osteomyelitis

osteomyelitis 

Nelaton (1834):coined osteomyelitis osteon:bone myelo:marrow

Osteomyelitis
Acute: <2weeks Early acute Late acute(4acute(45days) 

Subacute: 2weeks² 2weeks² 3months Chronic: >3months

Less virulent ± more immune

aureus Pseudomonas aeruginosa Serratia marcescens E.Organisms Commonly Isolated in Osteomyelitis Based on Patient Age  Infants (<1 year) Group B streptococci Staphylococcus aureus Escherichia coli Children (1 to 16 years) S. aureus Streptococcus pyogenes Haemophilus influenzae  Adults (>16 years) Staphylococcus epidermidis S. coli  .

Risk factors              Trauma (orthopaedic surgery or open fracture) Prosthetic orthopaedic device Diabetes Peripheral vascular disease Chronic joint disease Alcoholism Intravenous drug abuse Chronic steroid use Immunosuppression Tuberculosis7 Tuberculosis7 HIV and AIDS Sickle cell disease Presence of catheter-related blood stream infection4 catheterinfection4 .

osteomyelitis       General factors Anaemia Debility Infection Poor nutrition Poor immune status  Local factor  Hair pin bend vessels  Metaphyseal haemorrhage  Defective Phagocytosis  Rapid groth at metaphysis  Trabeculae of degenerating cartilage  Vasospasm  Anoxia .

path ph i l g .

premature neonates) ‡ Swelling ‡ pain Vague Cannot pinpoint onset Fever/swelling-mild Fever/swelling  Sub acute Chornic Spurulent drainage .Clinical feature  Early Acute Febrile illness ‡Limping to walk ‡Avoidance of using the extremity ‡ Late Acute (Infant.

pelvis.Disadvantage-fracture SCAN.BEST .NECROTIC PORTION SCANTECHNETIUM 99 BONE SCAN(85% PPV)-when diag unclearPPV)unclearclavicle.osteomyelitis.lab   - - - COMPLETE BLOOD COUNT CULTURE (24-48hrs later) (241-JOINT FLUID 2-BLOOD 3-DEEP BONE BIOPSY 23LEUKERGY ESR C REACTIVE PROTIEN LEUCOCYTE COUNT X RAY-LAGS 2wks BEHIND RAYRADIONUCLEOTIDE SCAN.Disadvantagehealing.fibula SPECT INDIUM/GALLIUM SCAN USGUSG-SUBPERIOSTEAL ABSCESS MRIMRI.tumour C T SCAN.

A BLOOD CULTURE IS PROBABLEPOSITIVE IN SETTING OF CLINICAL AND RADIOLOGICAL FEATURES OF OSTEOMYELITIS LIKELYLIKELY.MORREY AND PETERSON´S CRITERIA    DEFINITION.THE PATHOGEN IS DEFINITIONISOLATED FROM BONE OR ADJACENT SOFT TISSUE AS THERE IS HISTOLOGIC EVIDENCE OF OSTEOMYELITIS PROBABLE.TYPICAL CLINICAL FINDING AND DEFINITE RADIOGRAFFIC EVIDENCE OF OSTEOMYELITIS ARE PRESENT AND RESPONSE TO ANTIBIOTIC THERAPY .

Peltola and vahvanen¶s criteria  -Pus on aspiration -Positive bacterial culture from bone or blood -Presence of classic signs and symptoms of acute osteomyelitis -Radiographic changes typical of osteomyelitis *--Two of the listed findings must be present for --Two establishment of the diagnosis. .

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.    PlainPlain-film radiograph showing osteomyelitis of the second metacarpal (arrow). Periosteal elevation. cortical disruption and medullary involvement are present.

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CONTIGEUOUS FOCUS 3. OSTEOMYELITIS WITH VASCULAR INSUFFICIENCY . HEMATOGENOUS 2.WALDVOGEL 1970 1.

WEILAND 1984          TYPE 1 ± -OPEN EXPOSED BONE WITHOUT OSSEOUS INFECTION BUT SOFT TISSUE INFECTION TYPE 2 ± CIRCUMFERENTIALCORTICAL+ENDOSTEAL INFECTION INCREASE SCLEROTIC THICKENING OF CORTEX INCREASE DENSITY AREAS OF BONY RESORPTION+SEQUESTRUM TYPE 3 ± CORTICAL+ENDOSTEAL INFECTION+A SEGMENTAL BONE DEFECT  .

GORDON¶S 1988    TYPE A ± NONUNION WITHOUT SEGMENTAL LOSS TYPE B .>3cm SEGMENTAL LOSS WITHOUT INTACT FIBULA .>3cm SEGMENTAL LOSS WITH INTACT FIBULA TYPE C .

4.GER¶S 1982 1. 3. 2. SIMPLE SINUS CHRONIC SUPERFICIAL MULTIPLE SINUSES MULTIPLE SKIN-LINED SINUSES SKIN- .

3. 2. HEMATOGENOUS OSTEOMYELITIS OSTEOMYELITIS WITH FRACTURE UNION OSTEOMYELITIS WITH FRACTURE NONUNION POST OPERATIVE OSTEOMYELITIS WITHOUT FRACTURE . 4.KELLY¶S 1984 1.

> 6cm.> 56cmFIBULA18months .MAY¶S 1989      TYPE 1.> 6cm.INTACT TIBIA NEEDED GRAFT.INTACT FIBULA ± 1241218months TYPE 5.32GRAFT6months TYPE 3.UNUSABLE FIBULA.WITHSTAND FUNCTIONAL LOAD ± 16-12weeks TYPE 2.DEFECT < 6cm. INTACT FIBULA ± 36-12months TYPE 4.

TABLE 1 Waldvogel Classification System for Osteomyelitis      Hematogenous osteomyelitis Osteomyelitis secondary to contiguous focus of infection No generalized vascular disease Generalized vascular disease Chronic osteomyelitis (necrotic bone) .

metaphyseal osteomyelitis is shown in G. F).The Penny classification of chronic osteomyelitis in children includes both diaphyseal and metaphyseal types. . type V (multiple walled-off abscesses. D). B). and walledtype VI (multiple microabscesses.         Diaphyseal osteomyelitis may be broken down into the following types: type I (typical. type IV (cortical. A). type III (sclerotic. C). E). type II (atrophic.

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DE CIERNY-MADER CIERNY   12 STAGES DISEASE PROCESS ± REGARDLESS OF ± 1-ETIOLOGY 2-REGIONALITY 3-CHRONICITY DYNAMIC .

The Cierny-Mader CiernyStaging System Anatomic Type Description  Stage 1 Medullary osteomyelitis  Stage 2 Superficial osteomyelitis  Stage 3 Localized osteomyelitis  Stage 4 Diffuse osteomyelitis Physiologic Class  A host Normal host  B.host Systemic compromise (Bs) Local compromise (Bl) Systemic and local compromise (Bls)  C host Treatment worse that the disea .

Local Vascularity.Systemic or Local Factors That Affect Metabolism. and Immune Surveillance            Local (Bl) Arteritis Chronic lymphedema Extensive scarring Major vessel compromise Neuropathy Radiation fibrosis Small vessel disease Tobacco abuse 2 packs/day) Venous stasis           ‡ Systemic (Bs) Chronic hypoxia Diabetes mellitus Extremes of age Immune disease Immunosuppression or immune deficiency Malignancy Malnutrition Renal and/or hepatic failure .

Nade¶s principles      Antibiotic is effective before pus forms Antibiotic cannot sterilise avacular tissue Antibiotic prevents reformation of pus once removed Pus removal restores periosteum---periosteum---restores blood flow Antibiotic should be continued after surgery .

3. 2.Nade¶s indications for surgery Abscess formation Severely ill & moribund child Failure to respond to IV antibiotics for >48 hrs 1. .

2week iv change to oral (avoid quinolones) stage 2 ± 2wk+ superficial debridement stage3& 4 -4-6wk iv (from last major deb) .management   Antibiotic:stage1---Antibiotic:stage1---.

cancellous bone flap+/Illizarov external fixation-9mth fixation- .wherever Sution irrigation(not recommended) Secondary intention-discouraged intentionLocal flap+/.Surgical mx        Debridement surgery is fondation of osteomyelitis treatment External fixator prior/during Complete wound closure.

b transfer  .>3cms vascu.Antibiotic impregnated Acrylic beads removed in 2-4 wks 2Replased with cancellous bone -vanco/tobra/genta -degrada beads -implantable pump Infected pseudorthosis .

bone grafting +/.brace/cast +/Soft tissue coverage After debridement .Cierney mader  Stage1 Children Adult Stage2 Bone exposed :NO hardwarehardwareNosurgery Intramedulary reaming+/reaming+/.

Cierney mader  Stage3 Sequester Deberidment ed Reconstruction of bone +above &soft tissue Stage4 instability Structural stability Obliterating debridement gaps -bone graft -Illizarov .free flaps -vascular bone .

Osteomyelitis and hiv ‡ ‡ ‡ ‡ Uncommon (.5%-2%) (.5%Mortality(20%) S.aureus(mc) m.tuberculosis (not common) Atypical ±mac Bortonella cmv fungi DD -kaposi¶s sarcoma -avn -lymphoma .

Musculoskeletal &hiv    Arthritis Myositis Osteomyelitis .

      Spondylarthropathy reiter¶s psoriatic Acute symmetric polyarthritis Hiv asso Arthritis Painful articular syn Septic arthritis Myositis² Myositis² AZt hiv related polymyositis .

THANK 38 .

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