INFECTION

ACUTE, SUBACUTE AND CHRONIC

OSTEOMYELITIS
Dr. Andi Dhedie P. Sam, M.Kes, Sp.OT
General aspect of infection
 Micro-organisms enter
the bones and joints :
 directly : a break in the
skin (a pinprick, a stab
wound, a laceration, an
open fracture or an
operation)
 indirectly via the blood
stream from a distant site:
the nose or mouth, the
respiratory tract, the
bowel or the genito-
urinary tract.
GENERAL ASPECTS OF INFECTION

 Acute pyogenic infections are characterized by:

 The formation of pus or abscess (Local effect)
a concentrate of defunct leucocytes, dead and dying bacteria
and tissue debris.
 Spread further afield via lymphatics or via the bloodstream
(systemic effect)
causing lymphangitis and lymphadenopathy, bacteraemia
and septicaemia, with systemic reaction : vatigue, mild
pyrexia, severe illness, fever, toxaemia and shock.
General aspect of infection
 Chronic infection
 follow on acute infection or start from beginning
 The formation of granulation tissue (a combination of
fibroblastic and vascular proliferation)  fibrosis.
 Host Response:
 Age of patient (very young or too old is more resistance),
 state of malnutrition,
 immuno-supresan
 other disease like diabetes

 Local Factors :
 damaged muscle and foreign bodies
 bone structure itself consist of collection of rigid
compartment make it more susceptible for vascular damage
and cell death..
General aspect of infection
 The principles of treatment are:
 (1) to provide analgesia and general supportive measures;
 (2) to rest the affected part;
 (3) effective antibiotic or chemotherapy; and
 (4) surgical eradication of infected and necrotic tissue.

For acute infections, the timing of surgery is all-important: in

the early stages, antibiotics should be given a chance and the
clinical condition carefully monitored to detect signs of
improvement or deterioration; if there is pus, it must be let
out and the sooner the better.
ACUTE HAEMATOGENOUS
OSTEOMYELITIS
 Acute osteomyelitis is almost invariably a disease of
children.
 This predilection for the metaphysis has been attributed
to the peculiar arrangement of the blood vessels in that
area: the non-anastomosing terminal branches of the
nutrient artery twist back in hair­pin loops before entering
the large network of sinusoidal veins; the relative
vascular stasis favours bacterial colo­nization.
 In young infants, in
whom there is still a free
anastomosis between
metaphyseal and
epiphyseal blood vessels,
infection can just as
easily lodge in the
epiphysis
 In adults, haematogenous
infection is more
common in the vertebrae
than in the long bones.
Pathology of
acute ostemyelitis
 Inflammation
acute inflammatory reaction, vascular
congestion, exudation of fluid,
infiltration of PMN, increase of
intraosseus pressure
 Suppuration
Subperiosteal abscess, end plate and
intervertebral disc infection
 Necrosis
avascular necrosis of growth plate
in infant. Bacterial toxins and
leucocytic enzymes also may play
their part in the advancing tissue
destruction.
 reactive new bone formation
 resolution and healing.
NEW BONE FORMATION
 New bone forms from the deep layers of the stripped
periosteum.
 This is typical of pyogenic infection and is usually
obvious by the end of the second week. With rime the
new bone thickens to form an involucrum enclosing the
infected tissue and sequestra.
 If the infection persists, pus and tiny sequestrated
splcules of bone may continue to discharge through
perforations (cloacae) in the involucrum and track by
sinuses to the skin surfaces; the condition is now
established as a chronic osteomyelitis.
(a) Infection in the metaphysis may spread cowards the surface, to form a subperiosteal abscess
(b). Some of the bone may die, and is encased in perio steal new bone as a sequestrum (c).The
encasing involucrum is sometimes perforated by sinuses.
RESOLUTION
 Once common, chronic osteomyelitis following on acute
is nowadays seldom seen. If infection is controlled and
intraosseous pressure released at an early stage, this dire
progress can be aborted. The bone around the zone of
infection is at first osteoporotic (probably due to
hypcraemia).
 Clinical features
 The patient, usually a child,
presents with severe pain, malaise
and a fever; in neglected cases,
toxaemia may be marked.
 X-RAYS NORMAL DURING
FIRST 10 DAYS
 Ultrasound may detect a
subperiosteal collection of fluid
in the early stages of
osteomyelitis, but it cannot
distinguish between a haematoma
and pus.
 Radioscintigrapby with 99mTc-HDP reveals increased
activity in both the perfusion phase and the bone phase..
It has relatively low specificity and other inflammatory
lesions can show similar changes.
 In doubtful cases, scanning with Ga-citrate or In labelled
leucocytes may be more revealing.
 MRI is extremely sensitive, even in the early phase of
bone infection, and can help to differentiate between
soft-tissue infection and osteomyelitis.
 The most typical feature is a reduced intensity signal in
T1-weighted images.
 Investigations

 The most certain way to confirm the clinical diagnosis is

to aspirate pus from the metaphyseal subperiosteal
abscess or the adjacent joint.
 The white cell count and C-reactive protein values are
usually high and the haemoglobin concentration
diminished; the ESR also rises but it may take several
days to do so and it often remains elevated even after the
infection subsides.
 Blood culture is positive in only about half the cases of
proven infection.
 Differential diagnosis

 Cellulitis
 Streptococcal necrotizing myositis

 Acute suppurative arthritis

 Acute rheumatism

 Sickle-cell crisis

 Gaucher's disease
 Treatment

 Supportive treatment for pain and dehydration;

 Splintage of the affected part;

 Antibiotic therapy 3 – 6 weeks; and

 Surgical drainage
 ANTIBIOTIC TREATMENT
 Older children and fit adult : Staphylococcus group
 Flucloxacillin and fusidic acid i.v 1 – 2 weeks
 Orally antibiotics 3 – 6 weeks

 Children < 4 years ; Haemophilus group and gram

negatife organisms
 Cephalosporins (cefuroxime or cefotaxime) i.v or orally
 Amoxicillin-clavulanic acid combination (co-amoxiclav, a β-
lactamase inhibitor)
SUBACUTE OSTEOMYELITIS
 Relative mildness
 The organism being less
virulent (Staphylococcus
aureusor ) and the patient
more resistance (or both);
 More variable in skeletal
distribution than acute
osteomyelitis
 The Distal femur and the
proximal and distal tibia are
favorite sites.
PATHOLOGY
 Well defined cavity in cancellous bone  glairy
seropurulent fluid (rare pus)
 Cavity is lined by granulation tissue of mixture of acute
and chronic inflammatory cells.
 The surrounding bone trabeculae are often thickened
Clinical features
 The patient : child or adolescent
 Pain near one of the larger joints for several weeks or
even months
 A limp or slight swelling, muscle wasting and local
tenderness
 Normal temperature to slight higher

 White cell count may be normal but ESR is raised

IMAGING
 Plain X-Ray
 A circumscribed, oval or round cavity 1 – 2 cm in diameter
on tibia or femoral metaphysis or in epiphysis or in cuboidal
bone (calcaneus)
 Cavity surrounded by halo of sclerosis (the classic Brodie’s
abscess)
 Metaphysis lesion  little or no periosteal reaction
 Diaphysial lesion  periosteal new bone formation and
cortical thickening
 Radioisotope scan
DIAGNOSIS
 Differential diagnosis : Osteoid osteoma with appearance
as malignant bone tumour
 Certain examination by Biopsy for bacteriological
culture.
TREATMENT
 Conservative
 Immobilization and antibiotics (flucloxacillin and fusidic
acid) for 6 weeks than thereafter for 6 – 12 months
 Curretage; indicate for lesion after biopsy and also for
the case with no healing with conservative treatment. 
Antibiotics
CHRONIC OSTEOMYELITIS
 The usual organisms (and with time there is always a
mixed infection) are Staph. aureus, E. coti, S. pyogenes,
Proteus and Pseudomonas;
 In the presence of foreign implants Staph. cpidermidis,
which is normally non-pathogenic, is the commonest of
all.
 Pathology
 Bone is destroyed or devitalized in a discrete area at the
focus of infection or more diffusely along the surface of
a foreign implant.
 Cavities containing pus and pieces of dead bone
(sequestra) are surrounded by vascular tissue, and
beyond that by areas of sclerosis -the result of chronic
reactive new bone formation. The sequestra act as
substrates
 The histological picture is one of chronic inflammatory
cell infiltration around areas of acellular bone or
microscopic sequestra.
Chronic osteomyelitis chronic bone infection, with a persistent sequestrum,
may be a sequel to acute osteomyelitis (a). More often it follows an open
fracture or operation (b). Occasionally it presents as a brodie's abscess (c).
 Clinical features

 The patient presents because pain, pyrexia, redness and

tenderness have recurred (a 'flare'), or with a discharging
sinus.
 In long-standing cases the tissues are thickened and often
puckered or folded in where a scar or sinus is attached to
the underlying bone.
 There may be a sero-purulent discharge and excoriation
of the surrounding skin.
 In post-traumatic osteomyelitis the bone may be
deformed or non-united.
 Imaging
 X-ray examination
Bone resorption with thickening and sclerosis of surrounding bone,
loss of trabeculation, area osteoporosis, periosteal thickening,
sequestra, or the bone crudely thickened and misshapen
 Radioisotope scintigraphy
Sensitive but not specific. Using 99m Tc-HDP for showing increased
activity of perfusion and bone phase and 67 Ga-Citrate or In-
labelled leucocytes for showing hidden foci of infection
 CT and MRI
Show the extent of bone destruction and reactive edema, hidden
abscess and sequestra
 Investigations

 ESR and blood white cell count

may be increased;  are helpful
in assessing the progress of bone
infection but they are not for
diagnostic.
 Organisms cultured from
discharging sinuses should be
tested repeatedly for antibiotic
sensitivity; with time, they often
change their characteristics and
become resistant to treatment.
 Treatment
 Antibiotics ; Fucidic acid,
clindamycin and cephalosporins
 Local treatment : incision and
drainage
 Operation
THANK
YOU