osteomylitis

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Information about osteomylitis
Health & Medicine

Published on October 4, 2008

Author: prammy4u

Source: slideshare.net

osteomyelitis Moderator: Dr peeyush sharma Presenter: Dr Pramod mahender

osteomyelitis Nelaton (1834):coined osteomyelitis osteon:bone myelo:marrow

Nelaton (1834):coined osteomyelitis

osteon:bone

myelo:marrow

Osteomyelitis >3months Chronic: Less virulent – more immune 2weeks—3months Subacute: Early acute Late acute(4-5days) <2weeks Acute:

Early acute

Late acute(4-5days)

Organisms Commonly Isolated in Osteomyelitis Based on Patient Age Infants (<1 year) Group B streptococci Staphylococcus aureus Escherichia coli Children (1 to 16 years) S. aureus Streptococcus pyogenes Haemophilus influenzae Adults (>16 years) Staphylococcus epidermidis S. aureus Pseudomonas aeruginosa Serratia marcescens E. coli

Infants (<1 year) Group B streptococci Staphylococcus aureus Escherichia coli

Children (1 to 16 years) S. aureus Streptococcus pyogenes Haemophilus influenzae

Adults (>16 years) Staphylococcus epidermidis S. aureus Pseudomonas aeruginosa Serratia marcescens E. coli

Risk factors Trauma (orthopaedic surgery or open fracture) Prosthetic orthopaedic device Diabetes Peripheral vascular disease Chronic joint disease Alcoholism Intravenous drug abuse Chronic steroid use Immunosuppression Tuberculosis 7 HIV and AIDS Sickle cell disease Presence of catheter-related blood stream infection 4

Trauma (orthopaedic surgery or open fracture)

Prosthetic orthopaedic device

Diabetes

Peripheral vascular disease

Chronic joint disease

Alcoholism

Intravenous drug abuse

Chronic steroid use

Immunosuppression

Tuberculosis 7

HIV and AIDS

Sickle cell disease

Presence of catheter-related blood stream infection 4

osteomyelitis General factors Anaemia Debility Infection Poor nutrition Poor immune status Local factor Hair pin bend vessels Metaphyseal haemorrhage Defective Phagocytosis Rapid groth at metaphysis Trabeculae of degenerating cartilage Vasospasm Anoxia

General factors

Anaemia

Debility

Infection

Poor nutrition

Poor immune status

Local factor

Hair pin bend vessels

Metaphyseal haemorrhage

Defective Phagocytosis

Rapid groth at metaphysis

Trabeculae of degenerating cartilage

Vasospasm

Anoxia

pathophysiology Primary & secondary spongiosa Limit reticuloendothelial cells Immature cell, anoxia Hairpin bend ( metaphyseal arteries) Sluggish circulation infection

Clinical feature Spurulent drainage Chornic Vague Cannot pinpoint onset Fever/swelling-mild Sub acute (Infant;premature neonates) Swelling pain Late Acute Febrile illness Limping to walk Avoidance of using the extremity Early Acute

Spurulent drainage

Vague

Cannot pinpoint onset

Fever/swelling-mild

(Infant;premature neonates)

Swelling

pain

Febrile illness

Limping to walk

Avoidance of using the extremity

lab COMPLETE BLOOD COUNT CULTURE (24-48hrs later) 1-JOINT FLUID 2-BLOOD 3-DEEP BONE BIOPSY LEUKERGY ESR C REACTIVE PROTIEN LEUCOCYTE COUNT X RAY-LAGS 2wks BEHIND RADIONUCLEOTIDE SCAN- Disadvantage-fracture healing,osteomyelitis,tumour C T SCAN- NECROTIC PORTION TECHNETIUM 99 BONE SCAN(85% PPV)-when diag unclear-clavicle,pelvis,fibula SPECT INDIUM/GALLIUM SCAN USG-SUBPERIOSTEAL ABSCESS MRI- BEST

COMPLETE BLOOD COUNT

CULTURE (24-48hrs later)

1-JOINT FLUID 2-BLOOD 3-DEEP BONE BIOPSY

LEUKERGY

ESR

C REACTIVE PROTIEN

LEUCOCYTE COUNT

X RAY-LAGS 2wks BEHIND

RADIONUCLEOTIDE SCAN- Disadvantage-fracture healing,osteomyelitis,tumour

C T SCAN- NECROTIC PORTION

TECHNETIUM 99 BONE SCAN(85% PPV)-when diag unclear-clavicle,pelvis,fibula

SPECT

INDIUM/GALLIUM SCAN

USG-SUBPERIOSTEAL ABSCESS

MRI- BEST

MORREY AND PETERSON”S CRITERIA DEFINITION- THE PATHOGEN IS ISOLATED FROM BONE OR ADJACENT SOFT TISSUE AS THERE IS HISTOLOGIC EVIDENCE OF OSTEOMYELITIS PROBABLE- A BLOOD CULTURE IS POSITIVE IN SETTING OF CLINICAL AND RADIOLOGICAL FEATURES OF OSTEOMYELITIS LIKELY- TYPICAL CLINICAL FINDING AND DEFINITE RADIOGRAFFIC EVIDENCE OF OSTEOMYELITIS ARE PRESENT AND RESPONSE TO ANTIBIOTIC THERAPY

DEFINITION- THE PATHOGEN IS ISOLATED FROM BONE OR ADJACENT SOFT TISSUE AS THERE IS HISTOLOGIC EVIDENCE OF OSTEOMYELITIS

PROBABLE- A BLOOD CULTURE IS POSITIVE IN SETTING OF CLINICAL AND RADIOLOGICAL FEATURES OF OSTEOMYELITIS

LIKELY- TYPICAL CLINICAL FINDING AND DEFINITE RADIOGRAFFIC EVIDENCE OF OSTEOMYELITIS ARE PRESENT AND RESPONSE TO ANTIBIOTIC THERAPY

Peltola and vahvanen’s criteria -Pus on aspiration -Positive bacterial culture from bone or blood -Presence of classic signs and symptoms of acute osteomyelitis -Radiographic changes typical of osteomyelitis *--Two of the listed findings must be present for establishment of the diagnosis .

-Pus on aspiration -Positive bacterial culture from bone or blood -Presence of classic signs and symptoms of acute osteomyelitis -Radiographic changes typical of osteomyelitis *--Two of the listed findings must be present for establishment of the diagnosis .

 

Plain-film radiograph showing osteomyelitis of the second metacarpal (arrow). Periosteal elevation, cortical disruption and medullary involvement are present.

Plain-film radiograph showing osteomyelitis of the second metacarpal (arrow).

Periosteal elevation,

cortical disruption and

medullary involvement are present.

 

WALDVOGEL 1970 HEMATOGENOUS CONTIGEUOUS FOCUS OSTEOMYELITIS WITH VASCULAR INSUFFICIENCY

HEMATOGENOUS

CONTIGEUOUS FOCUS

OSTEOMYELITIS WITH VASCULAR INSUFFICIENCY

WEILAND 1984 TYPE 1 – -OPEN EXPOSED BONE WITHOUT OSSEOUS INFECTION BUT SOFT TISSUE INFECTION TYPE 2 – CIRCUMFERENTIALCORTICAL+ENDOSTEAL INFECTION INCREASE SCLEROTIC THICKENING OF CORTEX INCREASE DENSITY AREAS OF BONY RESORPTION+SEQUESTRUM TYPE 3 – CORTICAL+ENDOSTEAL INFECTION+A SEGMENTAL BONE DEFECT

TYPE 1 –

-OPEN EXPOSED BONE WITHOUT OSSEOUS INFECTION BUT SOFT TISSUE INFECTION

TYPE 2 –

CIRCUMFERENTIALCORTICAL+ENDOSTEAL INFECTION

INCREASE SCLEROTIC THICKENING OF CORTEX

INCREASE DENSITY

AREAS OF BONY RESORPTION+SEQUESTRUM

TYPE 3 –

CORTICAL+ENDOSTEAL INFECTION+A SEGMENTAL BONE DEFECT

GORDON’S 1988 TYPE A – NONUNION WITHOUT SEGMENTAL LOSS TYPE B - >3cm SEGMENTAL LOSS WITH INTACT FIBULA TYPE C - >3cm SEGMENTAL LOSS WITHOUT INTACT FIBULA

TYPE A – NONUNION WITHOUT SEGMENTAL LOSS

TYPE B - >3cm SEGMENTAL LOSS WITH INTACT FIBULA

TYPE C - >3cm SEGMENTAL LOSS WITHOUT INTACT FIBULA

GER’S 1982 SIMPLE SINUS CHRONIC SUPERFICIAL MULTIPLE SINUSES MULTIPLE SKIN-LINED SINUSES

SIMPLE SINUS

CHRONIC SUPERFICIAL

MULTIPLE SINUSES

MULTIPLE SKIN-LINED SINUSES

KELLY’S 1984 HEMATOGENOUS OSTEOMYELITIS OSTEOMYELITIS WITH FRACTURE UNION OSTEOMYELITIS WITH FRACTURE NONUNION POST OPERATIVE OSTEOMYELITIS WITHOUT FRACTURE

HEMATOGENOUS OSTEOMYELITIS

OSTEOMYELITIS WITH FRACTURE UNION

OSTEOMYELITIS WITH FRACTURE NONUNION

POST OPERATIVE OSTEOMYELITIS WITHOUT FRACTURE

MAY’S 1989 TYPE 1- WITHSTAND FUNCTIONAL LOAD – 6-12weeks TYPE 2- INTACT TIBIA NEEDED GRAFT- 3-6months TYPE 3- DEFECT < 6cm, INTACT FIBULA – 6-12months TYPE 4- > 6cm,INTACT FIBULA – 12-18months TYPE 5- > 6cm- UNUSABLE FIBULA- > 18months

TYPE 1- WITHSTAND FUNCTIONAL LOAD – 6-12weeks

TYPE 2- INTACT TIBIA NEEDED GRAFT- 3-6months

TYPE 3- DEFECT < 6cm, INTACT FIBULA – 6-12months

TYPE 4- > 6cm,INTACT FIBULA – 12-18months

TYPE 5- > 6cm- UNUSABLE FIBULA- > 18months

TABLE 1 Waldvogel Classification System for Osteomyelitis Hematogenous osteomyelitis Osteomyelitis secondary to contiguous focus of infection No generalized vascular disease Generalized vascular disease Chronic osteomyelitis (necrotic bone)

Hematogenous osteomyelitis

Osteomyelitis secondary to contiguous focus of infection

No generalized vascular disease

Generalized vascular disease

Chronic osteomyelitis (necrotic bone)

The Penny classification of chronic osteomyelitis in children includes both diaphyseal and metaphyseal types . Diaphyseal osteomyelitis may be broken down into the following types: type I (typical, A), type II (atrophic, B), type III (sclerotic, C), type IV (cortical, D), type V (multiple walled-off abscesses, E), and type VI (multiple microabscesses, F). metaphyseal osteomyelitis is shown in G.

Diaphyseal

osteomyelitis may be broken down into the following types:

type I (typical, A),

type II (atrophic, B),

type III (sclerotic, C),

type IV (cortical, D), type

V (multiple walled-off abscesses, E), and

type VI (multiple microabscesses, F). metaphyseal osteomyelitis is shown in G.

 

 

DE CIERNY-MADER 12 STAGES DISEASE PROCESS – REGARDLESS OF – 1-ETIOLOGY 2-REGIONALITY 3-CHRONICITY DYNAMIC

12 STAGES

DISEASE PROCESS – REGARDLESS OF – 1-ETIOLOGY

2-REGIONALITY

3-CHRONICITY

DYNAMIC

The Cierny-Mader Staging System Anatomic Type Description Stage 1 Medullary osteomyelitis Stage 2 Superficial osteomyelitis Stage 3 Localized osteomyelitis Stage 4 Diffuse osteomyelitis Physiologic Class A host Normal host B- host Systemic compromise (Bs) Local compromise (Bl) Systemic and local compromise (Bls) C host Treatment worse that the disea

Anatomic

Type Description

Stage 1 Medullary osteomyelitis

Stage 2 Superficial osteomyelitis

Stage 3 Localized osteomyelitis

Stage 4 Diffuse osteomyelitis

Physiologic

Class

A host Normal host

B- host Systemic compromise (Bs)

Local compromise (Bl)

Systemic and local compromise (Bls)

C host Treatment worse that the disea

Systemic or Local Factors That Affect Metabolism, Local Vascularity, and Immune Surveillance Local (Bl) Arteritis Chronic lymphedema Extensive scarring Major vessel compromise Neuropathy Radiation fibrosis Small vessel disease Tobacco abuse 2 packs/day) Venous stasis Systemic (Bs) Chronic hypoxia Diabetes mellitus Extremes of age Immune disease Immunosuppression or immune deficiency Malignancy Malnutrition Renal and/or hepatic failure

Local (Bl)

Arteritis

Chronic lymphedema

Extensive scarring

Major vessel compromise

Neuropathy

Radiation fibrosis

Small vessel disease

Tobacco abuse

2 packs/day)

Venous stasis

Systemic (Bs)

Chronic hypoxia

Diabetes mellitus

Extremes of age

Immune disease

Immunosuppression or

immune deficiency

Malignancy

Malnutrition

Renal and/or hepatic

failure

Nade’s principles Antibiotic is effective before pus forms Antibiotic cannot sterilise avacular tissue Antibiotic prevents reformation of pus once removed Pus removal restores periosteum---- restores blood flow Antibiotic should be continued after surgery

Antibiotic is effective before pus forms

Antibiotic cannot sterilise avacular tissue

Antibiotic prevents reformation of pus once removed

Pus removal restores periosteum---- restores blood flow

Antibiotic should be continued after surgery

Nade’s indications for surgery Abscess formation Severely ill & moribund child Failure to respond to IV antibiotics for >48 hrs

Abscess formation

Severely ill & moribund child

Failure to respond to IV antibiotics for >48 hrs

management Antibiotic: stage1---- 2week iv change to oral (avoid quinolones) stage 2 – 2wk+ superficial debridement stage3& 4 -4-6wk iv (from last major deb)

Antibiotic: stage1---- 2week iv

change to oral

(avoid quinolones)

stage 2 – 2wk+

superficial debridement

stage3& 4 -4-6wk iv

(from last major deb)

Surgical mx Debridement surgery is fondation of osteomyelitis treatment External fixator prior/during Complete wound closure;wherever Sution irrigation(not recommended) Secondary intention-discouraged Local flap+/- cancellous bone Illizarov external fixation-9mth

Debridement surgery is fondation of osteomyelitis treatment

External fixator prior/during

Complete wound closure;wherever

Sution irrigation(not recommended)

Secondary intention-discouraged

Local flap+/- cancellous bone

Illizarov external fixation-9mth

Antibiotic impregnated Acrylic beads removed in 2-4 wks Replased with cancellous bone -vanco/tobra/genta -degrada beads -implantable pump Infected pseudorthosis .>3cms vascu.b transfer

Antibiotic impregnated Acrylic beads

removed in 2-4 wks

Replased with cancellous bone

-vanco/tobra/genta

-degrada beads

-implantable pump

Infected pseudorthosis .>3cms vascu.b transfer

Cierney mader Soft tissue coverage After debridement Bone exposed Stage2 :NO hardware-Nosurgery Intramedulary reaming+/- bone grafting +/- brace/cast Children Adult Stage1

Cierney mader Structural stability Obliterating debridement gaps -bone graft -Illizarov - free flaps -vascular bone instability Stage4 Deberidment Reconstruction of bone &soft tissue Sequestered +above Stage3

Osteomyelitis and hiv Uncommon (.5%-2%) Mortality(20%) S.aureus(mc) m.tuberculosis (not common) Atypical –mac Bortonella cmv fungi DD -kaposi’s sarcoma -avn -lymphoma

Uncommon (.5%-2%)

Mortality(20%)

S.aureus(mc)

m.tuberculosis (not common)

Atypical –mac

Bortonella

cmv

fungi

DD -kaposi’s sarcoma

-avn

-lymphoma

Musculoskeletal &hiv Arthritis Myositis Osteomyelitis

Arthritis

Myositis

Osteomyelitis

Spondylarthropathy reiter’s psoriatic Acute symmetric polyarthritis Hiv asso Arthritis Painful articular syn Septic arthritis Myositis— AZt hiv related polymyositis

Spondylarthropathy

reiter’s

psoriatic

Acute symmetric polyarthritis

Hiv asso Arthritis

Painful articular syn

Septic arthritis

Myositis—

AZt

hiv related polymyositis

THANK YOU

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