Osteomyelitis Reşat ÖZARAS, MD, Prof. Infection Dept.

OSTEOMYELITIS Infection of bone marrow and and adjacent bone Several classifications

The duration of the disease Acute osteomyelitis Subacute osteomyelitis Chronic osteomyelitis

The way of occurence 1 - Hematogenous osteomyelitis 2 – Osteomyelitis secondary to direct transmission - Any vascular disease may/not associate 3 - Chronic osteomyelitis (necrotic bone)

Anatomical classification Stage 1: medullary osteomyelitis Stage 2: superficial osteomyelitis Stage 3: localized osteomyelitis Stage 4: diffuse osteomyelitis

SYSTEMIC AND LOCAL FACTORS Systemic Local Malnutrition Chronic lymphedema Renal, hepatic failure Venous failure Diabetes mellitus Vascular insufficiency Chronic hipoxia Arteritis Alcohol and/or tobacco use Tissue scar Malignant disorders Radiation fibrosis Advanced age Neuropathy Immune suppression HIV/AIDS

ETIOLOGY Babies (<1 year) Group B streptococci S. aureus E. coli Children ( years) S. aureus S. pyogenes H. influenzae Adult(> 16 years) S. epidermidis S. aureus P. aeruginosa

EPIDEMIOLOGY Acute hematogenous osteomyelitis: a disorder of childhood period A trend to increase: traffic accidents, increasing rates of orthopedic interventions. Adults– Vertebtal osteomyelitis (Spondylodiscitis)

CLINICAL FEATURES Acute Hematogenous Osteomyelitis - Systemic disorder - No structural bone changes - A history of less than 10 days - No previous episodes Subacute Hemotogenous Osteomyelitis -Systemic disorder (not as severe as the acute form) -Bone changes -A history of more than 10 days - No previous episodes Chronic osteomyelitis -Systemic disorder may/not associate -Bone changes - There is/are previous episode(s).

Clinical Features Depends on the way of development (hematogenous, direct, from adjacent tissues), patient's characteristics and the period of the disorder Hematogenous osteomyelitis – fever, fatigue, restlessness – Tenderness, pain, and edema on the affected site – Decreased mobility of the affected extremity – Muscle spasms

From adjacent tissue; pain, redness, swellings, a draining sinus from the site of trauma, wound, or operation Dorsal/back pain in vertebral osteomyelitis.

RADIOLOGICAL FINDINGS Plain X-ray; Diagnosis and the course of the disease Increase in density of the surrounding soft tissues (first 10 days) Periostal reaction (after 10 days) Bone loss in subacute period

Bone scan For early diagnosis

Computed tomography Sentitive for soft tissue inflammation as well. Diagnosis and follow-up of the therapy

Magnetic Resonance Soft tissue and bone marrow inflammation Early diagnosis

Differential Diagnosis Rheumatic fever Cellulitis Ewing’s sacroma Septic arthritis Osteosarcoma Eosinophilic granuloma Thrombophlebitis

Vertebral Osteomyelitis Frequent etiology: – S. aureus, – M. tuberculosis, – Brucella Gram-negative bacilli (Gastrointestinal or urinary system) Postoperative Pain and disability May be indolent and fever may not be seen

Tx Antibiotics Surgery Underlying disorder

Meticilin-sensitive Staph. → Cefazolin or Sulbactam/ampicillin Meticilin-resistant Staph →Vancomycin or teicoplanin Brucella → Rifampin+doxycycline Tuberculosis → INH+RIF+PZA+EMB Antibiotics

Etiology N (%) Pyogenic44 Post-op10 Others34 Brucella24 Tuberculosis32 Total100

Pyogenic MicroorganismCases (%) Gram-positive Staphylococcus aureus (endocarditis) Gram-negative Pseudomonas aeruginosa Enterobacter cloacae Salmonella enteritidis Escherichia coli Fungus

Children: Acute hematogenous Adult: Chronic (hematogenous---from adjacent tissues…