2. Osteomyelitis
Osteomyelitis is defined as an inflammation
of the bone caused by an infecting
organism.
The infection may be limited to a single
portion of the bone or may involve the
marrow, cortex, periosteum, and the
surrounding soft tissue.
3. CLASSIFICATION
Duration of symptoms
(acute, subacute, and chronic)
Mechanism of infection
exogenous or hematogenous.
Based on the host response to the disease.
pyogenic or nonpyogenic
4. When the duration of osteomyelitis is more
than 3 weeks, its called ch. Osteomyelitis.
Causes-
1.Trauma causing open fractures.
2.Post operative.
3.Osteomyelitis with chronic etiology-
- TB
- Brodie’s abscess.
- Fungal osteomyelitis.
5. CHRONIC OSTEOMYELITIS
Chronic osteomyelitis
is difficult to eradicate
completely.
Systemic symptoms
may subside, but one
or more foci in the
bone may contain
purulent material,
infected granulation
tissue, or a
sequestrum
6. PATHOLOGY
Necrosis. stage of new bone formation
involucrum. with sequestrum inside, with a
persistent discharging sinus. pus from bone
escapes through multiple hole in involucrum
7. CHRONIC 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.
8. Chronic osteomyelitis
Secondary infections are common, and sinus
track cultures usually do not correlate with
cultures obtained at bone biopsy.
Multiple organisms may grow from cultures
taken from sinus tracks and from open
biopsy specimens of surrounding soft tissue
and bone.
10. Cierny and Mader Staging System
MedullaryEndosteal
disease
TypeI Medullary
Endosteal disease
II Superficial Cortical
surface infected because of
coverage defect
III Localized Cortical
sequestrum that can be
excised without
compromising stability
IV Diffuse Features of I,
II, and III plus mechanical
instability before or after
débridementl sequestrum
11. D/D
1.TB osteomyelitis- watery discharge.
- previous h/o TB, sinus with undermined
margin with blue colour.
2. Ewing's sarcoma- A primary malignant tumor of
bone, usually arising as a central tumor in long bone.
(biopsy)
3. Soft tissue chronic infection. (X-ray)
12. Diagnosis
Clinical, Laboratory, and Imaging studies.
The “gold standard” is to obtain a biopsy
specimen for histological and microbiological
evaluation of the infected bone.
17. CT Scan
Cortical bone and surrounding soft tissues
and is especially useful in identifying
sequestra.
18. MRI
The extent of the pathological insult by
showing the margins of bone and soft-tissue
edema.
Well-defined rim of high signal intensity
surrounding the focus of active disease seen
(rim sign).
21. Sinus tracks can be injected with methylene blue 24
hours before surgery to make them easier to locate
and excise.
22. TECHNIQUE
• Expose the infected area of bone and excise all sinus tracks
completely.
• Incise the indurated periosteum and elevate it 1.3 to 2.5 cm on
each side.
• Use a drill to outline a cortical window at the appropriate site
and remove it with an osteotome.
• Remove all sequestra purulent material and scarred and necrotic
tissue . If sclerotic bone seals off a cavity within the medullary canal
open it into the canal in both directions to allow blood vessels to
grow into the cavity.
23. After removing all suspicious matter, carefully excise the overhanging
edges of bone and avoid leaving a cavity or dead space. If a cavity cannot be
filled by the surrounding soft tissue, a local muscle flap or a free tissue
transfer can be used to obliterate the dead space.
If there is a nonunion present with any bony instability the bone must be
stabilized preferably with an Ilizarov-type external frame.
If possible close the skin loosely over drains and ensure that no excessive
skin tension is present. If closure is impossible, pack the wound open
loosely or apply an antibiotic bead pouch and plan for delayed closure or
skin grafting at a later time.
Appropriate antibiotics should be used before during and after the
operation.
24. AFTER TREATMENT
6-week course of intravenous antibiotics is
given after surgical débridement
The limb is splinted until the wound has
healed, and then it is protected to prevent
pathological fracture
25. Methods described to eliminate
dead space
(1) Bone grafting with primary or secondary closure
(2) Antibiotic polymethyl methacrylate (PMMA)
beads as a temporary filler of the dead space before
reconstruction
(3) Local muscle flaps and skin grafting with or
without bone grafting
(4) Microvascular transfer of muscle, myocutaneous,
osseous, and osteocutaneous flaps
(5) The use of bone transport (Ilizarov technique).
26. Open Bone Grafting (Papineau
technique)
STAGE I: DéBRIDEMENT
STAGE II: GRAFTING (autogenous cancellous bone
grafting)
STAGE III: WOUND COVERAGE