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Unformatted text preview: OSTEOMYELITIS OSTEOMYELITIS M.RASOOLINEJAD, MD DEPATMENT OF INFECTIOUS DISEASE TEHRAN UNIVERSITY OF MEDICAL SCIENCE OSTEOMYELITIS OSTEOMYELITIS INFLAMMATORY PROCESS IN BONE & BONE MARROW ACUTE & CHRONIC PATHOPHYSIOLOGY PATHOPHYSIOLOGY Hematogenous Osteomyelitis Contiguous­Focus Osteomyelitis Peripheral Vascular Disease­associated PATHOPHYSIOLOGY PATHOPHYSIOLOGY Microorganisms enter bone (Phagocytosis). Phagocyte contains the infection Release enzymes Lyse bone PATHOPHYSIOLOGY PATHOPHYSIOLOGY Bacteria escape host defenses by: Adhering tightly to damage bone Persisting in osteoblasts Protective polysaccharide­rich biofilm PATHOPHYSIOLOGY PATHOPHYSIOLOGY Pus spreads into vascular channels Raising intraosseous pressure Impairing blood flow Chronic ischemic necrosis Separation of large devascularized fragment (Sequestra) New bone formation (involucrum) PATHOLOGY PATHOLOGY Acute Infiltration of PMNs Congested or thrombosed vessels Chronic Necrotic bone Absence of living osteocyte Mononuclear cells predominate Granulation & fibrous tissue Hematogenous Hematogenous Osteomyelitis HEMATOGENOUS OSTEPMYELITIS HEMATOGENOUS OSTEPMYELITIS Rapidly growing bone Children: Long bone, Femur, Tibia, Humerus Older patients: Vertebral bone HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Neonate & infant < 1 year old Septic arthritis is common. Growth deformities is common. Soft tissue involvement is common. HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Children: 1 – 16 years old Most frequent in the metaphysis of long bone. Slugging blood flow through a sinusoidal venous system. Deficency of phagocytic cells. Poor collateral circulation Susceptibility of this region to trauma. HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Children: 1 – 16 years old History of antecedent trauma in 30% Involucrum Sequestration Associated septic arthritis HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Adult Less common Spread infection to joint space. Vertebral Osteomyelitis is common> 50y HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Special consideration Sickle cell disease Injection drug users (IDUs) Hemodialysis HIV/AIDS Immunosuppression Prosthetic orthopedic device HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Microbiologic features Staphylococci Aureus, Epidermidis Streptococci Group A & B Haemophilus influenzae Gram­negative enteric bacilli Anaerobes Polymicrobial Mycobacterial Fungi HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Clinical manifestation Classic presentation: Sudden onset Usually presentation: Slow, insidious High fever, Night sweats Fatigue, Anorexia, Weight loss Restriction of movement Local edema, Erythema, & Tenderrness HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Differentials Cellulitis Gas gangrene Neoplasm Aseptic bone infection Clenched fist osteomyelitis osteomyelitis HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Diagnosis & work­up Lab study: WBC May be elevated, Usually normal { C­Reactive Protein (CRP) Erythrocyte Sedimentation Rate (Usually is elevated at presentation Falls with successful therapy) Blood culture ( Acute osteomyelitis + ve > 50% ) HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Diagnosis & work­up Imaging Radiology: Normal Soft tissue swelling Periosteal elevation Lytic change Sclerotic changew HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Diagnosis & work­up Imaging MRI: Early detection Superior to plan X ray & CT Scan & radionuclide bone scan in slected anatomic location. Sensitivity 90 – 100% HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Diagnosis & work­up Imaging Radionuclide bone scan: A 3­phase bone scan ( Technetium 99m ) Positive as early as 24 h after onset of symptoms. False positive Tumor, osteonecrosis Artheritis, Cellulitis, Abscess HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Diagnosis & work­up Imaging CT – Scan: Useful in evaluation of Spinal, pelvic, Sternum, Calcaneus Provides exellent images of bone cortex Is used for biopsy localization Os + gaz in diabetic foot Os Septic arthritis Septic Of Right hip HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Diagnosis & work­up Ultrasonography Simple & inexpensive Demonstration anomaly 1 – 2 days after onset Soft tissue abscess, Fluid collection, & Periosteal elevation It allows for aspiration It doesn’t allow for evaluation of bone cortex. It doesn’t allow for evaluation of bone cortex. HEMATOGENOUS OSTEOMYELITIS HEMATOGENOUS OSTEOMYELITIS Diagnosis & work­up Neddle Aspiration or Open biopsy: From: Soft tissue collection Subperiosteal abscess Intraosseos lesions For: Smear Culture Pathology TREATMENT TREATMENT Initial treatment shoud be aggressive. Inadequate therapy Chronic disease Antibiotic use: Parenteral High doses Good penetration in bone Full course Empiric therapy Surgery TREATMENT TREATMENT Empiric Initial Therapy Neonate S.aureus PRP + Infant<2 y G –ve bacilli Cefotaxime Children S.aureus PRP + H.Infenza Ceftriaxone Adult S.aureus PRP or 1st ceph TREATMENT TREATMENT Indication for Surgery Diagnostic Hip joint involvement Neurologic complication Poor or no response to IV therapy Sequestration TREATMENT TREATMENT Monitoring Therapeutic Response 1.Symptoms & Signs 2.ESR & CRP 3.Radiography 4.Serial Bone Scan? PROGNOSIS PROGNOSIS Is related to: Causative organisms Duration of symptoms & sign Patient age Duration of antibiotic therapy COMPLICATION COMPLICATION Bone abscess Bacteremia Fracture Loosing of the prosthetic implant Overlying soft­tissue cellulitis Draining soft­tissue tract Post Osteomyelitis Treatment Post Septic Osteomyelitis Septic Post Osteomyelitis Scar Post Osteomyelitis Deformity of the Forearm Post CONTIGUOUS­FOCUS CONTIGUOUS­FOCUS OSTEOMYELITIS Contiguous­focus Osteomyelitis Contiguous­focus Osteomyelitis Clinical setting: Postoperative infection Contamination of bone Contiguous soft tissue infection Puncture wounds Contiguous­focus Osteomyelitis Contiguous­focus Osteomyelitis Microbiologic features Staphylococci Aureus, Epidermidis Gram­negative bacteria Anaerobic infection Unusual organisms Clostridia, Nocardia Contiguous­focus Osteomyelitis Contiguous­focus Osteomyelitis Diagnosis Leukocyte count Blood culture (infrequently positive) ESR & CRP Radiologic evaluation Technetium bone scan Open bone biopsy Culture of wound & draining sinuses?? Contiguous­focus Osteomyelitis Contiguous­focus Osteomyelitis Treatment Surgery is essential. Antibiotics Specific Duration ...
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This note was uploaded on 01/02/2012 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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