A Seminar On

CHRONIC OSTEOMYELITIS
By Y.Bharath Kumar

INTRODUCTION

Chronic osteomyelitis is difficult to eradicate completely. Systemic symptoms may subside, but one or more foci in the bone may contain purulent material, infected granulation tissue, or a sequestrum. Intermittent acute exacerbations may occur for years and often respond to rest and antibiotics. The hallmark of chronic osteomyelitis is infected dead bone within a compromised soft-tissue envelope. The infected foci within the bone are surrounded by sclerotic, relatively a vascular bone covered by a thickened periosteumand scarred muscle and subcutaneous tissue. This a vascular envelope of scar tissue leaves systemic antibiotics essentially ineffective.

In chronic osteomyelitis, secondary infections are common, and sinus track cultures usually do not correlate with cultures obtained at bone biopsy. Multiple organisms may grow from cultures taken from sinus tracks and from open biopsy specimens of surrounding soft tissue and bone. Eradication of chronic osteomyelitis generally requires aggressive surgical excision combined with effective antibiotic treatment. Surgery is not always the best option, however, especially in compromised patients. Consider an ambulatory immunocompromisedhost with multiple medical problems, including chronic osteomyelitis of the femur. For this patient, who might not survive the extensive surgical stress required to eradicate the disease, less aggressive alternatives should be considered. Limited surgical dbridement combined with suppressive antibiotics and nutritional support may limit the frequency of sinus drainage and pain in these difficult cases.

CLASSIFICATION

Cierny and Mader developed a classification system for chronic osteomyelitis, based on physiological and anatomical criteria, to determine the stage of infection.

Physiological Class:
Class A hosts have a normal response to infection and surgery. Class B hosts are compromised and have deficient wound healing capabilities. When the results of treatment are potentially more damaging than the presenting condition, the patient is considered a class C host.

Anatomical Class:

Anatomical criteria consist of four types. Type I, a medullary lesion, is characterized by endosteal disease. In type II, superficial osteomyelitis is limited to the surface of the bone, and infection is secondary to a coverage defect. Type III is a localized infection involving a stable, well-demarcated lesion characterized by full-thickness cortical sequestration and cavitation (in this type, complete dbridement of the area would not lead to instability). Type IV is a diffuse osteomyelitic lesion that creates mechanical instability,
either at presentation or after appropriate treatment

Table -- Cierny and Mader Staging System for Chronic Osteomyelitis

AnatomicalType I II III IV Medullary Superficial Localized Diffuse Cortical Cortical surface sequestrum Endostealdisease infected that can be because excised of without coverage compromising defect stability

Features of I, II, and III plus mechanical instability before or after dbridement

Physiological Class A host B host C host Normal Compromised Prohibitive Immunocompetent Local (B) or systemic with good local vascularity

(S) factors that compromise immunity or healing

Minimal disability, prohibitive morbidity anticipated, or poor prognosis for cure

Diagnosis