Osteomyelitis is an inflammatory process of bone caused by bacterial infection. It can be acute, subacute, or chronic depending on duration and host response. Common causes are Staphylococcus aureus and trauma. Acute osteomyelitis presents with fever, pain, and swelling near the infected bone in children. Treatment involves antibiotics and surgical drainage. Chronic osteomyelitis results from inadequate treatment of acute infection and is characterized by persistent sinus tracts and bone destruction. Surgical debridement along with long-term antibiotics is usually required to treat chronic osteomyelitis.

1. Osteomyelitis
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om/
1

2. Defination of Osteomyelitis
Osteomyelitis is defined as an
acute or chronic inflammatory
process of bone, bone marrow
and its structure secondary to
infection with micro organisms.
2

3. CLASSIFICATION
 Duration , Mechanism & Host response.
 Duration - Acute / Subacute /
Chronic
 Mechanism - Heamatogenous (tonsil ,
lungs , ear/ GIT)
- Exogenous (injection ,
open fractures)
 Host response - Pyogenic /
Granulomatous 3

4. ACUTE OSTEOMYELITIS
 Age : Infancy and childhood.
 Sex : Males predominate 4:1
 Location : Metaphysis of long bone.
 Poor nutrition, unhygienic
surroundings.
4

5. Etiological Agents
 Infants < 1 year – Group B streptococci
Staph aureus
E.coli
 1- 16 years – S. aureus , S. pyogens , H. Influenza
 > 16 years – S.aureus , S.epidermidis , Gram –ve
bacteria
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6. Pathogenesis
Introduction of bacteria from :
 Outside through a wound or continuity
from a neighboring soft tissue infection
 Hematogenous spread from a pre
existing focus (most common route of
infection)
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7. Pathogenesis
 Preexisting focus / Exogenous Infection
 Infective embolus enters
nutrient artery
 Trapped in a vessel of small
Caliber(metaphysis)
 Blocks the vessel
 Active hyperemia + PMN
cells exudate

8.  Hyperemia and immobilization causes
decalcification.
 Proteolytic enzymes destroy
bacteria and medullary
elements.
 The debris increase and
intramedullary pressure
increases.

9.  Follows paths of least resistance.
 Passes through Haversian canal
and Volkmann canal.
 Local cortical necrosis.

10.  Enter subperiosteal space.
 Strips periosteum.
 Perforation of periosteum / reach joint by
piercing capsule.
 Enters soft tissue and may
drain out

11. Acute Osteomyelitis Infants
 Joint involvement is
common
 Nutrient metaphyseal
capillaries perforate the
epiphyseal growth
plate, particularly in the
hip, shoulder, and knee.
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12. CLINICAL FEATURES
Fever (High Grade)
Child refuses to use limb
(pseudoparalysis)
Local redness , swelling , warmth
, oedema
Newborn – failure to thrive ,
drowsy , irritable.
12

13. Laboratory Tests
 Elevations in the peripheral white blood cell
count (WBC),
 Erythrocyte sedimentation rate (ESR), and C-
reactive protein (CRP) in children with
hematogenous osteomyelitis are variable and
nonspecific.
 Blood culture is positive in half of cases.
13

14. Differential Diagnosis
 Rheumatic fever : Onset is more
gradual, pain and tenderness are less
intense. Involvement is polyarticular.
Response to salicylates and ACTH is
dramatic.
 Acute suppurative arthritis : Pain and
tenderness are , limted to the joint,
joint movements is greatly restricted,
muscle spasm is intense, and
aspiration reveals purulent synovial
fluid. 14

15. Management of acute
osteomyelitis.

16. Drainage technique of acute
Hematigenous Osteomyelitis of tibia
 Use tourniquet whenever possibe.
 Make an anteromedial incision 5 – 7.5
cm long over the affected part of tibia.
 Incise periosteum longitudinally, gently
elevate the periostum 1.5 cm on each
side.
 Drill several holes 4mm in diameter
through the cortex into the medullary
cannal. If pus escapes through these
holes, use drill to outline a corticle
window 1.3 × 2.5 cm and remove the
cortex with osteotome. 16

17.  Evavuate the intramedullary pus and
remove the necrotic tissue.
 Irrigate the cavity with at least 3 L of
saline with a pulsatile lavege system.
 Close the skin loosely over drains.
 Limb is splinted in neutral position.
 Generally 6 weeks course of
antibiotics is given.
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18.  Bone abscess
 Septic Arthritis
 Septicemia
 Fracture
 Growth arrest
 Overlying soft-tissue cellulitis
 Chronic infection
18

19. Subacute Osteomyelitis
 It has an insidious onset, mild symptoms, lack
of systemic reaction
 Its relative mildness is due to:
 a) Organism being less virulent OR
 b) Patient more resistant OR
 c) (Both)
 Most common site: Distal femur, Proximal &
Distal Tibia
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20. Causative Organism
a) Staphyloccocus
aureus (30-60%)
b) Others
(Streptococcus,
Pseudomonas,
Haemophilus
influenzae)
c) Pseudomonas
aeruginosa (IV drug
user)
d) Salmonella (patient
with sickle cell
anaemia)
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 Gram Positive
Staph aureus

21. Clinical Features
 Pain (several weeks / months)
 Limping
 Swelling & Local tenderness
 Muscle wasting
 Body temperature usually normal (no
fever)
21

22. Radiological Finding
Brodie’s abscess
 A circumscribed, round/oval cavity
containing pus and pieces of dead bone
(sequestra) surrounded by sclerosis.
 Most commonly seen in tibial / femoral
metaphysis.
 May occur in epiphysis / cuboidal bone (eg:
calcaneum).
 Metaphyseal lesion cause no / little
periosteal reaction.
 Diaphyseal lesion may be associated with
periosteal new bone formation and marked
cortical thickening.
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23. A circumscribed, oval cavity
surrounded by a zone of
sclerosis at the proximal
tibia (Brodie’s abscess)
This is a lateral view X-ray of left
tibia and fibula. There is a marked
periosteal reaction at the
diaphysis.

24. Investigation’s
a) X-ray (may resemble osteoid
osteoma / malignant bone tumour)
b) Biopsy
c) Fluid aspiration & culture
d) ESR raised
e) WBC count may be normal
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25. Treatment
Conservative :
a) Immobilization
b) Antibiotics (flucloxacillin + fusidic acid)
for 6weeks
Surgical (if the diagnosis is in doubt / failed
conservative treatment) :
a) Open biopsy
b) Perform curettage on the lesion
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26. Chronic Osteomyelitis
 Definition:
“ A severe, persistent and
incapacitating infection of bone and
bone marrow ”
26

27. Aetiological Agents
Usual organisms (with time there is
always a mixed infection)
 Staph.aureus(commonest)
 Staph.pyogenes
 E.coli
 Pseudomonas
 Staph.epidermidis
(commonest in surgical implant)
27

28. Clinical Features
a) Pain
b) Pyrexia
c) Redness
d) Tenderness
e) Discharging sinus
(seropurulent
discharge)
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29. Pathogenesis
Inadequate treatment of acute OM
/Foreign implant /
Open fracture
Inflammatory process continues with time
together with persistent infection by
Staphylococcus aureus
Persistent infection in the bone leads to
increase in intramedullary pressure due
to inflammatory exudates (pus)
stripping the periosteum
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30. Pathogenesis (Contd.)
Vascular thrombosis
Bone necrosis (Sequestrum
formation)
New bone formation occur
(Involucrum)
Multiple openings appear in
this involucrum, through
which exudates & debris
from the sequestrum
pass via the sinuses
(Sinus formation)
30

32. Staging Of Osteomyelitis:
 The Cierny-Mader staging system.
 It is determined by the status of the
disease process.
 It takes into account the state of the
bone, the patient's overall condition
and factors affecting the development
of osteomyelitis.
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33. The Cierny-Mader
Classification
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34. The Cierny-Mader
Classification
 1: Medullary Osteomyelitis -
Infection confined to
medullary cavity.
 2: Superficial Osteomyelitis
- Contiguous type of infection.
Confined to surface of bone.
 3: Localized Osteomyelitis -
Full-thickness cortical
sequestration which can easily
be removed surgically.
 4: Diffuse Osteomyelitis -
Loss of bone stability, even
after surgical debridement.
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35. Radiographic Findings
1) X-ray examination
- Usually show bone resorption (patchy loss of density /
osteolytic lesion)
- Thickening & sclerosis around the bone
- Presence of sequestra
- Occasionaly it may present as a Brodie’s abscess
surrounded by vascular tissue and area of sclerosis
2) Radioisotope scintigraphy
- Sensitive but not specific
- Technetium labelled hydroxymethylene diphosphonate
(99mTc-HDP) may show increased activity in both perfusion
phase and bone phase
3) CT scan & MRI
- Show the extent of bone destruction, reactive oedema,
hidden abscess and sequestra
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36. MRI OF OSTEOMYELITIS OF METATARSAL
Active
osteomyelitis
displays a
decreased signal in
T1 weighted images
and appears bright
in T2 weighted
images.
36

37. AP & lateral view of the left wrist show a lobulated osteolytic lesion with
well-defined borders and surrounding sclerosis at the distal radius.
Minimal expansion, mild periosteal reaction and soft tissue swelling are
present.

38. Treatment - Antibiotics
- Chronic infection is
seldom eradicated by
antibiotics alone.
- Bactericidal drugs are
important to:
a) Stop the spread of
infection to healthy bone
b) Control acute flares
- Antibiotics used in treating
chronic osteomyelitis
(Fusidic acid,
Clindamycin, Cefazolin)
- Antibiotic (IV route) is
given for 10 days prior to
surgery.
- After the major
debridement surgery,
antibiotic is
continued for another 6
weeks (min) but usually
>3months.
[treat until inflammatory
parameters (ESR) are
normal]
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39. Surgical Treatment
- After 10 days of
antibiotic
administration,
debridement is
done to remove:
a) All the infected
tissue
b) Dead / devitalised
bone
(Sequestrectomy)
c) Sinus tract
- Wound is left open
EXCEPT:
a) Compromised
hosts (Class B host);
ankle, hand, spine
b) Type II lesions
(primary soft tissue
reconstruction and/or
host alteration)
c) Minimal necrosis
osteomyelitis
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40. 40
- After debridement is
done, a large dead
space is left in
the bone
- Among the methods of
managing dead space:
a) Open cancellous
grafting (Papineau
technique)
b) Primary closure with
local tissue (+/-
cancellous grafts)
c) Primary closure with
transferred tissues (+/-
cancellous grafts)
d) Primary closure over
antibiotic impregnated
beads

41. 41
- Papineau technique:
Cavity is packed with small cancellous bone
graft (preferably autogenous) mixed with an
antibiotic and fibrin sealant
- Primary closure with transferred tissue:
In muscle flap transfer, a suitable large wad of
muscle with its blood supply intact can be
mobilized and laid into the cavity. The surface is
later closed with a split-skin graft
- Primary closure with antibiotic impregnated
beads:
Porous gentamicin-impregnated beads are
used to sterilize the cavity. It is easier but less
successful. Furthermore, they are extremely
difficult to be removed if not taken out by 2-3
weeks

42. Complications
1) Pathological Fracture
- This occurs in the bone weakened by chronic
osteomyelitis
2) Deformity
– In children the focus of osteomyelitis destroys
part of the epiphysis growth plate.
3) Shortening/ lengthening
- Destruction of growth plate arrest growth.
- Stimulation of growth plate due to hyperemia.
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