CHRONIC OSTEOMYELITIS

Presenter:
Dr. Bijay Mehta
Moderator:
Dr. Kshitiz Sapkota
Contents
⚫DEFINITION
⚫CAUSATIVE ORGANISMS
⚫PREDISPOSING FACTOR
⚫PATHOLOGY
⚫CLINICAL FEATURES
⚫CLASSIFICATION
⚫DIAGNOSIS
⚫TREATMENT
⚫COMPLICATIONS
OSTEOMYELITIS
⚫OSTEOMYELITIS- TERM COINED BY NELATON

⚫The root words osteon(bone) and myelo(marro) are

combined with itis(inflammation) to define clinical
state in which bone is infected with microorganisms..
⚫IS INFLAMMATION OF BONE CAUSED BY AN
INFECTING ORGANISM.
⚫IS USUALLY DUE TO SINGLE ORGANISM BUT
POLYMICROBIAL INFECTION CAN OCCUR
⚫Infection may involve numerous region such as
marrow, cortex, periosteum and surrounding soft
tissue
⚫CLASSIFIED as ACUTE, SUBACUTE and CHRONIC
depending upon duration of symptom.
CHRONIC OSTEOMYELITIS
⚫Used to be dreaded sequele to acute hematogenous
osteomyelitis
⚫Now a days frequently follows open # or operation
Causative Organisms
Staphylococcus aureus
Escherichia coli
Streptococcus pyogens
Proteus mirabilis
Pseudomonas aeruginosa
Staphylococcus epidermidis – in presence of foreign
implant
Predisposing factors
⚫Acute hematogenous osteomyelitis if left untreated
⚫Local trauma such as open # or a prolonged bone
immobilization –commonest
⚫Very old or debilitated
⚫Substance abuse
⚫Malnutrition
⚫Diabetes ,skin infection ,malnutrition , lupus
erythematosus or any type of immune deficiency
PATHOLOGY
⚫Bone is devitalized in descrete area around infection
or diffusely around surface of foreign body
⚫Cavity containing pus and pieces of dead
bone(sequestrum) are surrounded by vascular tissue,
and beyond that by area of sclerosis – the result of
chronic reactive new bone formation-which may take
form of destinct bony sheath(involucrum)
⚫Sequestrum act same as foreign implant for bacterial
adhesion ensuring persistence of infection till
removed or drained through perforation in
involucrum and sinus
⚫Skin may seal off for weeks or month giving
appearance of healing only to reopen again when
tissue tension rises
⚫HISTOLOGICAL PICTURE
Chronic inflammatory cell infiltration around
area of acellular bone or microscopic sequestra
CLINICAL FEATURES
⚫PAIN
⚫PYREXIA
⚫REDNESS AND TENDERNESS have recurred (flare)
⚫Tissue often thickened and puckered or folded
inward-in longstanding cases
⚫seropurulent discharge and excoriation of
surrounding skin
⚫Bone deformed or un-united in case of post traumatic
osteomyelitis
⚫Hallmark of chronic osteomyelitis is infected dead
bone within a compromised soft tissue envelope.
⚫The infected foci within bone are surrounded by
sclerotic relatively avascular bone covered by
thickened periosteum and scarred muscle and
subcutaneous tissue
⚫In Chronic OM. secondary infection are common and
sinus tract culture doesn't correlate with culture
obtained by bone biopsy.
⚫Eradication generally requires aggressive surgical
debridement and dead space management combined
with effective antibiotic treatment.
⚫limited surgical debridement combined with
supressive ab and nutritional support may limit the
frequency of sinus drainage and pain in difficult cases.
CLASSIFICATION
⚫CIERNEY AND MADER developed classification
system based on physiological and anatomical criteria
to determine stage of infection
⚫Anatomical and physiological classes are combined to
designate one of 12 clinical stage of chr. OM
⚫Classification system is helpful in determining if
treatment should be simple or complex ,curative or
palliative , limb sparing or ablative.
Jones et al. Classification of chronic
hematogenous osteomyelitis in
children
⚫ BASED ON RADIOGRAPHIC APPEARANCE

TYPE A brodie abscess

TYPE B sequestrum involucrum
B1 localized cortical sequestrum
B2 sequestrum with normal or structural involucrum
B3 sequestrum with sclerotic involucrum
B4 sequestrum without sclerotic involucrum
TYPE C sclerotic

If proximal physis is damaged suffix P is added and if distal

physis is affected suffix D is added
DIAGNOSIS
⚫GOLD STANDARD –BIOPSY SPECIMEN FOR
HISTOLOGICAL AND MICROBIOLOGICAL
EVALUATION
⚫Is Based on CLINICAL,LABARATORY AND
IMAGING STUDIES.
⚫Physical examination focussed on integrity of skin
and soft tissue, determine area of tenderness ,assess
bone stability and neurovascular status of limb
⚫Laboratory study are non specific and give no
indication of severity of infection.
⚫Esr and crp are elevated in most patients
⚫Wbc elevated in only 35%
 Imaging studies
⚫ Done to aid in confirmation of
diagnosis and to prepare for surgical
treatment
1. Plain radiograph – initial study
performed
sign of cortical destruction
and periosteal reaction
strongly suggest dx of
om
2. Plain tomography –useful in detection
of sequestra
3. Sinography –valuable adjunct to
surgical planning
3. Isotopic bone scanning – more useful in acute OM
bcz they have negative plain film
⚫ technetium 99 scan- shows increased uptake in
areas of increased blood flow
non specific
has high negative predictive value
⚫ Gallium scan –increased uptake in area with
leucocyte or bacteria
normal gallium scan virtually excludes presence of
osteomyelitis so useful in follow up
⚫ Indium 111 labelled leukocyte more specific and used
especially in differentiating chronic osteomyelitis
from neuropathic arthropathy in diabetic foot.
4. CT - provides excellent definition of cortical bone
and useful in identifying sequestra
5. MRI – more useful for soft tissue evaluation than CT
provide fairly accurate extent of pathological
insult by showing margin of bone and soft
tissue edema.
rim sign-well defined rim of high signal intensity
surrounding the focus of active disease
6. Biopsy with culture and sensitivity
⚫Establishing diagnosis
⚫Determining proper antibiotic regime
⚫Both soft tissue and bone specimen should be sent for
microbiological study
TREATMENT
⚫MULTIFACTORIAL APPROACH
1. ANTIBIOTIC SUPRESSION
2. SURGICAL DEBRIDEMENT AND
RECONSTRUCTION
3. CORRECT HOST MORBIDITIES
e.g. optimization of blood sugar ,smoking cessation,
treatment of liver or renal malfunction
Antibiotics
⚫Choice of antibiotics –depends on Culture/ sensitivity
⚫Antibiotics alone cannot cure chronic osteomyelitis
without surgical intervention
⚫Duration of antibiotics – 6 weeks
Surgical Treatment
⚫Surgery consists of sequestrectomy and resection
of scarred and infected bone and soft tissue
⚫For soft tissue and dead space management
external fixators are generally used
⚫Reconstruction of bone and soft tissue should be
undertaken combined with culture sensitive
antibiotics.
Sequesterectomy and curettage
⚫Appropriate preparation done before surgery as it
may take more time to perform and more blood loss
than inexperienced surgeon anticipate
⚫Can inject methylene blue 24 hr before surgery into
sinus tract- easier to locate and excise
⚫
⚫ All sequestra,purulent material and scarred and necrotic tissue
are removed until active punctate bleeding bone –paprika sign is
achieved
⚫ Tissue sent for culture
⚫ Dead space can be filled with antibiotic PMMA beads.
⚫ A soft tissue, local muscle flap, or a free tissue transfer can be
performed at time of bead removal
⚫ If bone unstable, stabilize, preferably with ilizarov type external
fixator
⚫ Antibiotic before,during and after operation
⚫ Wound is splinted
Management of Dead Space
⚫Bone and soft tissue defect eliminated by
1. Bone grafting with primary or secondary suture
2. Use of antibiotic PMMA beads as a temporary filler of
dead space before reconstruction
3. Local muscle flap and skin grafting with or without
bone grafting
4. Microvascular transfer of muscle, myocutaneous,
osseous, and osteocutaneous flaps
5. Use of bone transport ( illizarov technique)
Management of Dead Space
OPEN BONE GRAFTING
Papineau et al.
Used when free flaps or soft tissue transfer option are
limited
⚫ OPERATION IS DIVIDED IN 3 STAGES
1. Debridement and stabilization
thoroughly debride and irrigate all sequestra and
necrotic bone
stabilize bone with external fixator and intramedullary
nail if needed
apply VAC
redebride and irrigate with VAC change every 48 to 96
hrs until healthy viable tissue bed
⚫Cancellous bone harvested from iliac crest or
proximal tibia
2 . GRAFTING
⚫Bony defect packed
⚫Dressed with adaptic and VAC sponge
⚫ vac changed every 72 to 96 hrs until healthy
appearing granulation tissue
⚫Local muscle pedicle graft can be used to enhance
blood supply to graft
3 Wound coverage
apply skin graft or allow spontaneous epithelization
POLYMETHYLMETHACRYLATE ANTIBIOTICS
BEAD CHAIN
⚫ Delivers antibiotics locally in concentration that exceeds
minimal inhibitory concentration
⚫ Local concentration achieved are 200 times than systemic
antibiotic administration maintaining low serum and low
systemic toxicity
Aminoglycosides are commonly employed antibiotics
Other are Penicillin ,Cephalosporin and Clindamycin
Vancomycin elutes less effectively
Fluoroquinolones ,Tetracycline and Polymyxin are not
used
⚫BONE CEMENT
has Gentamycin (500 mg /40 gm pack)
generally add 2 to 4 gm of Vancomycin with or
without Tobramycin 1.2 gm
add monomer
⚫Local antibiotic level last only 2 to 4 weeks after
placement ,foreign body that remains may be
colnized by glycocalyx forming bacteria
ANTIBIOTIC BEAD POUCH
Used if soft tissue coverage is impossible after initial
debridement
Also used to prevent infection in open #
⚫ Thorough debridement of necrotic tissue and irrigation
using 9 lit saline solution containing bacitracin
⚫ PMMA antibiotic bead prepared and rolling into small
spheres and placed on 18 to 20 gauge wire to form bead
chain
⚫ PMMA antibiotic bead chain placed in bony defect.
⚫ All wound extension closed with interrupted nylon suture
⚫Skin edge is dried and benzoid solution applied
⚫Adhasive polyethylene wound film (opsite)applied to
cover wound
second layer larger opsite dressing over first dressing
to prevent leakage
⚫Bead pouch changed every 72 hrs with repeat
debridement and irrigation until wound healthy for
soft tissue coverage
⚫Limb is immobilized
INTRAMEDULLARY ANTIBIOTIC
CEMENT NAIL
⚫Reamer irrigator aspirator system followed by
placement of antibiotic impregnated cement nail plus
pathogenic specific systemic antibiotic is safe and
effective
⚫Debride all necrotic and non viable soft tissue and
bone and prepare medullary cavity using reaming
technique
⚫Reamings sent for culture studies
⚫Cement rod moulded using t-95 chest tube using
desired antibiotic, cement and monomer.
⚫Once polimerization is complete plastic tube removed
and nail inserted with usual intramedullary nailing
technique
⚫Long leg, bent knee cast applied
⚫Non wt bearing for 6-8 wk
⚫Cement nail replaced with regular intramedullary nail
BIODEGRADABLE ANTIBIOTIC
DELIVERY SYSTEM
⚫ADVANTAGE OVER PMMA
secondary procedure not required for implant
removal
better antibiotic release
better compatibility profile
⚫Used when bony instability is not an issue and soft
tissue coverage is adequate
⚫Some biodegradable substrates contain
osteoconductive and osteoinductive materials
⚫Biodegradable substance used as antibiotic delivery
system classified into 3 main categories
1. Proteins – collagen ,gelatin, thrombin, and autologous
blood clot
2. Bone graft substitutes –calcium sulphate
3. Synthetic polymer – can be modified to release specified
drug quantities over specific amount of time
Properties of ideal biodegradable carrier
good biocompatibility
controllable degradation
ability to release any antibiotic at therapeutic level for
extended period of time
CLOSE SUCTION DRAIN
1 . LAUTENBACH TECHNIQUE of closed antibiotic
ingress and egress irrigation system
Allows change in antibiotic delivery based on culture
reports
Frequent occlusion of delivery catheter occurs which is
decreased with use of streptokinse
Also risk of prolonged hospitalization and secondary
contamination
Lautenbach drainage system
2 Negative pressure wound therapy (NPWT) or VAC
edema reduction
increase blood flow
increase granulation tissue
possibility of improved bacterial clearance
BUT
excessive bleeding can occur
SOFT TISSUE TRANSFER
⚫ Ranges from localized muscle flap on a vascular pedicle to
microvascular free tissue transfer
⚫ Transfer of vascularized muscle tissue improves blood
supply that is important in host defence mechanism and
for antibiotic delivery and osseous and soft tissue healing
⚫ local muscle flap m/c used in chr OM of tibia
⚫ Gastrocnemius muscle used for defect around proximal
third ,soleus around middle third
⚫ microvascular free muscle transfer around distal third
⚫ Adequate initial debridement is required
ILIZAROV TECHNIQUE
⚫Allows radical resection of infected bone
⚫Corticotomy is performed through normal bone
proximal and distal to area of disease
⚫Disadvantage
time required to achieve solid union
high incidence of complication
Use of distraction osteogenesis with ring fixation over
an intramedullary rod has been used for defect up to
13 cm
ADJUVANT THERAPY
⚫HYPERBARIC OXYGEN THERAPY
⚫GROWTH FACTOR
enhance osteogenesis
1. bone morphogenic protein
2. platelet rich plasma
⚫PHYSICAL ENERGY MODALITIES
1. pulsed electromagnetic fields
2. Ultrasound
AMPUTATION IN OSTEOMYELITIS
⚫Infrequently Performed

⚫INDICATIONS
⚫Malignancy
⚫Arterial insufficiency ,
⚫Major nerve paralysis,
⚫ Joint contracture and stiffness that make a limb
non-functional
⚫In certain patients for multiple operations and
prolonged antibiotic therapy
COMPLICATIONS
⚫Acute Exacerbations- Most common
⚫Growth Abnormalities
⚫Pathological Fractures
⚫Deformities
⚫Amyloidosis
⚫Malignant Transformation-0.2 to 1.6 %
most are squamous cell carcinoma from sinus tract
other are reticulum cell carcinoma , fibrosarcoma
REFERENCES:
⚫Campbell’s operative orthopaedics 13th edition
⚫Apley’s system of Orthopaedics and Trauma 10th
edition
⚫Essential Orthopedics : Principles and Practice,
Manish Kumar Vashney
THANK YOU