for UG Students. Un Common ones.

1. SPECIFIC OSTEOMYELITIS
Dr.V.Sarthy. DNB.
Assistant Professor
Dept of Orthopaedics
SSSMCRI.

2. OSTEOMYELITIS
• INFECTION
+
• INFLAMMATION

3. CLASSIFICATION

4. ACUTE HEMATOGENOUS OSTEOMYELITIS
SUBACUTE HEMATOGENOUS OSTEOMYELITIS
CHRONIC OSTEOMYELITIS
SCLEROSING OSTEOMYELITIS OF GARRÉ
CHRONIC RECURRENT MULTIFOCAL OSTEOMYELITIS
ANAEROBIC OSTEOMYELITIS
INFANTILE CORTICAL HYPEROSTOSIS (CAFFEY’S DISEASE)

5. SYPHILIS
YAWS
TUBERCULOSIS
BRUCELLOSIS
LEPROSY
MYCOTIC INFECTIONS
HYDATID DISEASE

6. Factors predisposing to bone infection
Malnutrition and
general debility
Diabetes mellitus
Corticosteroid
administration
Immune deficiency
Immunosuppressive drugs
Venous stasis in the
limb
Peripheral vascular
disease
Loss of sensibility
Iatrogenic invasive
measures
Trauma

7. GARRÉ’S SCLEROSING
OSTEOMYELITIS
• Chronic.
• Adolescent or Young adult.
• Staphylococcal Infection.
• Diaphysis of tubular bones & Mandible.
• Marked sclerosis & Cortical Thickening.
• No abscess formation or cavitation.
• Chronic pain & thickening.
• Treatment:
– Excise, Curette, Bone Graft.

8. MULTIFOCAL NON-SUPPURATIVE
OSTEOMYELITIS
• Not as rare as it seems.
• Several different syndromes with certain
common features.
• There is an association with chronic skin
infections.
SAPHO – standing for synovitis, acne, pustulosis,
hyperostosis and osteitis (Boutin and Resnick, 1998).

9. MULTIFOCAL NON-SUPPURATIVE
OSTEOMYELITIS
children
• Multifocal, Symmetrical &
Recurrent.
• Long bone metaphysis,
Clavicle, Anterior rib cage.
adults
• Sterno – Costo – Clavicular
Complex.
• Vertebrae.

10. MULTIFOCAL NON-SUPPURATIVE
OSTEOMYELITIS
Clinical Features:
• Sub acute inflammation.
• Round cell infiltration.
• Bone Thickening.
• No purulent discharge.
• No micro organism has
been isolated.
Treatment:
• Only palliative.
• Antibiotic are not useful.
• Prognosis is good.
• Lesion eventually resolve.
• Ankylosis of involved joints
in adults.

11. INFANTILE CORTICAL HYPEROSTOSIS
(CAFFEY’S DISEASE)
• Rare disease of infants
and young children.
• First few months of life.
• Swelling.
• No local signs of
inflammation.
• ESR, though, is usually
elevated.

12. INFANTILE CORTICAL HYPEROSTOSIS
(CAFFEY’S DISEASE)
periosteal new-bone formation resulting in thickening of the affected bone.

13. • Lesions may disappear after some time to reappear else where.
• Flat bone including, cranium, mandible, scapula, can also be
involved.
• Cause is not known.
• ? Virus.
• Antibiotics are of no use.
INFANTILE CORTICAL HYPEROSTOSIS
(CAFFEY’S DISEASE)

14. SPIROCHAETAL INFECTION
Syphilis Yaws.
Lyme
disease.

15. SYPHILIS
• Treponema pallidum.
• Acquired during sexual activity.
• Spreads to the regional lymph nodes and
thence to the blood stream.
congenital
acquired

16. Acquired.
Primary.
Secondary.
Tertiary.
Chancre.
• Rash.
• Bone & Joint changes.
Osteitis.
Periosteitis.
CostoChondritis
Granulomatous Gummata.
Neuropathy.
Charcot’s
Arthropathy.

17. Radiology.

18. Gummata.
Pathology.
• Dense granulomatous lesion
associated with local bone
resorption and adjacent
areas of sclerosis.
• Pathological Fracture.
X- Ray.
• Discrete, punched-out
radiolucent areas in the
medulla or as more extensive
destructive lesions in the
cortex.
• The surrounding bone is thick
and sclerotic.
• Sometimes the predominant
feature is dense endosteal and
periosteal new bone formation
affecting almost the entire
bone (the classic ‘sabre tibia’ ).

19. Congenital Syphilis.
• Baby is sick and
irritable.
• Skin lesions.
• Hepato-splenomegaly.
• Anaemia.
• Pseudoparalysis.
• Several sites may be
involved.
• Often symmetrically,
with slight swelling and
tenderness, at the ends
or along the shafts of
the tubular bones.

20. X-ray changes
• Osteochondritis (‘metaphysitis’).
• Periostitis.

21. Other abnormalities which have come to be
regarded as ‘classic’ features in older children are:
• Hutchinson’s teeth.
• Erosion of the nasal bones.
• Thickening and expansion of the finger
phalanges (dactylitis).
• Painless effusions in the knees or elbows
(‘Clutton’s joints’).

22. Treatment.
• Early lesions will usually respond to
intramuscular injections of Benzylpenicillin
given weekly for 3 or 4 doses.
• Late lesions will require high-dosage
intravenous Penicillin for a week or 10 days.
• Some forms of tertiary syphilis will not
respond at all. An alternative would be
treatment with one of the Third generation
Cephalosporins.

23. Yaws.
• Treponema pertenue.
• Skin-to-skin contact.
• Tertiary stage - skeletal changes similar to those of
syphilis.
• X-rays show features such as cortical erosion, joint
destruction and periosteal new bone formation.
• With healing, soft-tissue scarring sometimes causes
joint contractures at the knee, the ankle or the foot.

24. Management.
• Benzylpenicillin.
• Erythromycin.
• Third-generation Cephalosporin.
• Topical treatment with Metronidazole gel is
advisable.
• Late cases of ulceration will require
painstaking cleansing and de-sloughing.

25. BRUCELLOSIS
• Subacute or Chronic granulomatous infection
in bones and joints.
• Three species of organism are seen in
humans:
– Brucella melitensis,
– B . abortus (from cattle) and
– B. suis (from pigs).

26. BRUCELLOSIS
• Infection usually occurs from drinking
unpasteurized milk.
• Coming into contact with infected meat (e.g.
among farmers and meat packers).
• About 50 per cent of patients with chronic
brucellosis develop arthritis.

27. Pathology.
• Foci of infection may occur in bones (usually
the vertebral bodies) or in the synovium of the
larger joints.
• The characteristic lesion is a chronic
inflammatory granuloma with round-cell
infiltration and giant cells. There may be
central necrosis and caseation leading to
abscess formation and invasion of the
surrounding tissues.

28. Clinical features
• Fever, headache and generalized weakness,
followed by joint pains and backache.
• Symptoms localize in a single large joint
(usually the hip or knee) or in the spine.
• The systemic illness follows a fluctuating
course, with alternating periods of fever and
apparent improvement (hence the older term
‘undulant fever’).

29. Brucellosis.
X-rays
• The picture is that of a
subacute arthritis, with loss
of articular space.
• Slowly progressive bone
erosion.
• Peri-articular osteoporosis.
• In the spine there may be
destruction and collapse of
adjacent vertebral bodies
with obliteration of the disc.
Investigation
• A positive agglutination test
(titre above 1/80).
• Joint aspiration or biopsy
may allow the organism to
be cultured and identified.

30. Treatment.
• Antibiotics:
– Combined onslaught with Tetracycline and
Streptomycin, for 3–4 weeks.
– Rifampicin and the newer Cephalosporin.
• Surgery:
– Abscess will need drainage, and necrotic bone and
cartilage should be meticulously excised.
– If the joint is destroyed, arthrodesis or
arthroplasty may be necessary once the infection
is completely controlled.

31. MYCOTIC INFECTIONS
Indolent granulomatous
reaction.
Abscess formation.
Destruction and Ulceration.

32. Spread.
Contiguous.
Haematogenous.

33. Mycotic
Infections.
Superficial.
Maduromycoses.
Sporothrix.
Candida.
Deep.
Blastomyces,
Histoplasma,
Coccidioides,
Cryptococcus,
Aspergillus
and other rare fungi.

34. MADUROMYCOSIS
• Organisms usually enter through a cut in the
foot.
• From there they spread through the
subcutaneous tissues and along the tendon
sheaths.
• The bones and joints are infected by direct
invasion.

35. Clinical features & Diagnosis
• Subcutaneous nodule.
• Swollen and indurated.
• Local abscesses form and break through the skin
as multiple sinuses.
• X-rays may show multiple bone cavities or
progressive bone destruction.
• The organism can be identified in the sinus
discharge or in tissue biopsies.

36. Management
• There is no really effective chemotherapy.
• Intravenous Amphotericin B.
• Necrotic tissue should be widely excised.
• Amputation is sometimes necessary.

37. CANDIDIASIS
• Candida albicans - Commensol
• Deep and systemic infections are rare except
under conditions of immunosuppression.
• Candida osteomyelitis and arthritis may follow
direct contamination during surgery or other
invasive procedures such as joint aspiration or
arthroscopy.

38. Management
• Tissue sampling and culture.
• Treatment consists of thorough joint irrigation
and curettage of discrete bone lesions,
together with:
– Intravenous Amphotericin B.

39. ACTINOMYCOSIS
• Actinomyces israelii - an anaerobic,
Gram-positive bacillus.
• Mandible – Commonest Site.
• Vertebrae & Pelvis.

40. • Firm, tender swelling in the soft tissues, going
on to form an abscess and one or more
chronic discharging sinuses.
• X-rays may show cyst-like areas of bone
destruction.
• The organism can be readily identified in the
sinus discharge, but only on anaerobic culture.

41. Treatment, by large doses of:
– Benzylpenicillin G.
– Tetracycline.
– Erythromycin.
But has to be continued for several months.

42. THE DEEP MYCOSES
• Histoplasmosis, Blastomycosis and
Coccidioidomycosis are rare causes of bone and
joint infection.
• Patients are usually Immunosuppressed.
• Diagnosis is usually delayed.
• Treatment with intravenous amphotericin B is
moderately effective.
• Operation may be necessary to drain an abscess
or to remove necrotic tissue.

43. HYDATID DISEASE
• Echinococcus.
• Parasitic infestation is
common among sheep
farmers, but bone
lesions are rare.

44. • The bones most commonly affected are the
vertebrae, pelvis, femur, scapula and ribs.
• Pain and swelling.
• Pathological fracture or compression of the
spinal cord.

45. Imaging

46. Investigations
• Casoni’s (complement fixation) test may be
positive, especially in longstanding cases.
• Needle biopsy should be considered, though
there is a risk of spreading the disease.

47. Treatment
• Albendazole.
• oral administration of :
– 10 mg per kg per day for 3 weeks,
• repeated at least 4 times with a one-week
‘rest’
• between courses. Liver, renal and bone
marrow function should be monitored during
treatment.

48. Indications for surgery
• Continuing enlargement or spread of the
lesion.
• Risk of fracture.
• Invasion of soft tissues and pressure on
important structures.

49. Surgery
• Curettage and bone grafting.
• Cavity can be ‘sterilized’ with copious amounts
of:
– hypertonic saline, alcohol or formalin.
• Radical resection, with the margin at least 2
cm, beyond the cyst.
• Not always possible.

50. Thank You.