Report discussion tutorial module 2 scenario 1

“ Infections of the Neuromusculoskeletal System”

Advisor : dr. Ika Dyah, Msi, Med.

Arranged by :
Group 9 Blok 8

Meeting I :
Moderator : Salma Ardelia Cahyawati H2A021098
Scriber : Shopiy Hanik Ubaidah H2A021093
Meeting II :
Moderator : Shopiy Hanik Ubaidah H2A021093
Scriber : Risma Amalia Deva H2A021083
Anggota :
Baharuddin Akmal H2A021041
Risma Amalia Deva H2A021083
Aulia Gistiana Adi H2A021091
Miftakhul Afifah H2A021092
Shopiy Hanik Ubaidah H2A021093
Muhammad Amril Abror H2A021094
Najda Shafwa Az-Zahra H2A021096
Sonya Dara Puspita H2A021097
Salma Ardelia Cahyawati H2A021098
Zulfa Luqyana Aprilia Basuki H2A021099

MEDICAL SCHOOL
MUHAMMADIYAH UNIVERSITY SEMARANG
2022/2023
Module 2: Infections of the Neuromusculoskeletal System
A 40 year old male patient came to the emergency room with complaints of
swelling, redness and pain in the right knee since the last 1 week. The patient also
complained of body heat, malaise for the last 2 days. The history of the patient fell
from a motorbike 1 month ago with an open wound in the right knee area. At that
time he was taken to the hospital emergency room and the patient refused to take
action. The current state of the wound has healed. The patient is an online
motorcycle taxi driver who has been unable to work for a month due to his
illness. Radiological picture: Lytic lesion on the right lateral area of the epiphysis

STEP I
1. Malaise (salma) : (gisti) feeling unwell, decreased appetite, aches, weight loss
and fatigue.
2. (najda) medical term to describe feelings of tiredness, discomfort, and unwell
for no known reason. this condition is not a disease but a symptom of certain
disease and can last for several weeks to years
3. Painful (sonya) :(zulfa) a medical term described as a disorder in bodily
functioning that results in reduced capacity.
4. Swelling (gisti) :
- (najda) is any abnormal enlargement of a body part. whenever. the organs, skin,
or other parts of the body enlarge. it’s typically the result of inflammation or a
build up of fluid. swelling can occur internally, or it can affect outer skin and
muscles.
- (Sonya) An increase in the interstitial component of extracellular volume
5. Epiphysis (Najda) :
- Deva : an additional articular end of a long bone growing from a secondary
ossification center that is cartilaginous during the growth period or separated from
the bony shaft by a carticaginous plate (bone end).
- (fifah) wider part at each end of to the bone and the diaphisis is also known as
the shaft of the long bones which makes up most of the length of the bone
6. Lytic lession (fifah) :
- (Akmal) An area of bone that is changed or damaged
- (Hanik) lesion skin is a part of the skin that has an abnormal growth or
appearance compared to the surrounding skin. There are two categories lesions :
primary and secondary.
STEP II
1. Why does swelling and redness appear after falling of the motorbike? (hnk)
2.What should the doctor do if the patient refuses to be examined? (aya)
3. What are the consequences of an open wound that is not handled properly? (gst)
4. What is the relationship between swollen, red and painful feet and fever
experienced by the patient? (Deva)
5. What should the doctor do next to make a correct diagnosis? (Salma)
6. What diagnosis fits the scenario?(fifah)
7. What are the complications of the patient’s disease?(ril)
8. What are the KODEKI relevant to the scenario? (sonya)
9. How does the Islamic view fit into the Scenario?

STEP III
1. why does swelling and redness appear after falling of the motorbike?
(Najda) This is one of the healing processes from wounds. After the stage of
hemostasis, which is inflammation or inflammation that is included in wound
healing. This process occurs when blood clots secrete chemicals that cause
inflammation.Therefore, when you experience a wound, redness or swelling will
appear. In this process white blood cells will also go to the wound and fight
bacteria and germs to prevent infection. White blood cells will later release a
chemical called growth factors. However, if it is accompanied by more severe
symptoms such as feeling unwell and the swelling does not deflate, it will be a
cause for concern. Swelling in wounds that occur continuously can be from germ
or bacterial infections. Infection can occur due to germs and bacteria that enter the
body through wounds that are left open. Another reason why a wound can become
infected and swollen is due to not maintaining cleanliness, such as being lazy to
change gauze and cleaning the wound using an antiseptic. Swollen wounds can
also be caused by certain health problems, such as diabetes and hypertension
(high blood pressure).

(Deva) In patients who had an accident that resulted in open wounds, the patient
was reluctant to take action after an open wound trauma occurred on his knee.
This causes breakdown of connective tissue, including skin, muscle, and bone,
exposes proteins that are easily coagulated by bacteria, such as collagen and
fibronectin, and increases the likelihood of inoculation. Damage to the adjacent
soft tissue will trigger a decrease in blood supply, and cause tissue necrosis which
is a place for bacteria to thrive. In addition, Trauma causes a decrease in immunity
and an inflammatory response to bacterial invasion. This bacterial infection will
cause symptoms of redness, pain, and swelling in the infected part, fever and
malaise.
2. What should the doctor do if the patient refuses to be examined?
(Sonya) Even if the patient has refused the medical action that will be given by
the doctor, it does not mean that the doctor has to give up or break the legal
relationship unilaterally. A doctor is bound by the doctor's oath and medical code
of ethics to carry out his medical duties in an honorable and ethical manner in
accordance with the dignity of the medical profession.
The treatment of a doctor who intentionally neglects a patient who refuses
treatment or medical action is an act that can be punished by crime, if the
treatment (omission) causes the patient's health to decline or even to the point of
death

3. What diagnosis fits the scenario?

(Gisti) Osteomyelitis, is an infection of the bone. Derived from the words osteon
(bone) and myelo (bone marrow) and combined with itis (inflammation) to
describe the clinical condition in which bone is infected by microorganisms.
Osteomyelitis can be acute or chronic. The acute form is characterized by a rapid
onset of systemic fever and local manifestations. Chronic osteomyelitis is the
result of untreated acute osteomyelitis.

(akmal) Based on the anamnesis of the scenario, the patient has osteomyelitis.
Osteomyelitis is an inflammatory process that occurs in bone and its structure,
the inflammatory process that occurs is classified based on the duration of time
ranging from acute, subacute to chronic. Osteomyelitis is an inflammatory
disease of bone and marrow caused by pyogenic organisms. The infectious
nature of osteomyelitis consists of acute, subacute and chronic to affect the
secondary structure of bone with the presentation of each type of characteristic
based on the time and attack of osteomyelitis.

4. What is the relationship between swollen, red and painful feet and fever
experienced by the patient?
(Hanik) Swollen feet and redness and pain are signs of inflammation in the skin
layers of the patient's feet. Infection in the soft tissue around the bone can spread
to the bone after a few days or weeks. Soft tissue infections can occur in areas
damaged by injury, radiation therapy or cancer, or ulcers in the skin caused by
poor blood supply or diabetes (diabetes). An infection of the sinuses, jaw or teeth,
can spread to the skull. Thus, the infection that occurs can cause the patient's
immunity to decrease and in the end can cause fever due to the body's response to
foreign bodies/exudates.
(Zulfa) In addition to the relationship between swollen, red and aching legs and
fever. The patient has also experienced open wounds and does not want to be
sutured. Because Through an open wound Bacteria can enter the body if there is
an open wound, such as a fracture with an open wound or direct contamination
during orthopedic surgery. The bacteria in question is Staphylococcus aureus.
These bacteria can be found on the skin or nose and generally do not cause health
problems. However, when a person's immune sustem is weak due to a disease or
certain conditions, these bacteria can cause infection. In addition, these bacteria
can enter the bone in several ways, including Through the blood stream Bacteria
from other parts of the body can spread to the bone through the blood stream.
Through infected tissue or joints. This condition allows bacteria to spread to the
bones near the infected tissues or joints.
5. What should the doctor do next to make a correct diagnosis?
(Deva) The scoring system is based on:
(i) clinical history and risk factors;
(ii) clinical examination and laboratory test results, including leukocyte count and
detection of inflammatory markers, such as through the erythrocyte sedimentation
rate (ESR) and C-reactive protein (CRP) level;
(iii) diagnostic imaging, such as ultrasonography, radiology, computed
tomography (CT), or magnetic resonance imaging (MRI);
(iv) microbiological culture analysis; and
(v) histopathology.

In the scenario clinical history, risk factors, clinical and radiological examinations
were found to determine the initial diagnosis. Microbiological culture (bone and
blood cultures) can be used to determine the correct diagnosis and treatment.
Bone biopsy is the gold standard for diagnosing bone and joint infections. Tissue
culture can reveal which microorganism is causing the infection and can also help
doctors choose an antibiotic that works well against that microorganism. A bone
biopsy is performed under local anesthetic numbing the area before inserting a
long needle into the affected bone. Blood cultures may also reveal the offending
organism if the infection is very severe and has entered the bloodstream

6. What are the consequences of an open wound that is not handled properly?
(Salma) A wound is said to be open if the wound damages the outermost layer of
skin. This damaged layer of skin will reveal the tissue underneath. If not treated
immediately, the lower tissue that is exposed to the outside environment can be at
risk of infection. When the wound is infected, this will prolong the wound healing
process. Bacteria and dirt can also secrete toxic substances that make it difficult
for wounds to heal. Therefore, it is important to prevent infection from negatively
affecting wound healing

7. What are the complications of the patient’s disease?

(Afifah) Compliacation of of osteomyelitis can be divided into acute and chronic.

Acute complications, including death from sepsis; abscess formation; and septic
arthritis especially of the hip joint. Chronic complications, including chronic
osteomyelitis, either recurrent or persistent; pathological fractures in areas of
fragile bones; joint contractures; and impaired bone growth. Impaired bone
growth can be in the form of overstimulation of growth (due to prolonged
hyperemia) or growth restriction (due to epiphyseal damage). and there are other
complications such as:

1. Septicemia. With the increasing availability of adequate antibiotic drugs, death

from septicemia is currently rare
2. Metastatic infection. Infection can metastasize to other joints, brain and lungs,
can be multifocal, and usually occurs in clients with malnutrition
3. Suppurative arthritis. It can occur in infants because the baby's epiphyseal plate
has not functioned properly
4. Growth disorders. Acute hematogenous osteomyelitis in infants can cause
damage to the epiphyseal plate resulting in growth retardation, the bones in
question become shorter

(Najda) if not treated properly, osteomyelitis has the risk of causing the following
complications :
- Septic arthritis, which is the spread of infection from within the bone to nearby
joints
- Osteonecrosis, namely bone death due to obstruction of blood circulation in the
bone
- Bone growth disorder in children, if the infection occurs in the soft parts of the
arm or leg bones called growth plates
- Squamous cell carcinoma of the skin, especially in chronic osteomyelitis
- Pathological fracture, his is a rare complication and can occur as a result of
extreme bone destruction or thinning of the cortex
- Inflammation of soft tissue (cellulitis)
- Spread of infection
- Bone abscess (pocket of pus)
- Bone deformity

8. What are the KODEKI relevant to the scenario?

Gisti : Article 10
A doctor is obliged to respect the rights of patients, colleagues and other health
workers, and must maintain the patient's trust.
Article coverage:
1. A doctor must behave with dignity, speak politely, behave politely, respect the
rights of patients, colleagues and other health workers.
2. A doctor is obliged to provide clear and adequate information and respect the
patient's opinion or response to the doctor's explanation.

Akmal :Article 5: Acts of Debilitating Psychic and Physical. Every action or

doctor's advice that may weaken psychological or physical endurance, must obtain
the consent of the patient/family and is only given for the benefit and good of the
patient

Deva :In the scenario the action taken by the doctor is correct, namely not taking
action without the patient's consent. Where this is based on:
- Article 45 paragraph (1) of Law Number 29 of 2004 Concerning Medical
Practice which states that "Any medical or dental action to be performed by a
doctor or dentist on a patient must obtain approval".
- Article 37 paragraph (1) of Law Number 44 of 2004 concerning Hospitals states
that "Any medical action performed at a hospital must obtain the consent of the
patient or his family"
From the various health-related laws and regulations it is very clear that any
medical action that will be performed by a doctor on a patient must be with the
patient's consent. The implementation of medical procedures carried out by a
doctor or hospital without prior notification and consent from the patient is an act
of medical malpractice and a criminal act of persecution.

9. How does the Islamic view fit into the Scenario?

(gisti) : “Every disease must have a cure. If a medicine is in accordance with the
disease then he will recover with the permission of Allah Subhanahu wa Ta'ala."
(HR. Muslim)
The hadith above explains that it is permissible for a person to treat his illness.
Because every disease has a cure. If the treatment is done correctly regarding the
disease, with the permission of Allah SWT, the illness will disappear and become
healthy again. Even so, healing sometimes occurs in a rather long time, if the
cause of the disease is not known or the cure has not been found,
(Zulfa) : “It is not a Muslim who is struck by a disease and the like, but Allah will
abort with him his sins like a tree that sheds its leaves" HR BUKHARI MUSLIM
(Salma) Meaning: "You must always fear Allah SWT and say takbir every time
there is a way up” narrated by Bukhari In this hadith it is explained that we should
always pray to Allah and be asked to always be careful while traveling
(Akmal) : Indeed, Allah sent down disease and its medicine and made for every
disease there is a medicine. So seek treatment, and do not seek treatment with
what is unlawful." (Narrated by Abu Dawud from Abu Darda)
STEP IV
STEP V
1. Student are able to explain definition and etiology relevan to scenario?
2. Student are able to explain pathopisiology and risk factor of the scenario
3. Student are able to explain Classification of osteomyelitis ?
4. Student are able to explain Diagnosis and differential diagnosis of
osteomyelitits?
5. Student are able to explain Expalin management treatment of scenario?
6. Student are able to explain complications and prognosis of osteomyelitis?
7. Student are able to explain Education of osteomyelitis
STEP VI
-
STEP VII
1. Student are able to explain definition and etiology relevan to scenario?
 Introduction
Bone infection is called osteomyelitis. It is an acute or chronic
inflammatory process involving the bone and its structures secondary
to infection with pyogenic organisms, including bacteria, fungi, and
mycobacteria. Interestingly, archeological finds showed animal fossils
with evidence of bone infection, making this a relatively old disease.[1]
Various terms were used to describe infected bone over the years until
Nelaton came up with the term osteomyelitis in 1844.[1] Before the
introduction of penicillin in the 1940s, management of osteomyelitis
was mainly surgically consisting of extensive debridement,
saucerization, and wound packing following which the affected area is
left to heal by secondary intention[1] resulting in high mortality from
sepsis. Since the availability of antibiotics, mortality rates from
osteomyelitis, including staphylococcal osteomyelitis, has improved
significantly.
 Etiology
Healthy intact bone is resistant to infection. The bone becomes
susceptible to disease with the introduction of a large inoculum of
bacteria, from trauma, ischemia, or the presence of foreign bodies
because bone sites to which microorganisms can bind are exposed.[2]
Certain bacteria such as Staphylococcus aureus adhere to the bone by
expressing receptors, called adhesins, for some components of the
bone matrix, including laminin, collagen, fibronectin, and bone
sialoglycoprotein. S. aureus expresses a collagen-binding adhesin,
which permits its attachment to bone cartilage while the fibronectin-
binding adhesin's role in attachment of bacteria to surgically
implanted devices in bone was recently discovered.[2] Also
interesting to note is that S. aureus can survive intracellularly after
 being internalized by cultured osteoblasts. Some bacteria create a
protective biofilm coating around themselves and underlying surfaces.
This characteristic of some bacteria to adhere to the bone and
surgically implanted devices following which they express phenotypic
resistance to antibiotic therapy and their ability to survive
intracellularly may explain the persistence of bone infections and high
failure rates of shorter courses of antimicrobial treatment.

2. Student are able to explain pathopisiology and risk factor of the scenario
 Pathopysiology
Bone can get infected via the hematogenous route of infection
through bacteremic seeding of bone from a distant source of infection,
contiguous spread from surrounding tissue and joints, or direct
inoculation of bone from trauma or surgery. Hematogenous
osteomyelitis occurs more frequently in children compared to adults,
and long bones are usually affected. In adults, hematogenous
osteomyelitis affects the vertebrae most commonly. Contiguous
osteomyelitis in young adults usually occurs in the setting of trauma
and related surgery, while in older adults, infection is typically related
to decubitus ulcers and infected joint arthroplasties.
Contiguous osteomyelitis frequently develops in debilitated
patients who are wheelchair or bedbound and are predisposed to
pressure-related skin ulcerations, especially in the sacrum, buttock,
hips, and heel. These ulcers are typically colonized by polymicrobial
flora from the skin and gastrointestinal tract such that soft tissue
infection can quickly spread to the underlying bone. Other sources of
contiguous osteomyelitis are trauma leading to infected, exposed skin,
and soft tissue. Osteomyelitis with direct inoculation of bacteria may
occur in the setting of open fractures, bone reconstructive surgery, or
with placing orthopedic hardware.
 Pathopysiology
Osteomyelitis is most often caused by Staphylococcus aureus.
Other causative organisms are salmonella, streptococcus, and
pneumococcus. The metaphysis of the bone is affected and the whole
bone may be affected. Bones are infected by bacteria through 3 routes:
hematogenous, through infection in nearby or directly during surgery.
Initial inflammatory reaction cause thrombosis, ischemia and bone
necrosis. Pus may spread downward into the medullary cavity or
cause a superiosteal abscess. A dead bone suquestra is formed. New
bone formation below perioteum that is explained above and around
the granulation tissue, perforated by the sinuses which allow pus to
drain.
  Risk Factor
Everyone can experience osteomyelitis. However, there are factors
that can increase a person's risk of developing this bone infection,
namely:
- Suffer from certain diseases or conditions, such as diabetes, sickle
cell anemia, peripheral arterial disease, HIV/AIDS, or rheumatoid
arthritis
- Are undergoing chemotherapy or hemodialysis (dialysis)
- Have a history of injuries or injuries, such as broken bones
- Have had osteomyelitis
- Have had bone surgery
- Have a prosthesis or assistive device that is attached to the body,
such as an artificial hip or fracture pin
- Suffering from alcohol addiction
- Taking corticosteroids for a long time
 Diseases that are risk factors for osteomyelitis are as follows:
Long term skin infection, immune system deficiency,Prosthetic
joints, Rheumatoid arthritis, Sickle cell anemia, Risk factors for poor
blood circulation, which include high blood pressure, cigarette
smoking, high blood cholesterol and diabetes, AIDS, Peripheral artery
disease, Hemodialysis In addition, several other factors also play a
role in increasing the risk of bone infection, namely: Drug use long-
term steroids Intravenous (IV) drug use Consuming alcohol
Injuries/fractures of bones History of orthopedic surgery.

3. Student are able to explain Classification of osteomyelitis

 Classification
There are two major classification schemes for osteomyelitis. The
first is by Lew and Waldvogel, while the other is by Cierny and Mader.
Lew and Waldvogel classified osteomyelitis based on the duration of
illness as acute or chronic and by the mechanism of infection (either
hematogenous or contiguous infection). Contiguous infection is
further classified based on the presence or absence of associated
vascular insufficiency.
The Cierny and Mader scheme provides guidance in patient
management. In this scheme, the classification of osteomyelitis is by
anatomic stage and the host health status.
The categories and corresponding anatomic types are:
- Stage 1: Disease confined to the medullary of the bone
- Stage 2: Superficial disease
- Stage 3: Localized spread
- Stage 4: Diffuse disease
The local and systemic factors which define host health status are:
- A: Normal host
- Bs: Host with systemic compromising factors
- Bl: Host with local compromising factors
- Bsl: Host with both local and systemic compromising
factors
- C: Host for whom treatment of the osteomyelitis is worse
than the disease itself
4. Student are able to explain Diagnosis and differential diagnosis of
osteomyelitits
 Diagnosis
A doctor first does an examination for signs such as tenderness and
swelling. They also ask about the person’s recent medical history,
particularly about accidents, operations, or infections.
They may then request:
- Blood tests for checking about:
a. C-reactive protein: Higher concentrations can indicate
inflammation.
b. White blood cell count: Higher levels may indicate an
infection.
c. Erythrocyte sedimentation rate: This refers to the distance
that red blood cells travel in 1 hour before settling, and the
rate may be elevated in someone with osteomyelitis.
 - Biopsy: The physician takes a small piece of tissue to test for
the type of bacteria or fungi that is causing the infection. The
type can determine the right treatment.
- Imaging tests: An X-ray, MRI, or CT scan can reveal any bone
damage.
The damage may not be visible for 2 weeks on an X-ray, so the
more detailed scans are more effective for recent injuries.
 Diagnosis
Symptoms of acute osteomyelitis usually develop over
several days. Patients will complain of dull pain in the involved
bone, accompanied with local symptoms such as tenderness,
redness, swelling, warmth, and systemic symptoms such as fever,
shivering, and malaise.
Clinical manifestations of chronic osteomyelitis are pain, erythem
a, edema, and occasionally formation of cutaneous sinus; the
latter is pathognomonic for osteomyelitis.
Diagnostic tests, particularly imaging techniques, play importa
nt roles in diagnosing osteomyelitis. However, results
of diagnostic imaging procedures should be interpreted with care
as they have a wide range of sensitivity and specificity.
Conventional radiography is both affordable and widely available,
and has been proven to be useful in diagnosing and excluding the
differential diagnoses of osteomyelitis. Imaging
findings in chronic osteomyelitis include cortical erosion, perioste
al reaction, and mixed lucency and sclerosis.
The diagnosis is often determined clinically and in combination
with radiological and histopathological results
- Blood tests – white blood cell checks are usually normal or
elevated; Inflammatory markers (CBC) are usually elevated
- Radiology – although less sensitive, Plain radiographs are
usually available, inexpensive, and can show improvement
after 10-14 days.
- Bone scan is sensitive but not specific.
- CT or MRI scan more expensive but sensitive and specific, and
can be optional. MRIs be contraindicated in patients wearing
metallic materials; because it causes artefacts on the CT.
- Biopsy-Radiology guide or biopsy for surgery, may be the first
choice in administering antibiotic therapy, this is
recommended for identify the causative organism
  Differential Diagnosis
The differential diagnosis for osteomyelitis is broad, and it is
essential to keep these in mind during the evaluation of a patient with
a suspected bone infection. These differentials include:
- Charcot arthropathy especially in people with diabetes
- SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis,
and osteitis)
- Arthritis including rheumatoid arthritis
- Metastatic bone disease
- Fracture, including pathological and stress fractures.
- Gout
- Avascular necrosis of the bone
- Bursitis
- Sickle cell vaso-occlusive pain crises

5. Student are able to explain Expalin management treatment of scenario

The initial goal is to control and destroy the infectious process :
- Immobilize the affected area: apply warm, normal saline soaks for 20
minutes several times a day.
- Blood culture: smear the abscess fluid to identify the organism and
choose an antibiotic.
- Intravenous antibiotic therapy around the clock.
- Give oral antibiotics if infection appears to be under control: continue
for 3 months.
- Bone debridement surgery if unresponsive to antibiotics maintain
additional antibiotic therapy.

An then there is a non-operative and operative treatment, there are :

a. Non operative :
Antibiotics: nafcillin or clindamycin (or vancomycin if infection
with Enterococcus spp. is suspected) and ciprofloxacin (except in
children when an aminoglycoside must be used). To fight MRSA,
linezolid has been shown to work effectively. Quinolones are used for
Gram-negative bacterial infections in adult patients with osteomyelitis.
 Antibiotic Treatment by Stage
- Stage 1. The vascularization in children are
way better than in adults and it also has
an effective response to infection.
Therefore, in children, osteomyelitis is
usually treated with antibiotic alone. In
adults, the operative intervention are often required together
with antibiotics. After the
last major of debridement, the patient is
treated with antimicrobial therapy for four
weeks. If the initial management fails and the
 infection is re-occured, another four-week course of
antibiotics and debridement arerequired.
In children, oral antibiotics can also be used.
- Stage 2. Shorter courses of antibiotics
are usually needed. In a study in which two-
week course of antibiotics was given
following debridement, the osteomyelitis
was arrested in both hosts with favorable results.
- Stage 3 and 4. Antibiotics should be given for four
two six weeks from the last major debridement. The failure
rate is high if an adequate debridement is not
performed even being treated with anti-microbial
agents. Even when all the necro-tic tissue has been adequately
debrided, the remaining bed of tissue must be considered
contaminated.Therefore, the four weeks treatment
of antibioticsis extremely required

b. Operative treatment
 Reconstruction of Bone Defects and Management of Dead
Space
Bone defect might occur following the adequate debridement,
termed a dead space. The goal of dead space management is to
replace dead bone and scar tissue with durable vascularized tissue.
A free vascularized bone graft that usually obtained from
the fibula or ilium has been used successfully to fill dead space.
One alternative technique is to place cancellous bone grafts
beneath local or transferred tissues where local augmenta-
tion is necessary. In order to temporarily maintain and sterilize
a dead space, antibiotic-
impregnated acrylic beads maybe used. The antibiotics
that are mostly used in beads including vancomycin,
tobramycin, and gentamicin. In one case
study of children, an additional option that may heal the soft tissue
wound is the vacuum-assisted closure system. It is a device that
applies localized negative pressureover the surface of foundsand
aids in the removal of fluid.A study of high energy soft tissue
injuries has reported that 57% of the patients did not require
additional treatment or a split thickness skin graft after undergoing
a split thickness pressure treatment for approximately twenty days.
The potential application of vacuum assisted closure system
ispromising. However, some studies were conductedin order to
determine its efficacy and risks in patients with established
osteomyelitis. One study has reported the development of an
anaerobic wound infection that was possibly potentiated by
topical negative pressure.
 Bone Stabilization
Stabilization using plates, screws, rods
and/or an external fixator must be done if
skeletal instability is present at the site of
infection. Internal fixation is less preferred because of its risks
of secondarily infecting
the sites of medullary rods and spreadingthe extent of the inf
ection. Ilzarovexternal fixation allows reconstruction of segmental
defects and difficult infected nonunions.The free flaps and
vascularized bone grafts techniques are also used quite often.
Together, debridement and immediate
muscle flap coverage are the primary
surgical strategies to provide effective, single-stage treatment
of chronic wounds of osteomyelitis and allow the restriction of
antibiotics to short-term use. Muscle flaps covered with skin
grafts provide durable coverage while allowing subsequent
ancillary procedures, such as bone grafts, to be performed.

 Soft Tissue Coverage

Small soft-tissue defects may be covered with a split-
thickness skin graft. In large soft-tissue defect or an inadequate
soft-tissue envelope, local muscle flaps and free vascularized
muscle flaps may be placed in one or two stages. Local
muscle flaps and free vascularized muscle transfers improve the
local biological environment by bringing in enoughblood supply
which is important for host defense mechanisms, antibiotic delivery,
as well asosseous and soft-tissue healing. Local and micro-
vascular muscle flaps as well as micro-vascular flaps
alone have been used in combination with antibiotics and
operative debridement. Most cases of long bone osteomyelitis
are posttraumatic or postoperative. Follow-ing the increasing
number of accidents and orthopedic procedures performed, it is
not likelythat this infection rate will decrease. However, the
clinician may reduce the chances that the chronic form of
the infection will develop. These following procedures as
surgical debridement, wound irrigation, and muscle flap or
vascularized tissue grafts havemajor roles in dead tissueremoval
and treatment, eliminating bacte-rial load, and filling up the dead
space with vascularized tissue. In order to decreasethe incidence of
acute and chronic osteo-myelitis, early antibiotics and
sensitivity-specific antibiotics also play a major role. Also,
internal fixation of contaminated dead bone inevitably leads to
osteomyelitis, therefore,this should be avoided.
6. Student are able to explain complications and prognosis of osteomyelitis
The prognosis for osteomyelitis varies, depending on the success
rate of therapy. Complications of osteomyelitis can lead to bone necrosis
requiring amputation, and even sepsis can occur which carries a risk of
death. If not treated properly, osteomyelitis has the risk of causing the
following complications:
Then the complication :
- Septic arthritis, which is the spread of infection from within the bone
to nearby joints
- Osteonecrosis, namely bone death due to obstruction of blood
circulation in the bone
- Bone growth disorders in children, if the infection occurs in the soft
parts of the arm or leg bones called growth plates
- Squamous cell carcinoma of the skin, especially in chronic
osteomyelitis

Complications of osteomyelitis can be divided into acute and

chronic.
 Acute complications, including death from sepsis; abscess
formation; and septic arthritis especially of the hip joint.
 Chronic complications, including chronic osteomyelitis, either
recurrent or persistent; pathological fractures in areas of fragile
bones; joint contractures; and impaired bone growth. Impaired
bone growth can be in the form of overstimulation of growth (due
to prolonged hyperemia) or growth restriction (due to epiphyseal
damage).

For Prognisis osteomyelitis : in acute osteomyelitis, most patients

do not have long-term complications if managed adequately. In contrast to
chronic osteomyelitis, the patient's recovery rate depends on the success of
cleaning the dead bone tissue. Recurrent infections require long-term
antibiotics and surgery. Indications for surgery include an abscess
requiring drainage and no improvement in symptoms despite adequate
intravenous antibiotics. A study mentioned that in 813 children who had
acute hematogenous osteomyelitis due to S. aureus, 44% required surgery
and 7% experienced recurrences. The duration of antibiotic treatment can
be up to 44 days.

7. Student are able to explain Education of osteomyelitis

 About the course of the disease and its management which takes a
long time. In addition, patients must also understand the risk factors for
osteomyelitis, such as in patients with diabetes mellitus, so that patients
can prevent recurrence of the disease.taking painkillers.
- Lifestyle changes, such as quitting smoking to improve blood
circulation.
- It is important to clean and care for wounds to prevent bacteria and
prevent infection. Always keep your hands clean by washing your
hands frequently.
- Use proper footwear, and use protective equipment when
exercising.
- Do vaccinations regularly according to the schedule recommended
by the doctor.
- medications needed by the patient, necessary supporting
examinations, medical therapy and surgery needed.
- Such education is important in the treatment of osteomyelitis
patients to ensure recovery without risk of recurrence. Patients
should know that osteomyelitis therapy requires a long time,
medication adherence, and thoroughness in treatment. Sometimes
patients need intravenous antibiotics through outpatient care, so
patients must be able to come to the health facility every day, or
receive nurse visits to the house. Family members or caregivers are
also an integral part of the care team, only with their support can
the morbidity of osteomyelitis be reduced
 DAFTAR PUSTAKA
1. Al- Qur’an and Hadist
2. KODEKI
3. Johns Hopkins Medicine (2021). Conditions and Disease. Osteomyelitis.
4. Gunawan, B Setiyohadi.2010. Diagnosis and management of
osteomyelitis.Indonesian Journal of Rheumatology. Vol 2
5. Ifeanyi I. Momodu; Vipul Savaliya.2022. Osteomyelitis. National library of
medicine
6. Kavanagh N, Ryan EJ, Widaa A, et al. 2018. Staphylococcal Osteomyelitis:
Disease Progression, Treatment Challenges, and Directions. American
Society for Microbiology. Vol 3 e- 0084.17
7. Rebecca A. Lerd JG, Calhoun JH, et al. 2008. Osteomyelitis and the Role of
Biofilms in Chronic Infection. Federation of European Microbiological
Societies. 52
8. dr. Masfiyah, M.Si. Med, SpMK. Osteomyelitis Kronik. Microbiology
Department. Unissula Press.
9. Schmitt SK. Osteomyelitis. Infect Dis Clin North Am. 2017, KODEKI
10. JonathanL MDAmerican Family Physician. 2001;63(12)