Osteomyelitis

Introduction and Definition

• Sumerian carvings : first descriptions of infections
• Galen of Pergamum (120 to 201 AD):value of purulence
• Osteomyelitis is defined as an inflammation of the bone caused by an
infecting organism.
• The infection may be limited to a single portion of the bone or may
involve numerous regions, such as the marrow, cortex, periosteum,
and the surrounding soft tissue.
• The infection generally is due to a single organism, but polymicrobial
infections can occur, especially in the diabetic foot.
Classification
• Depending on
1. Duration of symptoms: acute, subacute, or chronic
2. Mechanism of infection:
• Exogenous - caused by open fractures, surgery (iatrogenic), or contiguous
spread from infected local tissue
• Hematogenous- results from bacteremia.
• 3. Host response to the disease : pyogenic or nonpyogenic
Classification
Duration Route of spread Host response
(Waldogel`s)
Acute : <2 weeks Hematogenous: M/C Pyogenic

Subacute: 2-3 weeks Direct Non Pyogenic

Chronic: > 3weeks : Cierny Contiguity

and Mader classification
system based on host
factors and anatomic
criteria.
Residual
ACUTE HEMATOGENOUS
OSTEOMYELITIS
• m/c type of bone infection
• usually is seen in children: Bimodal distribution : <2years and 8 - 12
years.
• Generally involves the metaphyses of rapidly growing long bones.
• is more common in males in all age groups affected.
• caused by a bacteremia
Mechanism

Bacterial • Inflammatory reaction cause local ischemic

seeding necrosis of bone and subsequent abscess
formation

• Intramedullary pressure increases

Abscess causing cortical ischemia
enlarges
• Pus into the subperiosteal space

• If left untreated:
Subperiosteal
abscess Sequestra & in Chronic
osteomyelitis
Physis
<2years:
• some blood vessels cross the physis
• shortening or angular deformity in infants
• metaphysis has relatively fewer phagocytic cells than the physis or diaphysis
:m/c site of infection
• spread of infection into the epiphysis and then into the joint
• Physes of the proximal humerus, radial neck, and distal fibula also are
intraarticular, and infection in these areas can lead to septic arthritis.
• In severe infection, epiphyseal separation can occur
> 2years:
• physis effectively acts as a barrier
• Infection spreads into the diaphysis
• subperiosteal abscess and extensive sequestration formation
progress to chronic osteomyelitis
• septic arthritis is rare
• After the physes are closed: Generally the vertebral bodies are
affected.
• In adults is often seen in a compromised host
• Generally the vertebral bodies are affected
• Abscesses spread slowly and large sequestra rarely form.
• Direct spread from the metaphysis into the epiphysis and involve the joint
 Microbiology
Bacteria
Staphylococcus aureus older children and adults
Pseudomonas intravenous drug abusers
Salmonella Sickle cell or sickle cell C hemoglobinopathies.
Fungal long-term intravenous therapy or parenteral nutrition.
Gram-negative bacteria vertebral body infections in adults
Group B Streptococcus Healthy infants 2 to 4 weeks old
Haemophilus influenzae children 6 months to 4 years old
K. kingae children younger than 4 years. requires
molecular assays such as PCR
MRSA Dietrich et al.: MRSA v/s MSSA:
elevated temperature, CRP and absolute neutrophil
counts are copredictors of MRSA
Evaluation of Acute Haematogenous
Osteomyelitis
1. History and physical examination
2. Laboratory tests: WBC count, ESR,
CRP (useful in monitoring the course of treatment of acute osteomyelitis because it normalizes much
sooner than the ESR.
• Plain radiographs-generally are negative but may show
• soft-tissue swelling :after 1 to 3.
• periosteal reaction or bony destruction- after10 to 12 days
• septic arthritis, Ewing sarcoma, osteosarcoma, juvenile arthritis, sickle cell crises, Gaucher disease, and stress
fractures.
• Technetium-99m bone scan ― can confirm the diagnosis 24 to 48 hours after onset in 90% to 95% of
patients. a negative technetium-99m bone scan effectively rules
• out the diagnosis of osteomyelitis.
• MRI scan :show early inflammatory changes in bone marrow and soft tissue (T1-weighted low intensity,
T2&STIR: High intensity)
• Blood cultures.
• Bone aspiration
• Other : radiolabeled antibiotics scanning, FDG-PET, SPECT
Copley et al.: scoring system
• based on CRP values at admission and at 48 and 96hours; febrile days
on antibiotics; respiratory rate upon admission

Severity Score
Mild 0-3
Moderate 4-6
Severe 7-10
TREATMENT
• Surgery, Antibiotic treatment, intravenous fluids, appropriate
analgesics, and comfortable positioning of the affected limb.
• In 1983, Nade proposed five principles:
(1) an appropriate antibiotic is effective before abscess formation;
(2) antibiotics do not sterilize avascular tissues or abscesses, and such areas
require surgical removal;
(3) if such removal is effective, antibiotics should prevent their reformation, and
primary wound closure should be safe;
(4) surgery should not damage further already ischemic bone and soft tissue;
(5) antibiotics should be continued after surgery.
Monitoring
• Frequent serial examinations should be done.
• CRP value should be checked every 2 to 3 days after the initiation of
antibiotic therapy.
• If no appreciable clinical response to antibiotic treatment is noted
within 24 to 48 hours, occult abscesses must be sought and surgical
drainage should be considered.
• The two main indications for surgery are
(1) the presence of an abscess requiring drainage and
(2) failure of the patient to improve despite appropriate intravenous antibiotic
treatment.
SUBACUTE HEMATOGENOUS
OSTEOMYELITIS
• has a more insidious onset and lacks the severity of symptoms, which makes the
diagnosis of this disorder difficult.
• S. aureus and Staphylococcus epidermidis are the predominant organisms identified
• Systemic signs and symptoms are minimal.
• Temperature is only mildly elevated if at all.
• Mild-to-moderate pain is one of the only consistent signs suggesting the diagnosis.
• WBC counts generally are normal.
• ESR is elevated in only 50% of patients and blood cultures
• usually are negative.
• Even with an adequate bone aspirate or biopsy specimen, a pathogen is identified only
60% of the time.
• Plain radiographs and bone scans generally are positive
• result of increased host resistance,
• decreased bacterial virulence, or
• the administration of antibiotics before the onset of symptoms.
radiographic classification of Subacute Osteomyelitis
TYPE GLEDHILL CLASSIFICATION ROBERT ET AL. DIFFERENTIAL DIAGNOSIS
CLASSIFICATION
I :central metaphyseal Solitary localized zone of Ia—Punched-out Langerhans cell histiocytosis
radiolucency surrounded by radiolucency Brodie abscess
reactive new bone formation Ib—Punched-out
radiolucent
lesion with sclerotic
margin
II : eccentric metaphyseal lesion with Metaphyseal radiolucencies Eosinophilic granuloma;
cortical erosion; with cortical erosion osteogenic sarcoma

III:diaphyseal cortical Cortical hyperostosis in Localized cortical Osteoid osteoma

diaphysis; no onion skin periosteal
reaction reaction
IV: diaphyseal lesion with periosteal new Subperiosteal new bone and Onion skin Ewing sarcoma
bone formation, but without definite bony onion skin layering periosteal reaction
lesion

V: primary subacute epiphyseal Central radiolucency Chondroblastoma

osteomyelitis in epiphysis

VI: subacute osteomyelitis crossing physis Destructive process Tuberculosis; osteogenic

Treatment
• Biopsy and curettage followed by treatment with appropriate
antibiotics
• should be treated with intravenous antibiotics for 48 hours followed
by a 6-week course of oral antibiotics
BRODIE ABSCESS
• A Brodie abscess is a localized form of subacute osteomyelitis
• that occurs most often in the long bones of the lower extremities
• of young adults.
CHRONIC OSTEOMYELITIS
• difficult to eradicate completely
• major cause of musculoskeletal morbidity in children
• The hallmark of chronic osteomyelitis is infected dead bone within a
compromised
• secondary infections are common, and sinus track cultures usually do
not correlate with cultures obtained at bone biopsy soft-tissue
envelope.
Cierny and Mader Staging System for Chronic Osteomyelitis
ANATOMIC TYPE
I Medullary Endosteal disease
II Superficial Cortical surface infected
because of coverage defect

III Localized Cortical sequestrum that can

be excised without
compromising stability
IV Diffuse Features of I, II, and III plus
mechanical instability before
or after debridement

PHYSIOLOGIC CLASS
A host Normal Immunocompetent with
good local vascularity

B host Compromised Local (L) or systemic (S)

factors that compromise
immunity or healing
C host Prohibitive Minimal disability, prohibitive morbidity
anticipated, or poor
ANATOMIC TYPES

Ⅰ Ⅱ

Ⅲ
Ⅳ
DIAGNOSIS
• based on clinical, laboratory, and imaging studies.
• The “gold standard” is to obtain a biopsy specimen for histologic and
microbiologic evaluation of the infected bone.
• ESR, CRP are elevated in most patients, but the WBC count is elevated in only
35%.
• Plain radiographs : Signs of cortical destruction and periosteal reaction
• Isotopic bone scanning : more useful in acute osteomyelitis than in the chronic
form because the former typically has negative plain films.
• A normal gallium scan virtually excludes the presence of osteomyelitis and can
be useful as a follow-up examination after surgery.
• Indium-111–labelled leukocyte scans are more sensitive than technetium or
gallium scans and are especially useful in differentiating chronic osteomyelitis
from neuropathic arthropathy in the diabetic foot.
SINOGRAM
• CT provides excellent definition of cortical bone
• MRI: Rim sign, Sinus tracks and Cellulitis.
TREATMENT
• Antibiotic suppression and surgical debridement and reconstruction, host
morbidities need to be considered and measures taken to correct these, such as
• optimization of blood sugar levels in patients with diabetes,
• smoking cessation, and
• treatment of liver or renal malfunction.
• Surgery for chronic osteomyelitis consists of sequestrectomy and resection of
scarred and infected bone and soft tissue.
Sequestrectomy

Chronic osteomyelitis Right

radius in 15y/M:
Figure showing sequestrum
removed from right radius