Aetiology ,Pathophysiology,

principles of diagnosis &

management of Osteomyelitis
Outline
• Introduction

• Classification

• Acute Osteomyelitis
• Aetiology , pathogenesis , clinical features , investigations , treatment

• Chronic Osteomyelitis
• Aetiology , pathogenesis , clinical features , investigations , treatment
Osteomyelitis
• One of the most difficult and challenging problems confronted by
Orthopaedic Surgeons

• Early diagnosis and prompt treatment key .

Osteomyelitis
• Inflammation of bone and marrow by an infecting organism

• Single organism / polymicrobial

Classification of Osteomyelitis
• Duration
• Acute
• Sub acute
• Chronic

• Mechanism
• Exogenous (open fractures, surgery(iatrogenic), contiguous spread from
infected local tissue)
• Hematogenous
Acute Osteomyelitis
• Most common type of bone infection

• Usually seen in children

• Incidence reduced - higher standard of living , improved hygiene

• Duration of infection – within 2 weeks

Etiology
• Commonest is Staptylococcus aureus (70-90%)
• Streptococcus pyogenes, streptococcus pneumo ,
• Staph epidermidis (implant associated infection) , pseudomonas (IV drug
users)
• SCD – Salmonella
• < 4 yrs – hematophilus influenza , Escherichia coli
• Mycobacterium tuberculi

• Fungi – Histoplasma , Cryptococcus, candida , blastomyces species – unusual

causes
Acute Osteomyelitis - classification
• Hematogenous - long bones , vertebrae
• Post traumatic
• Contiguous spread

• Hematogenous is commonest in children

• Post traumatic /contigus spread - commonest in Adults
• Vertebral osteomyelitis – common in adults above 45
years
Hematogenous Osteomyelitis
• Predisposing factors
• Reduced immunity
• Lower local bone immunity, localized bone trauma
• Infection source- tonsillitis , boils , furuncles , UTI , endocarditis

• Commonly affects metaphyseal region of bone in children

Pathogenesis
Metaphysis
• Bacteremia of long PMN
bones migration

Inflammation
Stage of inflammation

• Acute inflammatory
reaction
• Increased intraosseous
pressure
• Intense pain
• Obstruction of blood flow
Stage of suppuration

2nd day pus appears in

medulla

Becomes sub periosteal

Re enters the bone again

Stage of necrosis

Week 1: evidence of necrosis

Increased intaosseous
pressure , periosteal
stripping , vascular stasis all
contribute to cause bone
death.
New bone formation \sequestra
Clinical features
• History of bone pain – constant and gradually increasing
• Restricted movements - pseudoparalysis
• Malaise , irritability , fatigue
• Chills
• Prostration
• Fever
• Limp
Clinical examination
• Local tenderness, swelling , erythema , differential warmth
Investigations
• Full blood count +ESR

• Leucocytosis , with neutrophilia

• Elevated ESR

• C-reactive protein - elevated

Investigation
• Microbial studies
• Blood culture

• Aspirate for MCS

Investigations
• Radiographs

• 1st 10 days ----radiographs appear

normal

• Mottling , periosteal reaction in

later stages

• Xray changes are usually 2 weeks

behind
Magnetic resonance Imaging

More sensitive

Can detect earlier than radiographs

Can distinguish soft tissue infection

from bony infection
Skeletal scintigraphy/ Bone Scan
technetium -99m diphosphonate
Differential diagnosis
• Cellulitis
• Sickle cell crisis

• Acute septic arthritis

• Acute rheumatic fever
Treatment
Supportive treatment
• Continuous bed rest
• Limb splintage
• Antipyretics
• Adequate analgesia
Treatment
• Antibiotics
• Commenced immediately after culture samples taken
• Empirical antibiotics then culture sensitive
• Initially parenteral (IV) for 2 weeks
• Oral for 4 weeks

• Monitor with CRP, ESR ,WBC

Surgical treatment
• Might not be necessary if antibiotics commenced first 48hrs after
onset of symptoms
• One third of patients with confirmed osteomyelitis are likely to need a
surgery
• Indications for surgery
• Surgery indicated if no improvement after 36hrs parenteral
antibiotics
• Signs of deep seated pus (swelling edema , fluctuancy)
• Pus aspirated
Surgical drainage

• Drainage of sub periosteal pus

• No pus- drill a few holes in bone

• Drainage of intramedullary pus – cortical window
Follow up
• Limb splintage

• Out patient follow up

Complications
• Spread to

• Pathological fracture

• Growth plate disturbance

• Persistent infection
Chronic osteomyelitis
• Presence of residual focus of infection (avascular bone and soft tissue
debris) which gives rise to recurrent episodes of clinical infection

• Significant impact on patients function and mobility especially in

young productive patient population
Aetiology
• Staphylococcus aureus – most common, up to 65% of casaes

• Enterococcus spp, streptococcs spp , pseudomonas aeruginosa

• Enterobacter spp

• Mycobacterium , anaerobes and fungi

• Polymicrobial in up to 20-30% of cases

Pathophysiology
• Source of bacteria
• Inadequately treated hematogenous acute osteomyelitis

• Contiguous spread following open fractures , internal fixation of

fractures and prosthetic replacements
Pathogenesis of Chronic osteomyelitis
• Acute bone infection obliteration and compression of
vascular channels

Bone necrosis

Sequestrum formation
Formation of Biofilm over sequestra , implant
/prosthesis
• Biofilm formation from cellular
debris , bacteria coating
• Biofilm reduces oxygen
tension and nutrient delivery
• Protects from host immune
systems i.e antibiotics and
phagocytosis
Clinical features
• No specific sign / symptom

• Some can be asymptomatic and found on routine evaluation for unrelated

conditions

• Chronic pain
• Persistent discharge from a wound
• Sinus tract

• Recurrent periods of acute flare ups

 Investigation
•
• Radiographs
Singraphy
CT Scan
MRI scan
Laboratory
• Full blood count - might be normal or elevated in acute
exacerbations

• C-reactive protein / ESR- non specific and can monitor response to

treatment
laboratory
• Microscopy /culture / sensitivity

• Swabs – surface contaminants

• Deep tissue cultures (more representative)
• Anaerobic , aerobic , fungal and mycobacterial culture

• Gold standard of diagnosis is tissue biopsy

Treatment
• Multidisciplinary

• Orthopaedic surgeon

• Plastic /reconstructive surgeon

• Infectious disease specialist

• psychologist
Treatment
• Treatment is individualized
• Counsel of risk of recurrence
Goal of treatment
• complete eradication of infection

• Preservation of soft tissue envelope

• Healing of bone segment

• Preservation of limb length and function

Treatment
• Antibiotics
• Not particularly useful before surgery as bacteria is inaccessible in biofilm

• Can be given in acute exacerbations for short courses

• Prolonged antimicrobial therapy – minimum of 6 weeks after surgery

Treatment
• Surgery
• Sequestrectomy
• Principles of surgery
• Adequate debridement
• Complete excision of all sinus tract , scar tissue and dead bone

• Management of dead space

• Bone graft , bone graft substitute ,muscle etc

• Soft tissue coverage

• Skeletal stabilization if necessary

Treatment
• Limb splintage

• Prolonged antibiotics
Prognosis
• 10-20 % recurrence

• Patients may need multiple surgeries