OSTEOMYELITIS

Su Djie To Rante

Introduction
Osteomyelitis is defined as inflammation of bone and marrow cavity. Micro-organisms may reach the musculoskeletal tissues by (a) direct introduction through the skin
a pinprick an injection, a stab wound, a laceration, an open fracture or an operation),

(b) direct spread from a contiguous focus of infection, or (c) indirect spread via the blood stream from a distant site

General aspects of infection

Infection as distinct from mere residence of microorganisms
is a condition in which pathogenic organisms multiply and spread within the body tissues. gives rise to an acute or chronic inflammatory reaction

The signs of inflammation are recounted in the classical mantra: redness, swelling, heat, pain and loss of function

Host susceptibility to infection is increased by local factors such as trauma, scar tissue, poor circulation, diminished sensibility, chronic bone or joint disease and the presence of foreign bodies systemic factors such as malnutrition, general illness, debility, diabetes, rheumatoid disease, corticosteroid administration and all forms of immunosuppression, either acquired or induced. Resistance is also diminished in the very young and the very old.

 Acute pyogenic bone infections are characterized by the formation of pus a concentrate of defunct leucocytes, dead and dying bacteria and tissue debris Chronic pyogenic infection may follow on unresolved acute infection persistence of the infecting organism in pockets of necrotic tissue. Chronic non-pyogenic infection may result from invasion by organisms that produce a cellular reaction formation of granulomas consisting largely of lymphocytes, modified macrophages and multinucleated giant cells

Classification
Waldvogel, 1971
Classification based on pathogenesis

Kelly, 1984
looked at anatomic and structural factors to further define osteomyelitis

May & Jupiter, 1989

5 parts, post-traumatic tibial osteomyelitis

Cierny & Mader, 1985

Most widely used in orthopedic literature. Their system classifies by the degree of anatomic involvement and by host physiology

Waldvogel
1. Hematogenous osteomyelitis, 2. Osteomyelitis secondary to a contiguous focus of infection, and 3. Osteomyelitis associated with peripheral vascular disease.

Kelly
Hematogenous osteomyelitis, Osteomyelitis with united fracture Osteomyelitis with nonunion, and Osteomyelitis without fracture.

Anatomic Classification

(Cierny-Mader)
1985

I:

II:

Classification Break-Down

Physiologic Classification
(Cierny-Mader, 1985)

Clinical Staging
(Cierny-Mader, 1985)

Anatomic Type
+

Clinical Stage

Physiologic Class
Example: IV B tibial osteomyelitis = diffuse tibial lesion in a systemically compromised host
S

Types of Pathophysiology
Acute/Hematogenous

Chronic/Nonhematogenous

The principles of treatment

1. to provide analgesia and general supportive measures; 2. to rest the affected part; 3. to identify the infecting organism and administer effective antibiotic treatment or chemotherapy; 4. to release pus as soon as it is detected; 5. to stabilize the bone if it has fractured; 6. to eradicate avascular and necrotic tissue; 7. To restore continuity if there is a gap in the bone; and 8. to maintain soft-tissue and skin cover

ACUTE HAEMATOGENOUS OSTEOMYELITIS

Mainly a disease of children The causal organism in both adults and children is usually
Staphylococcus aureus (found in over 70% of cases), Group A beta-haemolytic streptococcus (Streptococcus pyogenes), Group B streptococcus (especially in new-born babies) or the alphahaemolytic diplococcus S. pneumoniae.

Pathology
shows a characteristic progression marked by
inflammation, suppuration, bone necrosis, reactive new bone formation and, ultimately, resolution and healing or else intractable chronicity.

Clinical features
Children (usually a child over 4 years)
severe pain, malaise and a fever; in neglected cases, toxaemia may be marked. refuses to use one limb or to allow it to be handled or even touched. There may be a recent history of infection: a septic toe, a boil, a sore throat or a discharge from the ear.

 looks ill and feverish; PR > 100 and the temperature is raised. The limb is held still and there is acute tenderness near one of the larger joints pseudoparalysis. Local redness, swelling, warmth and oedema Lymphadenopathy is common but nonspecific.

 Infants : children under a year old, and especially in the newborn,

the constitutional disturbance can be misleadingly mild; the baby simply fails to thrive and is drowsy but irritable. a history of birth difficulties, umbilical artery catheterization or a site of infection (however mild) Metaphyseal tenderness and resistance to joint movement multiple infection is not uncommon, especially in babies who acquire the infection in hospital. Radionuclide bone scans may help to discover additional sites.

 Adults
The commonest site for haematogenous infection is the thoracolumbar spine. History of some urological procedure followed by a mild fever and backache. Local tenderness is not very marked and it may take weeks before x-ray signs appear; when they do appear the diagnosis may still need to be confirmed by fineneedle aspiration and bacteriological culture. Other bones are occasionally involved, especially if there is a background of diabetes, malnutrition, drug addiction, leukaemia, immunosuppressive therapy or debility

Diagnostic imaging
PLAIN X-RAY
During the first week : no abnormality of the bone. second week : a faint extra-cortical outline due to periosteal new bone formation; but treatment should not be delayed periosteal thickening more obvious ,patchy rarefaction of the metaphysis; ragged features of bone destruction appear. An important late sign : combination of regional osteoporosis with a localized segment of apparently increased density.

 ULTRASONOGRAPHY
Ultrasonography may detect a subperiosteal collection of fluid in the early stages of osteomyelitis, but it cannot distinguish between a haematoma and pus.

RADIONUCLIDE SCANNING
Radioscintigraphy with 99m Tc-HDP reveals increased activity in both the perfusion phase and the bone phase. highly sensitive, relatively low specificity In doubtful cases, scanning with 67 Ga-citrate or 111 In-labelled leucocytes may be more revealing.

 MAGNETIC RESONANCE IMAGING

In doubtful cases best method of bone marrow inflammation. It is extremely sensitive, even in the early phase of bone infection, and can therefore assist in differentiating between soft-tissue infection and osteomyelitis. However, specificity is too low to exclude other local inflammatory lesions.

Laboratory investigations
The most certain way to confirm the clinical diagnosis is to aspirate pus or fluid from the metaphyseal subperiosteal abscess, the extraosseous soft tissues or an adjacent joint. This is done using a 16- or 18-gauge trocar needle. Tissue aspiration positive result in over 60% of cases;

 Blood cultures positive in less than half the cases of proven infection. The C-reactive protein (CRP) within 1224 hours Erythrocyte sedimentation rate (ESR) within 2448 hours after the onset The white blood cell (WBC) countrises

Differential diagnosis
Cellulitis Acute suppurative arthritis Streptococcal necrotizing myositis Acute rheumatism Sickle-cell crisis Gauchers disease

Treatment
Supportive treatment for pain and dehydration. Splintage of the affected part. Appropriate antimicrobial therapy. Surgical drainage. Host physiology, bacterial virulence and bony stability

Antibiotic
Neonates and infants up to 6 months
Penicillin-resistant Staphylococcus aureus, Group B streptococcus and Gram-negative organisms flucloxacillin plus a third-generation cephalosporin like cefotaxime

Children 6 months to 6 years of age

Haemophilus influenzae, intravenous flucloxacillin and cefotaxime or cefuroxime

 Elderly and previously unfit patients

risk of Gram-negative infections, due to respiratory, gastrointestinal, or urinary disorder combination of flucloxacillin and a second- or thirdgeneration cephalosporin

Patients with sickle-cell disease

staphylococcal infection, salmonella and/or other Gramnegative organisms third-generation cephalosporin or a fluoroquinolone like ciprofloxacin.

Patients considered to be at risk of meticillinresistant Staphylococcus aureus (MRSA) infection

intravenous vancomycin (or similar antibiotic) together with a third-generation cephalosporin

Factors determine the effectiveness of antibacterial treatment :

The time interval between the onset of infection and the institution of treatment. The effectiveness of the antibacterial drug against the specific causative bacteria. The dosage of the antibacterial drug. The duration of antibacterial therapy.

DRAINAGE
If antibiotics are given early (within the first 48 hours after the onset of symptoms) drainage is often unnecessary. If the clinical features do not improve within 36 hours of starting treatment, or even earlier if there are signs of deep pus (swelling, oedema, fluctuation), and most certainly if pus is aspirated, the abscess should be drained by open operation

Complications
Epiphyseal damage and altered bone growth Suppurative arthritis Metastatic infection Pathological fracture Chronic osteomyelitis

SUBACUTE HAEMATOGENOUS OSTEOMYELITIS

Its relative mildness is presumably due to the organism being less virulent or the patient more resistant (or both)

Pathology
Typically there is a well-defined cavity in cancellous bone usually in the tibial metaphysis containing glairy seropurulent fluid (rarely pus). The cavity is lined by granulation tissue containing a mixture of acute and chronic inflammatory cells. The surrounding bone trabeculae are often thickened. The lesion sometimes encroaches on and erodes the bony cortex.

Clinical features
Usually a child or adolescent who has had pain near one of the larger joints for several weeks or even months. He or she may have a limp and often there is slight swelling, muscle wasting and local tenderness. The temperature is usually normal and there is little to suggest an infection. The WBC count and blood cultures usually show no abnormality but the ESR is sometimes elevated.

Imaging
The typical radiographic lesion is a circumscribed, round or oval radiolucent cavity 12 cm in diameter. Most often it is seen in the tibial or femoral metaphysis Sometimes the cavity is surrounded by a halo of sclerosis (the classic Brodies abscess)

Comparison acute and subacute osteomyelitis.

Subacute Acute

Pain Fever
Loss of function Prior antibiotic therapy Elevated WBC count Elevated ESR Blood cultures Bone cultures Initial radiograph Site

Mild Few patients

Minimal Often (30-40%) Few Majority of the patients Few positive 60% positive Frequently abnormal

Severe Majority of the patients

Marked Occasionaly Majority of the patients Majority of the patients 50 % positive 85% positive often normal

Any location (may cross Usually metaphysis physis)

Treatment
Immobilization and antibiotics (flucloxacillin and fusidic acid) intravenously for 4 or 5 days and then orally for another 6 weeks usually result in healing, though this may take up to 12 months. If the diagnosis is in doubt, an open biopsy is needed and the lesion may be curetted at the same time. Curettage is also indicated if the x-ray shows that there is no healing after conservative treatment

CHRONIC OSTEOMYELITIS
Inadequate treatment in acute phase The usual organisms are Staphylococcus aureus, Escherichia coli, Streptococcus pyogenes, Proteus mirabilis and Pseudomonas aeruginosa; in the presence of foreign implants Staphylococcus epidermidis

Pathology
Bone is destroyed or devitalized Cavities containing pus and pieces of dead bone (sequestra) The result of chronic reactive new bone formation which may take the form of a distinct bony sheath (involucrum). Sinuses Bone destruction, and the increasingly brittle sclerosis, sometimes results in a pathological fracture.

Clinical features
Pain, pyrexia, redness and tenderness have recurred (a flare), or with a discharging sinus. The tissues are thickened and often puckered 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.

Imaging
X-ray examination Radioisotope scintigraphy CT and MRI

Treatment
Antibiotic
to suppress the infection and prevent its spread to healthy bone to control acute flares

Local treatment Operation

Bibliography
Stein H, Lerner A. Advances in the treatment of chronic osteomyelitis. Current Orthopaedics(2001)15,451-456. Elsevier Science Ltd. Mast NH, Horwitz D. Osteomyelitis: a review of current Literature and concepts. Operative Techniques in Orthopaedics, Vol 12, No 4, 2002: pp 232241Elsevier Science (USA). Louis Solomon, H. Srinivasan, Surendar Tuli, Shunmugam Govender. Infection. In Apleys System of Orthopaedics and Fractures Ninth Edition. Hodder Arnold. 2010

Centripetal Flow
Rhinelander, CORR, 1974