OSTEOMYELITIS

M.RASOOLINEJAD, MD
DEPATMENT OF INFECTIOUS DISEASE
TEHRAN UNIVERSITY OF MEDICAL SCIENCE
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

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

Microbiologic features
Staphylococci Aureus, Epidermidis
Streptococci Group A & B
Haemophilus influenzae
Gram-negative enteric bacilli
Anaerobes
Polymicrobial
Mycobacterial
Fungi
 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
Lab study:
WBC May be elevated, Usually normal

{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
Imaging
Radionuclide bone scan:
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
Imaging
CT Scan:
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
Ultrasonography
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.

 HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Neddle Aspiration or Open biopsy:
From: Soft tissue collection
Subperiosteal abscess
Intraosseos lesions

For: Smear
Culture
Pathology
 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 S.aureus PRP +
Infant<2 y G ve bacilli Cefotaxime

Children S.aureus PRP +

H.Infenza Ceftriaxone

Adult S.aureus 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