💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...
Chronic Osteomyelitis
1. DR. SIJAN BHATTACHAN
IInd YEAR RESIDENT
ORTHOPAEDICS & TRAUMA SURGERY
CIVIL HOSPITAL
NAMS
CHRONIC
OSTEOMYELITIS
2. • Chronic inflammation of the bone and bone marrow
• Hallmark is infected dead bone within a compromised soft
tissue envelope.
• In past : dreaded sequel to acute hematogenous osteomyelitis
• At present : more frequently follows an open fracture or surgery
3. ▪ Staphylococcus aureus
▪ Escherichia coli
▪ Streptococcus pyogenes
▪ Proteus mirabilis
▪ Pseudomonas aeruginosa
▪ In the presence of foreign implants, Staphylococcus epidermidis,
▪ With time there is always a mixed infection
BACTERIOLOGY
4. THE HOST DEFENCES ARE INEVITABLY COMPROMISED
BY
▪ the presence of scar formation
▪ dead and dying bone around the focus of infection
▪ poor penetration of new blood vessels
▪ non-collapsing cavities in which microbes can thrive
▪ substance abuse, diabetes, peripheral vascular disease,
skin infections, malnutrition, lupus erythematoses or any
type of immune deficiency.
▪ the commonest of all predisposing factors is local trauma,
such as an open fracture or a prolonged bone operation,
especially if this involves the use of a foreign implant.
PREDISPOSING FACTORS
5. BACTERIA
▪ covered in a protein–polysaccharide slime (glycocalyx)
▪ protects them from both the host defenses and antibiotics
▪ have the ability to adhere to inert surfaces such as bone sequestra
and metal implants, where they multiply and colonize the area
▪ bacteria can survive inside osteoblasts and osteocytes and be released
when the cells die
PREDISPOSING FACTORS
6. • Bone is destroyed or devitalized, around
the focus of infection or along the surface
of a foreign implant.
• Cavities containing pus and pieces of dead
bone (sequestra) are surrounded by
vascular tissue and areas of sclerosis –
which may take the form of a distinct bony
sheath (involucrum).
• Pus and tiny sequestrated spicules of bone
may discharge through perforations (cloacae)
in the involucrum and track by sinuses to the
skin surface
PATHOLOGY
7. Sequestra act as substrates for bacterial adhesion in much the same
way as foreign implants, ensuring the persistence of infection until they
are removed or discharged through perforations in the involucrum
and sinuses that drain to the skin.
A sinus may seal off for weeks or even months, giving the appearance
of healing, only to reopen (or appear somewhere else) when the tissue
tension rises.
Bone destruction, and the increasingly brittle sclerosis, sometimes results in a
pathological fracture.
The histological picture is one of chronic inflammatory cell infiltration
around areas of acellular bone or microscopic sequestra
PATHOLOGY
8. • a ‘flare’ of pain, pyrexia, redness and
tenderness,
• a discharging sinus.
• thickened and often puckered tissues or
folded inwards where a scar or sinus
adheres to the underlying bone.
• a seropurulent discharge and excoriation of
the surrounding skin.
• In post-traumatic osteomyelitis the bone
may be deformed or ununited
CLINICAL FEATURES
9. ANATOMICAL TYPE
I Medullary Endosteal disease
II Superficial Cortical surface infected because of coverage
defect
III Localised Cortical sequestrum that can be excised without
compromising stability
IV Diffuse Features of I, II, III + mechanical instability before or
after debridement
PHYSIOLOGICAL CLASS
A Normal Immunocompetent with good local vascularity
B Compromised Local or systemic factors that compromise immunity
or healing
C Prohibitive Minimal disability,
Prohibitive morbidity anticipated or poor prognosis
for cure
CLASSIFICATION :
CIERNY AND MADER
11. BASED ON Radiographic appearance
type A Brodie abscess
type B sequestrum involucrum
B1 localized cortical sequestrum
B2 sequestrum with structural involucrum
B3 sequestrum with sclerotic involucrum
B4 sequestrum without structural involucrum
type C sclerotic
Physeal damage is indicated by the addition of “P” (proximal) or “D” (distal) to the
classification
CLASSIFICATION :
JONES ET AL. CLASSIFICATION OF CHRONIC
HEMATOGENOUS
OSTEOMYELITIS IN CHILDREN
15. 15
Type Description Rehabilitation Time
Type
1
Intact tibia and fibula. No osseous reconstruction necessary. 6–12 wk
Type
2
Intact tibia but requiring bone graft for structural support. 3–6 mo
Type
3
Tibial defect ≤6 cm. Intact fibula. Reconstruction required. 6–12 mo
Type
4
Tibial defect >6 cm. Intact fibula. Reconstruction required. 12–18 mo
Type
5
Tibial defect >6 cm without usable fibula. Recommended
amputation.
≥18 mo
May classification of tibial osteomyelitis
16. • The “gold standard” is to obtain a biopsy specimen for histological and
microbiological evaluation of the infected bone.
• Standard bacterial cultures still give negative results in about 20% of cases of overt
infection
• Histopathological features
-Dead bone (avascular/ no nuclei of osteocytes)
-Fibrosis of marrow space
-Chronic inflammatory cells
DIAGNOSIS
17. PLAIN X-RAY
➢ should be the initial study performed.
➢ may be no more than localized loss of trabeculation,
or an area of osteoporosis, or periosteal thickening
➢ bone resorption – either as a patchy loss of density or
as frank excavation around an implant– with
thickening and sclerosis of the surrounding bone.
➢ sequestra show up as unnaturally dense fragments, in
contrast to the surrounding osteopaenic bone
➢ sometimes the bone is crudely thickened and
misshapen, resembling a tumour
INVESTIGATIONS
18. • Sequestra- dead bone nidus with surrounding granulation tissue
• Involucrum- periosteal new bone forming later
18
19. INVESTIGATIONS
Blood Investigations
• nonspecific
• give no indication of the severity of the infection.
• Erythrocyte sedimentation rate and C-reactive protein are elevated in
most patients but the white blood cell count is elevated in only 35%.
20. INVESTIGATIONS
CT SCAN
➢ provides excellent definition of cortical bone and a fair evaluation of the
surrounding soft tissues
➢ especially useful in identifying sequestra
➢ Helps surgical planning.
21. INVESTIGATIONS
MRI
• more useful for soft tissue evaluation than CT
• MRI provides a fairly accurate determination of the extent of the pathological insult
by showing the margins of bone and soft tissue edema
• In chronic osteomyelitis, MRI may reveal a well defined rim of high signal intensity
surrounding the focus of active disease (rim sign)
• Sinus tracks and cellulitis appear as areas of increased signal intensity on T2-
weighted imaging.
• Drawbacks include cost, difficulty imaging around metal implants, and poor
delineation of cortical bone.
24. INVESTIGATIONS
RADIOISOTOPE SCINTIGRAPHY
• Sensitive but not specific.
• 99mTc-HDP scans show increased activity (bone turnover) in both the perfusion
phase and the bone phase
-Useful if MRI is not an option
• Gallium scan;
-shows increased uptake in areas where leukocytes or bacteria accumulate
-A normal gallium scan virtually excludes the presence of osteomyelitis and can be
useful as a follow up examination after surgery
• Indium111–labeled leukocyte scans; shows areas of inflammation
-More sensitive than Tc or gallium scan
-Usually negative in neoplasia
-Useful in diabetic foot; chronic osteomyelitis versus neuropathic foot
26. •FDG-PET
-Shows malignancies and infection; Increased glycolysis
-Most sensitive test for chronic osteomyelitis.
-More specific than MRI or bone scan
26
27. Teermat et al,The accuracy of diagnostic imaging for the
assessment of chronic osteomyelitis: a systematic
review and meta-analysis,J Bone Joint Surg Am. 2005
Nov;87(11):2464-71.
“FDG-PET has the highest diagnostic
accuracy for confirming or excluding the
diagnosis of chronic osteomyelitis.”
27
28. • Eradication of chronic osteomyelitis generally requires aggressive surgical
debridement and dead space management combined with effective antibiotic
regimen
• GOAL OF TREATMENT
(a) Suppress the infection
(b) Prevent its spread to healthy tissue
(c) Control acute flares
(d) Prevent pathological fractures
(e) Promote soft tissue healing
.
TREATMENT
29. Requires a multifaceted approach
A. Antibiotic
B. surgical debridement and reconstruction
C. Correction of host morbidities
.
TREATMENT
30. ANTIBIOTICS
Antibiotics alone rarely can eradicate the infection for numerous reasons
1. Bacteria are able to adhere to orthopaedic implants and bone matrix through
various receptors
2. Some can hide intracellularly while others can form a slimy coat that protects
them from phagocytic cells and antibiotics
TREATMENT
31. ANTIBIOTICS
• choice of antibiotic depends on microbiological studies,
• the drug must be capable of penetrating sclerotic bone and should be
non-toxic with long-term use
• Fusidic acid, clindamycin and the cephalosporins are good examples
• Vancomycin and teicoplanin are effective in most cases of meticillin-resistant
Staphylococcus aureus infection (MRSA)
• administered for 4–6 weeks (starting from the beginning of treatment or the
last debridement) before considering operative treatment.
TREATMENT
32. TREATMENT
• serum antibiotic concentrations should be measured at regular intervals
(kept at several times the minimal bactericidal concentration)
• Continuous collaboration with a specialist in microbiology is important.
• If surgical clearance fails, antibiotics should be continued for another 4 weeks
before considering another attempt at full debridement
33. LOCAL TREATMENT
• A sinus may be painless and need dressing simply to protect
the clothing
• Colostomy paste can be used to stop excoriation of the skin
• An acute abscess may need urgent incision and drainage
TREATMENT
34. INDICATIONS FOR SURGERY
FOR CHRONIC HAEMATOGENOUS INFECTION
➢intrusive symptoms
➢failure of adequate antibiotic treatment
➢clear evidence of a sequestrum or dead bone
FOR POST-TRAUMATIC INFECTIONS
➢An intractable wound and/or an infected ununited fracture
➢The presence of a foreign implant is a further incentive to operate
TREATMENT
The goal of surgery is eradication of the infection by achieving a viable and
vascular environment
35. Debridement
➢ All infected soft tissue and dead or devitalized bone, as well as any infected
implant, must be excised.
➢ After three or four days the wound is inspected and if there are renewed signs
of tissue death the debridement may have to be repeated – several times if
necessary.
➢ Antibiotic cover is continued for at least 4 weeks after the last debridement
TREATMENT
36. SEQUESTRECTOMY AND CURETTAGE
➢ require more time to perform and result in considerably more
blood loss than an inexperienced surgeon would anticipate.
➢ Appropriate preparation should be made before surgery
➢ Sinus tracks can be injected with methylene blue 24 hours
before surgery to make them easier to locate and excise
TREATMENT
37. SEQUESTRECTOMY AND CURETTAGE
➢ Remove all sequestra, purulent material, and scarred and
necrotic tissue
➢ Use a high-speed burr to débride necrotic or ischemic bone
until the “paprika sign” (active punctate bleeding bone) is
achieved, indicating healthy tissue.
➢ Tissue obtained at surgical debridement should be sent for
culture and pathology studies.
TREATMENT
39. TYPES OF SEQUESTRUM
According to shape
• Pencil / cylindrical / tubular - infants
• Ring – External Fixation
• Conical / Annular - Amputation stump
• Colariform – Perthes Disease
• Button hole – Radiation
• Kissing type – Peridiscal TB
TREATMENT
40. TYPES OF SEQUESTRUM
According to consistency
Coke like - Cancellous bone
Flake / Feathery – Cavity TB ( eg TB ribs)
Coarse Sand like – Out of cavity TB ( eg TB vertebral central body )
Fine Sand like – Viral OM
Ivory - Syphilis
According to colour
Black - Actinomycosis
Green - Pseudomonal Osteomyelitis
Bombay or Black – H2S and pollution
41. • DEALING WITH THE ‘DEAD SPACE’
• bone grafting with primary or secondary
closure
• use of antibiotic PMMA beads as a
temporary filler before reconstruction
• local muscle flaps and skin grafting with
or without bone grafting
• microvascular transfer of muscle,
myocutaneous, osseous, and
osteocutaneous flaps
• the use of bone transport (Ilizarov
technique)
TREATMENT
43. PAPINEAU ET AL. OPEN BONE GRAFTING TECHNIQUE
• formation of healthy granulation tissue in a bed of bone graft that will
become rapidly vascularized.
• The granulation tissue resists infection and is allowed to adequately drain.
• useful when free flaps or soft tissue transfer options are limited because of
anatomic location or in patients who smoke or are medically compromised
Three stages of surgery
(1) debridement and stabilization
(2) cancellous autografting
(3) skin closure
Culture-specific intravenous antibiotics should be continued beyond the last
surgical procedure.
TREATMENT
44. ARCHDEACON AND MESSERSCHMITT MODIFICATION OF PAPINEAU TECHNIQUE
Using a vacuum-assisted closure (VAC)
VAC is useful for decreasing edema and for closure of soft tissue dead space
VAC also stimulates the formation of granulation tissue.
TREATMENT
45. POLYMETHYLMETHACRYLATE (PMMA) ANTIBIOTIC
BEAD CHAINS
TREATMENT
Rationale
deliver levels of antibiotics locally in concentrations that exceed the minimal
inhibitory concentrations.
local concentrations of antibiotic achieved are 200 times higher than levels
achieved with systemic antibiotic administration.
Advantage : very high local antibiotic concentrations while maintaining low
serum levels and low systemic toxicity.
High concentrations of the antibiotic can be achieved only with primary
wound closure
If such closure cannot be performed, the wound can be covered with a
water impermeable dressing (bead pouch technique)
Suction drains are not recommended because the concentration level of the
antibiotic is diminished when they are used
46. POLYMETHYLMETHACRYLATE (PMMA) ANTIBIOTIC BEAD CHAINS
TREATMENT
EMPLOYED ANTIBIOTICS FOR USE WITH PMMA BEADS;
▪ Aminoglycosides (most common)
most commercially available bone cements have a prepackaged form available
with gentamicin (500 mg/40g pack)
▪ Penicillins
▪ Cephalosporins
▪Clindamycin
▪Vancomycin elutes much less efectively.
Fuoroquinolones, tetracycline, and polymyxin B are broken down during the
exothermic process of cement hardening and should not be used with PMMA
beads
47. POLYMETHYLMETHACRYLATE (PMMA) ANTIBIOTIC BEAD CHAINS
TREATMENT
Short term implantation : the beads are removed within 10 days
Long term implantation : left up to 80 days
Local bactericidal antibiotic levels last only 2 to 4 weeks after placement, and when
all the antibiotic has leached out of the bead, a foreign body remains that may be
colonized by glycocalyx forming bacteria.
PMMA also has been shown to inhibit local immune response by impairing various
phagocytic immune cells.
48. INTRAMEDULLARY ANTIBIOTIC CEMENT NAIL
TREATMENT
Debride and prepare the medullary canal with usual reaming technique
Send the reamings for culture studies
Irrigate the canal and bone with tubing or an irrigating reamer to mold the
cement rod,
use a T-95 chest tube cut to the desired length
50. Shyam et al, Use of antibiotic cement-impregnated intramedullary
nail in treatment of infected non-union of long bones,Indian J
Orthop. 2009 Oct-Dec; 43(4): 396–402.
50
Abstract
Background:
In cases with infected non-union, the primary step is eradication of the infection before attempting to achieve union.
Release of antibiotics from the bone cement at a high concentration and its penetration to the surrounding tissues,
including cortical and cancellous bone, prompted the use of antibiotic cement in the control of bone infection. The aim
of this study is to summarize our experience with the use of antibiotic cement-impregnated intramedullary nail
(ACIIN) for control of infection in cases of infected non-union with bone defect.
Materials and Methods:
We prospectively studied 25 cases of infected non-union (23 femora and two tibiae). There were 24 males and one
female, with the mean age being 33 years (range, 21–58 years). All patients had high-velocity road traffic accidents
except one patient who had farmland injury. There were seven closed fractures, one grade I compound, two grade II
compound fractures, five grade IIIA compound fractures, and 10 grade IIIB compound fractures. ACIIN was used in
all cases after adequate debridement. Patients were classified according to the amount of bone defect present after
debridement: group 1 with bone defect <4 cm (n=13), group 2 with bone defect ≥4–<6 cm (n=7), and group 3
with bone defect ≥6 cm (n=5). Infection control was judged on the basis of discharge through the wound and
laboratory parameters. All patients were followed-up, with an average follow-up time of 29 months (range, 18–40
months). The mean duration of retention of the intramedullary rod was 8 weeks (range, 6–12 weeks).
Results:
In group 1, all cases achieved infection control, with three patients achieving bone union without any need of
secondary procedure. In group 2, all cases achieved infection control but the time taken was significantly longer than
for group 1 (P value 0.0002). All the cases required a secondary procedure in the form of either interlocking
intramedullary nailing with iliac crest bone graft or Ilizarov ring fixator application to achieve union. None of the
cases in group 3 achieved infection control.
Conclusion:
ACIINs are useful for infection control in cases of infected non-union with bone defect <6 cm. In
51. BIODEGRADABLE ANTIBIOTIC DELIVERY SYSTEMS
TREATMENT
Advantage over PMMA beads : second procedure is not required to remove the
implant
Especially useful when bony instability is not an issue and sof tissue coverage is
adequate.
Some of these biodegradable substrates contain osteoconductive and
osteoinductive materials, which can be used to promote new bone formation
The biodegradable substances used as antibiotic delivery systems can be classifed
into three main categories:
1. proteins(collagen, gelatin, thrombin, and autologous blood clot )
2. bone graft materials and substitutes (calcium sulfate )
3. synthetic polymers
52. CLOSED SUCTION DRAINS : LAUTENBACH TECHNIQUE
• radical excision of all avascular and infected tissue
• closed irrigation and suction drainage using double-
lumen tubes and an appropriate antibiotic solution in
high concentration
• The ‘dead space’ is gradually filled by vascular
granulation tissue.
• The tubes are removed when cultures remain
negative in three consecutive fluid samples and the
cavity is obliterated
TREATMENT
53. SOFT TISSUE TRANSFER
• may range from a localized muscle flap on a vascular pedicle to microvascular
free tissue transfer.
• The 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.
• Gastrocnemius muscle for defects around the proximal third of the tibia,
soleus muscle is used for defects around the middle third of tibia
• A microvascular transfer of tissue may consist of muscle that is covered with a
skin graft or a myocutaneous, osseous, or osteocutaneous flap
TREATMENT
54. ILIZAROV TECHNIQUE
• Especially used if infection is associated to ununited fracture.
• Allows radical resection of the infected bone
• Useful in those need extensive resection of bone and reconstruction to achieve
stability
• A corticotomy is performed through normal bone proximal and distal to the area
of disease.
• The bone is transported until union is achieved
TREATMENT
55. ILIZAROV TECHNIQUE
Disadvantages
• the time required to achieve a solid union
• high incidence of associated complications.
Use of distraction osteogenesis with ring
fxation over an intramedullary rod has been
used for the treatment of segmental defects
of up to 13 cm
TREATMENT
56. Ilizarov for pandiaphyseal osteomyelitis
56
Bari et al. (2015) Treatment of Chronic Osteomyelitis in Children by Ilizarov Technique. MOJ
Orthop Rheumatol 2(4): 00054. DOI: 1
58. ADJUNCTIVE THERAPIES
• Hyperbaric oxygen therapy
has been used but has not proved to be reliably effective
• Growth factors
because of their ability to accelerate or enhance osteogenesis
✓ Bone Morphogenic Proteins (BMPs)
✓ Platelet rich plasma (PRP)
• Pulsed Electromagnetic Fields [PEMF] and Ultrasound
may directly interfere with biofilm formation
act synergistically with antibiotics to enhance their activity
TREATMENT
59. • The involucrum is sometimes insufficient
As a result of becoming dense and brittle bone
• Management
Bone fragments are realigned and immobilized as with any other
fracture
Plates and medullary nails have been used to fix infected fractures,
but they should be avoided if possible
External fixation or cast immobilization usually is
preferred.
If bone loss is signifcant, the defect can be filled with autogenous
bone graft, a vascularized osseous graft, or bone transport using
the Ilizarov technique
PATHOLOGICAL FRACTURE IN OSTEOMYELITIS
60. • Pathological fractures
• Flare up ( acute on chronic infection )
• Soft tissue infection and abscess
• Soft tissue contracture and deformity
• Amyloidosis
• Malignant transformation ( 0.2% to 1.6 %); Pre-existing sinus with increasing
pain, foul smelling discharge or hemorrhage ; SCC
COMPLICATIONS
61. AMPUTATION FOR OSTEOMYELITIS
• Performed infrequently for osteomyelitis. In certain patients, this form of
treatment may be preferable, however, to multiple operations and
prolonged antibiotic therapy.
• The prevalence of malignancy arising from chronic osteomyelitis has been
reported to be 0.2% to 1.6%
Amputation is the most reliable means of treating osteomyelitis associated
with malignant change
• Arterial insufciency, major nerve paralysis, or joint contractures and stifness
that make a limb nonfunctional are indications for amputation.
62. • Campbell's Operative Orthopaedics 13th edition
• Apley's System of Orthopaedics and Fractures 9th edition
• Miller Review of Orthopedics 6th edition
• Internet sources
References
