1. Dr. Om Parshuram Patil
Dept Of Orthopaedics
Under Guidance Of
Dr G.N.Pundkar
Prof and Head

2.  17 year old male came to the casualtyn with
Chief Complaints of
 Pain in rt thigh since 1 month
 Fever since 4 days
 History of trauma to rt thigh and leg one and half
month before, trivial in nature & due to fall
 No h/o Chronics diseases, weight loss

3.  Pain in rt thigh since one month which was insidious
in onset , gradually progressive dull aching in nature
,with no aggravating factors, reduced in severity since
last 4-5 days with associated fever since then
 Fever was high grade , intermittent, not associated
with chills and rigors

4.  On examination
 Local temp was raised than contralateral side in mid
thigh region
 Minimal swelling in rt thigh
 Diffuse tenderness in mid thigh region
 From hip to calf region
 Could not be localised to a particular area

5. Investigation TLC : 21,600
 Neutro : 80%
 Lympho :15%
 Mono :03%
 Eosino :02%
 Hb :12.3 gm %
 ESR :20 mm
 Sickling :negative
 Blood Group: O negative

6.  Usg Rt Thigh:
Evolving Abscess in rt thigh Deep muscle lateral
side, with surrounding muscle myositis, with
inflammatory changes in rt hip joint.
Started with Ceftriaxone and Linezolid for 7 days

7.  Xray 21/11/14
 Rt thigh AP /Lat
 S/o : Periosteal reaction in mid third upper third
junction of rt femur.. Suggesting
 acute osteomyelitis ?
 Ewings Sarcoma? With onion peel appearance

8. 21/11/14

9.  Pt was subjected biopsy through, latetral approach
and window was made over the lateral cortex with
multiple drilling holes
 Minimal cheesy material was drained out from
superficial part lateral cortex
 Cortical bone and surrounding soft tissue sent for
histopathology and culture

10.  Started with Antibiotics Ceftriaxone with sulbactum,
amikacin for three weeks
 Patient was relieved of symptoms partially after
procedure with reduced severity of pain and fever

11. Histopathology
 Of the tissue was suggestive of chronic osteomyelitis
29/11/14

12. Histopathology
Chronic osteomyelitis,
from infected femur s
The irregular
fragment of
devitalized bone
surrounded by dense
fibrous tissue heavily
infiltrated by plasma
cells, lymphocytes,
and only a few
granulocytes.
Inflammatory
Changes

13. Post operative Xray

14. Post op 3 weeks

15. 8/12/14
 TLC : 10200/cumm
 Neutro : 60%
 Lympho : 32%
 Mono : 04%
 Eosino : 04%
 Hb : 12.0 gm %
 ESR : 15 mm

16. 17/12/14
TLC : 12900/cumm
Neutro : 59%
Lympho : 37%
Mono : 03%
Eosino : 01%
Hb : 12.3 gm %
ESR : 12 mm

17.  Parenteral antibiotics were stopped on 21 days and
shifted to oral antibiotics .
 But radiological picture of the patients rt femur was
S/o
 Increased periosteal reaction disseminated to lower part
of femur
 ??? Onion peel appearance s/o ewings sarcoma

18. Further treatment Plan
 Saucerization and reaming of intramedullary cavity
with antibiotic impregnated nail for six weeks
 Drain window in the distal part of femur laterally
 Simultaneous repeat histopathological and culture
studies from the site.

19. Chronic Osteomyelitis

20. Classification of COM

21. Anatomical classification

22. Classification of COM

23. Diagnosis COM
Based on
Clinical
 laboratory and
 imaging studies

24. Clinical evaluation COM
Skin and soft tissue integrity
Tenderness
Bone stability
Neurovascular status of limb
Presence of sinus

25. Laboratory COM
 Erythrocyte sedimentation rate
 C reactive protein
 WBC count only elevated in 35%
 Biopsy for histological and microbiological
evaluation
 Staphyloccocus species
 Anaerobes and gram negative bacilli

26. Imaging studies in COM
Plain X rays
Cortical destruction
Periosteal reaction
Sequestra
Sinography

27. Sinography

28. Imaging -
 Isotopic bone scanning more useful in acute
than in chronic osteomyelitis
 Gallium scans increased uptake in areas
where leucocytes and bacteria accumulate.
Normal scan excludes osteomyelitis

29. COM Imaging
CT Scan
Identifying sequestra
Definition of cortical bone and
surrounding soft tissues

30. COM Imaging
 MRI
 Shows margins of bone and soft tissue
oedema
 Evaluate recurrence of infection after 1 year
 Rim sign- well defined rim of high signal
intensity surrounding the focus of active
disease
 Sinus tracks and cellulitis

31. Treatment of COM
 Surgical treatment mainstay
 Sequestrectomy
 Resection of scarred and infected bone
and soft tissue
 Radical debridement
 Resection margins >5mm

32. Surgical treatment of COM
 Adequate debridement leaves a dead space that
needs to be managed to avoid recurrence, or bony
instability
 Skin grafts,
 Muscle and myocutaneous flaps
 Free bone transfer
 Papineau technique
 Hyperbaric oxygen therapy
 Vacuum dressing

33. Treatment of COM
 Antibiotic duration is controversial
 6 week is the traditional duration
 1 week IV, 6 weeks of oral therapy
 Antibiotic polymethyl methacrylate (PMMA)
beads as a temporary filler of dead space
 Biodegradable antibiotic delivery system

34. Resection or excision for COM
 Resection of a segment of affected bone may
be necessary to control infection
 With techniques of bone and soft tissue
transport, massive resections can be
performed and reconstructed without
significant disability.

35. Amputation for osteomyelitis
 Amputation indications include
 Arterial insufficiency
 Major nerve paralysis
 Non functional limb-stiffness, contracture
 Malignant change
 Prevalence of maliganacy arising from COM
reported as 0.2 to 1.6% of cases.
 Most are squamous cell carcinoma, also reticulum
cell carcinoma,fibrosarcoma

36. Ewings Sarcoma

37. Epidemiology
 Incidence is 0.6 per million
 Males > Females
 65% in the 2nd decade of life
 Rare in blacks and Asians

38. Clinical Presentation
History:
 Pain most commonly (90%)
 Swelling (70%)
 Fever (20%)
 Pathological fracture
 Weight loss, malaise

39. Clinical Presentation
Physical Exam and Labs
 Local warmth, inflammation
 Pleural effusions
 Neurological signs if spinal involvement
 ESR, LDH, anemia, leukocytosis

41. Radiology
 Site
 Size
 Effect on bone
 Response of Bone
 Matrix
 Cortex
 Soft tissue

49. Pathology
 Cell of origin is unknown
 Previously a diagnosis of exclusion
 Reciprocal translocation

51. Pathology
 Gross: soft, tan, gray tissue
 Micro: nests of small round cells
 No osteoid or chondroid production
 Surface cell glycoprotein

52. Pathology
Differential Diagnosis
 Lymphoma
 Osteomyelitis
 Osteosarcoma
 Malignant Fibrous Histiocytoma
 Metastatic neuroblastoma in toddlers

53. Staging and Prognosis
 Local and distal staging
 Bone marrow aspirate
 Pre-chemotherapy investigations
 Biopsy

54. Staging and Prognosis
 Location
 Tumor Size
 Metastases at diagnosis
 Response to chemotherapy

55. Treatment
 Multidisciplinary approach
 Neoadjuvant chemotherapy, surgery
 Don’t prolong interval between chemo
 Radiation if indicated

56. Summary
 Rare but common
 Main ddx is lymphoma and infection
 Large soft tisse masses
 Neoadjuvant chemo and surgery
 75-80% disease free survival at 5 years

57. Thank you