Andre Sihombing

Inflammation of the bone

caused by an infecting organism
In the early 1900’s about 20% of
patients with osteomyelitis died
and patients who survived had
significant morbidity.
 Introduction-
• Oldest known evidence of
osteomyelitis fractured spine of
dimetrodon permian reptile 291-250
million years ago

• Hippocrates 460-370 BC infection

after fracture

• Nelaton credited with introducing

the term osteomyelitis in 1844 4
The key to successful management is
early diagnosis and appropriate
surgical and antimicrobial
treatment.
A multi disciplinary approach is
required, involving an orthopaedic
surgeon, an infectious disease
specialist, and a plastic surgeon in
complex cases with significant soft
tissue loss.
1) The duration - acute, subacute
and chronic

2) Mechanism of infection –
exogenous or hematogenous

3) The type of host response to the

infection- pyogenic or non
pyogenic
Most common type of bone
infection, usually seen in children
Decrease in incidence, could be due
to higher standard of living and
improved hygiene.
Bimodal distribution- younger than 2
years, and 8-12 years
More common in males
Caused by a bacteraemia

Bacteriological seeding of bone

generally is associated with
other factors such as localized
trauma, chronic illness,
malnutrition or an inadequate
immune system.
 Inchildren the infection generally
involves the metaphyses of rapidly
growing long bones

 Bacterial
seeding leads to an
inflammatory reaction which can
cause local ischaemic necrosis of
bone and subsequent abscess
formation
As the abscess enlarges,
intramedullary pressure increases
causing cortical ischaemia, which
may allow purulent material to
escape through the cortex into the
subperoisteal space.
A subperisoteal abscess then
develops

Ifleft untreated this process

eventually results in extensive
sequetra formation and chronic
osteomyelitis
In children younger than 2 years,
blood vessels cross the physis, thus
epiphysis may be involved

Limb shortening or angular

deformity may occur
Joint may be involved in some cases-
hip joint most common, especially
for intraarticular physes- proximal
humerus,radial neck, distal fibula

Metaphysis has relatively fewer

phagocytic cells than the physis or
diaphysis, hence more infection here
Inchildren older than 2 years the
physis effectively acts as a barrier to
the spread of a metaphyseal abscess

Metaphyseal cortex thicker, hence

diaphysis more at risk

After physes are closed acute

hematogenous osteomyelitis is much
less common
After the physes are closed,
infection can extend directly from
the metaphysis into the epiphysis
and involve the joint

Septic arthritis resulting from acute

hematogenous osteomyelitis
generally is seen only in infants and
adults.
Staphylococcus aureus most common
in older children and adults
Gram negative bacteria- increasing
trend- vertebral
Pseudomonas most common in
intravenous drug abusers
Salmonella in sicke cell
Fungal infections in chronically ill
patients on long term intravenous
therapy.
Infants-staph aureus most common
but group B streptococcus and gram
negative coliforms

Prematures staph aureus andgram

negative organisms

Hemophilus influenzae primarily in

children 6 months to 4 years old,
incidence decreased dramatically by
Ngetich, 2002 found that of children
presenting with haematogenous
osteomyelitis in Kenyatta national
hospital the commonest isolated
organism was staphylococcus aureus
accounting for 29 (60.4%)of the
cases, 15 (60%) of these were MRSA
strains
History and physical examination
 Fever and malaise
 Pain and local tenderness
 Sweliing
 Compartment syndrome in children
Laboratory tests
 White blood cell count
 Erythrocyte sedimentation rate
 C-reactive protein
 checked very 2- 3 days post

treatment initiation
 Aspiration for suspected abscess
Plain radiographs

Technetium-99m bone scan +/- MRI

Soft tissue swelling

Periosteal reaction

Bony destruction
(10-12 days)
Can confirm
diagnosis
24-48 hrs after
onset
Surgery and antibiotic treatment are
complementary, in some cases
antibiotics alone may cure the
disease.

Choice of antibiotics is based on the

highest bacteriocidal activity, the
least toxicity and the lowest cost
Nade’s 5 principles of treatment
1. An appropriate antibiotic is
effective before pus 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 already

ischaemic bone and soft tissue

5. Antibiotics should be continued after

surgery
 Thetwo main indications for surgery in
acute hematogenous osteomyelitis are:
1. The presence of an abscess requiring
drainage
2. Failure of the patient to improve
despite appropriate intravenous
antibiotic treatment
 The objective of surgery is to drain any
abscess cavity and remove all non viable or
necrotic tissue
 Subperiosteal abscess in an infant-several
small holes drilled through the cortex into
the medullary canal
 If intramedullary pus is found, a small
window of bone is removed
 Skin is closed loosely over drains and the
limb splinted
Generally a 6 week course of
intravenous antibiotics is given

Orthopedic and infectious

disease followup is continued for
at least 1 year
More insidious onset and lacks
severity of symptoms

Indolent course hence diagnosis

delayed for more than two
weeks.
 The indolent course of subacute
osteomyelitis is due to:
 increased host resistance
 decreased bacterial virulence
 administration of antibiotics before the
onset of symptoms
 Systemic signs and symptoms are minimal
 Temperature is only mildly elevated
 Mild to moderate pain
 White blood cell counts are generally normal

 ESR is elevated in only 50% of patients

 Blood cultures are usually negative

 Plain
radiographs and bone scans generally
are positive
S.Aureus and Staphylococcus
epidermidis are the predominant
organisms identified in subacute
osteomyelitis
Localized form of subacute
osteomyelitis occuring most
commonly in the long bones of the
lower extremeties

Intermittent pain of long duration is

most times the presenting
compliant, along with tenderness
over the affected area
 Onplain radiographs appears as a lytic lesion
with a rim of sclerotic bone

Saureus is cultured in 50% of patients and in

20% the culture is negative

 Thecondition requires open biopsy with

curetage to make the diagnosis

 Thewound should be closed loosely over a

drain
 Biopsyand curettage followed by treatment
with appropriate antibiotics for all lesions
that seem to be aggressive

 Forlesions that seem to be a simple abscess

in the epiphysis or metaphysis biopsy is not
recommended- IV antibiotics for 48 hrs
followed by a 6 week course of oral
antibiotics
Hallmark is infected dead bone
within a compromised soft tissue
envelope

The infected foci within the bone

are surrounded by sclerotic,
relatively avascular bone covered
by a thickened periosteum and
scarred muscle and subcutaneous
tissue
Sinus track cultures usually do not
corelate with cultures obtained at
bone biopsy
Based on
 Clinical
 laboratory and
 imaging studies
Skinand soft tissue integrity
Tenderness
Bone stability
Neurovascular status of limb
Presence of sinus
Erythrocyte sedimentation rate
C reactive protein
WBC count only elevated in 35%
Biopsy for histological and
microbiological evaluation
 Staphyloccocus species
 Anaerobes and gram negative
bacilli
Girasi,1981 found that the
commonest organisms found at the
orthopaedic unit at Kenyatta
national hospital, then in kabete
was staphylococcus aureus which
was resistant to penicillin and
ampicillin
Plain X rays
 Cortical destruction
 Periosteal reaction
 Sequestra
 Sinography
Isotopicbone scanning more useful
in acute than in chronic
osteomyelitis

Gallium scans increased uptake in

areas where leucocytes and bacteria
accumulate. Normal scan excludes
osteomyelitis
CT Scan
 Identifying sequestra
 Definition of cortical bone and
surrounding soft tissues
MRI
 Shows margins of bone and soft
tissue oedema
 Evaluate recurrence of infection
after 1 year
 Rim sign- well defined rim of high
signal intensity surrounding the
focus of active disease
 Sinus tracks and cellulitis
Surgical treatment mainstay
 Sequestrectomy
 Resection of scarred and infected
bone and soft tissue
 Radical debridement
 Resection margins >5mm
 Adequate debridement leaves a dead
space that needs to be managed to avoid
recurrence, or bony instability
 Skin grafts,
 Muscle and myocutaneous flaps
 Free bone transfer
 Papineau technique
 Hyperbaric oxygen therapy
 Vacuum dressing
 Antibioticduration is controversial
 6 week is the traditional duration
 1 week IV, 6 weeks of oral therapy
 Antibiotic polymethyl methacrylate
(PMMA) beads as a temporary filler of
dead space
 Biodegradable antibiotic delivery system
Resection of a segment of affected
bone may be necessary to control
infection

With techniques of bone and soft

tissue transport, massive resections
can be performed and reconstructed
without significant disability.
 Amputation indications include
 Arterial insufficiency
 Major nerve paralysis
 Non functional limb-stiffness,
contracture
 Malignant change
 Prevalence of maliganacy arising from
COM reported as 0.2 to 1.6% of cases.
 Most are squamous cell carcinoma, also
reticulum cell carcinoma,fibrosarcoma
Bone is thickened and distended,
but abscesses and sequestra are
absent.

Cause unknown

Thought to caused by a low grade,

possibly anaerobic bacterium
 Tuberculous spondylitis has been documented
in ancient mummies from Egypt and Peru
 It is one of the oldest demonstrated diseases
of humankind.
 Percival Pott presented the classic
description of TB spine in 1779.
 Since the advent of antiTB drugs and
improved public health measures, TB spine
has become rare in industrialized countries.
 However it is still a common diseasis in
developing countries.
 TB spine causes serious morbidity, including
permanent neurologic deficits and severe
deformity.
 Medical treatment or combined medical and
surgical strategies can control the disease in
most patients
 TB spine is common in developing countries>
developed countries
 Internationally approx. 1-2% of total TB cases
are attributable to Pott disease.
 As with other forms of TB, the frequency is
related to socioeconomic factors and
historical exposure to the infection.
 Sex: Males are more often affected
(1.5-2:1).
 Age: In developed countries Pott dx primarily
occurs in adults.
 In countries with higher rates of infection, it
mainly occurs in children
 Mortality/Morbidity : Pott disease is the
most dangerous form of musculoskeletal TB.
 It can cause bone destruction, deformity, and
paraplegia
 It commonly involves the thoracic and
lumbosacral spine.
 Pott disease is usually secondary to an
extraspinal source of infection.
 The basic lesion is a combination of
osteomyelitis and arthritis.
 Typically, more than one vertebra is
involved.
 The area usually affected is the anterior
aspect of the vertebral body adjacent to the
subchondral plate
 Tuberculosis may spread from that area to
adjacent intervertebral disks.
 In adults, disk disease is secondary to the
spread of infection from the vertebral body.
 In children, because the disk is vascularized,
it can be a primary site.
 Progressive bone destruction leads to
vertebral collapse and kyphosis.
 The spinal canal can be narrowed by
abscesses, granulation tissue, or direct dural
invasion
 This leads to spinal cord compression and
neurologic deficits.
 Kyphotic deformity occurs as a consequence
of collapse in the anterior spine.
 Lesions in the thoracic spine have a greater
tendency for kyphosis than those in the
lumbar spine.
A cold abscess can occur if the infection
extends to adjacent ligaments and soft
tissues.
 Abscesses in the lumbar region may descend
down the sheath of the psoas to the femoral
trigone region and eventually erode into the
skin.
 Presentation depends on the following:
 Stage of disease
 Site
 Presence of complications such as neurologic
deficits, abscesses, or sinus tracts.

 The reported average duration of

symptoms at the time of diagnosis is 3-4
months.
 The average duration of symptoms at the
time of diagnosis is 3-4 months
 Back pain is the earliest and most common
symptom.
 Patients have usually had back pain for weeks
prior to presentation.
 Pain can be spinal or radicular.
 Constitutional symptoms include fever and
weight loss.
 Neurologic abnormalities occur in 50% of
cases and can include spinal cord
compression with paraplegia, paresis,
impaired sensation, nerve root pain, or
cauda equina syndrome.
 Cervical
spine tuberculosis is a less common
presentation but is potentially more serious
because severe neurologic complications are
more likely.
 This condition is characterized by pain and
stiffness.
 Patients with lower cervical spine disease can
present with dysphagia or stridor.
 Symptoms can also include torticollis,
hoarseness, and neurologic deficits.
 The clinical presentation of TB in HIV
patients is similar to that of HIV negative
patients; however, the relative
proportion of individuals who are HIV
positive seems to be higher.
 Physical
examination should include the
following:
 Careful assessment of spinal alignment
 Inspection of skin, with attention to detection of
sinuses
 Abdominal evaluation for subcutaneous flank
mass
 Meticulous neurologic examination
 The thoracic spine is frequently reported as
the most common site of involvement
followed by lumber spine
 The remaining cases correspond to the
cervical spine.
 Spine deformity (kyphosis) of some degree
occurs in almost every patient.
 There may be large cold abscesses of
paraspinal tissues or psoas muscle that
protrude under the inguinal ligament.
 They may erode into the perineum or gluteal
area.
 Neurologic deficits may occur early in the
course of disease.
 Signs depend on the level of spinal cord or
nerve root compression
 Disease
involving the upper cervical spine
can cause rapidly progressive symptoms.
 Retropharyngeal abscesses occur in almost all
cases.
 Neurologic manifestations occur early and range
from a single nerve palsy to hemiparesis or
quadriplegia
 Ifthere is no evidence of extraspinal
tuberculosis, diagnosis can be difficult.
 Information from imaging studies,
microbiology, and anatomic pathology should
help establish the diagnosis
6:1 Lab studies
 Tuberculin skin test demonstrates a positive
finding in 84-95% of patients who are non–
HIV-positive.
 ESR may be markedly elevated (>100 mm/h).
 Microbiology studies to confirm diagnosis:
Obtain bone tissue or abscess samples to
stain for acid-fast bacilli (AFB), and isolate
organisms for culture and susceptibility.
 These study findings may be positive in only
about 50% of the cases.
6:2 Imaging studies
 Plain radiography demonstrates the following
characteristic changes of spinal tuberculosis:
 Lytic destruction of anterior portion of vertebral
body
 Increased anterior wedging
  Collapse of vertebral body
 Reactive sclerosis on a progressive lytic process
 Enlarged psoas shadow with or without
calcification
 Additional findings
 Vertebral end plates are osteoporotic.
 Intervertebral disks may be shrunk or destroyed.
 Fusiform paravertebral shadows suggest abscess
formation.
 Bone lesions may occur at more than one level.
 Intervertebral disks may be shrunk
or destroyed.
 Vertebral bodies show variable
degrees of destruction
 CT scanning
 CT scanning provides much better bony detail of
irregular lytic lesions, sclerosis, disk collapse,
and disruption of bone circumference.
 Low-contrast resolution provides a better soft
tissue assessment, particularly in epidural and
paraspinal areas.
 It detects early lesions and is more effective for
defining the shape and calcification of soft tissue
abscesses.
 In contrast to pyogenic disease, calcification is
common in tuberculous lesions
 MRI
 MRI is the criterion standard for evaluating disk
space infection and osteomyelitis of the spine
and is most effective for demonstrating the
extension of disease into soft tissues and the
spread of tuberculous debris under the anterior
and posterior longitudinal ligaments
  MRI is most effective for demonstrating neural
compression.
 In developed countries, MRI has nearly replaced
CT myelography.
 Procedures:
 Some patients are diagnosed following an open
drainage procedure (eg, following presentation
with acute neurologic deterioration).
Histologic Findings:
 Since microbiologic studies may be
nondiagnostic, anatomic pathology can be
very significant.
 Gross pathologic findings include
exudative granulation tissue with
interspersed abscesses.
 Coalescence of abscesses results in areas
of caseating necrosis.
7:1 Medical treatment
 Medical therapy requires combination
regimens with at least 3 antituberculous
drugs.
 A 3-drug regimen usually includes INH,
rifampin, and pyrazinamide.
 The duration of treatment ranges from 9-12
months
7:2 Surgical treatment
 Indications
 Neurologic deficit (acute neurologic
deterioration, paraparesis, paraplegia)
 Spinal deformity with instability
 No response to medical therapy
 Resources and experience are key factors in
the decision to use a surgical approach
 The most appropriate method of
reconstruction depends on the level of
vertebral spine involved and the extent of
bony destruction.
 Thelesion site, extent of vertebral
destruction, and presence of cord
compression or spinal deformity determine
the specific operative approach.
 In disease involving the cervical spine, the
following factors justify early surgical
intervention:
 High incidence and severity of neurologic deficits
 Severe abscess compression that may induce
dysphagia or asphyxia
 Instability of the cervical spine