Sie sind auf Seite 1von 39

Chronic Osteomyelitis

Frayna, Rajib V. Gorospe, Paul Andrew M. Ismael, Janie-Vi V. Liao, Jasper

OSTEOMYELITIS
Infection of bone and bone marrow Subdivided into : Acute Subacute Chronic In children, the long bones (such as the thigh bones) are

usually affected by osteomyelitis.


In adults, the vertebrae and the pelvis are most commonly

affected by osteomyelitis.

CLASSIFICATION

CHRONIC OSTEOMYELITIS
a severe, persistent, and sometimes incapacitating infection of

bone and bone marrow


usually occur in adults Chronic infection is more likely to develop in contiguous-focus than

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

Compound fractures Infection with organisms, such as Mycobacterium tuberculosis and

Treponema species (syphilis)

Contiguous spread from soft tissues, as may occur with diabetic ulcers

or ulcers associated with peripheral vascular disease

The specific microorganism(s) isolated from patients with

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

HOST FACTORS THAT AFFECT WOUND HEALING


Diabetes Use of steroids Poor nutrition Extensive scarring Use of tobacco products Cancer

Previous radiation therapy Organ failure Chronic lymphedema Old age

Cardinal Signs of Chronic Osteomyelitis


Draining sinus tracts Deformity Instability and local signs of impaired vascularity, range of

motion and neurologic status.


The incidence of deep musculoskeletal infection from open

fractures has been reported to be as high as 23 percent.

Common Signs and Symptoms


Pain in the bone Local swelling Redness, and warmth High fever Nausea An abscess at the site of infection.

Classification of Chronic Osteomyelitis

STAGE 1: Medullary Osteomyelitis


the biofilm nidus is confined to the endosteum as dense scar,

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.

STAGE 2: Superficial Osteomyelitis


the nidus is an exposed, bony surface at the base of a chronic,

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.

STAGE 3: Localized Osteomyelitis


The hallmark of type III osteomyelitis is presence of a full-

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.

STAGE 4: Diffuse Osteomyelitis


This is a permeative , through-and-through type of infection

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,

Karchmer AW. Probing to bone in infected pedal ulcers. JAMA. 1995;273:721 3.

Radiologic assessment of chronic osteomyelitis is performed

for the following reasons:


(1) to evaluate bone involvement (eg, the extent of active

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)

In osteomyelitis of the extremities, plainfilm radiography and

bone scintigraphy remain the primary investigative tools


Eckman MH, Greenfield S, Mackey WC, Wong JB,

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

diphosphonate is the radiopharmaceutical agent of choice.


Tumeh SS, Tohmeh AG. Nuclear medicine

techniques in septic arthritis and osteomyelitis. Rheum Dis Clin North Am. 1991;17:559 83.

The specificity of bone scintigraphy will not be high enough

to confirm the diagnosis of osteomyelitis in many clinical situations.


Littenberg B, Mushlin AI. Technetium bone

scanning in the diagnosis of osteomyelitis: a metaanalysis of test performance. Diagnostic Technology Assessment Consortium. J Gen Intern Med. 1992;7:158 64.

Nuclear Imaging using Tc-99m

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.

MAGNETIC RESONANCE IMAGING


The use of MRI is expanding because of its high sensitivity

and specificity as well as its ability to demonstrate associated soft tissue abnormalities.
Fauce, et.al ; Harrison s Principles of Internal

Medicine, 17th edition

MRI also provides greater spatial resolution in delineating the

anatomic extension of infection.


Meyers SP, Wiener SN. Diagnosis of

hematogenous pyogenic vertebral osteomyelitis by magnetic resonance imaging. Arch Intern Med. 1991;151:683 7

MRI

Ultrasound and CT Scan


Ultrasonography and computed tomographic (CT) scanning

may be helpful in the evaluation of suspected osteomyelitis.


Boutin RD, Brossmann J, Sartoris DJ, Reilly D,

Resnick D. Update on imaging of orthopedic infections. Orthop Clin North Am. 1998;29:41 66.

An ultrasound examination can detect fluid collections (e.g.,

an abscess) and surface abnormalities of bone (e.g., periostitis)


CT scan can reveal small areas of osteolysis in cortical bone,

small foci of gas and minute foreign bodies.

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

value of sinus-tract cultures in chronic osteomyelitis. JAMA. 1978;239:2772 5.

SURGICAL TREATMENT

Treatment Algorithm for Adult Chronic Osteomyelitis,2010*

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

neither safe nor feasible.

Stage Directed Limb Salvage


STAGE 1: Medullary Osteomyelitis
requires surgical excision of the nidus through a cortical window
either direct (unroofing the lesion) or indirect (reaming through the

canal) from above or below the nidus.


Truncated lesions, at a diaphyseal-metaphyseal junction (isthmus

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.

STAGE 2: Superficial Osteomyelitis


preoperative planning must focus on restoration of the soft-tissue

envelope
Surgical treatment begins with resection of soft tissues to

viable/supple margins and the bone to the paprika sign.


Paprika Sign

bleeding bone

Local transpositions and free flaps are the most common methods

used to restore and reconstruct type II osteomyelitis.

STAGE 3: Localized Osteomyelitis


debridement commonly leads to a composite, hard, and soft-tissue

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

STAGE 4: Diffuse Osteomyelitis


Debridement of a type IV lesion always culminates in an unstable

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

the reconstruction later taking place as a clean procedure.

THANK YOU.

Das könnte Ihnen auch gefallen