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INFECTIONS - PART III OSTEOMYELITIS

INFECTIONS - PART III OSTEOMYELITIS. BY DR. KAREN D’SA. INDEX. BRODIE’S ABSCESS (SUBACUTE HAEMATOGENOUS OSTEOMYELITIS) SCLEROSING OSTEOMYELITIS OF GARRE (NON SUPPURATIVE OSTEOMYELITIS) RECURRENT MULTI FOCAL OSTEOMYELITIS POST-TRAUMATIC OSTEOMYELITIS POST-OPERATIVE OSTEOMYELITIS.

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INFECTIONS - PART III OSTEOMYELITIS

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  1. INFECTIONS - PART IIIOSTEOMYELITIS BY DR. KAREN D’SA

  2. INDEX BRODIE’S ABSCESS (SUBACUTE HAEMATOGENOUS OSTEOMYELITIS) SCLEROSING OSTEOMYELITIS OF GARRE (NON SUPPURATIVE OSTEOMYELITIS) RECURRENT MULTI FOCAL OSTEOMYELITIS POST-TRAUMATIC OSTEOMYELITIS POST-OPERATIVE OSTEOMYELITIS

  3. BRODIE’S ABSCESS DEFINITION PATHOGENESIS ETIOLOGICAL AGENT PATHOLOGY SITE CLASSIFICATION CLINICAL FEATURES INVESTIGATIONS DIFFERENTIAL DIAGNOSIS TREATMENT

  4. DEFINITION It is a small Chronic… pyogenic… Osteomyelitic abscess , occurring insidiously without being preceded by an acute attack of Osteomyelitis Incidence is equal to that of Acute Osteomyelitis

  5. PATHOGENESIS

  6. ETIOLOGICAL AGENT STAPHYLOCOCCUS

  7. PATHOLOGY Well defined cavity…localised in the metaphysis of long bone … in cancellous bone containing seropurulent fluid or sterile , clear serous or jelly like fluid …. NO PUS !!!!!!!!!!!!! Cavity is lined by granulation tissue containing a mixture of acute and chronic inflammatory cells Surrounding bone trabeculae - thickened Lesion sometimes encroaches on and erodes the bony cortex

  8. SITE DISTAL FEMUR PROXIMAL AND DISTAL TIBIA

  9. CLASSIFICATION: ROBERT ET AL

  10. CLINICAL FEATURES Usually a child Pain near one of the large joints- several weeks or months , worse at night , exacerbated by activity Limp Slight swelling Muscle wasting Local tenderness Temperature - normal

  11. INVESTIGATIONS Fluid encountered , should be sent for bacteriological culture ; positive in half the cases X-ray : circumscribed, round or oval cavity 1-2 cm in diameter small cavity seen in metaphysis surrounded by halo of sclerotic bone Marked increase on radioisotope scan Biopsy

  12. DIFFERENTIAL DIAGNOSIS Metaphyseal eccentric lesions must be differentiated from non-ossifying fibroma Epiphyseal lesions must be differentiated from GCT , chondroblastoma Intracortical bone lesion must be differentiated from osteoidosteoma and haemangioma

  13. TREATMENT CONSERVATIVE Immobilization and Antibiotics Healing may take up to 12 months SURGICAL Open biopsy + lesion may be curetted at the same time Curettage is also indicated if Xray shows there is no healing after conservative treatment

  14. SCLEROSING OSTEOMYELITIS OF GARRE DEFINITION SITE CLINICAL FEATURES INVESTIGATIONS TREATMENT

  15. DEFINITION Chronic nonsuppurativesclerosingOsteomyelitis associated with fusiform osseous enlargement and no draining sinuses

  16. SITE There is NO ABSCESS CAVITY in the bone only a diffuse area of sclerosis in metaphysis or diaphysis of one of the tubular bones

  17. CLINICAL FEATURES Young adult History of low grade pain Swelling over the bone Recurrent attacks of more acute pain accompanied by malaise and fever

  18. INVESTIGATIONS X-rays show : Increased bone density Cortical thickening but no central cavity

  19. DIAGNOSIS Small segment of bone involved –mistaken for OsteoidOsteoma Marked periosteal layering of new bone –Ewing’s sarcoma At operation bone is thickened BUT there is no PUS and no ABSCESS CAVITY !!!!!!!!! Biopsy will disclose an inflammatory lesion with reactive sclerosis

  20. TREATMENT Abnormal area of bone is excised and exposed surface throroughly curetted

  21. RECURRENT MULTIFOCAL OSTEOMYELITIS Described by Bjorksten et al in 1978 Subacute inflammatory condition which occurs in children

  22. CLINICAL FEATURES Characterized by insidious appearance of pain and swelling near the end of one or more tubular bones Each exacerbation , child is feverish and has a raised ESR

  23. INVESTIGATIONS Xray shows : small lytic lesions in the metaphysis closely adjacent to the physis cavities are surrounded by sclerosis Bone scan shows increased uptake Bacteriological cultures are negative

  24. TREATMENT Palliative Antibiotics have no effect on the disease Prognosis is good Lesions heal without complications

  25. POST - TRAUMATIC OSTEOMYELITIS Open fractures -always contaminated - prone to infection Tissue injury + vascular damage + oedema + haematoma + dead bone fragments –-- “open pathway to the atmosphere” -----bacterial invasion Commonest cause of Osteomyelitis in adults

  26. CLINICAL FEATURES Fever Develops pain and swelling over the fracture site Wound is inflamed Seropurulent discharge

  27. INVESTIGATIONS Blood tests reveal increased CRP levels Leucocytosis Elevated ESR X-ray : more difficult to interpret because of bone fragmentation

  28. MRI : helps in differentiating between bone and soft tissue infection - less reliable in distinguishing between long standing infection and bone destruction due to trauma Microbiological investigation ; a wound swab should be examined and cultured for organisms which can be tested for antibiotic sensitivity

  29. TREATMENT Thorough cleansing and debridement of open fractures Provision of drainage by leaving the wound open and antibiotics Immobilization of the fracture ends Regular dressing of the wounds Repeated excision of all dead and infected tissue Loose implants should be removed , stable implants to be retained until fracture has united

  30. POST-OPERATIVE OSTEOMYELITIS Occur after any operation on bone but commonly after insertion of implant, internal fixation of fractures or joint replacement Organisms introduced directly into the wound from the atmosphere , the instruments , the patient or the surgeon Indirectly by haematogenous spread from distant focus

  31. CHARNLEY’S CLASSIFICATION Infection after joint replacement :

  32. PATHOLOGY : “RACE FOR THE SURFACE” Foreign implant -predisposing factor + important element in its persistence Bacteria as well as human tissue cells have an affinity for molecules on the surface of the implant Both compete for occupancy of the same surface If tissue wins ???? If bacteria wins ???

  33. Factors that favour bacterial invasion : Soft tissue damage and bone death Poor contact between implant and bone Loosening of the implant Corrosion of the implant Fragmentation of methylmethacrylate

  34. CLINICAL FEATURES

  35. INVESTIGATIONS –EARLY INFECTION ESR and white cell count elevated Blood culture positive Bacteriological examination of the wound Plain Xrays and MRI –cannot distinguish between tissue changes due to the operation and those associated with infection

  36. INVESTIGATIONS- LATE INFECTION X-ray : bone resorption Increased activity on radionuclide scanning MRI may show a localized area of high signal activity due to pus ESR is always elevated and may not return to normal for 6 months or longer Confirmation obtained by aspirating purulent material from the area or by culturing the organism in washings taken after aspiration

  37. TREATMENT “PREVENTION IS BETTER THAN CURE” Risk reduced by : 1.Prophylactic antibiotic 2.High quality implant material 3.Ensuring close fit and secure fixation of the implant

  38. TREATMENT

  39. THANK YOU

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