Slide1: OSTEOMYELITIS


Slide2: OSTEOMYELITIS INFLAMMATORY PROCESS IN BONE & BONE MARROW ACUTE & CHRONIC


Slide3: PATHOPHYSIOLOGY Hematogenous Osteomyelitis Contiguous-Focus Osteomyelitis Peripheral Vascular Disease-associated


Slide4: PATHOPHYSIOLOGY Microorganisms enter bone (Phagocytosis). Phagocyte contains the infection Release enzymes Lyse bone


Slide5: PATHOPHYSIOLOGY Bacteria escape host defenses by: Adhering tightly to damage bone Persisting in osteoblasts Protective polysaccharide-rich biofilm


Slide6: PATHOPHYSIOLOGY Pus spreads into vascular channels Raising intraosseous pressure Impairing blood flow Chronic ischemic necrosis Separation of large devascularized fragment New bone formation (involucrum) (Sequestra)


Slide7: PATHOLOGY Acute Infiltration of PMNs Congested or thrombosed vessels Chronic  Necrotic bone Absence of living osteocyte Mononuclear cells predominate Granulation & fibrous tissue


Slide8: Hematogenous Osteomyelitis


Slide9: HEMATOGENOUS OSTEPMYELITIS Rapidly growing bone Children: Long bone, Femur, Tibia, Humerus Older patients: Vertebral bone


Slide12: HEMATOGENOUS OSTEOMYELITIS Neonate & infant < 1 year old Septic arthritis is common. Growth deformities is common. Soft tissue involvement is common.


Slide13: 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.


Slide15: HEMATOGENOUS OSTEOMYELITIS Children: 1 – 16 years old History of antecedent trauma in 30% Involucrum Sequestration Associated septic arthritis


Slide16: HEMATOGENOUS OSTEOMYELITIS Adult Less common Spread infection to joint space. Vertebral Osteomyelitis is common> 50y


Slide18: HEMATOGENOUS OSTEOMYELITIS Special consideration Sickle cell disease Injection drug users (IDUs) Hemodialysis HIV/AIDS Immunosuppression Prosthetic orthopedic device


Slide19: HEMATOGENOUS OSTEOMYELITIS Microbiologic features Staphylococci  Aureus, Epidermidis Streptococci  Group A & B Haemophilus influenzae Gram-negative enteric bacilli Anaerobes Polymicrobial Mycobacterial Fungi


Slide20: 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


Slide21: HEMATOGENOUS OSTEOMYELITIS Differentials Cellulitis Gas gangrene Neoplasm Aseptic bone infection


Slide22: Clenched fist osteomyelitis


Slide23: 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% ) {


Slide24: HEMATOGENOUS OSTEOMYELITIS Diagnosis & work-up Imaging Radiology: Normal Soft tissue swelling Periosteal elevation Lytic change Sclerotic changew


Slide25: 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%


Slide26: 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


Slide27: 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


Slide28: Os + gaz in diabetic foot


Slide30: Septic arthritis Of Right hip


Slide31: 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 doesn’t allow for evaluation of bone cortex.


Slide32: HEMATOGENOUS OSTEOMYELITIS Diagnosis & work-up Neddle Aspiration or Open biopsy: From: Soft tissue collection Subperiosteal abscess Intraosseos lesions For: Smear Culture Pathology


Slide33: TREATMENT Initial treatment shoud be aggressive. Inadequate therapy  Chronic disease Antibiotic use: Surgery Parenteral High doses Good penetration in bone Full course Empiric therapy


Slide34: 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


Slide35: TREATMENT Indication for Surgery Diagnostic Hip joint involvement Neurologic complication Poor or no response to IV therapy Sequestration


Slide36: TREATMENT Monitoring Therapeutic Response Symptoms & Signs ESR & CRP Radiography Serial Bone Scan?


Slide37: PROGNOSIS Is related to: Causative organisms Duration of symptoms & sign Patient age Duration of antibiotic therapy


Slide38: COMPLICATION Bone abscess Bacteremia Fracture Loosing of the prosthetic implant Overlying soft-tissue cellulitis Draining soft-tissue tract


Slide39: Post Osteomyelitis Treatment


Slide40: Septic Osteomyelitis Post Osteomyelitis Scar


Slide41: Post Osteomyelitis Deformity of the Forearm


Slide42: CONTIGUOUS-FOCUS OSTEOMYELITIS


Slide43: Contiguous-focus Osteomyelitis Clinical setting: Postoperative infection Contamination of bone Contiguous soft tissue infection Puncture wounds


Slide44: Contiguous-focus Osteomyelitis Microbiologic features Staphylococci  Aureus, Epidermidis Gram-negative bacteria Anaerobic infection Unusual organisms Clostridia, Nocardia


Slide45: 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??


Slide46: Contiguous-focus Osteomyelitis Treatment Surgery is essential. Antibiotics  Specific Duration