Osteomyelitis

dr. Dewi Klarita Furtuna, M.Ked.Klin., Sp.MK

The key to successful management is early diagnosis and appropriate
surgical and antimicrobial treatment.
History : ??
• Osteomyelitis is an ancient disease, which has been present for the
last 250 million years and was first described in humans by
Hippocrates

• Nelaton is credited with introducing the term “osteomyelitis” in 1844

• The first paper on osteomyelitis in the Journal in February 1948, was

from the Royal Hospital for Sick Children in Glasgow

benefits of penicillin which had gradually become available in

the 1940s
Definition : ??
Introduction

Osteomyelitis
osteon (bone) ; myelo (marrow) ; itis (inflammation)

Infection in bone

differ from another (duration, etiology,

pathogenesis, bone involvement) & type
Osteomyelitis in of patient (infant, child, adult, or
long bones
immunocompromised)
Osteomyelitis :
• Osteomyelitis adalah infeksi dari jaringan tulang yang mencakup sumsum dan atau
kortek tulang dapat berupa eksogen (infeksi masuk dari luar tubuh) atau hemotogen
(infeksi yang berasal dari dalam tubuh). (Reeves,2001:257).

• Osteomyelitis adalah infeksi substansi tulang oleh bakteri piogenik (Overdoff,

2002:571).

• Osteomyelitis adalah infeksi pada tulang yang disebabkan oleh mikroorganisme.

Osteomyelitis biasanya merupakan infeksi bakteri dan jamur yang dapat
menyebabkan osteomyelitis jika mereka menginvasi tulang (Ros, 1997:90).

• Osteomyelitis adalah infeksi jaringan tulang (Price, 1995:1200)

• Osteomyelitis akut adalah infeksi tulang panjang yang disebabkan oleh infeksi lokal
akut atau trauma tulang, biasanya disebabkan oleh Escherichia coli, staphylococcus
aureus, atau streptococcus pyogenes (Tucker, 1998:429).
Classification :
1. Waldvogel et al.

2. Cierny et al
The Waldvogel system :
• Duration : Acute and chronic

• Source infection : hematogenous and contiguous focus

• vascular insufficiency
Cierny-Mader Staging System
Osteomyelitis Classification :
• Duration : Acute, Subacute or Chronic
• Route of infection : Hematogenous or Exogenous
• Host response : Pyogenic or non pyogenic
ETIOLOGY
PATHOGENESIS
1. The type of osteomyelitis is largely determined by :

- The mechanism of infection, the virulence of the infecting

organism,
- The immune status and comorbid conditions of the patient
- Osteomyelitis could develop through hematogenous seeding of
the bone from a remote source of infection, extension of the
infection from adjacent oft tissue overlying the involved bone; or
directly via inoculation of the bone following trauma or surgery.
2. Penyebaran Infeksi :
• Ke arah korteks membentuk abses subperiosteal dan selulitis pada
jaringan sekitarnya.
• Menembus periosteum membentuk abses jaringan lunak dan abses
dapat menembus kulit melalui suatu sinus dan menimbulkan
kematian tulang yang disebut sequester.
• Menyebar ke arah medula.
• Menyebar ke persendian terutama bila lempeng pertumbuhannya
intra artikuler. Penetrasi ke epifisis jarang terjadi.
Acute hematogenous
osteomyelitis
• distribution- younger than 2 years, and 8-12 years
• More common in males
• Caused by a bacteraemia
• Bacteriological seeding of bone generally is associated with other
factors such as localized trauma, chronic illness, malnutrition or an
inadequate immune system.
• In children the infection generally involves the metaphyses of rapidly
growing long bones

• Bacterial seeding leads to an inflammatory reaction which can cause

local ischaemic necrosis of bone and subsequent abscess formation

• As the abscess enlarges, intramedullary pressure increases causing

cortical ischaemia, which may allow purulent material to escape
through the cortex into the subperoisteal space
Sign : pain of affected area (localized pain) and loss of function, fever,
Localized erythema, swelling, inability to bear weight
Diagnosa : Diagnosa Banding :
• Lab Studies : leukosit, Marker Infection - Osteosarkoma
• Imaging : Rontgen, CT Scan, MRI - Ewing Sarkoma
•  Microbiologic Data :
- Blood cultures,
- Bone biopsy, debridement,
- Abscess drainage
Radiograph
• Soft tissue swelling

• Periosteal reaction

• Bony destruction
(10-12 days)
Treatment :
• Surgery and antibiotic treatment are complementary, in some cases
antibiotics alone may cure the disease.

• Choice of antibiotics is based on the highest bacteriocidal activity, the

least toxicity and the lowest cost
• The two main indications for surgery in acute hematogenous
osteomyelitis are:

1. The presence of an abscess requiring drainage

2. Failure of the patient to improve despite appropriate
intravenous antibiotic treatment
SUBACUTE HEMATOGENOUS
OSTEOMYELITIS
• More insidious onset and lacks severity of symptoms
• More than two weeks.
• The indolent course of subacute osteomyelitis is due to:
• increased host resistance
• decreased bacterial virulence
• administration of antibiotics before the onset of symptoms
• Systemic signs and symptoms are minimal
• Temperature is only mildly elevated
• Mild to moderate pain
BRODIE ABSCESS
• an intraosseous abscess related to a focus of subacute
pyogenic osteomyelitis
• patients are younger than 25 years of age and present with joint pain
and localized swelling.
• Signs and symptoms of systemic disease are frequently absent.
• Staphylococcus aureus (30%–60%), Pseudomonas (5%), Klebsiella (5%)
and coagulase negative Staphylococcus (5%) are causative organisms.
• 20% of cultures are negative for these organisms.
• Radiographically, an intramedullary area of central lucency with
sclerotic margins is characteristic.
Chronic Osteomyelitis
• “ A severe, persistent and incapacitating infection of bone and bone
marrow”

• Hallmark is infected dead bone within a compromised soft tissue

envelope

• surrounded by sclerotic, relatively avascular bone

Types

• A complication of acute Osteomyelitis

• Post traumatic

• Post operative
Clinical manifestations
• Hematogenous osteomylitis usually involves a single bone.
• The most common presenting complaints are focal pain, warmth,
erythema, swelling, and decreased use of the affected extremity.
• Fever, anorexia, irritability, and lethargy may accompany the focal
findings.
Factors responsible for chronicity

• Local factors: Cavity, Sequestrum, Sinus, Foreign body, Degree of

bone necrosis
• General: Nutritional status of the involved tissues, vascular disease,
DM, low immunity
• Organism: Virulence
• Treatment: Appropriateness and compliance
• Risk factors: Penetrating trauma, prosthesis, Animal bite
Treatment
• Antibiotics
• Surgical treatment
Preoperative assessment & preparation
Derbridement
Sequestrectomy
Local antibiotics
Stability
Treatment of bone cavity
Complications

• “Recurrence & Recurrence & Recurrence”

• Pathological fractures
• Growth disturbance
• Amyloid disease
• Epidermoid carcinoma of the fistula
• surgical drainage may be appropriate at earlier time if :
1. sequestrum is present
2. disease is chronic
3. the hip joint is involved
4. Presence of spinal cord compression
75-year-old man with acute recurrence of chronic post-
traumatic femoral osteitis which had been dormant for 17
years (Necrotizing soft tissue infections)
Treatmen Therapy :

Treatment algorithm of Cierny-Mader stage 1, or

hematogenous, long bone osteomyelitis.
Treatment algorithm of Cierny-Mader stage 2 long bone osteomyelitis
Initial Antibiotic Therapy for Treatment of Osteomyelitis in Adults
 Local Antibiotic Therapy
(Antibiotic Impregnated Beads)

• Antibiotic Impregnated beads & self-setting bone cement have used to

treat chronic osteomyelitis allowing the local delivery of high
concentrations of antibiotics, while avoiding potential systemic side
effects.
• Antibiotic usually used Vancomycin, Gentamycin, Tobra
• The beads are usually removed within 2-4 weeks and replaced with
cancellous bone graft
Kegagalan pemberian antibiotika dapat disebabkan oleh :

• Pemberian antibiotik yang tidak sesuai dengan mikroorganisme

penyebab
• Dosis tidak adekuat
• Lama pemberian tidak cukup
• Kesalahan hasil biakan
• Antibiotik antagonis
• Pemberian pengobatan suportif yang buruk
• Kesalahan diagnostik
Thank you For Not Sleeping…