Osteomyelitis

Fanny Indarto
SMF Ilmu Bedah UKRIDA
 Definition
• An infection of the bone, a rare but serious
condition.

WebMD
 Classification
• Acute, subacute, chronic
• Exogen, hematogen
• Pyogenic, non pyogenic
 Classification
• Acute osteomyelitis is usually considered to
occur within the first 6 weeks following
inoculation
• Chronic osteomyelitis being greater than 6
weeks.

Essential of Orthopedic Surgery, 2010

 Infection pathway
• Exogenous or hematogenous pathways.
• Exogenous delivery involves direct inoculation
of the bone from either trauma, surgery, or a
contiguous focus of infection.
• Hematogenous delivery is via the vascular
system into either osseous or synovial tissue
producing a localized focus of infection.
 Risks for Osteomyelitis

• Diabetes (most cases of osteomyelitis stem from

diabetes)
• Sickle cell disease
• HIV or AIDS
• Rheumatoid arthritis
• Intravenous drug use
• Alcoholism
• Long-term use of steroids
• Bone surgery, including hip and knee replacements,
also increase the chance for infection to invade a bone.
 Osteomyelitis
Children Adult
• Acute • Either acute or chronic
• Arm, leg bone • Pelvic, vertebrae. Diabetic
• Easier to treat  feet
• Persist, recure despite
treatment
• Pyogenic organisms elicit a rapidly progressive
course of pain, swelling, abscess formation,
and aggressive bone destruction. A gram-
positive staphylococci is a classic example.
• In contrast, less aggressive nonpyogenic
organisms invoke a more insidious
granulomatous reaction, classically seen with
acid-fast bacilli.
 Symptoms of Osteomyelitis
• The symptoms for acute and chronic
osteomyelitis are very similar and include:
– Fever, irritability, fatigue
– Nausea
– Tenderness and swelling around the affected bone
– Lost range of motion
– Osteomyelitis in the vertebrae makes itself known
through severe back pain, especially at night.
 Osteomyelitis

• The infection may be limited to a single

portion of the bone or may involve numerous
regions
• The infection generally is due to a single
organism, but polymicrobial infections can
occur, especially in the diabetic foot.
 Pathophysiology
• Cortical bone : increased local pressure which accompanies
inflammations  infarction of the marrow fat
coagulative necrosis initially and then is replaced by a
myxofibrous stroma.
• Cancellous trabeculae also are infarcted by the collapse of
the vessels and also undergo necrosis.
• These necrotic segments of bone often are not resorbed
and are termed sequestrae. These will calcify and remain
centrally located, and they appear radiologically as very
dense areas within the lytic portion of the process.
Reactive, viable bone often will form around a sequestrum;
this bone is called an involucrum.
Essential of Orthopedic Surgery, 2007
Campbell's, 2007
 Biofilm Pathophysiology
• Once implanted, the prosthesis is
progressively coated by a glycoprotein layer,
which favours the superficial adhesion of
bacteria.
• These are, themselves, coated with a biofilm
composed of polysaccharides (glycocalyx)
which protects them from the host’s immunity
system and from antibiotics

Infection & Local Treatment in Orthopedic

Surgery, 2007
Acute hematogenous osteomyelitis
• Hematogenous spread of bacteria to the bone is
a common event.
• It is seen most frequently in children, likely due
to the vascular anatomy at the epiphyseal
growth plate, although it is also commonly seen
in patients after illnesses involving bacteremias.
• Bacteriological seeding of bone generally is
associated with other factors such as localized
trauma, chronic illness, malnutrition, or an
inadequate immune system. In many cases, the
exact cause of the disease cannot be identified.
• After the physes are closed, acute hematogenous
osteomyelitis is much less common.
• Hematogenous seeding of bone in adults usually
is seen in a compromised host.
• Although it can occur anywhere and in any part
of the bone, generally the vertebral bodies are
affected. In these patients, abscesses spread
slowly, and large sequestra rarely form.
• If localized destruction of cortical bone occurs,
pathological fracture can result
 Etiology
• Staphylococcus aureus is the most common infecting
organism found in older children and adults with
osteomyelitis.
• Gram-negative bacteria have been found to cause an
increasing number of vertebral body infections in adults.
• Pseudomonas is the most common infecting organism
found in intravenous drug abusers with osteomyelitis.
• Fungal osteomyelitis is seen increasingly in chronically ill
patients receiving long-term intravenous therapy or
parenteral nutrition.
• Salmonella osteomyelitis has long been associated with SS
or SC hemoglobinopathies
• Bone infections in children are almost all due to
Staphylococcus aureus
• Infections of the bone can occur to a wide
variety of organisms, ranging from gram-positive
and gram-negative bacteria to microbacteria and
even fungi.
• Immunocompromised patients (particularly those
on immunosuppressive medications,
corticosteroids, or suffering from HIV infection)
can present with bone infections caused by very
unusual pathogens.
Campbell's, 2007
• In patients with acute osteomyelitis, the
radiologic features do not appear until 1 to 14
days after the onset of symptoms
 Biopsy
• when a bone infection is suspected, biopsy for
culture is nearly always necessary.
• Indeed, bony changes caused by bone
infection quite often mimic the appearance of
tumor.
• Nade proposed five principles for the treatment of
acute hematogenous osteomyelitis :
(1) an appropriate antibiotic is effective before pus
formation;
(2) antibiotics do not sterilize avascular tissues or
abscesses, and such areas require surgical removal;
(3) if such removal is effective, antibiotics should
prevent their reformation, and primary wound
closure should be safe;
(4) surgery should not damage further already
ischemic bone and soft tissue;
(5) antibiotics should be continued after surgery.

Campbell's, 2007
• Antibiotic treatment for severe bone
infections generally is not nearly as successful
as antibiotic treatment for most soft tissue
infections. Thus, prolonged IV therapy often is
indicated (6 weeks or more), and most severe
bone infections also are débrided surgically
• Chronic osteomyelitis may lead to a fistula or
chronically draining sinus. This is a commonly
seen problem in diabetic patients, but may
arise in any incompletely treated
osteomyelitis.
 Granulomatous Osteomyelitis
• chronic inflammatory process with central giant
cells and macrophages with a peripheral cuff of
lymphocytes and plasma cells.
• Plain radiographs generally are notable for
ossification and calcification with variable
degrees of lucency.
• The histology demonstrates granuloma formation
that is identical to that seen in other locations.
The most common granulomatous condition in
the skeletal system is due to tuberculosis
 Surgical Treatment
• three main facets:
(1) extensive debridement,
(2) vascular soft tissue coverage,
(3) bone stabilization.

Essential of Orthopedic Surgery, 2007

• Principles of treatment for adult osteomyelitis
apply with one important exception; namely, the
retention of implants for fixation of the fracture.
• In patients who present with an infection
surrounding an intramedullary nail or plate, the
wound should be aggressively debrided and the
implant maintained if fracture stability is being
achieved.
• Loose implants should be removed and either
replaced or substituted by another implant type
Essential of Orthopedic Surgery