
will intermittently and spontaneously drain pus (Bries, Kerr, & George, 2015).
Diabetic osteomyelitis can occur without any external wounds. Microvascular and macrovascular pathophysiologic changes, along
with an impaired immune response by patients with diabetes who have poor glycemic control can exacerbate the spread of infection
from other sources (Malhotra, Chan, & Nather, 2014).

Assessment and Diagnostic Findings

In acute osteomyelitis, early x-ray findings demonstrate soft tissue edema. In about 2 to 3 weeks, areas of periosteal elevation and
bone necrosis are evident. Radioisotope bone scans, particularly the isotope-labeled white blood cell (WBC) scan, and MRI help with
early definitive diagnosis. Blood studies reveal leukocytosis and an elevated ESR. Wound and blood culture studies are performed,
although they are only positive in 50% of cases. Therefore, treatment with antibiotics may be prescribed without isolating the
organism (Conterno a Turchi, 2013). With chronic osteomyelitis, large, irregular cavities, raised periosteum, sequestra, or dense bone
formations are seen On x - ray. Bone scans may be performed to identify areas of The ESR and the WBC count are usually normal. is
associated with chronic infection, may be evident. loures of blood specimens and drainage from the sinus tract Frequently unreliable
for isolating the organisms involved. An open bone biopsy is indicated as percutaneous aspirations reliable for gathering cultures to
identify the underlying pathogen (Bries et al., 2015).

Prevention
prevention of osteomyelitis is the goal. Elective orthopaedic very should be postponed if the patient has a current infecrion (e.g.,
urinary tract infection, sore throat). During surCorv. careful attention is paid to the surgical environment. Prophylactic antibiotics,
given to achieve adequate tissue levels at the time of surgery and for 24 hours after surgery, are helpful. Urinary catheters and drains
are removed as soon as possible to decrease the incidence of hematogenous spread of infection.
Aseptic postoperative wound care reduces the incidence of superficial infections and osteomyelitis. Prompt management of soft tissue
infections reduces extension of infection to the bone or hematogenous spread.

Medical Management
The initial goal of therapy is to control and halt the infective process. General supportive measures (e.g., hydration, diet high in
vitamins and protein, correction of anemia) are instituted. The area affected with osteomyelitis is immobilized to decrease discomfort
and to prevent pathologic fracture of the weakened bone. Pharmacologic Therapy Bone infections are more difficult to eradicate than
soft tissue infections because bone is mostly avascular and less accessible to the body's natural immune response. Because there is
decreased penetration by medications, antibiotic therapy is longer term than with other infections; typically it continues for 3 to 6
weeks. After the infection appears to be controlled, the antibiotic may be given orally. However, there is little evidence to support
optimal length of therapy (Conterno & Turchi, 2013).

Surgical Management
If the infection is chronic and does not respond to antibiotic therapy, surgical débridement is indicated. The infected bone is surgically
exposed, the purulent and necrotic material is removed, and the area is irrigated with sterile saline solution. A sequestrectomy
(removal of enough involucrum to enable the surgeon to remove the sequestrum) is performed. In many cases, sufficient bone is
removed to convert a deep cav. ity into a shallow saucer (saucerization). All dead, infected bone and cartilage must be removed before
permanent healing can occur. A closed suction irrigation system may be used to remove debris. Wound irrigation using sterile
physiologic line solution may be performed for extended periods if the ons remains. Typically, irrigation does not need to extend
beyond a week the wound is either closed tightly to obliterate the dead race or packed and closed later by granulation or possibly by
grafting. The débrided cavity may be packed with cancellous bone graft to stimulate healing. With a large defect, the cavity may be
filled with a vascularized bone transfer or muscle flap (in which a muscle is moved from an adjacent area with blood supply intact).
These microsurgery techniques enhance the blood supply. The improved blood supply facilitates bone healing and eradication of the
infection. These surgical procedures may be staged over time to ensure healing. Because surgical débridement weakens the bone,
internal fixation or external supportive devices may be needed to stabilize or support the bone to prevent pathologic fracture (van
Vugt, Geurts, & Arts, 2016).