Chronic Osteomyelitis

Orthopedics

Clinicals - History

Fact Explanation
Localized tenderness. , Due to on going Inflammation. Pain is due to the action of bradykinin and prostaglandins on local nerves. Localized tenderness. ,
Due to on going Inflammation. Pain is due to the action of bradykinin and prostaglandins on local nerves.
Pyrexia. , It occurs during disease flare ups due to on going Inflammation. The temperature set point of the hypothalamus is raised by the action of cytokines. Pyrexia. ,
It occurs during disease flare ups due to on going Inflammation. The temperature set point of the hypothalamus is raised by the action of cytokines.
Localized swelling. , It occurs during disease flare ups due to on going Inflammation as a result of increased capillary permeability , vasodilation and accumulation of fluid in the tissue. Localized swelling. ,
It occurs during disease flare ups due to on going Inflammation as a result of increased capillary permeability , vasodilation and accumulation of fluid in the tissue.
Seropurulent discharge. , Pus consists of necrotic tissue, dead neutrophils, dead macrophages and tissue fluid and is discharged by perforation of the involucrum, thus leading to the formation of a sinus. Seropurulent discharge. ,
Pus consists of necrotic tissue, dead neutrophils, dead macrophages and tissue fluid and is discharged by perforation of the involucrum, thus leading to the formation of a sinus.
Bony deformity. , Due to prior trauma that may lead to post-traumatic osteomyelitis. Bony deformity. ,
Due to prior trauma that may lead to post-traumatic osteomyelitis.
Exposed bone. Due to an open fracture resulting in inoculation by pathogenic organisms. Exposed bone.
Due to an open fracture resulting in inoculation by pathogenic organisms.
Chronic wound. May be due to an immunocompromised state, diabetic neuropathy or peripheral vascular disease . The wound may even be due to a squamous cell carcinoma at the discharging site of a sinus tract which may actually be a complication of chronic osteomyelitis. Chronic wound.
May be due to an immunocompromised state, diabetic neuropathy or peripheral vascular disease . The wound may even be due to a squamous cell carcinoma at the discharging site of a sinus tract which may actually be a complication of chronic osteomyelitis.
Discolored skin (necrotic tissue). May be due to diabetic foot infection, peripheral vascular disease. Discolored skin (necrotic tissue).
May be due to diabetic foot infection, peripheral vascular disease.
Back pain. Due to underlying medical conditions (eg.; diabetes mellitus, cancer, chronic renal disease, tuberculosis) or a history of intravenous drug use leading to vertebral osteomyelitis. Back pain.
Due to underlying medical conditions (eg.; diabetes mellitus, cancer, chronic renal disease, tuberculosis) or a history of intravenous drug use leading to vertebral osteomyelitis.
Joint pain (commonly of the hip and knee). , May be due to septic arthritis (may be a complication of chronic osteomyelitis). Joint pain (commonly of the hip and knee). ,
May be due to septic arthritis (may be a complication of chronic osteomyelitis).
Reduced range of movements in effected joint. Due to pain and spasm of muscles surrounding the joint. Reduced range of movements in effected joint.
Due to pain and spasm of muscles surrounding the joint.
Previous prosthetic implant. The prosthesis acts as a nidus for the growth of pathogenic organisms which may have been inoculated during the initial surgical procedure. Previous prosthetic implant.
The prosthesis acts as a nidus for the growth of pathogenic organisms which may have been inoculated during the initial surgical procedure.

Clinicals - Examination

Fact Explanation
Localized tenderness. , During disease flare ups due to Inflammation and tissue injury. , Localized tenderness. ,
During disease flare ups due to Inflammation and tissue injury. ,
Pyrexia. , During disease flare ups due to inflammation. , The temperature set point of the hypothalamus is raised by the action of cytokines. Pyrexia. ,
During disease flare ups due to inflammation. , The temperature set point of the hypothalamus is raised by the action of cytokines.
Swelling in affected region. , During disease flare ups due to ongoing inflammation , as a result of increased capillary permeability, vasodilation and accumulation of fluid in the tissue. Swelling in affected region. ,
During disease flare ups due to ongoing inflammation , as a result of increased capillary permeability, vasodilation and accumulation of fluid in the tissue.
Erythema in effected region. , During disease flare ups due to inflammation. It is due to increased blood flow to the affected region. , Erythema in effected region. ,
During disease flare ups due to inflammation. It is due to increased blood flow to the affected region. ,
Seropurulent discharge.,, Due to infection and sinus formation. Seropurulent discharge.,,
Due to infection and sinus formation.
Reduced movements of the affected joint. ,, Mainly due to pain. ,, Reduced movements of the affected joint. ,,
Mainly due to pain. ,,
Presence of ulcer. , The ulcer may be due to an immunocompromised state, diabetic neuropathy or peripheral vascular disease. The wound may even be due to a squamous cell carcinoma at the discharging site of a sinus tract which may actually be a complication of chronic osteomyelitis.,
1). Ischemic ulcer - Regular outline. Punched out clean edges. Bone may be exposed with no granulation tissue in the base.
2). Neuropathic ulcer - Regular outline which follows the skin contour. Consists of clean edges, often with exposed bone at the base.
3). Squamous cell carcinoma - rapid growth. Edges are raised and everted. May show the presence of local lymph node involvement.
Presence of ulcer. ,
The ulcer may be due to an immunocompromised state, diabetic neuropathy or peripheral vascular disease. The wound may even be due to a squamous cell carcinoma at the discharging site of a sinus tract which may actually be a complication of chronic osteomyelitis.,
1). Ischemic ulcer - Regular outline. Punched out clean edges. Bone may be exposed with no granulation tissue in the base.
2). Neuropathic ulcer - Regular outline which follows the skin contour. Consists of clean edges, often with exposed bone at the base.
3). Squamous cell carcinoma - rapid growth. Edges are raised and everted. May show the presence of local lymph node involvement.
Gangrene. 1).Wet gangrene - acute ischemia, local trauma or maybe complicated by infection.
2).Dry gangrene- commonly see in diabetic patients.
Gangrene.
1).Wet gangrene - acute ischemia, local trauma or maybe complicated by infection.
2).Dry gangrene- commonly see in diabetic patients.
Absent peripheral pulses and cold limbs. Due to peripheral vascular disease. Absent peripheral pulses and cold limbs.
Due to peripheral vascular disease.
Surgical scars. , Due to previous surgery (prosthetic implantation). , Surgical scars. ,
Due to previous surgery (prosthetic implantation). ,
Bone deformity. ,, Due to malunion, nonunion of old fractures. , Bone deformity. ,,
Due to malunion, nonunion of old fractures. ,
Spinal deformity. Gibbus formation in tuberculosis. Spinal deformity.
Gibbus formation in tuberculosis.

Investigations - Diagnosis

Fact Explanation
X-ray. , Bone resorption either as a patchy loss of density or as frank excavation around an implant with thickening and sclerosis of the surrounding bone. X-ray. ,
Bone resorption either as a patchy loss of density or as frank excavation around an implant with thickening and sclerosis of the surrounding bone.
Sinogram. Useful in localising the site of infection. Sinogram.
Useful in localising the site of infection.
Radioisotope scintigraphy. May detect increased activity in both the perfusion phase and the bone phase, Also useful to detect hidden foci of infection. Radioisotope scintigraphy.
May detect increased activity in both the perfusion phase and the bone phase, Also useful to detect hidden foci of infection.
Swabs from the wound discharge. ,, For organism culture and to check for antibiotic sensitivity. , Swabs from the wound discharge. ,,
For organism culture and to check for antibiotic sensitivity. ,
Bone biopsy. For organism culture and histopathology (will consist of necrotic tissue). Bone biopsy.
For organism culture and histopathology (will consist of necrotic tissue).
Blood culture. ,, For the evidence of disseminated systemic infection. , Blood culture. ,,
For the evidence of disseminated systemic infection. ,
Molecular techniques (Polymerase Chain Reaction). It will increase the sensitivity of organism detection. Molecular techniques (Polymerase Chain Reaction).
It will increase the sensitivity of organism detection.

Investigations - Management

Fact Explanation
Full blood count. , To detect acute flares and to assess the progress of the disease. Full blood count. ,
To detect acute flares and to assess the progress of the disease.
Erythrocyte sedimentation rate, C reactive protein. , To detect acute flares and to assess the progression of the disease. Erythrocyte sedimentation rate, C reactive protein. ,
To detect acute flares and to assess the progression of the disease.
X-ray. , Assess the union and graft incorporation. X-ray. ,
Assess the union and graft incorporation.
Swab culture from the discharging sinus. To check antibiotic sensitivity (organisms often change their characteristics). Swab culture from the discharging sinus.
To check antibiotic sensitivity (organisms often change their characteristics).
Fasting blood glucose level, Post prandial blood sugar level, HbA1C level. Monitor control of diabetes melitus. Fasting blood glucose level, Post prandial blood sugar level, HbA1C level.
Monitor control of diabetes melitus.
Blood picture. , To identify the etiology of the anemia (sickle cell, iron deficiency). , Blood picture. ,
To identify the etiology of the anemia (sickle cell, iron deficiency). ,
Full blood count. Assessment of anemic status. (due to anemia of chronic disease , sickle cell anemia etc which may give rise to non-healing ulcers.) Full blood count.
Assessment of anemic status. (due to anemia of chronic disease , sickle cell anemia etc which may give rise to non-healing ulcers.)
Erythrocyte sedimentation rate (ESR). ,, It may be elevated in non-infectious forms of inflammation ( arthritis etc.). Erythrocyte sedimentation rate (ESR). ,,
It may be elevated in non-infectious forms of inflammation ( arthritis etc.).
Serum protein electrophoresis. , Useful to detect immunocompromised disease status. Serum protein electrophoresis. ,
Useful to detect immunocompromised disease status.
Total iron binding capacity. To detect iron deficiency anemia. Total iron binding capacity.
To detect iron deficiency anemia.
Liver function tests. To detect liver disease. Liver function tests.
To detect liver disease.
Fasting blood sugar level,Post prandial blood sugar level. To detect Diabetes Mellitus. Fasting blood sugar level,Post prandial blood sugar level.
To detect Diabetes Mellitus.
X-rays, Computerized Tomography (CT) scans (if indicated). ,, Useful in disease assessment in clinical staging. ,, X-rays, Computerized Tomography (CT) scans (if indicated). ,,
Useful in disease assessment in clinical staging. ,,
Arteriograms. Useful in determining the exact anatomy and if microvascular reconstruction is planned. Arteriograms.
Useful in determining the exact anatomy and if microvascular reconstruction is planned.
Technetium 99 (99mTc) bone scan and indium-111 chloride scan12 (whole body and pinhole analysis). Useful to detect hidden foci of infection. , Technetium 99 (99mTc) bone scan and indium-111 chloride scan12 (whole body and pinhole analysis).
Useful to detect hidden foci of infection. ,

Management - Supportive

Fact Explanation
Patient education Cessation of smoking improves the outcome of treatment.
Smoking constricts the blood vessels and reduces the available oxygen supply.
Patient education
Cessation of smoking improves the outcome of treatment.
Smoking constricts the blood vessels and reduces the available oxygen supply.
Nutritional supplementation : 1) Malnutrition 2) Alcohol use 3)Immune compromise 4) Renal/liver failure 5)Diabetes. Optimize the condition of the patient and improve the outcome of treatment. Nutritional supplementation : 1) Malnutrition 2) Alcohol use 3)Immune compromise 4) Renal/liver failure 5)Diabetes.
Optimize the condition of the patient and improve the outcome of treatment.
Hyperbaric oxygen: used in advanced age, chronic hypoxia, arteritis, major vessel disease, extensive scarring, radiation fibrosis, extensive granulation beds. It increases the oxygen transport capacity of the blood.
Recent evidence notes that exposure to hyperbaric oxygen mobilizes stem/progenitor cells from the bone marrow by a nitric oxide (·NO)-dependent mechanism. This mechanism may support the recovery of damaged organs and tissues with hyperbaric oxygen.
Hyperbaric oxygen: used in advanced age, chronic hypoxia, arteritis, major vessel disease, extensive scarring, radiation fibrosis, extensive granulation beds.
It increases the oxygen transport capacity of the blood.
Recent evidence notes that exposure to hyperbaric oxygen mobilizes stem/progenitor cells from the bone marrow by a nitric oxide (·NO)-dependent mechanism. This mechanism may support the recovery of damaged organs and tissues with hyperbaric oxygen.
Methods of force distribution-physiotherapy. To reduce the incidence of pressure sores in debilitated patients. Methods of force distribution-physiotherapy.
To reduce the incidence of pressure sores in debilitated patients.
Blood glucose control. , Optimize the health status of diabetic patients. (Uncontrolled diabetes is a risk factor for peripheral vascular disease and complications such as gangrene, neuropathy etc.). Blood glucose control. ,
Optimize the health status of diabetic patients. (Uncontrolled diabetes is a risk factor for peripheral vascular disease and complications such as gangrene, neuropathy etc.).
Gamma-globulin therapy. Optimize the health status of immunocompromized patients. , (to maintain adequate antibody levels to prevent infections and confers a passive immunity ) Gamma-globulin therapy.
Optimize the health status of immunocompromized patients. , (to maintain adequate antibody levels to prevent infections and confers a passive immunity )
Arterial bypass surgery. Treatment for major vessel disease. , Arterial bypass surgery.
Treatment for major vessel disease. ,

Management - Specific

Fact Explanation
Antibiotic therapy. ,, Important in suppressing the infection and preventing its spread to healthy bone and in controlling acute flares. ,
Unless the patient is seriously ill, antibiotics are not started until the arrival of culture and antibiogram results. In the event of a severely compromised host, Ticarcillin, Cefazolin and Gentamicin are administered empirically . This antibiotics regime is administered intravenously for 4-6 weeks and covers the most common isolates (Staphylococcus aureus, Pseudomonas aeruginosa and anaerobes). The antibiotics are modified by culture and antibiogram results.
Antibiotics are always administered in parallel to surgical management. Long-term oral therapy with quinolones (ciprofloxacin and ofloxacin) can suppress the symptoms and signs of chronic refractory osteomyelitis. Local administration of gentamicin in a collagen fleece following marginal surgical resection is a useful component in the management of chronic osteomyelitis.
Antibiotic therapy. ,,
Important in suppressing the infection and preventing its spread to healthy bone and in controlling acute flares. ,
Unless the patient is seriously ill, antibiotics are not started until the arrival of culture and antibiogram results. In the event of a severely compromised host, Ticarcillin, Cefazolin and Gentamicin are administered empirically . This antibiotics regime is administered intravenously for 4-6 weeks and covers the most common isolates (Staphylococcus aureus, Pseudomonas aeruginosa and anaerobes). The antibiotics are modified by culture and antibiogram results.
Antibiotics are always administered in parallel to surgical management. Long-term oral therapy with quinolones (ciprofloxacin and ofloxacin) can suppress the symptoms and signs of chronic refractory osteomyelitis. Local administration of gentamicin in a collagen fleece following marginal surgical resection is a useful component in the management of chronic osteomyelitis.
Local treatment. , A sinus may need dressing to protect the clothing. Colostomy paste may be used to prevent excoriation of the skin.
An acute abscess may need urgent incision and drainage.
Local treatment. ,
A sinus may need dressing to protect the clothing. Colostomy paste may be used to prevent excoriation of the skin.
An acute abscess may need urgent incision and drainage.
Surgical managment. ,, Indications for surgery are chronic hematogenous infections, failure of adequate antibiotic treatment, presence of foreign implant(s), clear evidence of a sequestrum or dead bone etc.
Steps of surgery
1) Debridement - the approach is direct and atraumatic.
2) Wound is left open (stent dressing) Exceptions: compromised hosts (Systemic); ankle, hand, spine; Type II lesions (primary soft tissue reconstruction and/or host alteration); minimal necrosis osteomyelitis
3) In second look: Dead space management , :
a. Open cancellous grafting (Papineau technique) - useful when a free tissue transfer is not a treatment option and local tissue flaps are inadequate.
b.Primary closure with local tissue.
c. Primary closure with transferred tissues. (An alternative technique is to place cancellous bone grafts beneath local or transferred tissues where structural augmentation is necessary.)
d. Primary closure over antibiotic impregnated beads-may be used to sterilize and temporarily maintain dead space. The beads are usually removed within 3–4 weeks and replaced with a cancellous bone graft.
4) Antibiotics are adjusted according to the culture reports if needed.
Surgical managment. ,,
Indications for surgery are chronic hematogenous infections, failure of adequate antibiotic treatment, presence of foreign implant(s), clear evidence of a sequestrum or dead bone etc.
Steps of surgery
1) Debridement - the approach is direct and atraumatic.
2) Wound is left open (stent dressing) Exceptions: compromised hosts (Systemic); ankle, hand, spine; Type II lesions (primary soft tissue reconstruction and/or host alteration); minimal necrosis osteomyelitis
3) In second look: Dead space management , :
a. Open cancellous grafting (Papineau technique) - useful when a free tissue transfer is not a treatment option and local tissue flaps are inadequate.
b.Primary closure with local tissue.
c. Primary closure with transferred tissues. (An alternative technique is to place cancellous bone grafts beneath local or transferred tissues where structural augmentation is necessary.)
d. Primary closure over antibiotic impregnated beads-may be used to sterilize and temporarily maintain dead space. The beads are usually removed within 3–4 weeks and replaced with a cancellous bone graft.
4) Antibiotics are adjusted according to the culture reports if needed.

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