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Seminar on chronic osteomyelitis sch

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Seminar on chronic osteomyelitis sch

  1. 1. CHRONIC OSTEOMYELITISCHRONIC OSTEOMYELITIS Chair Person-Dr.C.V.MudgaDr.C.V.Mudgal Speaker – Dr.S.C.Hiremath. PG In orthopedics KIMS Hubli
  2. 2. IntroductionIntroduction Definition: “ A severe,persistent and incapacitating infection of bone and bone marrow ”  Chronic osteomyelitis is often defined as the presence of ongoing bone infection for longer than 1 month in the presence of devitalized bone
  3. 3. OsteomyelitisOsteomyelitis Nelaton (1834) : coined osteomyelitis 
  4. 4. OsteomyelitisOsteomyelitis Osteomyelitis (osteo- derived from the Greek word osteon, meaning bone, myelo- meaning marrow, and -itis meaning inflammation) simply means an infection of the bone or bone marrow. Infection mainly involves - Marrow spaces -Haversian canals -Subperiosteal Spaces
  5. 5. Bone and joint infections pose a formidable challenge to the Orthopaedic surgeon The high success rate obtained with antibiotic therapy in most bacterial diseases has not been obtained in bone and joint infections because of the physiological and anatomical characteristics of bone
  6. 6. The mere presence of bacteria in bone, whether from bacteremia or from direct inoculation, is insufficient to produce osteomyelitis Morrissy and Haynes have shown the relationship of trauma to osteomyelitis. Illness, malnutrition, and inadequacy of the immune system also can cause bone and joint infections.
  7. 7. As in other parts of the body, bones and joints produce inflammatory and immune responses to infection. Osteomyelitis occurs when an adequate number of a sufficiently virulent organism overcomes the host's natural defenses (inflammatory and immune responses) and establishes a focus of infection, for example; local skeletal factors also play a role in the development of infection The relative absence of phagocytic cells in the metaphyses of bones in children may explain why acute hematogenous osteomyelitis is more common in this location
  8. 8.  The peculiarity of an abscess in bone is that it is contained within a firm structure with little chance of tissue expansion  As infection progresses, purulent material works its way through the haversian system and Volkmann canals and lifts the periosteum off the surface of bone  The combination of pus in the medullary cavity and in the subperiosteal space causes necrosis of cortical bone.  This necrotic cortical bone, known as a sequestrum, can continue to harbor bacteria despite antibiotic treatment. Antibiotics and inflammatory cells cannot adequately access this avascular area, resulting in failure of medical treatment of osteomyelitis
  9. 9. Hematogenous osteomyelitis ofHematogenous osteomyelitis of Tubular bone in childTubular bone in child
  10. 10. Hairpin Bend vessels flow becomes considerably slower and more turbulent
  11. 11. Steps in the progression ofSteps in the progression of chronic osteomyelitischronic osteomyelitis
  12. 12. Factors That Turn Acute Bone InfectionFactors That Turn Acute Bone Infection to Chronic Osteomyelitisto Chronic Osteomyelitis:: Trauma (orthopaedic surgery or open fracture) Prosthetic orthopaedic device Diabetes Peripheral vascular disease Chronic joint disease Alcoholism Intravenous drug abuse Chronic steroid use Immunosuppression Tuberculosis HIV and AIDS Sickle cell disease Presence of catheter-related blood stream infection.
  13. 13. CHRONIC OSTEOMYELITISCHRONIC OSTEOMYELITIS The hallmark of chronic osteomyelitis is infected dead bone within a compromised soft-tissue envelope The infected foci within the bone are surrounded by sclerotic, relatively avascular bone covered by a thickened periosteum and scarred muscle and subcutaneous tissue. This avascular envelope of scar tissue leaves systemic antibiotics essentially ineffective
  14. 14. Factors responsible for chronicity Local factors: Cavity, Sequestrum, Sinus, Foreign body, Degree of bone necrosis General: Nutritional status of the involved tissues, vascular disease, DM, low immunity Organism: Virulence Treatment: Appropriateness and compliance Risk factors: Penetrating trauma, prosthesis, Animal bite
  15. 15. ETIOLOGYETIOLOGY ORGANISM POSSIBLE PROBLEM 1)Staphylococcus aureus Pressure ulcer, penetrating wound, open fracture, orthopedic surgery, vascular insufficiency disorder 2)Staphylococcus epidermidis Indwelling prosthetic device 3)Streptococcus viridans Abscessed tooth, gingival disease 4)Escherichia coli Urinary tract infection 5)Mycobacterium tuberculosis Tuberculosis
  16. 16. 6)Neisseria gonorrhoeae Gonorrhea 7)Pseudomonas sp. Puncture wounds, intravenous drugs 8)Salmonella sp. Sickle cell disease 9)Fungi, mycobacteria Immunocompromised host
  17. 17. According To Age 1)Infants < 1yr : Gr. B streptococci, S. aureus, E.coli 2) 1-16 yrs : S. aureus, S. pyogens, H.influenzae 3) > 16 yrs : S.aureus, S epidermidis, Gram –ve Bacilli
  19. 19. Before the discussion of diagnosis and treatment,it is vital to understand by which infections occur. Most infections encountered in orthopaedics are related to biofilm(A coherent cluster of bacterial cells imbedded in a matrix—which are more tolerant to most antimicrobials and the host defence than planktonic bacterial cells forming bacteria.)
  20. 20. Biofilm bacteria exist in one of the two states 1. Planktonic state 2. Stationary state
  21. 21. Planktonic state bacteria are free floating in the extra cellular matrix and are isolated and relatively small in quantity. In this state,body host defences can easily eradicate the organism through the usual immunological mechanisms. It is rare for planktonic bacteria to survive long in the extra cellular matrix despite numerous and repeat occurences of entry.
  22. 22. However,if the bacterial load is large and sustained,they can overwhelm the host defences and escape the effects of antibiotics. Then they can invade tissue and blood,leading to septicemia and death. Planktonic bacteria are metabolically active and reproductive.
  23. 23. This is important consideration for antibiotics treatments that work by either interfering with cellwall or protien synthesis or with reproduction. If planktonic bacteria encounter a suitable inert surface such as dead or necrotic tissue,foreign bodies or avascular body part by either dircet contamination,contiguous spreading or hematogenous seeding,they can attach and began the process of colonisation.
  24. 24. Juxta position of the bacteria with a surface or biomaterial is accomplished by vander waal’s forces,which allow bacteria to develop irreversible crosslinks with the surface (adhesion-receptor interaction). Following adhesion,bacteria begin to create a mucopolysachharide layer called biofilm or slime. Then they develop into colonies.
  25. 25. These colonies exhibit remarkably resilient behaviour. In the early stages of colonisation,sessile bacteria can be killed or neutralised by the host defences. However,some of these bacteria may ecape destruction and potentially act as a nidus for future infection.
  26. 26. Transition from colonisation to infection usually requires other condition to exist. This might occur if there was an inoculum that was larger than threshold levels,impaired host immune defence mechanisms,traumatised or necrotic tissues,foreign bodies or an a acellular or inanimate surface such as dead bone,cartilage or biomaterials.
  27. 27. Damaged bone,being relatively acellular,acts as a suitable surface for bacterial adhesion and colonisation. Devitalised bone divide of normal periosteum presents a collagen matrix to which bacteria can bind. Moreover,it has been suggested that bone sialo protein can act as a ligand for bacterial binding to bone.
  28. 28. Biomaterials and other foreign bodies are usually inert and susceptible to bacterial colonisation because they are inanimate. Following bacterial adherence and colonisation,the resistance to antibiotics appears to increase. Bacterial colonies can undergo phenotypic changes and appear to hybernate.
  29. 29. They can survive in a dormant state without causing infection,and this can explain the recovery of bacteria from asymptomatic hardware removal. So while colonisation is a necessary antecedent for infection,colonisation alone does not necessarily lead to infection.
  30. 30. Once colonisation occurs,body defences continue to identify bacteria as foreign. The subsequent collection of inflammatory cells brought into wall off the bacteria via chemotaxis manifest as purulence,which is a symptom of host’s attempt to isolate and destroy the infection. The accute inflammatory cells will also release a spectrum oxidative and enzymatic products in an attempt to penetrate the glycocalyx.
  31. 31. These mediators and enzymes are nonspecific and may be toxic to host tissues. Increased host tissue damage can lead to more surface substrate for local bacteria,creating cycle of tissue damage,host response,and exacerbation of infection. The host tissues will eventually react to limit the spread of infection macroscopically as well as microscopically.
  32. 32. The clinical manifestation of a sequestered infection is an abcess or involucrum. Alternatively,if the infection grows and reaches the skin or an internal epithealial surafce,a sinus tract forms as a route to dispel detritus. While the appearance of sinus tract is a manifestation of a locally devastating disease process and indicates severe underlying infection,it should be remembered that it can also prevent the accumulation of internal collection which can lead to bacterimia and septicimia.
  33. 33. Eventually the equilibrium may exist in the form of chronic infection,which is what many surgeons see in practice.  There is usually history of intermittent symptoms and drainage that has responded to some type of antibiotic regimen. Longstanding infections that were tolerated by healthy individuals may suddenly become limb or life threatening as the individual’s age.
  34. 34. Bacteria settle down in metaphysis Primary focus in metaphysis (form abscess in metaphysis) Subperiosteal abscess Sequestrum formation (dead bone ) Involucrum formation (new bone formed by cambium layer of periosteum) Pus eventually perforates periosteum and forms abscess in soft tissues. Ultimately abscess burst on surface and forms discharging sinus
  35. 35. Necrosis.  stage of new bone formation involucrum with sequestrum inside, there will always be a persistent discharging sinus.  pus from bone escapes through multiple hole in involucrum (Cloacae)
  36. 36. Pus spreads into vascular channels  Raising intraosseous pressure Impairing blood flow -> Chronic ischemic necrosis -> Separation of large devascularized fragment -> New bone formation ->(involucrum)
  37. 37. Chronic osteomylitis involving metaphysis ofChronic osteomylitis involving metaphysis of tibiatibia
  38. 38. Discharging sinusDischarging sinus
  39. 39. SEQUESTRUMSEQUESTRUM Dead piece of bone separated from living bone by a layer of unhealthy granulation tissue and lying freely in the cavity Types 1) Tubular – in pyogenic infections below 2 yrs 2) Feathery – pyogenic infections 3) Course sandy – tuberculosis 4) Dense ivory – syphilis
  40. 40. 5) Coloured ( Black) – in ulna & tibia osteomyelitis 6) Ring – Amputation stump & pin track infections 7) Bombay – Calcaneal OM 8) Corolliform – Pyogenic infections 9) Buttonhole – Pott’ puffy tumour, Tuberculosis of skull bones
  41. 41. Sequestrum ExposedSequestrum Exposed
  42. 42. Sequestrum RemovedSequestrum Removed
  43. 43. SequestrumSequestrum
  44. 44. CLASSIFICATIONCLASSIFICATION Duration Acute, Subacute , Chronic Route of infection Hematogenous or Exogenous Host response Pyogenic or Granulomatous
  45. 45. CLASSIFICATION OF CHRONICCLASSIFICATION OF CHRONIC OSTEOMYELITISOSTEOMYELITIS Cierny and Mader developed a classification system for chronic osteomyelitis, based on physiological and anatomical criteria, to determine the stage of infection The physiological criteria are divided into three classes based on three types of hosts
  46. 46. Class A hosts have a normal response to infection and surgery Class B hosts are compromised and have deficient wound healing capabilities When the results of treatment are potentially more damaging than the presenting condition, the patient is considered a class C host
  47. 47. Anatomical criteria consist of four types Type I, a medullary lesion, is characterized by endosteal disease In type II, superficial osteomyelitis is limited to the surface of the bone, and infection is secondary to a coverage defect
  48. 48. Type III is a localized infection involving a stable, well-demarcated lesion characterized by full- thickness cortical sequestration and cavitation (in this type, complete débridement of the area would not lead to instability) Type IV is a diffuse osteomyelitic lesion that creates mechanical instability, either at presentation or after appropriate treatment
  49. 49. Cierney & Mader Class.Cierney & Mader Class.
  50. 50. StageStage CharacteristicCharacteristic FeaturesFeatures II MedullaryMedullary Endosteal diseaseEndosteal disease IIII SuperficialSuperficial Cortical surface infected because of coverageCortical surface infected because of coverage defectdefect IIIIII LocalisedLocalised Cortical sequestrum that can be excised withoutCortical sequestrum that can be excised without compromising stabilitycompromising stability IVIV DiffuseDiffuse I, II and III plus mechanical instability before orI, II and III plus mechanical instability before or after debridement.after debridement. Anatomical Type Cierney and Mader staging system of Chronic Osteomyelitis
  51. 51. ClassClass Host’s immuneHost’s immune systemsystem FeaturesFeatures A hostA host NormalNormal Immunocompetent with good local vascularityImmunocompetent with good local vascularity B hostB host CompromisedCompromised Local or systemic factors that compromiseLocal or systemic factors that compromise immunity or healingimmunity or healing C hostC host ProhibitiveProhibitive Minimal disability, prohibitive morbidityMinimal disability, prohibitive morbidity anticipated, poor prognosis for cure, treatmentanticipated, poor prognosis for cure, treatment worse than diseaseworse than disease Physiological classification
  52. 52. Cierney and Mader staging system ofCierney and Mader staging system of Chronic OsteomyelitisChronic Osteomyelitis Anatomical typeAnatomical type
  53. 53. Clinical StagingClinical Staging (Cierny-Mader, 1985)(Cierny-Mader, 1985) Anatomic Type + CLINICAL STAGE Physiologic Class Example: IV B S tibial osteomyelitis = diffuse tibial lesion in a systemically compromised host
  54. 54. USE OF THIS CLASSIFICATION - To decide whether treatment should be 1) Simple or Complex 2) Curative or Palliative 3) Limb sparing or Ablative
  55. 55. CLINICAL FEATURESCLINICAL FEATURES DURING THE PERIOD OF INACTIVITY - Usually no symptoms - Skin over the focus is dusky, thin, scarred, poorly nourished - Break in the skin causes ulceration that heals slowly - Muscles are scarred & leads to contractures of the adjacent joints
  56. 56. DURING ACUTE EXACERBATION - Aching pain worsening at night, overlying soft tissue becomes edematous, warm redddened & tender - patient is febrile - As infection progresses, sinus may open up & drain extruding small sequestrum at intervals
  57. 57. - Intervals between flare ups may be months or years - Flare ups may be due to poor general condition & lowered resistance - Recurrent toxemia will eventually cause debilitary & sometimes fatal amyloidosis
  58. 58. DIAGNOSISDIAGNOSIS The diagnosis of chronic osteomyelitis is based on CLINICAL, LABORATORY & IMAGING studies
  59. 59. POSSIBLE CLINICAL FINDINGS - Asymptomatic - Pain - Fever - Tenderness
  60. 60. - Erythema - Swelling - Sinus Tract - Limp - Drainage
  61. 61.  LAB. INVESTIGATIONS - Nonspecific - Gives no indication of severity of infection 1) Raised ESR & CRP 2) Raised WBC ( Raised Lymphocytes) in 35% patients 3) Biopsy with Culture & Sensitivity (Gold Standard)
  62. 62. IMAGINGIMAGING For confirmation of the diagnosis To prepare for surgical treatment However no technique can absolutely confirm or exclude the presence of osteomyelitis
  63. 63. 1) It takes from 10 to 21 days for an osseous lesion to become visible on conventional radiography, because a 30–50% reduction of bone density must occur before radiographic change is apparent - earliest radiographic changes appears after 8 to 10 days - In early stages, bone appears moth eaten & osteoporotic due to CORTICAL DESTRUCTION with sclerotic areas - PERIOSTEUM IS ELEVATED by subperiostel laminations of new bone -grdually each necrotic dense area becomes surrounded by white ring representing new bone formation, the INVOLCRUM
  64. 64. Ssequestrum with normal structuralSsequestrum with normal structural involucrum of a proximal humerus.involucrum of a proximal humerus.
  65. 65. Radiographs of a distal femur highlighting the features ofRadiographs of a distal femur highlighting the features of diffuse osteomyelitis peripheral sclerosis, sequestrum, anddiffuse osteomyelitis peripheral sclerosis, sequestrum, and involucrum.involucrum.
  67. 67. SINOGRAPHYSINOGRAPHY  Helpful if the sinus is present in locating focus of the infection in chronic osteomyelitis
  68. 68. SinogramSinogram
  69. 69. A) Anteroposterior view of the right femur demonstrates severalA) Anteroposterior view of the right femur demonstrates several radiodense, sharply marginated foci within lucent cavities suggestive ofradiodense, sharply marginated foci within lucent cavities suggestive of sequestrationsequestration (B) Oblique view showing retrograde(B) Oblique view showing retrograde opacification of a sinus tract defining the course and extent of the fistula andopacification of a sinus tract defining the course and extent of the fistula and confirming the communication with an abscess inconfirming the communication with an abscess in the bone.the bone.
  70. 70. ScintigraphyScintigraphy Radio nucleotide TC 99m Poly Phosphate scan Gallium citrate scan Indium Sensitivity (84 to 100 percent) and specific (70 to 96 percent)
  71. 71. 1)99M Tc Scan - Action binds to hydroxyapetite crystals - Shows increased uptake in the areas of increased blood flow or oseoblastic activity - lacks specificity
  72. 72. 2) 67 Ga Scan - shows increased uptake in areas where leucocytes or bacteria accumulate - normal Ga scan excludes presence of osteomyelitis - useful as follow up examination after surgery
  73. 73. 3) 111 Indium leucocyte scan - more sensitive than Tc or Ga scans - especially useful in differentiating chronic osteomyelitis from neuropathic arthropathy like diabetic foot
  74. 74. These leukocytelabeledThese leukocytelabeled images suggest multiple areasimages suggest multiple areas of bilateral pedal osteomyelitis.of bilateral pedal osteomyelitis.
  75. 75. Various combinations of aforementioned scintigraphic method remain the gold standard diagnostic method in post traumatic infections. This is especially true because the presence of metallic implants limits the usefullness of MRI scanning. Flourodeoxy glucose (FDG)-PET scan enables noninvasive detection and demonstration of the chronic osteomyelitis with 97% accuracy.
  76. 76. 18 FDG PET Scan Meta-analysis showed –Fluorodeoxyglucose positron emission tomography has the highest accuracy for confirming or excluding the diagnosis of Chr OM
  77. 77. CT SCAN - Provides excellent difinition of cortical bone - especially useful in identification of Sequestra
  78. 78. CT ScanCT Scan
  79. 79. MRI SCAN - more sensitive than nuclear studies - reveals a well defined rim of high signal intensity surrounding the focus of active disease ( RIM SIGN)
  80. 80. This MRI scan demonstrates extensiveThis MRI scan demonstrates extensive intramedullary involvement as well as surrounding soft tissueintramedullary involvement as well as surrounding soft tissue edema in aedema in a patient with post-traumatic osteomyelitis of the right femoralpatient with post-traumatic osteomyelitis of the right femoral diaphysis.diaphysis.
  81. 81. A case of chronic osteomylitis of fibulaA case of chronic osteomylitis of fibula
  82. 82. MR images chronic osteomyelitis of rightMR images chronic osteomyelitis of right distal femur.distal femur.
  83. 83. MOLECULAR DIAGNOSTICSMOLECULAR DIAGNOSTICS Identification procedures based on molecular analysis and RNA or DNA typing are currently in development to facilitate diagnosis in osteomyelitis. The most commonly used method is PCR technique. Unfortunately,PCR cannot easily delineate between nuclear materials from living or dead bacteria. This increases likelihood of false positive results.
  84. 84. TREATMENTTREATMENT To wait is to invite disaster.
  85. 85. Chronic OM generally cannot be eradicated without surgical treatment Surgery for Chronic OM consists of sequestrectomy & resection of scarred & infected bone & soft tissue
  86. 86. THE GOALS OF SURGERY - Eradication of infection by achieving a viable & vascular environment - Radical debridement - Prevent recurrences
  87. 87. SEQUESTRECTOMY & CURETTAGESEQUESTRECTOMY & CURETTAGE 1) All sinus tracts are excised completely along with sequestra, purulent material & scarred and necrotic tissue if sclerosis bone seals off a cavity within the medullary canal, it is opened into the canal in both directions to allow blood vessels to grow into the cavity
  88. 88. When medullary canal is infected intramedullary reaming as a debridement technique has shown favourable results in the treatment of medullary osteomyelitis.
  89. 89. Sequestrectomy and curettage, A, Affected bone is exposed, and sequestrum is removed, B, All infected matter is removed,C, , Wound is either packed open or closed loosely over drains.
  90. 90. AFTER TREATMENT - Limb is splinted until the wound is healed & then it is protected to prevent pahological fracture - prolonged antibiotic therapy is given usually for 6 weeks - bony & soft tissue defects must be filled to reduce chances of continued infection & loss of function
  91. 91. METHODS TO ELIMINATE THIS DEAD SPACE 1) Bone grafting with primary or secondary closure 2) use of PMMA beads 3) local muscle flaps & skin grafting with or without bone grafting 4) microvascular transfer of muscle, myocutaneos, osseous & osteocutaneous flaps 5) use of bone transport( Ilizarov’s technique)
  92. 92. Four basic methods of immediate, biological management of dead space using living tissue or cancellous bone grafts.
  93. 93.  OPEN BONE GRAFTING( PAPINEAU TECHNIQUE) This procedure is based on the following principles: - granulation tissue markedly resists infection - autogenous cancellous bone grafts are rapidly revascularized and are resistant to infection -the infected area is completely excised -adequate drainage is provided -adequate immobilization is provided -antibiotics are used for prolonged periods
  94. 94. DONE IN 3 STAGES 1)Excision of infected tissue without or with stabilization using an external fixator or an intramedullary rod 2) Cancellous autografting 3) skin closure
  95. 95. A, Chronic osteomyelitis B, After débridement and development of granulation tissue C, Open bone graft D, Blood clot in place
  96. 96.  PMMA BEAD CHAINS -The rationale for this treatment is to deliver levels of antibiotics locally in concentrations that exceed the minimal inhibitory concentrations -The antibiotic is leached from the PMMA beads into the postoperative wound hematoma and secretion, which act as a transport medium -Aminoglycosides are the most commonly employed antibiotics for use with PMMA beads -most commercially available bone cements have a prepackaged form available with GENTAMICIN or VANCOMYCIN - In short-term implantation, the beads are removed within 10 days and in long-term implantation, they may be left for 80 days
  97. 97. Preparation of antibiotic beads
  98. 98. BIODEGRADABLE ANTIBIOTIC DELIVERY SYSTEMS -Biodegradable substrates contain osteoconductive and osteoinductive materials, which can be used to promote new bone formation - Bioabsorbable substrates (calcium sulfate or calcium phosphate) that can be mixed with antibiotics ( Vancomycin or Tobramycin) -These beads typically resorb by about 8 weeks after surgery
  99. 99. Polymethylmethacrylate (PMMA) beads connectedPolymethylmethacrylate (PMMA) beads connected together in a chain are the most widely used drugtogether in a chain are the most widely used drug delivery system.
  100. 100. Advantages - 2nd procedure is not required to remove the implant - Calcium in the substrate can be used in new bone formation - as the beads resorb, they are slowly replaced by new bone & soft tissue & this process may decrease the need for further reconstructive or coverage procedure
  101. 101. CLOSED IRRIGATION & SUCTION -For resistant focal infections, topical instillation of solution containing mild detergent ( eg. Alevaire) & one or more antibiotic seems to be effective - detergent inhibits the formation of penicillinase - so penicillins used with detergents becomes effective against resistant, bacterial strains
  102. 102. -Closed suction antibiotic ingress and egress high- volume irrigation systems(Lautenbach continuous irrigation method) can be used over 3 to 21 days - the material collected through suction tube is cultured every day when 3 successive negative cultures are obtained, the antibiotic detergent solution is discontinued
  103. 103. Detergents or soaps have been showed to be the only irrigation solutions that remove additional bacteria beyond the affect of mechanical irrigation alone. Castille soap has recently been reported to be useful in this situation.
  104. 104. SOFT TISSUE TRANSFER - Soft-tissue transfers to fill dead space left behind after extensive debridement may range from a localized muscle flap on a vascular pedicle to microvascular free tissue transfer - transfer of vascularized muscle tissue improves the local biological environment by bringing in a blood supply that is important in the host's defense mechanisms and for antibiotic delivery and osseous and soft-tissue healing.
  105. 105. - Most commonly, a local muscle flap is used in the treatment of chronic osteomyelitis of the tibia - The gastrocnemius muscle is used for defects around the proximal third of the tibia - the soleus muscle is used for defects around the middle third - A microvascular free muscle transfer is required for defects around the distal third of the tibia
  106. 106. - When a microvascular free muscle flap is used, and segmental bone loss has occurred, autogenous cancellous bone grafting can be done about 6 weeks after the initial free flap transfer - free fibular graft can be used for segmental bone loss of the tibia - If chronic osteomyelitis involves segmental bone loss of the tibia and the fibula, the results of a free fibular graft are not good, and amputation or reconstruction by the Ilizarov technique is advised
  107. 107.  ILIZAROV’S TECHNIQUE - The Ilizarov technique has been helpful in the treatment of chronic osteomyelitis and infected nonunions - This technique allows radical resection of the infected bone - A corticotomy is performed through normal bone proximal and distal to the area of disease. The bone is transported until union is achieved - Disadvantages of this technique include the time required to achieve a solid union and the high incidence of associated complications -
  108. 108. Mr. J.S. bow hunting with his IlizarovMr. J.S. bow hunting with his Ilizarov external fixator frame in place illustrates that patients areexternal fixator frame in place illustrates that patients are able to remainable to remain active during their treatmentactive during their treatment..
  109. 109. BELFAST TECHNIQUE 2 Stage Technique - in 1st stage, all necrotic & infected tissues are debrided & is covered with soft tissue transfer - in 2nd stage , at later time autogenous cancellous grfating is done after infection has been completely subsided
  110. 110. SILVER IONTOPHORESIS - Electrically generated silver ions have been shown to have antibacterial properties - can be used as adjuvent treatment in management of chronic osteomyelitis
  111. 111. Ionophorosis Delivary of silver IonsIonophorosis Delivary of silver Ions
  112. 112. HYPERBARIC OXYGEN THERAPYHYPERBARIC OXYGEN THERAPY Used as adjuvent to other methods of treatment
  114. 114. HBO enhances oxygen-dependent leukocyte killing through the production of hydrogen peroxide and superoxide by providing increased oxygen tension in the hypoxic tissue. Secondly, optimal tissue oxygen tension enhances osteogenesis and neovascularizationnto fill the dead space with new bone and soft tissues.
  115. 115. HBO has also been shown to enhance osteoclastic activity to remove bony debris. Finally, HBO also potentiates the antimicrobial effects of aminoglycosides, and possibly sulpha drugs and vancomycin, in the killing of susceptible bacteria Patients with osteomyelitis are usually treated at 2.0-2.5 ATA for 90-120 min per day and typically receive 20-40 treatments
  116. 116. AMPUTATION FOR CHRONIC OSTEOMYELITIS - Malignant change of sinus tract - Madura Mycosis - Joint contractures & stiffness
  117. 117. COMPLICATIONSCOMPLICATIONS Growth disturbances Pathological fractures Muscle contractures Secondary septicemia Epithelioma Malignant changes( Squamous cell ca,Reticulum cell ca, Fibrosarcoma) Joint stiffness Amyloidosis
  118. 118. Novel techniques underdevelopment include the use of compounds that promote detachment of stationary colonised bacteria into the planktonic state,where they are easier to eradicate. The techniques include surface treatments that inhibit colonisation and the use of light activated dye that destroys ceratain bacteria in wounds.
  119. 119. In this technique indocyanine green,which is a harmless dye,is placed into the wound and activated with near infrared light. The light resulsts in the dye releasing molecules that are toxic to the MRSA. The mechanism of action is varied and unlike standard antibiotics that development of resistence is unlikely. These and other methods under development may provide novel adjunctive treatments to help treat osteomyelitis.
  120. 120. PROPHYLAXISPROPHYLAXIS Prevention is always better than cure. Prophylactic antibiotics have an important role in the treatment of closed fractures,the use of which will reduce post operative osteomyelitis in elective cases. Antibiotic administration is not a substitute for proper aseptic technique,but it is a validated additional measure to reduce post operative infection.
  121. 121. The current recommendation is that antibiotic should be administered 30-60 mins befor the incision is made.
  122. 122. MISCELLANEOUS CONDITIONSMISCELLANEOUS CONDITIONS SCLEROSING OM OF GARRE - Idiopathic cortical sclerosis - mc site Tibia -chronic form of disease in which the bone is thickened and distended, but abscesses and sequestra are absent -affects children and young adults -cause is unknown, but it is thought to be an infection caused by a low-grade, possibly anaerobic bacterium
  123. 123. CLINICAL FEATURES - Intermittent pain - Swelling & Tenderness over affected bone
  124. 124. INVESTIGATIONS - ESR : slightly raised - C/S : usually negative - X Ray : expanded bone with generalised sclerosis - Biopsy : chronic low grade non specific OM
  125. 125. DIFFERTIAL DIAGNOSIS - Paget’s disease - Osteoid osteoma
  126. 126. TREATMENT - Fenestration of sclerotic bone - Antibiotics
  127. 127. RESIDUAL STAGE OFRESIDUAL STAGE OF OSTEOMYELITISOSTEOMYELITIS - characterized by a complete absence of the signs and symptoms of infection, including drainage -The bone is sclerotic, and its blood supply and strength are normal -During this stage of osteomyelitis, the bone bears the same relation to normal bone that scar tissue bears to normal connective tissue -Adhesions of skin to bone are more common if the bone is subcutaneous -Injury to such tissues frequently causes skin breakdown and even recurrence of infection
  128. 128. TREATMENT -correcting leg-length inequality or angular and joint deformities -contracted scars must be released -adherent scars must be replaced by myocutaneous flaps
  129. 129. PATHOLOGICAL FRACTURE INPATHOLOGICAL FRACTURE IN OSTEOMYELITISOSTEOMYELITIS -Because the involucrum is sometimes insufficient, the shaft of a long bone may fracture during the acute or subacute stage of osteomyelitis before immobilization has been started -all operations necessary to combat the infection should be carried out thoroughly, and bone fragments are then realigned and immobilized as with any other fracture -External fixation or cast immobilization usually is preferred -If bone loss is significant, the defect can be filled with autogenous bone graft, a vascularized osseous graft, or bone transport using the Ilizarov technique
  130. 130. Osteomyelitis of Right Femur withOsteomyelitis of Right Femur with pathological fracturepathological fracture
  131. 131. CHRONIC RECURRENTCHRONIC RECURRENT MULTIFOCAL OSTEOMYELITISMULTIFOCAL OSTEOMYELITIS CRMO was first described by Giedion and colleagues in 1972 Inflammatory bone disease characterized by an insidious onset of mild-to-moderate pain with signs of inflammation over the affected parts, which tend to recur often affects the metaphysis of long bones, especially the tibia, femur, and clavicle
  132. 132. ETIOLOGICAL FACTORS - Infectious disease : Propiobacterium acne - Autoimmune Diseases : Psoriasis & IBD - Genetic Predisposition : LPIN2 gene
  133. 133. CLINICAL FEATURES - Nonspecific : pain, swelling, restricted mobility - Duration : from days to several years
  134. 134. INVETIGATIONS - raised ESR & CRP with normal WBC count - Cultures : negative - Biopsy : may be useful
  135. 135. PATHOLOGICAL CONDITIONSPATHOLOGICAL CONDITIONS ASSO. WITH CRMOASSO. WITH CRMO • - Palmoplantar pustulosis • - Psoriasis • -IBD ( Crohn’s disease & Ulcerative colitis) • - SAPHO Syndrome( Synovitis, Acne, Pustulosis, Hyperostosis, osteitis) • - Majeed syndrome-( CRMO,Cong. Dyserythropoetic anaemia, inflammatory dermatosis)
  136. 136. - Wegner’s granulomatosis - Takayasu’s arteritis - Pyoderma gangrenosum - Sweet syndrome(Febrile neutrophilic dermatoses) - Acne fulminans -Spondyloarthropathy
  137. 137. TREATMENTTREATMENT No effective treatment for CRMO available Cases of disease remission after treatment with IFN gamma have been reported Resolution of symptoms followed by recurrence months later is characteristic of this disease Generally, the symptoms continue to recur over 2 years, and the disease generally is self-limiting The long-term prognosis seems to be good
  138. 138. OSTEOMYELITIS AFTEROSTEOMYELITIS AFTER PUNCTURE WOUND OF THEPUNCTURE WOUND OF THE FOOTFOOT Association of Pseudomonas osteomyelitis with puncture wounds to the foot Treatment consists of surgical drainage, curettage when indicated, and appropriate antibiotic treatment
  139. 139. OSTEOMYELITIS OF SPECIFICOSTEOMYELITIS OF SPECIFIC REGIONSREGIONS 1) CALCANEUM - Cancellous bone with thin periosteum firmly adherent to the bone - Periosteum is usually perforated - destruction of the cortex is not extensive -sequestrum formation is minimal
  140. 140. TREATMENT - Gaenslen’s approach: through plantar surface of heel
  141. 141. 2) SPINE • Commonly affects lumbar spine > thoracic spine > cervical spine • Usual site : vertebral bodies • Simultaneous involvement of the 2 adjacent vertebral end plates with intervening discs
  142. 142. ETIOLOGY - richly vascular metaphyseal bone near anterior longitudinal ligament - avascular disc - end arterial supply of interosseous artery in adults
  143. 143. X Ray Findings - disc space narrowing with end plate erosion with vertebral body destruction - vertebral end plate sclerosis with increased density in subchondral bone - spinal fusion
  144. 144. TREATMENT - IV Antibiotics - Rest - Spinal immobilisation - Surgery
  145. 145. 3) DISTAL THIRD FEMUR -Chronic osteomyelitis of the distal third of the femur is difficult to treat. Because the periosteum may become completely separated posteriorly by a subperiosteal abscess, this part of the bone may lose most of its blood supply, and sinuses often persist - A mass of scar tissue forms that interferes with revascularization of the bone; the scar tissue is relatively inaccessible surgically because of the proximity of large vessels and nerves
  146. 146. 4) ILIUM 1) Treatment during Acute Phase -large subperiosteal abscesses develop on the medial and lateral cortices -Early symptoms may suggest acute appendicitis or pyogenic arthritis of the hip joint -Ghahremani reported a relatively high incidence of osteomyelitis of the ilium in patients with Crohn disease (granulomatous enteritis and colitis) -He found it was necessary to resect the involved bowel before the osteomyelitis could be cured
  147. 147. 2) Treatment during chronic phase -the entire bone often is involved -infection is so diffuse that it is impossible to remove the individual sequestra and drain all the abscesses -Because most of the iliac wing can be removed without causing significant disability, resecting it usually is preferable to less radical operations
  148. 148. 4) ISCHIUM & PUBIS -an abscess develops either beneath the external or internal obturator muscles or in the ischiorectal fossa -Osteomyelitis of the ischial tuberosity is common in bedridden and paraplegic patients who develop pressure sores with secondary infection, necrosis, and osteomyelitis -Effective treatment requires debridement of all necrotic tissue and infected bone, and a soft-tissue transfer usually is required to close the defect
  149. 149. SPECIFIC TYPESSPECIFIC TYPES TUBERCULOUS OM - chronic granulomatous infection caused by AFB - usually secondary to primary elsewhere - commonly involving metaphysis in children & epiphysis in adults
  150. 150. - Tubercle follicle is formed of epitheloid cells, lymphocytes, langhans giant cells with central caseation necrosis with peripheral fibrosis by fibroblasts in central portion of shaft - Caseated pus extends peripherally forms subperiosteal absces, enters soft tissue planes with least resistance to infection as cold abscess
  151. 151. CLINICAL FEATURES -swelling - local tenderness - muscle spasm - cold abscess with chronic discharging sinus
  152. 152. INVESTIGATIONS - Tubeculin test - Biopsy :typical tubercles - Blood : lymphocytosis - X Ray: osteoporosis, loss of outline of articular cortex, granular foci
  153. 153. TREATMENT - Sinuses with sequestra : curretage & excision - AKT
  154. 154. To conclude the treatment of chronic osteomyelitis should be in collaboration with other specialities like infectious disease,psychiatry,medicine,micro vascular surgery,social work and physical and occupational therapy. However,even with access to these experts and appropriate surgery,the success rate for treatment of osteomyelitis is still significantly less than 100%. There is no doubt that prevention remains the best overall strategy.