OSTEOMYELITIS IN OSTEOMYELITIS IN ADULTSADULTS

OSTEOMYELITISOSTEOMYELITIS

Nelaton (1834): coined Nelaton (1834): coined osteomyelitisosteomyelitis

The root words The root words osteon (bone) osteon (bone) and and myelo (marrow)myelo (marrow) are combined with are combined with itis itis (inflammation)(inflammation) to define the to define the clinical state in which bone is clinical state in which bone is infected with microorganisms.infected with microorganisms.

CLASSIFICATIONCLASSIFICATION The two most widely used in the The two most widely used in the

medical literature and in clinical medical literature and in clinical practice are those presented by practice are those presented by

Waldvogel et al Waldvogel et al

Cierny et al.Cierny et al.

WALDVOGEL WALDVOGEL CLASSIFICATIONCLASSIFICATION

According to the duration of the diseaseAccording to the duration of the disease acute acute chronicchronic

On the basis of the pathogenesisOn the basis of the pathogenesishematogenous hematogenous secondary to a contiguous focus of infection secondary to a contiguous focus of infection associated with peripheral vascular diseaseassociated with peripheral vascular disease

ACUTE / CHRONIC OMACUTE / CHRONIC OM

The term The term acute osteomyelitis acute osteomyelitis is used is used

clinically to signify a newly recognized bone clinically to signify a newly recognized bone

infection. Patients usually present within infection. Patients usually present within

several days to one weekseveral days to one week after the onset of after the onset of

symptoms. In addition to local signs of symptoms. In addition to local signs of

inflammation and infection, patients have inflammation and infection, patients have

signs of systemic illness signs of systemic illness

The relapse of a previously treated or The relapse of a previously treated or

untreated infection is considered a sign of untreated infection is considered a sign of

chronic diseasechronic disease. Clinical signs persisting for . Clinical signs persisting for

more than 10 days more than 10 days correlate roughly with correlate roughly with

the development of necrotic bone and the development of necrotic bone and

chronic osteomyelitis. The clinical pattern chronic osteomyelitis. The clinical pattern

may evolve over months or even years and may evolve over months or even years and

is characterized by lowgrade inflammation; is characterized by lowgrade inflammation;

the presenceof pus, microorganisms,and the presenceof pus, microorganisms,and

sequestra; a compromised soft-tissue sequestra; a compromised soft-tissue

envelope;and sometimes a fistula.envelope;and sometimes a fistula.

HEMATOGENOUS OM –HEMATOGENOUS OM –Follows BacteremiaFollows BacteremiaUsually occurs inUsually occurs in Children – long bones, usually of lower extremitiesChildren – long bones, usually of lower extremities Middle aged adults who use IV Drugs – Vertebrea, Pubic Symphysis, Middle aged adults who use IV Drugs – Vertebrea, Pubic Symphysis,

Sternoclavicular & Sacroiliac jointsSternoclavicular & Sacroiliac joints Elderly – VertebreaElderly – VertebreaPredisposing factorsPredisposing factors include any cause of persistent bacteremia include any cause of persistent bacteremia central venous catheter infectionscentral venous catheter infections endocarditisendocarditis hemoglobinopathies such as sickle cell disease hemoglobinopathies such as sickle cell disease immunodeficiency states chronic granulomatous diseaseimmunodeficiency states chronic granulomatous diseaseClinical FeaturesClinical FeaturesChildren - fever, evidence of inflammation including pain at the involved Children - fever, evidence of inflammation including pain at the involved

site, erythema, warmth, and induration; Blood cultures are often positive site, erythema, warmth, and induration; Blood cultures are often positive Adults – course is often more indolentAdults – course is often more indolent Pain is the common manifestationPain is the common manifestation Only about half of adults with vertebral osteomyelitis have a fever. Only about half of adults with vertebral osteomyelitis have a fever. Percussion tenderness and paraspinal muscle tenderness is more Percussion tenderness and paraspinal muscle tenderness is more

common, and the disease may progress to paraparesis or paraplegia.common, and the disease may progress to paraparesis or paraplegia. Blood cultures are often negative, so needle biopsy with multiple Blood cultures are often negative, so needle biopsy with multiple

specimens for microbiologic and pathological examination is the specimens for microbiologic and pathological examination is the diagnostic procedure of choicediagnostic procedure of choice

…….HEMATOGENOUS OM (cont.).HEMATOGENOUS OM (cont.)EtiologyEtiology

Usually caused by only a single microbial speciesUsually caused by only a single microbial species

in over 50% of cases, the organism is Staphylococcus aureusin over 50% of cases, the organism is Staphylococcus aureus

OM in intravenous drug users is often secondary to Pseudomonas aeruginosa OM in intravenous drug users is often secondary to Pseudomonas aeruginosa

Elderly adults with vertebral osteomyelitis may have infections due to gram-negative urinary Elderly adults with vertebral osteomyelitis may have infections due to gram-negative urinary

pathogens.pathogens.

Neonates are predisposed to infections from group B streptococci or gram-negative bacilli. Neonates are predisposed to infections from group B streptococci or gram-negative bacilli.

Patients with sickle-cell disease, often have infections due to Salmonella. Patients with sickle-cell disease, often have infections due to Salmonella.

Mycobact Tuberculosis (Pott’s disease) Mycobact Tuberculosis (Pott’s disease)

Brucellosis due to exposure to cattle, sheep, goats, pigs, or consumption of unpasteurized dairy Brucellosis due to exposure to cattle, sheep, goats, pigs, or consumption of unpasteurized dairy

products; products;

Coxiella burnetii associated with farm animalsCoxiella burnetii associated with farm animals

The endemic fungi such as Blastomyces dermatitidis or Coccidiodes immitis; and atypical The endemic fungi such as Blastomyces dermatitidis or Coccidiodes immitis; and atypical

mycobacteria or Bartonella henselae in patients with HIV disease.mycobacteria or Bartonella henselae in patients with HIV disease.

Patients who are immunosuppressed and have central venous catheters may have infections Patients who are immunosuppressed and have central venous catheters may have infections

due to opportunistic fungi such as Candida, Aspergillus, or Rhizopus.due to opportunistic fungi such as Candida, Aspergillus, or Rhizopus.

OM SECONDARY TO A CONTIGUOUS FOCUS OM SECONDARY TO A CONTIGUOUS FOCUS OF INFECTION OF INFECTION

Direct infection of a bone from an exogenous source Direct infection of a bone from an exogenous source

Extension of an infection from a contiguous focusExtension of an infection from a contiguous focus

This is the most common OM in adults.This is the most common OM in adults.

The long bones of the extremities, such as the tibia and femur, are the most The long bones of the extremities, such as the tibia and femur, are the most

common sites of involvement.common sites of involvement.

Clinical Features Clinical Features - - Patients usually present with only local Patients usually present with only local

symptoms of erythema, swelling, and pain. As the symptoms of erythema, swelling, and pain. As the

infection becomes more chronic, persistent purulent infection becomes more chronic, persistent purulent

sinus-tract drainage forms. Most patients do not have sinus-tract drainage forms. Most patients do not have

a fever, leukocytosis, or an elevated ESRa fever, leukocytosis, or an elevated ESR

… …OM SECONDARY TO A CONTIGUOUS FOCUS OF INFECTIONOM SECONDARY TO A CONTIGUOUS FOCUS OF INFECTION

EtiologyEtiology

Infection is polymicrobial in 30% to 50% of cases and blood cultures Infection is polymicrobial in 30% to 50% of cases and blood cultures are unlikely to be positiveare unlikely to be positive

S. aureus remains the most likely S. aureus remains the most likely pathogenpathogen Aerobic gram-negative bacilli can be found in 30% of cases. Aerobic gram-negative bacilli can be found in 30% of cases. Anaerobic organisms should be suspected following bites, Anaerobic organisms should be suspected following bites,

extensions of dental or sinus infections, or associated with extensions of dental or sinus infections, or associated with decubitus ulcers, especially of the sacrum or pelvic bones.decubitus ulcers, especially of the sacrum or pelvic bones.

Infections associated with cat bites are often due to Infections associated with cat bites are often due to Pasteurella Pasteurella multocida, while human bite infections multocida, while human bite infections may involve may involve Eikenella Eikenella corrodens.corrodens.

P. aeruginosa is P. aeruginosa is associated with foot osteomyelitis after puncture associated with foot osteomyelitis after puncture wounds in wearers of sneakers. wounds in wearers of sneakers.

Staphylococcus epidermidis Staphylococcus epidermidis is a likely pathogen associated with is a likely pathogen associated with infections associated with orthopedic hardware devices,such as infections associated with orthopedic hardware devices,such as plates, rods, or prosthetic joints.plates, rods, or prosthetic joints.

OM ASSOCIATED WITH PERIPHERAL OM ASSOCIATED WITH PERIPHERAL VASCULAR DISEASEVASCULAR DISEASE

Found almost exclusively in the feet in patients with a long history of diabetes mellitus and Found almost exclusively in the feet in patients with a long history of diabetes mellitus and

peripheral neuropathy.peripheral neuropathy.

Bone involvement usually occurs after an extension of soft tissue infection involving a plantar Bone involvement usually occurs after an extension of soft tissue infection involving a plantar

ulcer. ulcer.

Clinical FeaturesClinical Features

erythema and drainageerythema and drainage

either no pain (if there is advanced neuropathy) or excruciating pain (if the destruction of bone has either no pain (if there is advanced neuropathy) or excruciating pain (if the destruction of bone has

been acute).been acute).

patients are afebrile,patients are afebrile,

present with an ulcer without evidence of surrounding inflammation. The ulcer size (> 2 cmpresent with an ulcer without evidence of surrounding inflammation. The ulcer size (> 2 cm22) and ) and

depth (> 3 mm) are predictive of the likelihood of bone involvement. If bone can be felt with a sterile depth (> 3 mm) are predictive of the likelihood of bone involvement. If bone can be felt with a sterile

blunt probe, the likelihood of osteomyelitis is high.blunt probe, the likelihood of osteomyelitis is high.

a high ESR, especially if it is over 70 mm/hour, is helpful in making the diagnosis of osteomyelitisa high ESR, especially if it is over 70 mm/hour, is helpful in making the diagnosis of osteomyelitis

… …OM ASSOCIATED WITH PERIPHERAL VASCULAR DISEASEOM ASSOCIATED WITH PERIPHERAL VASCULAR DISEASE

ETIOLOGYETIOLOGY

Most infections are polymicrobialMost infections are polymicrobial S. aureus remains the most common S. aureus remains the most common

pathogenpathogen others include others include Enterococcus faecalis, Enterococcus faecalis,

group group B streptococci, B streptococci, Enterobacteriaceae, anaerobic Enterobacteriaceae, anaerobic bacteria bacteria (especially peptococci, (especially peptococci, peptostreptococci, and peptostreptococci, and Bacteroides Bacteroides species), and P. aeruginosaspecies), and P. aeruginosa

CIERNY-MADER STAGING SYSTEM FOR OSTEOMYELITIS

The Cierny-Mader system classifies osteomyelitis on the degree of anatomic involvement and the

physiologic features of the host and has been helpful in stratifying treatment and prognosis

for long bone infections. The stages in this system are dynamic and may be altered by changes in

the medical condition of the patient (host), successful antibiotic therapy and other treatments.

Anatomic type

Stage 1: Medullary osteomyelitis - Confined to medullary cavity, examples include

hematogenous osteomyelitis or associated with intramedullary rods

Stage 2: Superficial osteomyelitis - Exposed infected bone at the base of a wound

Stage 3: Localized osteomyelitis - Full thickness cortical sequestration that can

be removed without compromising stability

Stage 4: Diffuse osteomyelitis - Involvement of both cortex and medullary cavity

associated with loss of stability

Physiologic class

A host: healthy & has no systemic or local compromising factors

B host: is affected by one or more compromising factors

Bs: systemic compromise - Malnutrition, renal or hepatic failure, diabetes, chronic hypoxia,

immune deficiency, malignancy, extremes of age

Bl: local compromise - Chronic lymphedema, venous stasis, major vessel compromise, arteritis,

extensive scarring, radiation fibrosis, small-vessel diseases, neuropathy, tobacco abuse

Bls: local and systemic compromise

C host: Treatment worse than the disease. The host is so severely compromised that the radical

treatment necessary would have an unacceptable risk-benefit ratio. Suppressive antibiotic

therapy and/or amputation recommended

The anatomical & physiological classes are combined to designate 1 of 12 clinical stages of

osteomyelitis. Eg. A type II lesion in a class A host is designated as stage IIA OM. This system is

helpful in determining if t/t should be simple /complex, curative/palliative, limb sparing/ablative

…CIERNY-MADER STAGING SYSTEM FOR OSTEOMYELITIS (cont.)

PATHOGENESIS Infection Inflammatory response

Phagocytes attempt to contain infection by liberating enzymes

enzymes lyse the bone

pus forms

pus travels through haversian system

increased intra osseous pressure

endarteritis and impaired blood flow

ischemic necrosis of bone

pus breaks through the cortex

abscesses

subperiosteal / soft tissue elevated periosteum- deposits new bone ( involucrum )

sites of rupture of periosteum – (cloacae)

This process may take several months and may get halted at any stage depending upon the host resistance and virulence of infecting organisms If infection gets completely eradicated, the necrosed bone does not separate but is gradually replaced by process of creeping substitution

Sequestrum :

is a devitalized avascular segment of bone, surrounded, by pus /infected granulation tissue and is more dense than surrounding bone .Because of avascularity , sequestrum does not decalcify , is more radio opaque and heavy , so sinks in waterIts outer surface is usually jagged / irregular due to erosive process by proteolytic enzymes in granulation tissue

Types of Sequestra:

1 Tubular ( Diaphyseal) – Pyogenic Osteomyelitis 2 Trapezoid - Pyogenic Osteomyelitis 3 Ring -At end of stumps, around Steinman pin, wires, Schanz screws 4 Flake/ Feathery - Tuberculous Osteomyelitis( in cavity ) 5 coarse sandy - Tuberculous Osteomyelitis ( out of cavity ) 6 Fine sandy - Viral Osteomyelitis 7 Black - Actinomycosis

.)

Involucrum :

is derived from the word “volvere” i.e. to wrap .It is the result of reactive new bone formed by periosteal reaction , in an attempt to wall off the infection by forming a thick tense wall It is jagged on its inner surface but smooth on its outer surface

Cloacae :

are single or multiple openings in involucrum and are caused by rupture of periosteum due to pus under tension .Exudates , sequestra are extruded through the cloacae on the surface

Important factors in the pathogenesis of osteomyelitisImportant factors in the pathogenesis of osteomyelitis

1.1. In the early stages of colonization, bacteria can still be killed or contained by In the early stages of colonization, bacteria can still be killed or contained by

host defences. But they can remain viable whenhost defences. But they can remain viable when

Inoculum is larger than threshold levelsInoculum is larger than threshold levels

Host defences are impairedHost defences are impaired

Tissue on which bacteria colonizes is traumatized or necroticTissue on which bacteria colonizes is traumatized or necrotic

A foreign body is presentA foreign body is present

Surface is acellular or inanimate (dead bone, cartilage, biomaterials)Surface is acellular or inanimate (dead bone, cartilage, biomaterials)

2.2. Formation of glycocalyx by the bacteria surrounding the infecting organisms. Formation of glycocalyx by the bacteria surrounding the infecting organisms.

This glycocalyx protects the organisms from the action of phagocytes and This glycocalyx protects the organisms from the action of phagocytes and

prevents access by most antimicrobials. The biofilms are community of prevents access by most antimicrobials. The biofilms are community of

metabolically inactive bacteria & will only form on inert or nonviable surfaces. metabolically inactive bacteria & will only form on inert or nonviable surfaces.

3.3. Gaining access to the interior of cells Gaining access to the interior of cells that may contribute to the that may contribute to the

understanding of understanding of the persistence and flare-ups of osteomyelitis.the persistence and flare-ups of osteomyelitis.

chronic osteomyelitis(contd.)

The diagnosis of osteomyelitis is based on

clinical examination, imaging and laboratory

studies. The gold standard is to take biopsy for

histopathology and microbiological evaluation

LABORATORY STUDIES1.Leucocyte count

Increase – Acute OM

Normal – Chronic OM

2. ESR – Peak elevation of ESR occurs at 3 to 5 days after infection and returns to normal after about 3 weeks after treatment is started

Persistently increase ESR after treatment in a compromise host – a reason other than OM

Not Diagnostic however return of ESR to normal in course of t/t is a favorable prognostic sign

3. C-Reactive protein

• Increase in both acute and chronic OM.

• Decrease faster than ESR.

• More sensitive than ESR.

CRP increases within 6 hrs of infection, reaches a peak elevation 2 days

after infection and returns to normal within one week after adequate

treatment has begun

4. Serum Creatinine level – To monitor drug toxicity

5. LFT – To monitor drug toxicity

6. Serum albumin level – For nutritional status

7. Total iron binding capacity – For nutritional status

R A D I O G R A P H I C D I A G N O S I SR A D I O G R A P H I C D I A G N O S I SO F O S T E O M Y E L I T I SO F O S T E O M Y E L I T I S

No radiographic technique can make or exclude a diagnosis of No radiographic technique can make or exclude a diagnosis of osteomyelitis with certainty.osteomyelitis with certainty.

1.1.Plain film RadiographsPlain film Radiographslag at least two weeks behind the process of infection lag at least two weeks behind the process of infection The earliest changes are swelling of the soft tissue, periosteal thickening The earliest changes are swelling of the soft tissue, periosteal thickening and/or elevation, and focal osteopenia. and/or elevation, and focal osteopenia. The more diagnostic lytic changes are delayed and are associated with The more diagnostic lytic changes are delayed and are associated with subacute and chronic osteomyelitis.subacute and chronic osteomyelitis.Osteoporosis is a feature of metabolically active living bone; the segment Osteoporosis is a feature of metabolically active living bone; the segment that fails to become osteoporotic is metablically inactive and possibly dead.that fails to become osteoporotic is metablically inactive and possibly dead.Sinography can be performed if a sinus track is present and can be a Sinography can be performed if a sinus track is present and can be a valuable adjunct to surgical planning.valuable adjunct to surgical planning.

2. Ultrasound – 2. Ultrasound – may detect a subperiosteal collection of fluid in early stages may detect a subperiosteal collection of fluid in early stages of osteomyelitisof osteomyelitis..

3. Computarized Tomograhy - 3. Computarized Tomograhy - is particularly helpful inis particularly helpful in detecting smaller areas of cortical destruction, detecting smaller areas of cortical destruction, Small foci of gas or foreign bodies, Small foci of gas or foreign bodies, sequestra formation (areas of necrotic bone separated by sequestra formation (areas of necrotic bone separated by

granulation tissue from living bone)granulation tissue from living bone) involucra (a layer ofliving bone that has formed along the involucra (a layer ofliving bone that has formed along the

sequestrum),sequestrum), cloacae (an opening in the involucrum through which the cloacae (an opening in the involucrum through which the

sequestrum and granulation tissue may be discharged)sequestrum and granulation tissue may be discharged) surrounding soft-tissue abscesses and surrounding soft-tissue abscesses and the replacement of the normal bone marrow fat with pus.the replacement of the normal bone marrow fat with pus.These features often predict the need for surgical debridement, These features often predict the need for surgical debridement,

and therefore can be helpful in planning and determining the and therefore can be helpful in planning and determining the need for surgical therapy.need for surgical therapy.

One disadvantage of this study is the scatter phenomenon, One disadvantage of this study is the scatter phenomenon, which occurs when metal is present in or near the area of which occurs when metal is present in or near the area of bone infection and results in a substantial loss of image bone infection and results in a substantial loss of image resolution.resolution.

4. Magnetic resonance imaging4. Magnetic resonance imaging MRI has very high sensitivity and specificity for the diagnosis MRI has very high sensitivity and specificity for the diagnosis

of osteomyelitis.of osteomyelitis. The typical appearance is a localized area of abnormal The typical appearance is a localized area of abnormal

marrow with decreased signal intensity on T1-weighted marrow with decreased signal intensity on T1-weighted images and increased signal intensity on T2-weighted images and increased signal intensity on T2-weighted images. images.

Sinus tracts are seen as areas of high signal intensity Sinus tracts are seen as areas of high signal intensity extending from the marrow and bone through the soft extending from the marrow and bone through the soft tissues and through the skin on T2-weighted imagestissues and through the skin on T2-weighted images

Useful for differentiating between bone and soft-tissue Useful for differentiating between bone and soft-tissue infection, which is often a problem with radionuclide studies.infection, which is often a problem with radionuclide studies.

Unlike radionuclide studies, magnetic resonance imaging is Unlike radionuclide studies, magnetic resonance imaging is not useful for whole-body examinations.not useful for whole-body examinations.

Also, a metallic implant in the region of interest may produce Also, a metallic implant in the region of interest may produce focal artifacts, thereby decreasing image qualityfocal artifacts, thereby decreasing image quality

The intravenous contrast agent gadopentetate di-The intravenous contrast agent gadopentetate di-NN--methylglucamine, a paramagneticmaterial, may also be methylglucamine, a paramagneticmaterial, may also be useful in differentiating vascularized and inflamed tissue useful in differentiating vascularized and inflamed tissue from the peripheralrim enhancement characteristic of an from the peripheralrim enhancement characteristic of an abscessabscess

5. Radionuclide Scans5. Radionuclide Scans

Performed when the diagnosis of osteomyelitis is ambiguous or to Performed when the diagnosis of osteomyelitis is ambiguous or to help gauge the extent of bone and soft-tissue inflammation.help gauge the extent of bone and soft-tissue inflammation.

Technetium-99m methylene diphosphonate bone scanning can Technetium-99m methylene diphosphonate bone scanning can detect abnormalities as early as 24–48 hours, and are almost detect abnormalities as early as 24–48 hours, and are almost always positive by 8 days. Osteomyelitis causes increased uptake always positive by 8 days. Osteomyelitis causes increased uptake in all the three phases (flow phase, equilibruim phase and delayed in all the three phases (flow phase, equilibruim phase and delayed phase)phase)

A technetium-99m scan may be negative for a patient with A technetium-99m scan may be negative for a patient with documented osteomyelitis because of a decrease in blood flow to documented osteomyelitis because of a decrease in blood flow to the infected area (subperiosteal pus, sequestrum, joint effusion, the infected area (subperiosteal pus, sequestrum, joint effusion, vasospasm, soft tissue swelling)vasospasm, soft tissue swelling)

Trauma, arthritis, overlaying cellulitis, tumor, synovitis, or the Trauma, arthritis, overlaying cellulitis, tumor, synovitis, or the neuropathic osteoarthropathy commonly observed in the feet of neuropathic osteoarthropathy commonly observed in the feet of diabetic patients can cause false-positive scans.diabetic patients can cause false-positive scans.

A gallium67 citrate scan, which accumulates in inflammatory sites, A gallium67 citrate scan, which accumulates in inflammatory sites, is generally sensitive but not specific in the diagnosis of is generally sensitive but not specific in the diagnosis of osteomyelitis, because overlaying cellulitis, inflammatory arthritis, osteomyelitis, because overlaying cellulitis, inflammatory arthritis, tumors, hematomas, neuropathic osteoarthropathy, and fractures tumors, hematomas, neuropathic osteoarthropathy, and fractures can also cause positive scanscan also cause positive scans

… …Radionuclide ScansRadionuclide Scans

Indium111-labelled leukocyte scans, although likely more Indium111-labelled leukocyte scans, although likely more specific than bone scanning, can be false-positive in patients specific than bone scanning, can be false-positive in patients with cellulitis or other inflammatory conditions, and can be with cellulitis or other inflammatory conditions, and can be false-negative in chronic infections.false-negative in chronic infections.

To enhance spatial resolution, gallium or indium scanning is To enhance spatial resolution, gallium or indium scanning is sometimes combined with bone scanning, which increases not sometimes combined with bone scanning, which increases not only the cost but also the time of obtaining the results.only the cost but also the time of obtaining the results.

M I C R O B I O L O G I C D I A G M I C R O B I O L O G I C D I A G N O S I SN O S I S

O F O S T E O M Y E L I T I SO F O S T E O M Y E L I T I SKey to the successful management of osteomyelitis is the Key to the successful management of osteomyelitis is the isolation of the involved pathogens before the initiation of isolation of the involved pathogens before the initiation of antibiotics in order to tailor optimal antimicrobial therapyantibiotics in order to tailor optimal antimicrobial therapyIn acute osteomyelitis, especially in children, blood cultures In acute osteomyelitis, especially in children, blood cultures are positive in more than half of patientsare positive in more than half of patientsIn patients with acute hematogenous osteomyelitis of long In patients with acute hematogenous osteomyelitis of long bones, a needle aspirate is often performed. If subperiosteal bones, a needle aspirate is often performed. If subperiosteal pus is found, it is cultured; if not, the needle is inserted into pus is found, it is cultured; if not, the needle is inserted into the marrow cavity and an aspirate is performedthe marrow cavity and an aspirate is performedPatients with vertebral osteomyelitis who do not require Patients with vertebral osteomyelitis who do not require immediate surgical therapy should have a closed biopsy of immediate surgical therapy should have a closed biopsy of the bone performed, often under radiographic guidance. If the bone performed, often under radiographic guidance. If the biopsy is negative, it should be repeated, using either a the biopsy is negative, it should be repeated, using either a closed or open technique. If 2 closed-needle biopsies are closed or open technique. If 2 closed-needle biopsies are negative, open surgical biopsy should be undertaken.negative, open surgical biopsy should be undertaken.

......M I C R O B I O L O G I C D I A G N O S I S O F O S T E O M Y E L I T I ......M I C R O B I O L O G I C D I A G N O S I S O F O S T E O M Y E L I T I SS

Patients with chronic osteomyelitis frequently have draining Patients with chronic osteomyelitis frequently have draining sinus tracts. Culture of material fromthe sinus tracts do not sinus tracts. Culture of material fromthe sinus tracts do not necessarily reflect the pathogens that are infecting the bone. necessarily reflect the pathogens that are infecting the bone. However, growth of However, growth of S. aureus in pure culture from the tract S. aureus in pure culture from the tract does have a high predictive value for its presence in bone. The does have a high predictive value for its presence in bone. The most reliable specimens are biopsies ofthe bone material.most reliable specimens are biopsies ofthe bone material.The best way to make a microbiologic diagnosis is with either The best way to make a microbiologic diagnosis is with either an open or a needle biopsy, but open biopsies are invasive, and an open or a needle biopsy, but open biopsies are invasive, and needle biopsies may be false-negative due to sampling errors.needle biopsies may be false-negative due to sampling errors.Culture swabs of grossly purulent material, curettage, or Culture swabs of grossly purulent material, curettage, or needle aspirates of the ulcer base can also be performed, needle aspirates of the ulcer base can also be performed, because bone infections are usually an extension of the soft because bone infections are usually an extension of the soft tissue infection.tissue infection.

TREATMENTTREATMENTIf osteomyelitis is suspected on clinical grounds, blood and fluid If osteomyelitis is suspected on clinical grounds, blood and fluid samples should be taken and then treatment should be started samples should be taken and then treatment should be started immediately without waiting for final confirmation of the immediately without waiting for final confirmation of the diagnosis.diagnosis.

Four important aspects for the management of the patientFour important aspects for the management of the patient1.1.Supportive treatment for pain and dehydrationSupportive treatment for pain and dehydration2.2.Splintage of the affected partSplintage of the affected part3.3. If the patient is a compromised host, an effort is made to If the patient is a compromised host, an effort is made to correct or reduce the host defect or defects. In particular, correct or reduce the host defect or defects. In particular, attention should be paid togood nutrition, to a smoking cessation attention should be paid togood nutrition, to a smoking cessation program, and to controlof specific diseases such as diabetes. program, and to controlof specific diseases such as diabetes. Thus, an attempt is made to improve the nutritional, medical, and Thus, an attempt is made to improve the nutritional, medical, and vascular statusof the patient and to provide optimal treatment of vascular statusof the patient and to provide optimal treatment of any underlying disease.any underlying disease.4. 4. Antimicrobial therapyAntimicrobial therapy5. 5. Surgical proceduresSurgical procedures

… … treatment (cont.)treatment (cont.)

NADE’S PrinciplesNADE’S Principles

1.1. an appropriate antibiotic will b effective before pus formationan appropriate antibiotic will b effective before pus formation

2.2. Antibiotics will not sterilize avascular tissues or abscess and Antibiotics will not sterilize avascular tissues or abscess and

such areas require surgical removalsuch areas require surgical removal

3.3. If such removal is effective, antibiotics should prevent there If such removal is effective, antibiotics should prevent there

reformation and therefore primary wound closure should be reformation and therefore primary wound closure should be

safe.safe.

4.4. Surgery should not further damage already ischeamic bone Surgery should not further damage already ischeamic bone

and soft tissue.and soft tissue.

5.5. Antibiotics should be continued after surgery.Antibiotics should be continued after surgery.

… … treatment (cont.)treatment (cont.)

ANTIMICROBIAL THERAPYANTIMICROBIAL THERAPY

Ideally, the treatment of osteomyelitis should be based on the results Ideally, the treatment of osteomyelitis should be based on the results of bone cultures. After culture specimens are obtained by means of a of bone cultures. After culture specimens are obtained by means of a bone biopsy or during débridement, a parenteral antimicrobial bone biopsy or during débridement, a parenteral antimicrobial regimen is begun to cover the clinically suspected pathogens. Once regimen is begun to cover the clinically suspected pathogens. Once the organism is identified, the treatment may be modified according the organism is identified, the treatment may be modified according to the sensitivity of the isolated microorganismsto the sensitivity of the isolated microorganisms

Length of therapy - The traditional duration of treatment in most Length of therapy - The traditional duration of treatment in most stages of osteomyelitis (Cierny-Mader Stages 1, 3, and 4) is four to stages of osteomyelitis (Cierny-Mader Stages 1, 3, and 4) is four to six weeks. The rationale for this duration is based on the observation six weeks. The rationale for this duration is based on the observation that revascularization of bone after débridement takes about four that revascularization of bone after débridement takes about four weeks.weeks.

Parenteral versus oral therapy - The decision to use oral rather than Parenteral versus oral therapy - The decision to use oral rather than parenteral antibiotics should be based on results regarding parenteral antibiotics should be based on results regarding microorganism sensitivity, patient compliance, infectious disease microorganism sensitivity, patient compliance, infectious disease consultation, and the surgeon’s experience. The drugs of proven consultation, and the surgeon’s experience. The drugs of proven efficacy in the oral treatment of osteomyelitis are clindamycin, efficacy in the oral treatment of osteomyelitis are clindamycin, rifampin, cotrimoxazole, and fluoroquinolonesrifampin, cotrimoxazole, and fluoroquinolones

The role of synergistic or combination antimicrobial therapy - Oral The role of synergistic or combination antimicrobial therapy - Oral rifampin is currently used as a combination drug in both parenteral rifampin is currently used as a combination drug in both parenteral and oral regimens for and oral regimens for Staphylococcus aureus infections. Rifampin Staphylococcus aureus infections. Rifampin kills intracellular organisms.kills intracellular organisms.

… … treatment (cont.)treatment (cont.)

ANTIMICROBIAL THERAPYANTIMICROBIAL THERAPY

Monitor patients on therapy - Even though the serum bactericidal Monitor patients on therapy - Even though the serum bactericidal activity has been associated with a favorable outcome in the activity has been associated with a favorable outcome in the treatment of hematogenous osteomyelitis in general, it is not treatment of hematogenous osteomyelitis in general, it is not necessary to follow serum bactericidal levels83 because most necessary to follow serum bactericidal levels83 because most treatment failures are probably due to a lack of adequate treatment failures are probably due to a lack of adequate surgical débridement rather than inadequate antibiotic efficacy.surgical débridement rather than inadequate antibiotic efficacy.

STAGE 1STAGE 1

Stage-1 osteomyelitis in adults is usually treated with antibiotics Stage-1 osteomyelitis in adults is usually treated with antibiotics and operativeintervention.and operativeintervention.appropriate parenteral antimicrobial therapy for four weeks, dated from the initiation of the appropriate parenteral antimicrobial therapy for four weeks, dated from the initiation of the

therapy or from the last therapy or from the last major operative débridementmajor operative débridement

Patient responds

Arrest

Medical management fails

Bone & soft tissue debridement & retreat as above

…treatment (cont.)

ANTIMICROBIAL THERAPY

STAGE 2In Stage-2 osteomyelitis shorter courses of antibiotics are usually needed

Debridement of cortex and soft tissue coverage

Appropriate antibiotic for 2 weeks

STAGE 3 & 4

Patients with Stage-3 or 4 osteomyelitis are treated with antimicrobial therapy for four to six weeks, dated from the last major débridement. Without adequate débridement,the failure rate is high regardless of the duration of therapy. Even when all necrotic tissue has been adequately débrided, the remaining bed of tissue must be considered contaminated with the responsible pathogen or pathogens. Therefore, it is important to treat the patient with antibiotics for at least four weeks. The arrest rate is about 98% in A hosts and 80% (forStage 4) to 92% (for Stage 3) in B hosts.

Treatment algorithm of Cierny-Treatment algorithm of Cierny-Mader Stages-3 and 4 long-bone Mader Stages-3 and 4 long-bone

osteomyelitisosteomyelitis..

… …treatment (cont.)treatment (cont.)

SUPPRESSIVE ANTIBIOTIC THERAPYSUPPRESSIVE ANTIBIOTIC THERAPYo When operative treatment of osteomyelitis is not feasible, When operative treatment of osteomyelitis is not feasible,

suppressive antibiotic therapy, usually administered orally, is suppressive antibiotic therapy, usually administered orally, is usually given to control the disease and to prevent flare-ups.usually given to control the disease and to prevent flare-ups.

o Ideal drugs for suppression must possess good Ideal drugs for suppression must possess good bioavailability,have low toxicity, and be able to penetrate bone bioavailability,have low toxicity, and be able to penetrate bone adequately.adequately.

o The suppressive regimen should be directed by the results of The suppressive regimen should be directed by the results of cultures.cultures.

o Suppressive therapy is traditionally administered for six months. Suppressive therapy is traditionally administered for six months. If the infection recurs after discontinuation of the therapy, a new, If the infection recurs after discontinuation of the therapy, a new, lifelong suppressive regimen is begun.lifelong suppressive regimen is begun.

Suppressive therapy for infections around orthopaedic implants Suppressive therapy for infections around orthopaedic implants has been studied extensively. Rifampin (in combination with other has been studied extensively. Rifampin (in combination with other antibiotics), fusidic acid, ofloxacin, and cotrimoxazole have been antibiotics), fusidic acid, ofloxacin, and cotrimoxazole have been administered, for six to nine months, to patients with infections administered, for six to nine months, to patients with infections around implants.around implants.

……treatment (cont.)treatment (cont.)

S U R G I C A L M A N A G E M E N TS U R G I C A L M A N A G E M E N TGeneral principles of surgical therapy includeGeneral principles of surgical therapy include

1.1. To remove dead , devitalized and infected bone To remove dead , devitalized and infected bone

2.2. To obliterate any dead space left after debridementTo obliterate any dead space left after debridement

3.3. To obtain soft tissue coverage of exposed boneTo obtain soft tissue coverage of exposed bone

Surgery to be undertaken only whenSurgery to be undertaken only when – –

1 .Signs and symptoms of acute infection have subsided1 .Signs and symptoms of acute infection have subsided

2 . Living bone can be distinguished from dead bone (Sequestra has 2 . Living bone can be distinguished from dead bone (Sequestra has separated)separated)

3 .When sufficient involucrum has formed to maintain length and 3 .When sufficient involucrum has formed to maintain length and contour of the bone contour of the bone

BONE DEBRIDEMENTBONE DEBRIDEMENT

The goal of débridement is to leave healthy, viable tissue.The goal of débridement is to leave healthy, viable tissue.

Débridement of bone is done until punctate bleeding is noted, Débridement of bone is done until punctate bleeding is noted,

giving rise to the term giving rise to the term the the paprika signpaprika sign. However, even when . However, even when

all necrotic tissue has been adequately débrided, the remaining all necrotic tissue has been adequately débrided, the remaining

bed of tissue must still be considered contaminated. bed of tissue must still be considered contaminated.

The extent of operative débridement - B hosts treated with The extent of operative débridement - B hosts treated with

marginal resection (i.e., with a clearance margin of <5 mm) had marginal resection (i.e., with a clearance margin of <5 mm) had

a higher rate of recurrence than did normal hosts. The extent of a higher rate of recurrence than did normal hosts. The extent of

resection therefore appears to be much more important in B resection therefore appears to be much more important in B

hosts, whereas a marginal resection may be acceptable in hosts, whereas a marginal resection may be acceptable in

normal hosts.normal hosts.

…Bone DebridementTreatment contd.

Procedure

☞ Surgery is done under tourniquet

☞ Infected areas of bone are exposed

☞ Sinus tracts are excised

☞ The periosteum is incised and elevated. Limited elevation

of periosteum is done so as to permit a required

cortical window at the diseased site. Use of subperiosteal

bone levers/ periosteum elevator is undesirable

☞ Cortical window at the appropriate site is marked with a

drill and opened with an osteotome

…Bone debridement

☞ All the Sequestra , purulent material ,scarred and necrotic tissue

are excised

☞ If sclerotic bone seals the ends of the cavity within the medullary

canal , this is opened in both directions. It allows blood vessels

to grow into the cavity

☞ Overhanging edges of bone are carefully excised to avoid leaving

a cavity or dead space and convert the deep cavity into a

superficial saucer like cavity

☞ Tourniquet is removed so as to see oozing bone all around

☞ Sclerosed ,nonviable bone if any is also removed

…Bone Debridement

There are few sites where radical excisionradical excision can easily be done by excision of a segment of whole bone and radical excision does not have any residual appreciable functional or cosmetic defect

Such sites are :

•upper 3/4th of fibula•ribs•clavicle•Metacarpals/metatarsals•tarsal bones•scapula

Obliteration of dead space:

Adequate debridement often leaves a large dead space that must be managed to prevent recurrence and significant bone loss that may result in bony instability. Appropriate reconstruction of both the bones and soft tissue defect may be needed

.)

Various methods to obliterate the dead space so left are

☞ surrounding soft tissue ☞ local muscle flap ☞ vascularized muscle pedicle flap ☞ microvascular free tissue transfer

which may be of three types . osseous free flaps . osteocutaneous free flaps . myocutaneous free flaps

☞ Autogenous cancellous bone graft ☞ PMMA antibiotic bead chain ☞ Biodegradable substances impregnated with antibiotics ☞ free fibular grafts ☞ bone transport by Ilizarov

.)

Soft tissue coverageSoft tissue coverage

. Primary wound closure

. If the soft tissue conditions do not permit primary closure, the most favoured and acceptable method consist of delayed closure after 4-7 days, when the wound looks healthy ,and there is no collection of purulent material at the depth of wound . The success of such secondary closure depends on

1 rapid and complete conrol of subjacent bone infection

2 presence of healthy vascular granulating surfaces on the sides and

depth of wound and

3 anatomical configuration of the wound which permits the wound

surfaces to be brought together without excessive tension

.)

When secondary closure is not possible options available to the surgeon are

1 Initial split thickness graft so as to obtain complete closure of the wound : The

disadvantage of this procedure is that it leaves an unstable scar specially if grafts are

placed on exposed bone but such scars mature in course of time . The advantages are

: It is simple ,safe and can be done by any surgeon . As such, wherever feasible ,it is

most commonly employed method

2 Where collaboration with a plastic surgeon colleague is available and the patient can

afford prolonged and expensive treatment ,following options are available

1.Full thickness rotation flaps

2. Cross limb flaps

3.Free flap

4. Muscle pedicle graft5. Bone graft to fill up bone cavities combined with subsequent full thickness skin flaps 6.Use of Ilizarov techniques where major gaps are left in a bone and bone transport is required to fill bone gap

All the three objectives can be All the three objectives can be achieved as:achieved as:

A single stage procedureA single stage procedure Two Stage procedure- Two Stage procedure- The Belfast The Belfast

Technique (McNally et al)Technique (McNally et al)

Three Stage Procedure-Three Stage Procedure- The Pappineau’s The Pappineau’s TechniqueTechnique

The Belfast TechinqueThe Belfast Techinque

Two stage procedureTwo stage procedure

Radical debridmentRadical debridment Delayed autogenous bone Delayed autogenous bone

grafting when necessary grafting when necessary

Pappineau’s method:

This is a three stage operation :1.Excision of infected tissue with or without

stabilization( external fixator/intramedullary nail

2.Autogenous cancellous bone graft

3.Skin closure

chronic osteomyelitis(contd.)

Treatment contd

Principles(Pappineau’s technique)

Granulation tissue markedly resists infectionAutogenous cancellous bone graft are resistant to infection and are rapidly revascularized

Infected area is completely excised

Adequate drainage is provided

Adequate stabilization is provided

Antibiotics are used for prolonged period

.)

Pappineau’s method continued

Stage 1 : Radical debridement with or without stabilization and pack the wound open

with dressings soaked in antibiotics . First dressing after 4 to 5 days then daily .Excise

infected tissue as necessary and delay second stage till signs of infection have

disappeared and healthy granulation tissue is present throughout

Stage 2 : Bone grafting … strips of autogenous cancellous bone are packed in

concentric and overlapping layers till cavity is overfull . Again pack the wound open with

dressing soaked in antibiotic . First dressing between 3rd to 5th day . Replace any graft

that adheres to dressing. Continue dressing until the graft stabilize. Muscle pedicle graft

to enhance the blood supply may also be done along with .

Stage 3 : Wound coverage : if spontaneous epithelisation do not provide adequate

wound coverage this can be provided by secondary wound closure ,skin grafts,

myocutaneous flaps , muscle pedicle flaps and free flaps

.)

PMMA Antibiotic bead chain technique::

The rationale for this treatment is to deliver levels of antibiotics

locally in concentrations that exhibit the minimal inhibitory concentrations .Local concentrations of antibiotic achieved are up to 200 times higher than levels achieved with systemic administration. This has the advantage of obtaining very high local antibiotic concentrations while maintaining low serum levels and low systemic toxicity

High concentration of antibiotic can be achieved only with primary wound closure ;if such closure cannot be performed, the wound can be covered with a water impermeable dressing (bead pouch technique)

.)

Biodegradable antibiotic delivery system (Osteoset Reabsorbable Bead kit,Wright Med. Technologies)

Various biodegradable antibiotic system have been evaluated . The advantage of these is, that a second procedure to remove the implants is not required . Furthermore these substances act as an osteoconductive bone graft substitute as well as deliver antibiotics locally like PMMA beads and gets reabsorbed in about 8 weeks after surgery

.)

Closed suction drainage ..

To deliver antibiotic locally at higher concentration ,Surgeons ( Hashmi et al ),have recommended closed irrigation by antibiotic solution and continuous suction of irrigated fluid . However secondary contamination and infection with new organism may occur and therefore most surgeons have abandoned this method

Hyperbaric Oxygen therapy

Hyperbaric oxygen therapy has been recommended for

treatment of chronic osteomyelitis but has not proved to be effective

in isolation .It can be used as adjuvant to traditional methods of

treatment

.)

Amputation .

is reserved only for those extreme cases of chronic osteomyelitis where:

1. persistence of severe pus pouring infection of very long duration , not responding to multiple operative interventions

2 . systemic complication like amyloidosis / CRF3 . infection associated with extensive deformation of

neighboring joints and low socioeconomic status of the patient / high risk patients who cannot afford / tolerate multiple surgeries

4 . chronic osteomyelitis associated with vascular complications

5 . chronic osteomyelitis with epithelioma

INFECTED IMPLANTSINFECTED IMPLANTSThe absolute number of patients with implant-associated The absolute number of patients with implant-associated infections is on the rise due to the lifelong risk for bacterial seeding infections is on the rise due to the lifelong risk for bacterial seeding on the implant.on the implant.Infections associated with prosthetic joints occur less frequently Infections associated with prosthetic joints occur less frequently than aseptic failures, but represent the most devastating than aseptic failures, but represent the most devastating complication with high morbidity and substantial cost . complication with high morbidity and substantial cost . In patients with primary hip replacement, the infection rate during In patients with primary hip replacement, the infection rate during the first 2 years is usually less than 1%, and in those with knee the first 2 years is usually less than 1%, and in those with knee replacement less than 2%. replacement less than 2%. Infection rates after revision surgery are usually considerably Infection rates after revision surgery are usually considerably higher (40%) than after primary replacement higher (40%) than after primary replacement About 5% of internal fixation devices become infected . The About 5% of internal fixation devices become infected . The incidence of infection after internal fixation of closed fractures is incidence of infection after internal fixation of closed fractures is generally lower (2%), whereas the incidence may exceed 30% after generally lower (2%), whereas the incidence may exceed 30% after fixation of open fractures fixation of open fractures

INFECTED IMPLANTSINFECTED IMPLANTS The pathogenesis of implant-associated infection involves interaction between The pathogenesis of implant-associated infection involves interaction between

microorganisms, the implant and the host microorganisms, the implant and the host

The foreign implant is both a predisposing factor and an important element in its The foreign implant is both a predisposing factor and an important element in its

persistence. persistence.

Bacteria as well as human tissue cells have an affinity for the molecules on the Bacteria as well as human tissue cells have an affinity for the molecules on the

surface of implant. Both compete for occupancy on the same surface – tissue cells surface of implant. Both compete for occupancy on the same surface – tissue cells

by adaptation and integration; bacteria by adhesion and colonization. This contest by adaptation and integration; bacteria by adhesion and colonization. This contest

has been aptly called the has been aptly called the race for the surface. race for the surface. If the tissue cells win, implant is If the tissue cells win, implant is

incorporated, if bacteria win the resultant infection usually persists until the implant is incorporated, if bacteria win the resultant infection usually persists until the implant is

removed.removed.

Implant-associated infections are typically caused by microorganisms growing in Implant-associated infections are typically caused by microorganisms growing in

structures, known as biofilms . As orthopaedic implants and materials are structures, known as biofilms . As orthopaedic implants and materials are

increasingly moving towards minimizing the immune response they are becoming increasingly moving towards minimizing the immune response they are becoming

more and more inert and hence susceptible to bacterial adhesion and colonization,more and more inert and hence susceptible to bacterial adhesion and colonization,

CLASSIFICATION OF PERIPROSTHETIC INFECTIONSCLASSIFICATION OF PERIPROSTHETIC INFECTIONS1.1. Positive Intraoperative Cultures – Two or more positive cultures from the Positive Intraoperative Cultures – Two or more positive cultures from the

surgical site. surgical site. Treatment - appropriate parentral antibiotics for 6 weeksTreatment - appropriate parentral antibiotics for 6 weeks

2.2. Early Postoperative Infection – Infection occurs within first month after Early Postoperative Infection – Infection occurs within first month after arthroplasty. Clinically apparent wound infections or infections of hematomas that arthroplasty. Clinically apparent wound infections or infections of hematomas that have progressed to deep infectionshave progressed to deep infections

Treatment - debridement, exchange of the polyethylene liners, retention of the Treatment - debridement, exchange of the polyethylene liners, retention of the components, and intravenous administration of antibiotics for 4 weeks.components, and intravenous administration of antibiotics for 4 weeks.

3.3. Late Chronic Infection - infection is apparent more than 1 month after the operation Late Chronic Infection - infection is apparent more than 1 month after the operation and has an insidious clinical onset . and has an insidious clinical onset . Typically, patients have never had a pain-Typically, patients have never had a pain-free interval after the operationfree interval after the operation

Treatment - Treatment - debridement, removal of the components, and appropriate debridement, removal of the components, and appropriate antibiotics for 4 to 6 weeks. This may be followed by implantation of a new antibiotics for 4 to 6 weeks. This may be followed by implantation of a new prosthesis after the patient has been free of infection.prosthesis after the patient has been free of infection.

4. Acute Hematogenous Infection - The acute infection is characterized by the 4. Acute Hematogenous Infection - The acute infection is characterized by the precipitous onset of clinical symptoms in a previously well-functioning hip.precipitous onset of clinical symptoms in a previously well-functioning hip.

Treatment - If the prosthesis is well fixed, treat the infection in the same manner as for an Treatment - If the prosthesis is well fixed, treat the infection in the same manner as for an early postoperative infection; if the prosthesis is loose, treatment should be the same early postoperative infection; if the prosthesis is loose, treatment should be the same as for a late chronic infection.as for a late chronic infection.

Infections in internal fixation devicesInfections in internal fixation devices A patient with an infected internal fixation device usually has A patient with an infected internal fixation device usually has increasing or new onset of pain that may be located at the implant increasing or new onset of pain that may be located at the implant insertion site or at the fracture site. The pain is often described as dull insertion site or at the fracture site. The pain is often described as dull and deep within the extremity and exacerbated by activity. and deep within the extremity and exacerbated by activity. Local signs may include cellulitis, abscess formation, and wound Local signs may include cellulitis, abscess formation, and wound drainage. drainage. Constitutional symptoms include fever, chills, night sweats, Constitutional symptoms include fever, chills, night sweats, tachycardia, and anemia. tachycardia, and anemia. Past medical history may reveal risk factors such as cigarette Past medical history may reveal risk factors such as cigarette smoking, diabetes, alcohol abuse, previous open fracture, or previously smoking, diabetes, alcohol abuse, previous open fracture, or previously draining wound draining wound Several recent studies have shown a high infection rate in patients Several recent studies have shown a high infection rate in patients undergoing delayed intramedullary fixation following external fixation, undergoing delayed intramedullary fixation following external fixation, particularly if there has been an infected pin site .particularly if there has been an infected pin site .

The method of treatment of infection after internal fixation is based upon:

The time of onset after internal fixation (Early/Late)

The status of fracture healing.

The stability of the implants and fracture.

The extent of radiographic bone involvement.

The type and virulence of the organism.

The patients general condition and health

Obtain radiographs as soon as the diagnosis is suspected to assess the stability

of the fixation construct. Radiolucency around the fixation devices suggests loose

hardware. Assess fracture healing as well. Do not confuse periosteal reaction

from the infection with fracture callus Plain tomography may assist in the

assessment of fracture healing. Finally, classic signs of osteomyelitis with

involucrum or sequestrum may be present

a 46-year-old man with chronic osteomyelitis. The a 46-year-old man with chronic osteomyelitis. The patient was treated with debridement followed by patient was treated with debridement followed by

insertion of aminoglycoside-impregnated insertion of aminoglycoside-impregnated

methylmethacrylate beads and a local muscle flap.methylmethacrylate beads and a local muscle flap.

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