Beruflich Dokumente
Kultur Dokumente
OSTEOMYELITIS
Infection of bone and bone marrow Subdivided into : Acute Subacute Chronic In children, the long bones (such as the thigh bones) are
affected by osteomyelitis.
CLASSIFICATION
CHRONIC OSTEOMYELITIS
a severe, persistent, and sometimes incapacitating infection of
in hematogenous osteomyelitis
results when bone tissue dies as a result of the lost blood supply relatively common as a sequelae from open fractures or gunshot
wounds
The presence of a foreign body makes establishment of chronic
infection.
ETIOLOGY
Inadequate treatment of acute osteomyelitis A hematogenous type of osteomyelitis Trauma Iatrogenic causes such as joint replacements and the internal fixation
of fractures
Contiguous spread from soft tissues, as may occur with diabetic ulcers
bacterial osteomyelitis is often associated with the age of the patient or the clinical scenario.
Staphylococcus aureus is implicated in most cases of acute
hematogenous osteomyelitis and is responsible for up to 90 percent of cases in otherwise healthy children.
Staphylococcus epidermidis, S. aureus, Pseudomonas
aeruginosa, Serratia marcescens and Escherichia coli are commonly isolated in patients with chronic osteomyelitis.
Risk Factors
Recent trauma Diabetes Mellitus Hemodialysis Patients IV Drug abuse Immunocompromised Patients
Altered neutrophil defense, humoral immunity and cell-
mediated immunity
infarcted marrow, dead bone, or a medullary implant. Softtissue involvement is usually reactive in nature and responsive to removal of the nidus and a short course of antibiotics.
open wound. The medullary contents are not involved. Common examples include bone at the base of a pressure sore (decubitus) and chronic wounds associated with Papineau bone grafts.
thickness, cortical sequestrum. The canal is involved (type I pattern), there may be a soft-tissue deficit (type II pattern), and in- dwelling hardware is commonly present.
Example : an infected fracture union with plate fixation and
presence of a sequestered, butterfly fragment. To distinguish this from a type IV osteomyelitis, the involved bony segment will still be stable following a complete debridement.
combining the characteristics of types I, II, and III osteomyelitis with the additional feature of instability
intrinsically unstable rendered unstable with debridement
Diagnostic Tools
Diagnosis
based primarily on the clinical findings, with data from the
initial history, physical examination and laboratory tests serving primarily as benchmarks against which treatment response is measured.
The palpation of bone in the depths of infected pedal ulcers
in patients with diabetes mellitus is strongly correlated with the presence of underlying osteomyelitis (sensitivity, 66 percent; specificity, 85 percent; positive predictive value, 89 percent; negative predictive value, 56 percent).
Grayson ML, Gibbons GW, Balogh K, Levin E,
intramedullary infection or abscess superimposed on areas of necrosis, sequestrum and fibrosis) (2) to identify soft tissue involvement (areas of cellulitis, abscess, and sinus tracts)
Kaplan S, Sullivan L, et al. Foot infections in diabetic patients. JAMA. 1995;273:712 20.
The chronic phase of the disease is characterized by thick, irregular, sclerotic bone interspersed with radiolucencies, an elevated periosteum, and chronic draining sinuses .
Diagnostic Tools
For nuclear imaging, technetium Tc-99m methylene
techniques in septic arthritis and osteomyelitis. Rheum Dis Clin North Am. 1991;17:559 83.
scanning in the diagnosis of osteomyelitis: a metaanalysis of test performance. Diagnostic Technology Assessment Consortium. J Gen Intern Med. 1992;7:158 64.
POINT TO CONSIDER On a bone scan, osteomyelitis often cannot be distinguished from a soft tissue infection, a neurotrophic lesion, gout, degenerative joint disease, postsurgical changes, a healing fracture, a noninfectious inflammatory reaction or a stress fracture. In many instances, a bone scan will be positive despite the absence of bone or joint abnormality.
and specificity as well as its ability to demonstrate associated soft tissue abnormalities.
Fauce, et.al ; Harrison s Principles of Internal
hematogenous pyogenic vertebral osteomyelitis by magnetic resonance imaging. Arch Intern Med. 1991;151:683 7
MRI
Resnick D. Update on imaging of orthopedic infections. Orthop Clin North Am. 1998;29:41 66.
GOLD STANDARD
Histopathologic and microbiologic examination of bone is
the gold standard for diagnosing osteomyelitis. Cultures of sinus tract samples are not reliable for identifying causative organisms. Therefore, biopsy is advocated to determine the etiology of osteomyelitis.
Mackowiak PA, Jones SR, Smith JW. Diagnostic
SURGICAL TREATMENT
Treatment Format
To justify the morbidity and risk of limb salvage, the expected
outcome must offer distinct advantage(s) over an amputation or observation, alone. If treatment for cure is contraindicated or excessive, the patient is classified a C-host and offered palliation (incision/drainage, oral antibiotics, ambulatory aides, and pain medication).
Amputation is indicated when limb salvage and palliation are
and beyond), require combined reaming and unroofing to complete the excision
Due to the limited involvement of investing soft tissues in type I
lesions, the dead space remaining after debridement is usually confined to the medullary canal. A primary closure, an antibiotic depot within the canal and a short course of systemic antibiotics will, therefore, usually suffice for treatment.
envelope
Surgical treatment begins with resection of soft tissues to
bleeding bone
Local transpositions and free flaps are the most common methods
deficit.
If the excision will be of such a magnitude as to threaten the
mechanical stability of the remaining bony segment, the limb may be prophylactically stabilized with use of an osseous transfer , an external fixator, or stabilized in situ, following debridement, with an antibiotic depot (antibiotic-coated implant/spacers or antibiotic rods).
If osseous reconstruction is indicated or a significant dead space
exists following debridement, reconstruction will usually follow a course of local antibiotic therapy
bony segment.
Instability, an insidious zone of injury, bone loss, and a predominantly
compromised (B-host) patient population make type IV lesions the most difficult to treat.
Nearly all treatment protocols call for a staged reconstruction with
THANK YOU.