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What is Osteomyelitis? Infection of the bone Often confused with septic arthritis Can occur in infants, children, and adults Most commonly occurs: Children ends of long bones in arms and legs Adults spine, feet, or pelvis Two classifications used: Waldvogel Classification best for clinical application Cierny and Mader Classification best for surgical treatment proposals Only 2 out of 10,000 people get osteomyelitis Adults and children are affected in different ways
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Osteomyelitis Holly Schlicht April 22,2014 What is
Osteomyelitis? Infection of the bone
Often confused with septic arthritis Can occur in infants,
children, and adults Most commonly occurs: Children ends of long
bones in arms and legs Adults spine, feet, or pelvis Two
classifications used: Waldvogel Classification best for
clinicalapplication Cierny and Mader Classification best
forsurgical treatment proposals Only 2 out of 10,000 people get
osteomyelitis Adults and children are affected in different ways
Waldvogel Classification of Osteomyelitis
Hematogenous Secondary to bacterialtransport through the
blood.Majority of infections inchildren Contiguous Bacterial
inoculation from anadjacent focus. E.g.:Posttraumatic
Osteomyelitis,infections from prostheticdevices Associated with
vascularinsufficiency Infections in patients withdiabetes affecting
the feet,hanseniasis, or peripheralvascular insufficiency Acute
Osteomyelitis initial episodes of osteomyelitis Edema, formation of
pus,vascular congestion,thrombosis of small vessels Chronic
Osteomyelitis recurrence of acute cases Large areas of
ischemia,necrosis, and bonesequestra Acute osteomyelitis can lead
to chronic osteomyelitis because without treatment, the infection
and inflammation block the blood vessels and causes the bone to
die. Chronic osteomyelitis is harder to treat Sequestra= a fragment
of dead bone attached to healthy bone Duration of Infection
Mechanism of BoneInfection Cierny and Mader Classification of
Osteomyelitis
Host healthy Patient without comorbidities Local Compromise
Smoking, chroniclymphedema, venous stasis,arthritis, large scars,
fibrosisby radiotherapy Systemic Compromise Diabetes
mellitus,malnutrition, renal or hepaticfailure, chronic
hypoxia,extremes of age Poor clinical conditions Surgical treatment
will havehigher risk than theosteomyelitis itself Medullary
Infection restricted to the bonemarrow. Superficial Infection
restricted to corticalbone Localized Infection with clearly
definededges and bone stabilitypreserved Diffuse Infection spread
to the entirebone circumference, withinstability before or
afterdebridement Anatomical Stage Host Classification Pathology of
Osteomyelitis
Staphylococcus bacteria most common bacteriato cause Osteomyelitis
Bacteria enters bone causing an infection. Bacteria can enter bone
via bloodstream, from anearby infection, or direct contamination
Risk factors include: Open wound over a bone Open fracture Recent
surgery Injection around bone Medications that weaken immune system
Pre-morbid conditions (diabetes) When I say risk factors, these are
events that can cause osteomyelitis. Pre-morbid conditions include
diabetes (the most common), cancer, sickle cell anemia, high blood
cholesterol, immune system deficiencies, and peripheral vascular
disease Signs and Symptoms Fever or chills Irritability or lethargy
Fatigue
Pain in the area of infection Swelling, warmth, redness, &
possibly pus overthe area of infection Nausea Unexplained weight
loss Excessive sweating Stiffness Decreased ROM Ways to diagnose
Physical Examination Medical History X-rays
Blood Tests Bone Scans Computed Tomography (CT) Scan Magnetic
Resonance Imaging (MRI) **Bone Tissue Biopsy** Bone tissue biopsy
is important because it allows the physician to know exactly which
bacteria has caused the infection MRI is most useful in the
diagnosing of acute osteomyelitis X Rays MRI Treatment Antibiotics
Lifestyle changes (i.e. quitting smoking)
Treatment of underlying cause (i.e diabetes) Surgery May include
one or more of the followingprocedures: Drainage of the infected
area Removal of diseased bone and tissue Restoration of blood flow
to bone Removal of any foreign objects Amputation of the limb
Prognosis If caught early on then prognosis is very good
Delay of diagnosis can lead to permanentdeficits 31% of
Osteomyelitis recurrence happenswithin 1 year of diagnosis
Suspected Functional Losses
**Depends where the Osteomyelitis is located and theseverity of the
condition** *WALKING* Decreased strength, ROM, and endurance
Decreased ADL (bathing, dressing, sleeping, etc.) Decreased IADL
(driving, cleaning, running errands, etc.) Decreased performance of
social activities Psychological changes Lifestyle/role changes Loss
of limb(s) OT Implications **PSYCHOSOCIAL** **Pain
Reduction**
Teach and educate clients to fully participate in: Self care Work
or school Play or leisure IADL Patient positioning Example: We need
to educate staff, patient, and caregivers that staticpositioning of
a limb can cause other problems like DVTs. OT Implications Cont.
Patient education: Strengthening and ROM
Energy conservation Work simplification Home modifications *Patient
can be in a wheelchair permanently after having osteomyelitis
sofurniture, doorways, cabinets, etc. will need to be modified for
the patientto function independently in his/her new lifestyle*
Medication management Strengthening and ROM Vocational
rehabilitation Leisure exploration Adaptive equipment Prosthetic
training Provide resources (i.e. support groups, books, blogs,etc.)
Model Model of Human Occupation (MOHO)
Based on three subsystems: volition, habituation,and performance
capacity. Learning how the impairment has affected thepersons life
and using the persons interests togain full participation in
functional activities Theories Biomechanical Rehabilitation
Intervention approach aimed at increasing ROM,strength, and
endurance to improve functionaloutcomes Rehabilitation Intervention
approach that focuses on the clientsability to return to the
fullest physical, mental,social, vocational, and economic
functioning as ispossible while using compensation and adaptation
Focus on the clients abilities instead of disabilities Treatment
Session Session 2:
17 year old female who is a senior in high school and hasdiabetes
Acquired Staphylococcus bacteria (staph infection) from thelocker
room at school through an open abrasion on her thighthat she got
while playing softball Staph infection spread to the bone resulting
in acute osteomyelitis of thefemur On antibiotics to fight off
infection and decrease the chances of surgery Pain and constant
fatigue make it difficult to participate in socialand leisure
activities Problem: Decreased participation in social and leisure
activitiesdue to pain and constant fatigue Goal: Patient will
utilize energy conservation/work simplificationtechniques
independently during all functional and socialactivities by
discharge Treatment Session Cont.
Introduction, Homework Review, & Pain level- 10 min. Activity-
40 min.* *OT learned that prom is coming up and it is important to
the patientto attend it* Patient will utilize energy conservation
techniques while shopping andgetting ready for prom Dresses will be
hanging around the clinic area like a store and thepatient will go
pick a dress out to wear to prom Client will walk for as long as
she can and practice using her wheelchairand walker provided by the
OT whenever she feels tired or increased painlevels Patient will
apply makeup at the dresser and will be reminded, if needed,of
techniques to use to decrease fatigue OT will cue patient to
utilize her energy conservation techniquesthroughout the activity
(taking breaks, laying makeup out before applyingit, sitting down
to get ready, etc.) and offer new strategies if needed Having the
client walk as long as she can works on strengthening as well as
endurance Treatment Session Cont.
End of Activity and Reflection- 10 minutes Therapist will get
patients feedback about the session and willremind her of the
importance of the energy conservationtechniques Introduction of
pain management techniques andexercises to look at for next session
Patient should continue to utilize energyconservation and work
simplification techniquesduring all activities End of Session Two
groups of children with Osteomyelitis:
Article 1 The impact of evidence-based clinical practice guidelines
applied by a multidisciplinary team for the care of children with
osteomyelitis Purpose to evaluate the impact ofevidence-based
clinical practice guidelines asapplied by a multidisciplinary team
throughdaily surveillance and management Two groups of children
with Osteomyelitis: Group 1 consisted of 210 children who had
beentreated before implementation of guideline-driventreatment
Group 2 consisted of 61 children who had beentreated using
guidelines applied by themultidisciplinary team Two groups were
compared with respect to:
patient demographics length of hospital stay contagious infection
the percentage of patients who had blood and tissuecultures the
rates of positive cultures causative organism MRI utilization and
timing surgical procedures initial antibiotic utilization
antibiotic changes duration of intravenous and/or oral antibiotic
use the rate of readmission Results Group 2 had better outcomes in
almost allsignificant differences found between twogroups
including: Shorter delay time of MRI after admission Higher
Percentage of patients who had had a bloodculture before antibiotic
& higher percentage ofpatients who had had a culture of tissue
from theinfection site Higher percentage of patients in whom the
infectingorganism was identified on tissue or blood culture Fewer
number of antibiotic changes Shorter length of stay in hospital and
fewerreadmissions Take home message! A guideline-driven treatment
applied througha multidisciplinary approach resulted in amore
efficient diagnostic workup, a higherrate of identifying the
causative organism,improved adherence to initial
antibioticrecommendations with fewer antibiotic changes, and
shorter hospital stays withfewer readmissions Diagnosis of DFO
confirmed by probe-to-bone test and X-ray
Article 2 Antibiotics versus conservative surgery for treating
diabetic foot osteomyelitis: A randomized comparative trial Purpose
to compare the outcomes of treatment ofdiabetic foot osteomyelitis
(DFO) in patients treatedexclusively with antibiotics versus
patients treatedexclusively with conservative surgery and short
termpostoperative antibiotics 2 groups: 24 in Antibiotic Group (AG)
22 in Surgery Group (SG) Diagnosis of DFO confirmed by
probe-to-bone test andX-ray Inflammatory markers measurements taken
atbeginning and end of study Antibiotics for 90 days and
conventional surgeryimmediately with postoperative antibiotics for
10 days 12 week follow up of both groups Probe-to-bone test
determined osteomyelitis if the bone felt hard and gritty when
touched with the probe Results Eighteen patients in the AG and 19
patients inthe SG achieved primary healing healing from either only
antibiotics or only surgerydepending on which group the individual
was in Majority of the inflammatory markers wentdown in both groups
The primary wound healing andnormalization of inflammatory markers
fromboth treatments shows that DFO can bereduced after both
antibiotic treatment andconservative surgery. 70 patients
identified for this study
Article 3 Prospective evaluation of a shortened regimen of
treatment for acute osteomyelitis and septic arthritis in children
Hypothesis majority of children with acute septicarthritis and
acute osteomyelitis could be managed by 3full days of intravenous
antibiotics followed by 3 weeksof oral therapy 70 patients
identified for this study 34 from Birmingham Childrens Hospital 36
from The Royal Childrens Hospital in Melbourne Septic arthritis
(SA)= 33 Acute osteomyelitis (OM)= 37 Diagnosis of septic arthritis
positive blood or aspiratecultures or a large number of joint
aspirate white blood cellcount Diagnosis of osteomyelitis based on
clinical findings(pain and fever) and positive culture and/or
imaging (i.e.MRI). All patients were assessed clinically for limb
functionincluding pain, swelling, range of motion of
affectedjoints, and ability to weight bear for lower limb problems
Temperature and inflammatory marker measurementswere taken Patients
began high dosage of intravenous antibioticafter evaluation for 3
days After 3 days patients were reevaluated to determinewhether or
not they were ready to switch to low dosageoral medication for 3
weeks 59% of patients were able to switch to oral medicationsafter
3 days and 86% by day 5 with the average inpatientcare duration
being five days. Patients were followed up 3 weeks, 6 weeks, 3
months, 6months, and one year Results 58 patients (28 patients with
osteomyelitis and 30patients with septic arthritis) were clinically
andhematologically normal at three week follow up andremained
normal through discharge Some patients were recommended to continue
oralmedication, some readmitted to hospital for IVantibiotics, and
some had complications thatcorrected themselves without extra
treatment. By year follow up all patients were clinically
andhematologically normal Take home message children with acute
septicarthritis and acute osteomyelitis can be treated with 3days
of high dose IV antibiotic and three weeks oforal medication
instead of the usual prolonged use ofantibiotics References
eomyelitis treatment-diagnosis-symptoms
conditions/osteomyelitis/basics/causes/con litis
and_Septic_Arthritis/ Lima, A. L. L., Oliveria, P. R., Carvalho, V.
C., & Cimmerman, S.(2014). Recommendations for the treatment of
osteomyelitis. TheBrazilian Journal of Infectious Diseases,
References cont. (Articles)
Copley, L. A. B., Kinsler, M.A., Gheen, T., Shar, A., Sun, D.,
&Browne, R. (2013). The impact of evidence-based clinical
practiceguidelines applied by a multidisciplinary team for the care
ofchildren with osteomyelitis. The Journal of Bone and
JointSurgery, 95 (8), doi: /JBJS.L.00037 Lazaro-Martinez, J. L.,
Aragon-Sanchez, J., & Garica-Morales, E.(2014). Antibiotics
versus conservation surgery for treatingdiabetic foot
osteomyelitis: A randomized comparative trial.Diabetes Care, 37
(4), doi: /dc Jagodzinski, N. A., Kanwar, R., Graham, K., &
Bache, C. E. (2009). Prospective evaluation of a shortened regimen
oftreatment for acute osteomyelitis and septic arthritis in
children.Journal of Pediatric Orthopedics, 29 (5), doi:
/BPO.0b013e3181ab472d. References cont. Resources
therapy.advanceweb.com/sharedresources/AdvanceforOT/Resource
s/DownloadableResources/OT_051503_energy_patient.pdf
https://patienteducation.osumc.edu/Documents/sav-eng.pdf
%20Health%20Information/Alternative%20Ways%20to%20Control%20
Pain.pdf FAF DDC/$file/Osteomyelitis.pdf Questions anyone?
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