Chronic Osteomyelitis

Severe, persistent, and incapacitating

infection of bone and bone marrow of
more than 6 weeks duration characterised
by recurrent attacks of inflammation with
sinuses discharging.
Used to be common sequel to acute
haematogenous osteomyelitis.
Nowadays, frequently follows an open
fracture or operation.

Common organisms
Usual causative organisms:
S. aureus
E. coli
S. pyogenes
Proteus
Pseudomonas
S. epidermidis (commonest in the presence of
foreign implant)

Pathology
Acute OM commonly leads to chronic OM
because of > 1 of these reasons:

1) delayed & inadequate tx:

causes spreads of pus within the medullary
cavity & subperiosteally

death of a part of the bone
(sequestrum formation)
2) type & virulence of organisms
body defense mechanism may not be able to
control

3) decreased host resistance
malnutrition compromises bodys defence
mechanisms

4) iatrogenic
joints replacements & internal fixation of
fracture.

Chracterised by
formation of a
sequestrum, involucrum
and discharge of pus.

Clinical Features
Chronic discharging sinus
Commonest presenting symptoms
Onset of sinus may be traced back to an episode of acute OM
during childhood
Often sinuses heal for short periods, only to reappear with each
acute exacerbation
Sero-purulent thick pus
H/o extrusion of small bone fragments from the sinuses
Pain
Usually minimal but may become aggravated during acute
exacerbations
Swelling, redness
Malaise, fatigue
Non-healing ulcer, deformed/non-united bone
Fever (only during acute exacerbation)
Physical Examination
Chronic discharging sinus
Fixed to underlying bone
Sprouting granulation tissue at its opening, indicating
a sequestrum within the bone
Sequestrum may be visible at the mouth of the sinus
itself
Sinus may be surrounded by healed puckered scars
(previous healed sinuses)

Thickened, irregular bone
Compare the girth of the affected bone with the
normal side
Tenderness
On deep palpation
Usually mild
Adjacent joint
May be stiff
Either due to excessive soft tissue scarring around
the joint, or because of associated arthritis of the joint

Investigations
Blood
ESR:
During acute flares: CRP, WCC may be
Antistaphylococcal antibody titres may be elevated

Pus culture
Organisms cultured from discharging sinuses should
be tested repeatedly for antibiotic sensitivity
With time, they often change their characteristics and
become resistant to treatment


X-ray:
- Bone resorption - thickening, irregular &
sclerosis of the cortices (surrounding bone).
- Sequestra (dense fragments)
- Bone cavity - an area of rarefaction surrounded
by sclerosis.
- Involucrum & cloacae.
Radioisotope scintigraphy (bone scan):
- sensitive but not specific.
- increased uptake at metaphysis.

Treatment
Principal of treatment: mainly surgical
Antibiotics:
During acute exacerbations
During post-operative period
The aim of surgical intervention is
Removal of dead bone
Elimination of dead space
Removal of infected granulation tissue and
sinuses

Operative procedures
1) Sequestrectomy
Removal of sequestrum
If it lies within the medullary cavity, a window is made
in the overlying involucrum & the sequestrum
removed
Must have adequate involucrum formation before
performing sequestrectomy

2) Saucerization
A bone cavity is a non-collapsing cavity so
that there is always some pent-up pus inside
it.
This is responsible for the persistence of
infection
The cavity is converted into a saucer by
removing its wall. This allows free drainage of
the infected material.

3) Curettage
The wall of the cavity, lined by infected granulation
tissue, is curettaged until the underlying normal-
looking bone is seen.
The cavity is sometimes filled with Gentamicin
impregnated beads to fill up the dead space.
4) Excision of an infected bone
Affected bone can be excised en-bloc without
compromising the functions of the limb
Close the gap by Ilizarovs method of transporting a
viable segment of the bone from adjacent part.
5) Amputation
May be preferred in a case with a long-standing
discharging sinus, especially if the sinus undergoes
malignant change.

Complications
Acute exacerbation or flare up
Occurs commonly
Subsides with a period of rest and antibiotics

Growth abnormalities
Shortening when growth plate is damaged
Lengthening increased vascularity of the growth
plate d/t nearby osteomyelitis
Deformity - part of the growth plate is damaged & the
remaining keeps growing

A pathological fracture
May occur through weakened area of the bone
Conservative treatment
Joint stiffness
May occur because of scarring of the soft tissues or a
secondary infection of the joint
Sinus tract malignancy
A rare complication
It occurs many years after the onset of osteomyelitis
Squamous cell carcinoma
Need amputation
Amyloidosis