OSTEOMYELITIS

DEPATMENT OF INFECTIOUS DISEASE

TEHRAN UNIVERSITY OF MEDICAL SCIENCE

M.RASOOLINEJAD, MD

OSTEOMYELITIS
INFLAMMATORY PROCESS IN BONE & BONE MARROW ACUTE & CHRONIC

PATHOPHYSIOLOGY
Hematogenous Osteomyelitis
Contiguous-Focus Osteomyelitis
Peripheral Vascular Disease-associated

PATHOPHYSIOLOGY

Microorganisms enter bone (Phagocytosis). Phagocyte contains the infection Release enzymes Lyse bone

PATHOPHYSIOLOGY
Bacteria escape host defenses by:
Adhering tightly to damage bone Persisting in osteoblasts Protective polysaccharide-rich biofilm

PATHOPHYSIOLOGY
Pus spreads into vascular channels Raising intraosseous pressure Impairing blood flow Chronic ischemic necrosis Separation of large devascularized fragment
(Sequestra)

New bone formation (involucrum)

PATHOLOGY
Acute Infiltration of PMNs Congested or thrombosed vessels Chronic Necrotic bone Absence of living osteocyte Mononuclear cells predominate Granulation & fibrous tissue

Hematogenous Osteomyelitis

HEMATOGENOUS OSTEPMYELITIS

Rapidly growing bone Children: Long bone, Femur, Tibia, Humerus

Older patients: Vertebral bone

HEMATOGENOUS OSTEOMYELITIS
Neonate & infant < 1 year old
Septic arthritis is common.

Growth deformities is common.

Soft tissue involvement is common.

HEMATOGENOUS OSTEOMYELITIS
Children: 1 16 years old
Most frequent in the metaphysis of long bone.

Slugging blood flow through a sinusoidal venous system.

Deficency of phagocytic cells. Poor collateral circulation

Susceptibility of this region to trauma.

HEMATOGENOUS OSTEOMYELITIS
Children: 1 16 years old
History of antecedent trauma in 30%

Involucrum
Sequestration Associated septic arthritis

HEMATOGENOUS OSTEOMYELITIS

Adult
Less common
Spread infection to joint space. Vertebral Osteomyelitis is common> 50y

HEMATOGENOUS OSTEOMYELITIS

Sickle cell disease Injection drug users (IDUs) Hemodialysis HIV/AIDS Immunosuppression Prosthetic orthopedic device

Special consideration

HEMATOGENOUS OSTEOMYELITIS

Microbiologic

Staphylococci Aureus, Epidermidis Streptococci Group A & B Haemophilus influenzae Gram-negative enteric bacilli Anaerobes Polymicrobial Mycobacterial Fungi

features

HEMATOGENOUS OSTEOMYELITIS

Clinical manifestation

Classic presentation: Sudden onset Usually presentation: Slow, insidious High fever, Night sweats Fatigue, Anorexia, Weight loss Restriction of movement

Local edema, Erythema, & Tenderrness

HEMATOGENOUS OSTEOMYELITIS

Differentials
Cellulitis Gas gangrene Neoplasm Aseptic bone infection

Clenched fist osteomyelitis

HEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-up

WBC May be elevated, Usually normal

Lab study:

C-Reactive Protein (CRP) Erythrocyte Sedimentation Rate (Usually is elevated at presentation Falls with successful therapy)

Blood culture ( Acute osteomyelitis + ve > 50% )

HEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-up

Imaging

Radiology:
Normal Soft tissue swelling Periosteal elevation Lytic change Sclerotic changew

HEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-up

Imaging MRI:

Early detection Superior to plan X ray & CT Scan & radionuclide bone scan in slected anatomic location. Sensitivity 90 100%

HEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-up

Radionuclide bone scan:

Imaging

A 3-phase bone scan ( Technetium 99m ) Positive as early as 24 h after onset of symptoms. False positive Tumor, osteonecrosis Artheritis, Cellulitis, Abscess

HEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-up

CT Scan:

Imaging

Useful in evaluation of Spinal, pelvic, Sternum, Calcaneus

Provides exellent images of bone cortex

Is used for biopsy localization

Os + gaz in diabetic foot

Septic arthritis Of Right hip

HEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-up

Simple & inexpensive Demonstration anomaly 1 2 days after onset Soft tissue abscess, Fluid collection, & Periosteal elevation It allows for aspiration
It doesnt allow for evaluation of bone cortex.

Ultrasonography

HEMATOGENOUS OSTEOMYELITIS

Diagnosis & work-up

From: Soft tissue collection Subperiosteal abscess Intraosseos lesions For: Smear Culture Pathology

Neddle Aspiration or Open biopsy:

TREATMENT
Initial treatment shoud be aggressive. Inadequate therapy Chronic disease

Antibiotic use: Parenteral High doses Good penetration in bone Full course Empiric therapy

Surgery

TREATMENT
Empiric Initial Therapy
Neonate Infant<2 y Children Adult S.aureus G ve bacilli S.aureus H.Infenza S.aureus PRP + Cefotaxime PRP + Ceftriaxone PRP or 1st ceph

TREATMENT
Indication for Surgery

Diagnostic Hip joint involvement Neurologic complication Poor or no response to IV therapy Sequestration

TREATMENT
Monitoring Therapeutic Response

1.Symptoms & Signs

2.ESR & CRP 3.Radiography

4.Serial Bone Scan?

PROGNOSIS
Is related to:
Causative organisms Duration of symptoms & sign
Patient age Duration of antibiotic therapy

COMPLICATION
Bone abscess Bacteremia
Fracture Loosing of the prosthetic implant Overlying soft-tissue cellulitis Draining soft-tissue tract

Post Osteomyelitis Treatment

Septic Osteomyelitis

Post Osteomyelitis Scar

Post Osteomyelitis Deformity of the Forearm

CONTIGUOUS-FOCUS OSTEOMYELITIS

Contiguous-focus Osteomyelitis

Clinical setting:
Postoperative infection Contamination of bone Contiguous soft tissue infection

Puncture wounds

Contiguous-focus Osteomyelitis

Microbiologic features
Staphylococci Aureus, Epidermidis Gram-negative bacteria Anaerobic infection Unusual organisms Clostridia, Nocardia

Contiguous-focus Osteomyelitis

Diagnosis
Leukocyte count Blood culture (infrequently positive) ESR & CRP Radiologic evaluation Technetium bone scan Open bone biopsy Culture of wound & draining sinuses??

Contiguous-focus Osteomyelitis

Treatment
Surgery is essential. Antibiotics Specific Duration