- 730.__ (Osteomyeliitis, periostitis, and other injections involving bone)
Osteomyelitis Etiology / Epidemiology / Natural History
- Hematogenous: M>F, vertebrae most common site
- Most common organism: S aureus. Pseudomonas aeruginosa in IV drug users.
- Associated with open fractures, diabetics (espcially foot), following musculoskeletal surgery.
- Brodie's Abcess: sclerotic bonesurrounding dense fibours tissue found in chronic osteomyelitis usuallly along the distal tibia.
Osteomyelitis Clinical Evaluation
- Pain, fever, chills, swelling, erythema
Osteomyelitis Xray / Diagnositc Tests
- CBC with differential, ESR (rises within 2 days, continues to rise for 3-5 days even with treatment), CRP (rises witin 6 hours, peaks at 48 hrs, normal witin 1 week), blood cultures, gram stain, CXR. Consider Acid-fast staining, fungal cultures, prolonged incubation times (especially fro infections after arthroscopic surgery).
- Serum IL-6 is indicative of early periprosthetic infection (DiCesare PE, JBJS 2005;87A:1921).
- Xray: demonstrate soft-tissue swelling / loss of tissue planes early. Bone abnormalities require 30-40% bone losss.
- MRI: highest sensitivity and specificity for infection / osteomyelitis. low signal intensity in bone marrow on T1 images may indicate osteomyelits (bone marrow normally has high-signal intensity on T1 images).
- Bone scan: technetium 99m; gallium citrate Ga 67; indium-111 leukocyte-labeled etc.
Osteomyelitis Classification / Treatment
- Stage 1 (Medullary): operative debridment and 4 weeks of antibiotics based on cultures and sensitivities, skeletal stabilization (ex fix), soft tissue coverage (3-7 days after debridement) as indicated.
- Stage 2 (superficial): operative debridment and 2 weeks of antibiotics based on cultures and sensitivities, skeletal stabilization (ex fix), soft tissue coverage (3-7 days after debridement)as indicated.
- Stage 3(Localized): operative debridment and 6 weeks of antibiotics based on cultures and sensitivities, skeletal stabilization (ex fix), soft tissue coverage (3-7 days after debridement) as indicated.
- Stage 4 (Diffuse): operative debridment and 6 weeks of antiobitics based on cultures and sensitivities, skeletal stabilization (ex fix), soft tissue coverage (3-7 days after debridement)as indicated.
- Suppressive treatment with rifampin and a fluoroquilolone or Bactrim for 6 months indicated for patients with contraindications for surgery.
- Surgical Debridement: Resect soft tissuesto supple, well-perfused margins. Resect bone tangentiallyuntil exposed surfaces bleed in a uniform, haversian (cortical)or sinusoidal (cancellous) pattern (paprika sign).40All foreign bodies and surgical implants are removed, the woundis lavaged of debris, and the surgical field is prepared forclosure (Sachs BL, CORR 1984;184:256).
- Consider antibiotic beads (vancomycin, tobramycin, gentamycin) especially if lesions with dead space. Beads are typically removed after 4 weeks.
- Consider biodegradeable antibiotic beads (Liu SJ, J Biomed Mater Res 2002;63:807).
- Consider antibiotic impregnated cancellous bone grafts. (Chan YS, J Trauma 2000;48:246).
- Consider Hyperbaric oxygen
- Consider Amputation
- Host Categories: (A)normal, (B)compromised, (C)treatment worse then disease
- Correct any host limitations: smoking, poor nutrition, diabetes control
Osteomyelitis Associated Injuries / Differential Diagnosis
- Healing fracture
- Benign tumor
- Squamous cell carcinoma (Marjoliin's ulcer)
Osteomyelitis Follow-up Care
- Antibiotics generally managed by infectios disease specialitst based on cultures and sensitivities taken during operative debridement.
- Follow responce to treatment with serial ESR and CRP. CRP returns to normal in 1 week, ESR in 3 weeks with adequate treatment.
- Follow-up for wound and ex fix management.
Osteomyelitis Review References