Osteomyelitis R4Patt

Osteomyelitis
Teerapat Phopimonwattana , MD
References
Outline
• Pathogenesis , Pathogens and Risk factors
• Common classifications
• Diagnosis & Treatments
• Most important viable

1.Bone involvement
2.Anti microbial resistance pattern
3.Need soft tissue coverage
4.Host status
Definition : Morrey and Peterson
• Definite OM
• Present of organism in bone or adjacent soft tissue
• Probable OM
• Positive Blood culture
• Clinical and radiographic features of OM
• Likely OM
• Clinical and radiographic feature of OM
• Responses to ATB
• Absence of positive culture
Definition : Peltola and Vahvanen
2 of 4 criteria
• 1.Pus aspirated from bone

• 2.Positive bone or blood culture
• 3.Classic symptoms
• (Localized pain , swelling , warm , limited ROM)
• 4.Radiographic changes
• Typical of OM
Classification
Duration Mechanism
Acute hematogenous osteomyelitis Exogenous
Subscute hematogenous osteomyelitis Hematogenous
Chronic osteomyelitis
Mechanism
• Exogenous
• Open fracture
• Surgery (Iatrogenic)
• Contiguous
• Spread from local infected tissue
• Hematogenous
• Bacterial
Acute hematogenous osteomyelitis
• Most common
• Usually in children (Based on blood supply & structure of bone)
• Caused by Bacteremia
• Bimodal age
• <2 yrs old : Hip Most common
• 8-12 yrs old
In children
Endothelial
Relative
Area of gaps in Metaphyseal
absence of
turbulence growing bone
tissue
flow metaphyseal infection
macrophages
vessels
Well-developed reticuloendothelial system of the diaphysis

prevent infection expansion
Biofilm
Biofilm
Seeding infection
In children
Pathophysiology: Osteomyelitis
Dead bone = sequestrum
New bone = involucum
Bacterial colonization
(Metaphysis) Osteoblast die and bone trabeculae
resorbed by Osteoclast in 12 -18 hr
Inflammatory Response
1 IL-1 , PE2 Bone resorption
§Lymphocyte Osteoclastic
activating factor
§Macrophage
§Monocyte Purulent exudate exit porous Cortical necrosis =
metaphyseal cortex sequestrum
§Vascular endothelial cell
3
Accumulation of
2 Periosteal
inflammatory cell elevate
Thrombosis medullary vessels
Reducing the host's ability to fight New bone forming around

infection necrotic = involucum
Organism
• Staph aureus : Most common

• Strep gr B : Infant (2-4 wk)
• Foot punctate wound : P. aeruginosa
• Pseudomonas : IV drug used
• Fungal : Long term IV Rx / Parenteral nutrition
• Salmonalla : Hemoglobinopathies
• H.influenza : 6 mo – 4 yrs
Outline
Outline
History and Physical exam
• Fever and malaise : in early stages

• Pain , swelling and local tenderness : more common
• Compartment syndrome
Laboratory
• CBC : WBC often normal

• ESR and CRP : Usually elevated
ESR and CRP
• ESR 3-1-3
-Unreliable in neonate,
anemia,sickle cell,steroid
• CRP 6-2-6
-Early Dx and
determine resolution
• Serum Procalcitonin
• Sens 85.2%
• Spec 87.3%
• Real-time PCR
• Guide ATB therapy until culture results become available
Standard Radiographic : Generally Negative
• 5% : abnormal initially
• 33% : abnormal in 1 wk
• 90% : abnormal in 4 wks
• DDx
• Septic arthritis
• Ewing sarcoma
• Osteosarcoma
• Juvenile arthritis
• Sickle cell
• Gaucher disease
• Stress fracture
MRI
• Sens 98% , Spec 75%

• Early inflame change in Bone marrow and Soft tissue
• Intraosseous and subperiosteal abscess
• Gadolinium : post OP (Artifact,infected relate marrow edema,abscess)
• T1 : low signal
• T2 : High signal
Tech – 99m
• 24 – 48 hr after onset in 90-95%
• If negative >> effectively Rule out
Ultrasound
• Subperiosteal abscess
• Thickening of periosteum
• Swelling surrounding soft tissue
• Operator dependent
Culture
• 50% identified from H/C

• Bone aspiration +/- CT U/S guide
Treatment
Principles for the treatment of acute hematogenous osteomyelitis
(1) an appropriate antibiotic is effective before abscess 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 Operative Orthopaedics 14th

Treatment
• General supportive
• IV fluid
• Analgesic
• Comfort positioning of limb : Splint
• Start Empirical IV ATB (if no Abscess in MRI,U/S)

• F/U CRP 2-3 days
• IF clinical not improve >> Search for Abscess
Treatment
• IV ATB : controversial
• Suggested duration (Implant related)

• IV ATB first 2 wks. Followed by oral ATB
• 6 wks in implant removal
• 12 wks in device retention
Main indication for surgery
• 1.Present Abscess require drainage

• 2.Failure despite appropriate IV ATB
Objective of surgery
• Drain any abscess cavity
• Remove all nonviable or necrotic tissue
Classification
Duration Mechanism
Subacute hematogenous OM
• Incidious onset
• Lacks the severity of symptoms
Diagnosis
• Systemic signs and symptoms are minimal
• Temp mildly elevated
• Mild to Moderate pain
• WBC : normal
• ESR : Elevate 50%
• H/C : Negative
• Tissue C/S : Positive 60% = S.aureus and S.epidermidis
• Plain radiograph and Bone scan : Positive

Radiographic classification
Radiographic classification
• Aggressive lesion
• Biopsy and curettage
• Appropriate ATB
• Simple abscess in epiphysis or metaphysis

• Biopsy is Not recommended
• IV ATB 48 hrs followed by 6 wks oral ATB
Brodie abscess
• Form of Subacute OM
• Long bones of young adults
• S.aureus 50%
• C/S negative 20%
• Mx : Open biopsy and curettage
Classification
Duration Mechanism
Chronic Osteomyelitis
• Difficult to eradicate completely
• Infected dead bone within a compromised soft tissue envelope
• Secondary infection are common : Sinus tract
• Higher risk for DVT
Classification “Cierny-Mader” Radiogpahic
Classification “Cierny-Mader” Host
• Class A : Healthy
• Class B
• 1 = Local
• 2 = Systemic
• Both
• Class C : Risk > Benefits
• Severe co-morbid
• Sufficiently limited lesion
Classification “Jones” Radiographic
• A : Brodie abscess
• B : Sequestrum inbolucrum
• B1 = Localized cortical sequestrum
• B2 = Sequestrum with Structural involucrum
• B3 = Sequestrum with Sclerotic involucrum
• B4 = Sequestrum without Structural involucrum
• C : Sclerotic
• Physeal damage : P = Proximal , D = Distal

Diagnosis
• Gold standard obtain a biopsy specimen for

Histological and Microbiologic evaluation of the infected bone
Campbell's Operative Orthopaedics 14th

Imaging
• Plain radiograph
• Cortical destruction
• Periosteal destruction
• Sinography
• Injected Methylene blue 24 hrs before Sx
• Adjunct to surgical planning
• Sinus tract > 1 yr :

should be excised sent
for Patho to R/O Carcinoma
Radiographic sign
• Diffuse demineralization
• Soft tissue swelling
• Trabeculae destruction , Lysis
• Cortical permeation
• Periosteal reaction
• Sequestrum
• Involucrum
Imaging
Isotopic bone scanning
• Acute > Chronic OM
• Tech-99m bone scan
• Increase uptake : Blood flow or osteoblast activity
• Gallium scans
• Increase uptake : leukocyte or bacteria accumulate
• F/U
• Indium-111 labeled leukocyte scans
• More sens
• Differentiating Chronic OM VS Neuropathic in DM foot
Imaging
CT
• Determine the extent of bone destruction

• Detect soft tissue abnormal , gas forming
• Abscess
• Surgical planning
• Less sensitive at detecting soft tissue changes

Imaging
MRI
• Accurate extent lesion : margin of bone and soft tissue

• Advantage
• Well defined rim of high signal : active disease
• OM VS primary bone CA
• Sinus tract and Cellulitis : T2 high signal
• Disadvantage
• Cost , Artifact around metal implants , poor delineation cortical bone
Treatment
• Multi department
• Orthopedic Surgeon
• ID specialist
• Plastic Surgeon
• ATB suppression & Surgical DB & Reconstruction
• Host :
• U/D , Blood sugar , Smoking , Liver/Renal malfunction
Treatment
1. Eradication of the infection by achieving a viable & vascular environment
sequestrectomy and resection of scarred and infected bone and soft tissue
medullary canal is infected > IM reaming or reamer–irrigator–aspirator (RIA)
dressings soaked in antibiotic or antibiotic pouch technique (Suction drains : not recommend)
2. Reconstruction of large dead space
BG with primary or secondary closure
ATB PMMA beads before reconstruction
Local muscle flaps and skin grafting with or without bone grafting
microvascular transfer of flaps ( muscle, myocutaneous, osseous, and osteocutaneous )
bone transport (Ilizarov technique)
3. Appropriate antibiotic
6 weeks of IV antibiotics
limb-splinted for prevent pathologic fracture

Treatment
Treatment
Treatment
-PMMA Antibiotic Bead Chains
antibiotic bead pouch
intramedullary antibiotic cement nail
-Biodegradable Antibiotic Delivery Systems
-Closed Suction Drains
-Hyperbaric oxygen therapy
-Growth factors: BMPs, PRP
-Pulsed electromagnetic fields [PEMF] and ultrasound
I&D for OM of Specific regions
Calcaneus
• S.aureus : MC Bacterial OM
• P.aeruginosa : Neurological damage foot
Amputation for OM
• Most reliable treatment associated with Malignant changes
“Squamous cell carcinoma & Fibrosarcoma”
• Arterial insuff , Major nerve paralysis , Joint contracture and stiffness

are make limb Nonfunction
Take Home Message
Organism
(Acute hematogenous osteomyelitis)
• Staph aureus : Most common

• Strep gr B : Infant (2-4 wk)
• Foot punctate wound : P. aeruginosa
• Pseudomonas : IV drug used
• Fungal : Long term IV Rx / Parenteral nutrition
• Salmonalla : Hemoglobinopathies
• H.influenza : 6 mo – 4 yrs
Take Home Message
“Cierny-Mader”
Host
• Class B
• 1 = Local
• 2 = Systemic
• Both
Take Home Message
Take Home Message
Acute (<2 wk) Subacute (2wk – 3mo) Chronic (>3 mo)
Bimodal (<2,8-12) Host resistance ↑,Low virulence ↓↓ *Sinus tract

(+- Partial treat ATB)
Inflam reaction ↑ Minimal systemic sign Subside systemic symptom
Fever,Pain,Swelling,Tender Mild to Mod pain Intermittent acute exacerbate
WBC ⏤ WBC ⏤ Non Specific
ESR↑ , CRP↑ ESR↑, H/C Neg
Film : negative Film 6 stages Film : Cierny-Mader
+- 10-12 days : skeletal change
MRI : LowT1,HighT2
U/S : DDx = Cellulitis,abscess,septic
joint,Tumor
Mx Mx Mx
-No abscess : IV ATB -Simple : IV ATB -Sx : DB Sequestrectomy +
-Sx : Abscess , Fail IV ATB -Aggressive : Bx & Curettage & ATB Remove Scar+Dead bone&soft tissue
*Recon bone loss
Examination
group B Streptococcus
What malignant disease most commonly develops in
conjunction with chronic osteomyelitis with sinus drainage?
• Fibrosarcoma
• Lymphoma
• Melanoma
• Basal cell carcinoma
• Osteosarcoma
What malignant disease most commonly develops in
conjunction with chronic osteomyelitis with sinus drainage?
• Fibrosarcoma
• Lymphoma
• Melanoma
• Basal cell carcinoma
• Osteosarcoma
Amputation for OM
• Most reliable treatment associated with Malignant changes
“Squamous cell carcinoma & Fibrosarcoma”
• Arterial insuff , Major nerve paralysis , Joint contracture and stiffness

are make limb Nonfunction
• Classification “Cierny-Mader” Radiogpahic
• Classification “Cierny-Mader” Host
• Class B
• 1 = Local
• 2 = Systemic
• Both
Thanks you J

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Osteomyelitis

• Most important viable

• 1.Pus aspirated from bone

Subscute hematogenous osteomyelitis Hematogenous

Well-developed reticuloendothelial system of the diaphysis

Reducing the host's ability to fight New bone forming around

• Staph aureus : Most common

• Fever and malaise : in early stages

• CBC : WBC often normal

• Sens 98% , Spec 75%

• 50% identified from H/C

(1) an appropriate antibiotic is effective before abscess formation

Campbell's Operative Orthopaedics 14th

• Start Empirical IV ATB (if no Abscess in MRI,U/S)

• Suggested duration (Implant related)

• 1.Present Abscess require drainage

Subscute hematogenous osteomyelitis Hematogenous

• Plain radiograph and Bone scan : Positive

• Simple abscess in epiphysis or metaphysis

Subscute hematogenous osteomyelitis Hematogenous

• Physeal damage : P = Proximal , D = Distal

• Gold standard obtain a biopsy specimen for

Campbell's Operative Orthopaedics 14th

• Sinus tract > 1 yr :

• Determine the extent of bone destruction

• Less sensitive at detecting soft tissue changes

• Accurate extent lesion : margin of bone and soft tissue

limb-splinted for prevent pathologic fracture

• Arterial insuff , Major nerve paralysis , Joint contracture and stiffness

• Staph aureus : Most common

Bimodal (<2,8-12) Host resistance ↑,Low virulence ↓↓ *Sinus tract

• Arterial insuff , Major nerve paralysis , Joint contracture and stiffness

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