CHRONIC OSTEOMYELITIS

-Keerthan N [150]
-S Keerthika [151]
 When the duration of osteomyelitis is more than 6 weeks, its called
chronic Osteomyelitis.
 Causes-
1.Trauma causing open fractures.
2.Post operative.
3.Osteomyelitis with chronic etiology-
- TB
- Brodie’s abscess.
- Fungal osteomyelitis.
 Chronic osteomyelitis is difficult to eradicate

completely.

 Systemic symptoms may subside, but one or

more foci in the bone may contain purulent

material, infected granulation tissue, or a

sequestrum
PATHOLOGY

Necrosis stage of new bone formation involucrum

with sequestrum inside, with a persistent discharging sinus

pus from bone escapes through multiple hole in involucrum.

 The hallmark of chronic osteomyelitis is infected dead bone
within a compromised soft-tissue envelope.
 The infected foci within the bone are surrounded by
sclerotic, relatively avascular bone covered by a thickened
periosteum and scarred muscle and subcutaneous tissue.
 This avascular envelope of scar tissue leaves systemic
antibiotics essentially ineffective
 Secondary infections are common, and sinus track cultures usually

do not correlate with cultures obtained at bone biopsy.

 Multiple organisms may grow from cultures taken from sinus

tracks and from open biopsy specimens of surrounding soft tissue

and bone
CLINICALLY
 Pain, swelling.
 Discharging sinus.
 Bone thickening.
 Deformity.
 Joint stiffness.
 Shortening of limb
 Pathological fracture.
 Sinus track malignancy
Diagnosis
 Diagnosis is suspected clinically but can be
confirmed radiologically by its characteristic
features. The disease begins in childhood but may
present later. The lower-end of the femur is the
commonest site.
Examination
 Examination: Some of the salient features observed
on examination are as follows:

• Chronic discharging sinus: This is a characteristic

feature of chronic infection. A sinus fixed to the
underlying bone indicates that infection is
coming from the bone.
• Thickened, irregular bone: This can be
appreciated on comparing the girth of the
affected bone with that of the bone on the normal side.
• Tenderness on deep palpation, usually mild, is
present in some cases .
• Adjacent joint may be stiff, either due to
excessive scarring in the soft tissues around the
joint, or because of associated arthritis of the joint.
INVESTIGATION

1)Radiological examination:
The following are some of the salient radiological features seen
in chronic osteomyelitis:

• Thickening and irregularity of the cortices

• Patchy sclerosis
• Bone cavity: This is seen as an area of rarefaction
surrounded by sclerosis
• Sequestrum: This appears denser than the surrounding normal bone
because the decalcification which occurs in normal bone, does not occur
in dead bone. Granulation tissue surrounding the sequestrum gives rise
to a radiolucent zone around it.

• Involucrum and cloacae may be visible

 Sinogram : In this test, a sterile thin catheter is introduced into the
sinus as far as it can go. Then, a radio-opaque dye is injected, and X-
rays taken. The radio-opaque dye travels to the root of the infection,
and thus helps localise it better. It is indicated in situations where one
cannot tell on X-rays where the pus may be coming from.
 CT scan and MRI: are sometimes indicated in
patients where diagnosis is in doubt. CT scan is
of particular use in better defining the cavities
and sequestra, which sometimes cannot be seen
on routine X-rays
 Blood: A blood examination is usually of no help.
ESR may be normal or mildly elevated. Total blood
counts may be normal, may be increased during
acute exacerbation only

 Pus:It may also help in

selecting the pre-operative antibiotics as and when
operation is performed. Pus culture may grow the causative organism.
Treatment
 Principles of treatment: Treatment of chronic osteomyelitis
is primarily surgical

 Aim of surgical intervention is:

(i) removal of dead bone; (ii) elimination of dead
space and cavities; and (iii) removal of infected
granulation tissue and sinuses
 Operative procedures: Following are some of the operative
procedures commonly performed:

 a) Sequestrectomy : This means removal of the

sequestrum . If it lies within the medullary
cavity, a window is made in the overlying
involucrum and the sequestrum removed
 b) Saucerisation: A bone cavity is a ‘non-collapsing cavity’, so that
there is always some pent-up pus inside it. This is responsible for the
persistence of an infection. In saucerisation, the cavity is converted
into a ‘saucer’ by removing its wall . This allows free drainage of the
infected material
 c) Curettage: The wall of the cavity, lined by infected
granulation tissue, is curetted until the underlying normal-
looking bone is seen.

 d) Excision of an infected bone

 e) Amputation
 In most cases, a combination of these procedures is
required.

 After surgery the wound

is closed over a continuous
Suction irrigation system
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