Chronic Osteomyelitis

Factors responsible for chronicity

Local factors: Cavity, Sequestrum, Sinus, Foreign body, Degree of bone necrosis General: Nutritional status of the involved tissues, vascular disease, DM, low immunity Organism: Virulence Treatment: Appropriateness and compliance Risk factors: Penetrating trauma, prosthesis, Animal bite

Chronic Osteomyelitis
Types

A complication of acute Osteomyelitis Post traumatic Post operative

Chronic Osteomyelitis
Clinical picture

Continuous or intermittent suppuration and

sinus formation with acute exacerbations.

Pain, fever, redness, and tenderness during acute exacerbations. Discharging sinus with +ve/-ve culture. Pathological fracture.

Chronic Osteomyelitis
Investigation Lab tests/ culture Plain X-ray: Bone rarefaction surrounded by the dense sclerosis, sequestration and cavity formation Sinogram Bone scan & gallium scan To detect chronic multifocal osteomyelitis CT Scan & MRI Biopsy

Chronic Osteomyelitis
Complications

Recurrence & Recurrence & Recurrence Pathological fractures Growth disturbance Amyloid disease Epidermoid carcinoma of the fistula

CHRONIC OSTEOMYELITIS

Sequel of acute/open fracture/opt. C/F: pain, discharging sinus, scars Xray- bone resorption, sequestra, CT/MRI: extent of bone loss, oedema, hidden abscess Lab-raised ESR pus-cs

TREATMENT

Antibiotics. Local treatment. Operations. After care.

TUBERCULOSIS

A surgeon could gain experience in the management of TB. Of bone and joint only if he choose to work in econmically less developed countries.
(edit, Br.Med.J>1968)

T.B. OSTEOMYELITIS

1/3 population infected. Over 80,000 people in Nepal have TB. 22,000 develop Pul. TB every year. Total 50,000. 10,000 die of TB. LEADING CAUSE OF DEATH. 1 3% skeletal TB

TB

Cause by Mycobacterium tuberculosis, occasionally by M.bovis/africanum. Also known as tubercle bacilli as they produce lesion tubercles. Acid fast bacilli. Transmission airborne droplets. Risk- extent of exposure to droplets and susceptibility to infection.

TB Primary infection

Exposure to tubercle bacilli Lungs multiplication of bacilli in terminal alveoli (Ghon focus) lymphatic drain it to hilar lymph nodes (PRIMARY COMPLEX) BLOOD SPREAD.

TB

C/F:Cough >3wks.,sputum production, weight loss, monoarticular. Respiratory haemoptysis, chest pain, breathlesness. Constitutional:fever/night sweat , tiredness , loss of appetite. Physical sign: non specific,muscle wasting, loss of ROM

TB

3 days sputum. Ziehl-Neelsen stain. X-ray: cavitation, infilteration, lymphadenopathy. Full blood count:Relative lymphocytosis,^ ESR,Anemia. Serology. Lymphnode biopsy. CT/ MRI

BONE TUBERCULOSIS

Spread from primary complex to any bone/joints. Can effect any bone but the weight bearing bones are more likely to be affected. Spine commonest, hip, knee , foot.

STAGES OF ARTICULAR TB

1 SYNOVITIS. 2 EARLY ARTHRITIS. 3 ADVANCED ARTHRITIS. 4 ADV.ART. PATHOLOGICAL DISLOCATION / SUBLUXATION. 5 AFTER MATH TERMINAL OF GROSS ARTHRITIS.

STAGES

C/F

XRAY SOFT TISSUE SWELLING, OSTEOPOROSIS JT.SPACE DIMINITION AND MARGINAL EROSION

PROGNOSIS NEAR NORMAL RESTORATION UPTO 75%

1 synovitis ROM>75% 2 early arthritis ROM50-75%

3 Adv. arthritis
4Adv. Arth path/disln 5 Aftermath

ROM >75% ALL DIRECTION

DO GROSS DEFORMITY

DESTRUCTION OF JT. SURFACE

DISORGANISE JT. DIS/SUB.LOCATION DEFORMED JT. , OA

ANKYLOSIS

ANKYLOSIS ANKYLOSIS

TB - TYPES

Caseous exudativemore destruction, exudation & abscess formation. Symptoms more marked. Onset is less insidious.

Granular type less destructive. Abscess formation rare. Dry lesion. adults

TUBERCULOSIS

Spine is the most common site of skeletal TB

TUBERCULOSIS

Pathology

Blood borne - settles in vertebral body anteriorly usually more bone destruction, more sequestra, larger abscess, gaseous pus than pyogenic OM intervertebral discs preserved until late disease

TB SPINE -Classification

12345-

pre-destructive early destructive. mild angular kyphos. moderate angular kyphos. severe kyphos (humpback)

STAGES 1 & 2

Predestructive straightening of curvatures , spasm of perivertebral muscles, MRImarrow oedema.

Early destructive Diminished disk space and paradiscal erosion.MRI-marrow oedema and break of osseous margin.CT-marginal erosion /cavitaion

STAGE 3,4&5 Body destruction with Kyphos

Mild moderate severe

2-3 vertebra >3 body >3 body

Kyphosis 10-30* 30-60* >60*

TB SPINE D/D

AGE- anomalies. Infection. Tumour. Traumma. Osteoporosis ,Osteochondrosis. Spondylolisthesis.

TB SPINE

C/F:Back pain of variable duration, fever and weight loss. O/E: local tenderness, spasm, mild kyphosislate Gibbus, cold abscess and paraparesis. DIAGNOSIS: XRAY-erosion of the anterior edges of the superior and inferior boarders of adjacent vertebral bodies with narrowing of disc space. USG :paravertebral abscess. Biopsy/ CT scan

TB HIP

C/F: pain/limping, irritable hip child. Gradual loss of range of movement, flexion deformity, wasting of thigh muscles. Xray: both hip to compare.Early changes rarefaction of the bone and widening of the joint space, later destruction of the joint. Synovial bioposy.

TB KNEE / ANKLE.

C/F: pain and synovial swelling, muscle wasting., contracture, draining sinuses. X-ray. Synovial biopsy.

PRINCIPLES OF MANAGEMENT OF TB

General. Rest, mobilization & brace. Abscess, effusion & sinuses. Antitubercular drugs. surgery

TB PROBLEMS

Diagnosis. Treatment . Anti tuberculous drugs.

Tuberculous lesion

Resolve completely. Complete healing with varying degree of deformity / loss of function. Lesion may be complete walled off and the caseous tissue may calcified. Persist as a low grade ch.fibromatous granulating & caseating lesion. Infection may spread. Damage growth centre with shortening.

CONCLUSION

Slow progressive course of clinical symptoms and radiological signs of tuberculosis creates difficulty in early diagnosis. Anti tuberculous treatment is effective but the functional outcome depends on early diagnosis before the development of radiological evidence of joint destruction. Always keep TB in D?Diagnosis

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