OSTEOMYELITIS

INFECTIOUS PROCESS OF THE BONE AND ITS MARROW IS CALLED OSTEOMYELITIS

INFECTION OF JOINT IS CALLED SEPTIC ARTHRITIS

TYPES OF OSTEOMYELITIS
ACCORDING TO DURATION
ACUTE SUBACUTE e.g. BRODIES ABSCESS CHRONIC

ACCORDING TO MECHANISM
EXOGENOUS (TRAUMA, SURGERY, CONTIGIOUS INFECTION) ENDOGENOUS OR HAEMATOGENOUS

ACCORDING TO HOST RESPONSE

PYOGENIC NON PYOGENIC e.g. GRANULOMATOUS, VIRAL, FUNGAL

BACTARIOLOGY

PATHOPHYSIOLOGY

COMMON SITES OF INFECTION

NATURAL HISTORY
INFLAMMATION SUPPORATION NECROSIS REACTIVE NEW BONE FORMATION RESOLUTION

CLINICAL FEATURES
CHILDREN PAIN FEVER MALAISE TENDERNESS
FAILS TO THRIVE IRRITABLE LESS CONSTITUTIONAL SYMPTOMS

INFANTS

INVESTIGATIONS
BLOOD WBC,ESR, BLOOD CULTURE C REACTIVE PROTEINS ASPIRATE MICROSCOPY,CULTURE XRAYS BONE SCAN (Tc.Ga. Indium) MRI

DIFFERENTIAL DIAGNOSIS
CELLULITIS BONE TUMOUR PERIOSTIETIS AC.RHEUMATISM SICKLE CELL DISEASE GAUCHERS DISEASE

SEQUENCE OF TREATMENT
IMMEDIATE ADMISSION INVESTIGATIONS ANELGESICS SPLINTAGE ANTIBIOTICS (IF NO IMPROVEMENT WITHIN 24_36 Hrs) SURGICAL INTERVENTION IS INDICATED

TREATMENT ANTIBIOTICS
<02 YEARS OF AGE ( H. INFLUENZEA) 2nd / 3rd GENERAT ION CEPHOLOSPORIN OR AMOXICILLIN
>02 YEARS OF AGE 1st. GENERATION CEPHALOSPORIN OR PENICILLIN BROAD SPECTRUM ANTIBIOTICS

TREATMENT ANTIBIOTICS
IF HYPERSENSITIVE TO PENICILLIN USE LINCOMYCIN FUCIDIC ACID ERYTHROMYCIN QUINOLONES

TREATMENT ANTIBIOTICS
RATIONALE OF TREATMENT
BACTERICIDAL INITIAL BOLUS DOSE INTRAVENOUS COMBINATION OF DRUGS

DURATION OF TREATMENT
PARENTAL 03 WEEKS ORAL 03 WEEKS

TREATMENT SURGICAL
ASPIRATION INCISION/DRAINAGE PERIOSTIAL INCISION BURR HOLES SEQUESTRECTOMY IF NEEDED

PROGNOSIS

MORTALITY MORBIDITY METASTATIC ABSCESSES BEFORE THE CLOSURE OF GR. PL.

LLD, BOWING

AFTER SKELETAL MATURITY JOINT INVOLVEMENT PATHOLOGICAL FRACTURE CH.OSTEOMYELITIS.

CH. OSTEOMYELITIS
ACUTE _____CHRONIC
CHRONIC TO START WITH e.g. TB, FUNGUS POST.TRAUMATIC COMPOUND FRS. POST. OPERATIVE

MORBID ANATOMY
THICKENED BONE SEQUESTRAE INVOLUCRUM CLOACAE PUS /GRANULATION TISSUE IMPLANTS ,CEMENT.

CLINICAL FEATURES
PAIN WITH OR WITHOUT LOW GRADE FEVER DISCHARGING SINUSES SCARS

INVESTIGSTIONS
BLOOD CP. WBC,ESR,HB% ASPIRATE C.S. XRAYS C.T. M.R.I. RADIO ISOTOPE BONE SCAN Tc.,Ga.

TREATMENT
ANTIBIOTICS LOCAL TREATMENT SKIN CARE DRESSENGS OPERATIVE

OPERATIVE TREATMENT
SEQUESTRECTOMY DEBRIDEMENT SAUCERIZATION CONTINUOUS IRRIGATION DOUBLE LUMEN TUBES GENTYCIN BEADS MUSCLE FLAPS PAPINEAU TICHNIQUE IMPLANT REMOVAL/EXTENAL FIXATOR

THE END

POST. TRAUMATIC OSTEOMYELITIS

ESSENCE OF TREATMENT IS PROPHYLAXIS IN ESTABLISHED CASES DEBRIDEMENT DRAINAGE REPEATED WOUND EXISIONS REMOVAL 0F LOOSE IMPLANTS USE EXTERNAL FIXATION OTHERWISE KEEP IMPLANT TILL UNION

POST. OPERATIVE OSTEOMYELITIS

EARLY WITHIN 03 MONTHS SUPERFICIAL DEEP BOTH
FOLLOWING EARLY COVERT INFECTION FOLLOWING A LONG COARSE OF NORMALCY

LATE

PROPHYLAXIS AGAINST POST. OP. OSTEOMYELITIS

AVOID OP. ON IMMUNOSUPPRESSED TREAT FOCUS OF INFECTION OPTIMAL STERILIZATION PROPHYLACTIC ANTIBIOTICS IMPLANT MATERIAL SURGICAL TECHNIQUE ULTRA CLEAN OP.THEATRE

OSTEOMYELITIS AFTER ORIF. OF FRS.

STABLE SEPTIC FRACTURE IS BETTER THAN UNSTABLE SEPTIC FRACTURE
SO KEEP THE IMPLANT TILL UNION OR CONVERT TO EXTERNAL FIXATION

OSTEOMYELITIS AFTER JOINT REPLACEMENTS

DIFFICULT TO DIAGNOSE ASPIRATE C/S ANTIBIOTICS STABLE PROSTHESIS CONSERVATIVE LOOSE PROSTHESIS REMOVAL SUPERFICIAL INFECTION DRAINAGE ANTIBIOTICS REVISION SURGERY IN INFETION IS TWO STAGE SURGERY ALTERNATIVES TO REVISION EXCISION ARTHRODESIS

TUBERCULOSIS OF BONES AND JOINTS

05% OF ALL CASES OF PUL. TB. GET THIS INFECTION IN BONES/JOINTS
30% HAVE MULTIPLE LESIONS

COMMON IN SPINE AND LARGE SYNOVIAL JOINTS

ROUTES OF SPREAD
FROM SUBCHONDRAL BONE TO THE JOINT
FROM SYNOVIUM TO THE JOINT

FROM BOTH TO THE JOINT

TYPES
SPINAL WITHOUT PARAPLEGIA WITH PARAPLEGIA ARTICULAR MAJOR SYNOVIAL JOINTS EXTRA ARTICULAR BONES: LONG BONES, SKULL, RIBS, PHALANGES. TENDON SHEATH/BURSA: BURSITIS COMPOUND PALMER/DORSAL GANGLIAN

PATHOLOGY
SYNOVIUM
INFLAMMATION CARTILAGE DESTRUCTION BONE INVOLVEMENT SOFT TISSUE SWELLING ABSCESSES/SINUSES

PATHOLOGY
BONE/JOINT
CHRONIC TB. RESPONSE TB.GRANULOMA PUS CAVITY CONTAINING PUS AND BONE PIECES DESTRUCTION OF ART. CARTILAGE DESTRUCTION OF GROWTH. PLATE IN IMMATURE SKELETON

HEALING
EARLY STAGE
FULL RESOLUTION WITH TREATMENT LATE STAGE CARTILAGE DESTRUCTION,FIBROUS ANKYLOSIS,MUSCLE ATROPHY AND RECURRENT FLARES

CLINICAL FEATURES
H/O TB. CHILD/YOUNG/ADULTS PAIN/SWELLING OF JOINT NIGHT CRIES IN ADVANCED CASES MOVEMENTS REDUCED/PAINFUL MUSCLE ATROPHY COLD ABSCESS/SINUSES DEFORMITY/CONTRACTURES

INVESTIGATIONS
BLOOD ESR,C.P. SKIN TESTS MANTAUX TEST,HEAF TEST,DOT TEST ASPIRATE AFB STAINING 10_20% +IVE CULTURE BIOPSY CULTURE >80% +IVE HISTOPATHOLOGY CASEATING GRANULOMA CONFIRMATORY

XRAYS
SOFT TISSUES SWELLING DECREASED JOINT SPACE EROSION OF CARTILAGE NO PERIOSTEAL REACTION OSTEOPENIA BONE GETTING WASHED OUT

XRAYS
GROWTH PLATE MAY BE ENLARGED CYSTIC LESIONS IN THE BONE BONE EROSIONS COLLAPSE OF BONE/JOINT DEFORMITY

DIFFERENTIAL DIAGNOSIS
RH. ARTHRITIS SUBCUTE ARTHRITIS OF OTHER VARIETIES HAEMORRHAGIC ARTHRITIDES SEPTIC ARTHRITIS

DIAGNOSTIC POINTS
LONG HISTORY MONOARTICULAR SYNOVIAL THICKENING MUSCLE ATROPHY OSTEOPENIA/REDUCED JOINT SPACE MANTAUX TEST +IVE/RAISED ESR BIOPSY IS CONFIRMATORY

TREATMENT
GENERAL
CHEMOTHERAPY SURGERY

TREATMENT. GENERAL
REST
SPLINTAGE/TRACTION BUILD NUTRITION CORRECT ANAEMIA

TREATMENT CHEMOTHERAPY
04 DRUGS COMBINATION 2_3 MONTHS 03DRUGS COMBINATION 6_7 MONTHS RIFAMPICIN INH MYAMBUTOL PYRAZINAMIDE AVOID MYAMBUTOL IN CHILDREN

TREARMENT SURGERY
DRAIN ABSCESS PUS,GRANULATION TISSUE AND ANY NECROTIC BONE OSTEOTOMY: CORRECT DEFORMITY ARTHRODESIS: SOUND FUSION IN FUNCTIONAL POSITION ARTHROPLASTY: JOINT REPLACEMENT ATLEAST 1_2 YEARS AFTER COMPLETE RESOLUTION

CLINICAL STAGES
SYNOVITIS STAGE
ARTHRITIS STAGE CARTILAGE INVOLVEMENT

AFTERMATH HEALED STAGE DEFORMITY

REGIONAL SURVEY HIP

SYNOVITIS STAGE
PAIN IN GROIN/HIP/KNEE WORSE AT NIGHT HIP IS IRRITABLE WORSE IN MORNING POSTURE OF FLEXION/ABDUCTION MOVEENTS PAINFUL TREATMENT BED REST,TRACTION SPLINTAGE AND ANTI TB. DRUGS

REGIONAL SURVEY HIP

HEALED STAGE
FROM SYNOSITIS STAGE WITH TREATMENT USUALLY FULL RECOVERY FROM ARTHRITIS STAGE EVEN WITH TREATMENT MAYGET DEFORMITY CONTRACTURES AND SHORTENING TREATMENT: OSTEOTOMY FOR DEFORMITY ARTHRODESIS FOR SOUND FUSION

REGIONAL SURVEY KNEE

SYNOVITIS STAGE
ANTI TB. DRUGS SPLINTAGE/POP.CYLINDER

ATHRITIS STAGE
CONTINUE ANTI TB.TREATMENT SPLINTAGE/WEIGHT REIEVING CALIPERS/CRUTCH WALKING SURGERY: TO DRAIN/ DEBRIDE ABSCESS

REGIONAL SURVEY KNEE

HEALED STAGE FROM SYNOVITIS STAGE :
SHOW FULL RECOVERY FROM ARTHRITIS STAGE : MAY END UP WITH FIBROUS ANKYLOSIS AND/OR DEFORMITY/CONTRACTURES TREATMENT: KNEE ARTHRODESIS TOTAL KNEE REPLACEMENT IN SELECTED CASES AFTER 1_2YEARS OF COMPLETE RESOLUTION MAY