chronic osteomyelitis

1. CHRONIC OSTEOMYELITIS
Presenter-Dr Md Nayeemuddin
Moderator-Dr PG SHAH

2. INTRODUCTION
• In pre antibiotic era mortality and morbidity
following osteomyelitis was very high.
• Antimicrobials drugs have changed the course
of osteomyelitis but in developing and under
developed countries , where health care
facilities are inadequate ,osteomyelitis
remains a problem.

3. Reason for such a situation(4 failures).
• Failure to suspect correct diagnosis within the
first 3 – 4 days of onset due to lack of a “high
index of suspicion”.
• Failure to perform the simple clinical
investigations which can confirm the suspicion.
• Failure to initiate properly planned therapeutic
program.
• Failure to continue treatment till the disease is
eliminated.

4. INTRODUCTION (Contd).
• Hematogenous osteomyelitis is the generic name
for a whole spectrum of clinical manifestations ,
the cause of which is infection of bone and
marrow from circulating organisms in the blood
from distant source.
• The infection can be acute , subacute and
chronic osteomyelitis depending on the nature ,
virulence and dose of the infecting organisms ,
the age , immune system and general condition
of host.

5. INTRODUCTION (Contd)
• ACUTE OSTEOMYELITIS – produces the signs
of systemic and local infection
• SUBACUTE OSTEOMYELITIS – does not show
signs of systemic involvement though local
signs are there
• CHRONIC OSTEOMYELITIS – presents with
discharging sinus and recurrent infections.

6. PATHOLOGY
• In any infection of bone , there is an attempt
at repair that ,if incomplete it results in
chronic persistence of infection.
• This repair is accomplised by hyperemia of the
surrounding tissue , which effects the
decalcification of the bone.
• Granulation tissue forms and carries in
osteoclasts n osteoblasts.

7. PATHOLOGY(contd).
• Necrotic cancellous bone is readily absorbed and
replaced by new bone.
• Dead cortex is gradually absorbed about its
surface and is detached from living bone to form
a sequestrum.(this requires several months)
• SEQUESTRUM – is a piece of dead bone ,
surrounded by infected granulation tissue trying
to “eat” the sequestrum away. It appears pale
having smooth inner surface and a rough outer.

8. Different types of SEQUESTRA
TYPE DISEASE
TUBULAR PYOGENIC
RING EXTERNAL FIXATORS
BLACK ACTINOMYCOSIS
CORALLIFORM PERTHE’S DISEASE
COKE TUBERCULOSIS
SANDY TUBERCULOSIS
FEATHERY SYPHILIS

9. PATHOLOGY (Contd)
• When SEQUESTRUM IS COMPLETE, it lies in the free
cavity and is LESS attacked by granulation tissue and is
absorbed more slowly.
• Meanwhile , the surrounding living bone attempts to
wall off the infection by forming a thick , dense wall , the
INVOLUCRUM.
• (INVOLUCRUM is the dense sclerotic bone overlying the
sequestrum).
• An involucrum usually has multiple openings , the
cloacae , through which exudate , bone debris , and
sequestra find exit and pass through sinus tracts to the
surface.

10. Pathology (contd).
• CONSTANT DESTRUCTION of neighboring soft
tissue leads to
THIN skin which is easily traumatised , skin
epithelium grows inwards to line the sinus tract.
• In chronic osteomyelitis of long standing ,
multiple cavities and sequestra exist throughout
the bone
• The shaft becomes thickened , irregular and
deformed.

13. BACTERIOLOGY
• STAPHLOCOCCUS AUREUS ,is the most common infecting
organism.
• Other organisms are – group A streptococci , pseudomonas
aeruginosa , proteus , E.coli , staphylococcus epidermidis .
• Hemophilus influenzae – culprit in childrens below 2 years
of age.
• Bacteroids.
• Salmonella in patients suffering from sickle cell anaemia.

16. CLINICAL PICTURE
• During the period of inactivity no symptoms
are present.
• The bone is misshapen and the shin is dusky
,thin , scarred and poorly nourished.
• A break in the skin causes an ulceration that is
slow to heal.
• Muscles are scarred and cause contractures of
the adjacent joints.

17. CLINICAL PICTURE(contd)
• Pain is aching type and usually worsens in the
night.
• The overlying soft tissues become swollen ,
edematous , warm , reddened and tender.
• As the infection progresses a sinus is formed n
is drained indefinitely.
• Spontaneous closure of the sinus and
subsidence of infection often occur following
explusion of large fragment.

18. CLINICAL PICTURE(contd)
• Recurrent flare ups occurs indefinitely over a
period of months and years . A sinus may
drain continously.
• Recurrent toxemia over a long period will
causes amyloidosis.

19. DIAGNOSIS
• The diagnosis is based on
Clinical ,
Laboratory and
Imaging studies.
• The “GOLD STANDARD” is to obtain a biopsy
specimen for histological and microbiological
evaluation of the infected bone.

20. CLINICAL
• Physical examination should be focused on
integrity of skin and soft tissue .
• Determination of area of tenderness.
• Assessing bone stability.
• And evaluation of neuro vascular status of the
limb

21. LABORATORY
• Lab studies generally are
nonspecific and give no
indication for severity of the
infection.
• ESR and C- Reactive protein are
elevated in most patients.
• But WBC’S elevated in only 35%.

22. Multiple imaging technique are available to evaluate chronic
osteomyelitis ,however no technique can absolutely confirm
or exclude presence of osteomyelitis.
• Imaging should be done to
confirm the diagnosis and
prepare for surgery.
• Initial plain radiographs to
be performed it yields
valuable info .
• Signs of cortical destruction
and periosteal reaction
strongly suggest the
diagnosis of osteomyelitis.

23. • Sinography can be preformed if a sinus track is present and
can be valuable adjunct to surgical planning.
• Isotopic bone scanning is more useful in acute osteomyelitis
than chronic osteomyelitis.
• CT provides excellent definition of cortical bone and a fair
evaluation of the surrounding soft tissues and is especially
useful in identifying sequestra.
• MRI provides a fairly accurate measure of pathological
insult to bone and soft tissue , so it is superior to CT in soft
tissue evaluation.
• MRI may reveal a well defined rim of high signal intensity
surrounding the focus of active disease (RIM SIGN).

24. TREATMENT
• Requires a multi faceted approach.
• In addition to antibiotic and surgical debridement
n reconstruction.
• 1st objective is removal of dead
bones(sequestrum).
• 2nd objective is to find a method of obliterating
any dead space left after debridement.
• 3rd objective is to obtain soft tissue coverage of
exposed bone which is a part of the objective of
the obliterating dead space.

25. TREATMENT(contd).
• In spite of somewhat clear objectives, the
actual decision making process is not always
easy or clear cut.
• The real test of a surgeon’s judgement lies not
only in deciding when to operate , but also
how to avoid meddlesome surgery.
• Total eradication of all areas of potentially
infected bone is hardly possible.

26. TREATMENT(contd).
• Surgery for osteomyelitis consists of sequestrectomy and
resection of scarred and infected bone and soft tissue.
• Ring External fixators are generally used for soft tissue and
dead space management after radical debridement.
• The GOAL of surgery is to eradicate infection by achieving a
viable and vascular environment.
• Extensive debridement creates a large dead space – this is
treated with ANTIBIOTIC POLYMETHYL METH ACRYLATE
(PMMA) beads that fills the dead space and prevents
recurrences.

27. TREATMENT(contd).
• The duration of post operative antibiotics is
controversial .
• Traditionally , a 6 week course of intravenous
antibiotics is prescribed after surgical
debridement.

28. TREATMENT(contd).
• The methods to eliminate the dead space are –
1. Bone grafting with primary and secondary closure.
2. Use of PMMA as a temporary filler of dead space.
3. Local muscle flaps and skin grafting with or
without bone grafting.
4. Microvascular transfer of muscle , osseous flaps.
5. The use of bone transport (ILIZAROV TECHNIQUE).

29. TREATMENT(contd).
• SEQUESTRECTOMY AND CURETTAGE FOR
CHRONIC OSTEOMYELITIS
SEQUESTRECTOMY means removal of the
sequestrum .if it lies within the medullary
cavity , a window is made in the overlying
involucrum and the sequestrum removed .
One must wait for adequate involucrum
formation before performing sequestrectomy.

30. SEQUESTRECTOMY AND CURETTAGE
FOR CHRONIC OSTEOMYELITIS.
• Sequestrectomy and curettage require more
time to perform and result in considerably
more blood loss than an inexperienced
surgeon would anticipate.
• Sinus tracks can be injected with methylene
blue 24 hours before surgery to make them
easier to locate and excise.

31. OPEN BONE GRAFTING
• Papineau et al described an open bone grafting
technique for the treatment of chronic
osteomyelitis .
• This procedure relies on the formation of healthy
granulation tissue in a bed of bone graft that will
become rapidly vascularised.
• The granulation tissue resists infection and is
allowed to adequately drained.
• This technique is used when free flaps or soft
tissue transfer options are limited because of
anatomic location .

32. OPEN BONE GRAFTING (contd)
• Archdeacon and messerschmitt described a
modification of the papineau technique using
a vaccum assisted closure (VAC).
• VAC helps in decreasing the edema and for
the closure of soft tissue dead space.
• It also promotes the formation of granulation
tissue.

33. POLYMETHYLMETHACRYLATE
ANTIBIOTIC BEAD CHAINS
• IT IS COMMONLY USED.
• Studies have shown that the
local concentrations achieved
are 200 times more than
intravenous.
• High concentration can be
achieved by primary closure of
the wound.
• Short term (10 days), long
term(80days) , permanent
implantation of PMMA beads
is possible.

34. BIODEGRADABLE ANTIBIOTIC
DELIVERY SYSTEM
• It offers a significant advantage over PMMA in
that a second procedure is not required to
remove the implant.
• It is useful when bone stability is not an issue and
soft tissue coverage is adequate.
• Many manufacturers produce a variety of
bioabsorbable substrates(calcium sulfate or
calcium phosphate)that can be mixed with
antibiotics like vancomycin and tobramycin).
• Its still under study.

36. SOFT TISSUE TRANSFER
• It is mainly done to fill dead space which is left
behind after extensive debridement.
• Success rate reported in the literature ranges
from 66% to 100%.
• For eg chronic osteomyelitis of tibia a local
muscle graft from gastrocnemius or soleus is
used for transfer.

37. ILIZAROV TECHNIQUE
• This technique allows radical resection of the
infected bone
• A corticotomy is performed through the
normal bone proximal and distal to the area of
the disease.
• Disadvantage is – long time to achieve solid
unioun and high chances of infections.
• The treatment of segmental defects of upto
13cms can be achieved.

38. ADJUNCTIVE THERAPIES
• Hyperbaric Oxygen is not reliably effective but
is used as more traditional methods of
treatment.
• Bone morphogenic proteins (BMPs) and even
Platelet Rich Plasmas (PRPs) have been
advocated as it has the ability to acccelerate
or enchance osteogenesis.

39. COMPLICATIONS
• An acute exacerbation of the infections occurs commonly.
• Growth Abnormalities :
shortening –if growth plate is damaged.
Lengthening – coz of increased vasularity of the growth
plate due to near by osteomyelitis.
• Pathologic fracture .
• Joint stiffness – may occur because of scarring of soft tissues around the
joint.
• Sinus tract malignancy – rare complication (squamous cell carcinoma)
• Muscle contracture.
• Epithelioma.
• Amyloidosis.