Osteomyelitis: Types, Treatment and Complications

Osteomyelitis is defined as infection and inflammation of bone and bone marrow. This is a painful bone infection that causes swelling, and bone damage and can lead to bone loss. Antibiotics play an important role in preventing the spread of infection from bone to the blood and if there is Abscess formation it needs to be drained or if the bone is severely damaged then there is a possibility that bone needs to be removed.

Types Of Osteomyelitis

According to Waldvogel's classification:

• Acute osteomyelitis (<2weeks duration)
• Subacute osteomyelitis (2 to 4 weeks duration)
• Chronic osteomyelitis (>4 weeks duration)

1. Acute Osteomyelitis

• It spreads hematogenously and is most common in children younger than five years of age.
• The most common sites involved are the proximal tibia, distal femur, and proximal femur.
• The most common Organism involved is Staphylococcus Aureus but in children below 4 years of age the most common organism involved is Hemophilus influenza.
• Pathophysiology- On the second or third day of infection pus starts developing and there is evidence of bone death by the end of the first week. There is the formation of new bone from deep layers of stripped periosteum by the end of the second week, it is called as periosteal reaction.
• Metaphysis is the most common part of bone affected in children and adults.
• Due to pain the child will not be able to lift or move the limb it is called pseudo paralysis.

Investigations

• X-ray is normal during the first 10 days and at the end of the second week, there is a new periosteal bone formation which is a classical X-ray sign of acute pyogenic osteomyelitis.
• The late X-ray signs will show a segment of high-density dead bone which indicates that acute is converted to chronic osteomyelitis.
• MRI is extremely sensitive even in the early phase.
• Aspiration of pus is the most specific diagnostic test to confirm the disease. 

Treatment

• First-line treatment is pain management, antibiotic therapy, splinting of the affected part, and surgical drainage of the pus if present.
• Flucloxacillin and fusidic acid are infused intravenously in older children and adults with Staphylococcus infection.
• Salmonella osteomyelitis is treated with cotrimoxazole.
• Streptococcal osteomyelitis is treated with benzylpenicillin.
• Full weight bearing is allowed only after four weeks.

Complications

• Septic arthritis
• Growth disturbances
• Chronic osteomyelitis

Also Read: De Quervain Tenosynovitis: Causes, Symptoms, Risk Factors, Diagnosis, Treatment and Complications

2. Subacute Osteomyelitis

It is a well-defined cavity in the cancellous bone and the causative agent is Staphylococcus aureus. The patient will not have a fever and the WBC count will be normal.

Types of Subacute Osteomyelitis

• Brodie’s Abscess – These are localized Abscess in the cancellous bone, In children it is present in the metaphyseal area whereas in adults it is present at the epiphyseal metaphyseal junction. The treatment is surgical drainage.
• Garre’s Osteomyelitis - There is no abscess cavity and it is called as dry osteomyelitis. Sclerosis can be seen in metaphysis or diaphysis. Upper Tibia is the most commonly involved site.
• Typhoid Osteomyelitis - It is also called salmonella osteomyelitis. The mode of spread is hematogenous and it is associated with sickle cell anemia. Treatment is surgical.

Also Read: Adult Still Disease: Causes, Symptoms, Risk Factors, Diagnosis, Treatment and Complications

3. Chronic Osteomyelitis

• Osteomyelitis persisting more than four weeks is called chronic osteomyelitis and the most common causing Organism is Staphylococcus aureus.
• If the patient is having any foreign body implant then the causative agent is Staphylococcus epidermidis or Staphylococcus albus.
• The patient will have a discharging sinus in which the pus comes out by breaking the skin via a sinus tract and there will be a classical waxing-waning pattern.
• Sequestrum or discharge of bone chips or fish bone-like material is very pathognomic for chronic osteomyelitis.
• There will be a deformity due to pathological fracture.
• On X-ray sequestrum will be seen as a radiopaque structure.

Investigations

• The first step for investigation is an X-ray. The X-ray will show a patchy loss of density and there will be loss of cortico-medullary differentiation. Sequestrum will appear on X-ray only after four to six weeks.
• A sinogram can be done to determine the sinus tract.
• CD scan plays a major role in the detection of sequestrate.
• MRI is most specific to diagnosing the extent of pathology in bone and soft tissue. 

Treatment

There are four major steps-

1. Radical debridement is done by Sequestrectomy and Saucerization. In this, there is the removal of infective bone. If the source of infection is implants, then these can be removed because these are sources of biofilm and the antibiotics can’t penetrate the biofilms.
2. The dead spaces formed after the debridement should be managed properly because these can act as a nidus for the recurrence of infection. Various methods for Dead Space management are Papineau-Rhiedlander’s technique, VAC therapy, and Ilizarov technique.
3. Soft tissue coverage should be done by muscle slaps and skin grafting.
4. Antibiotic therapy with intravenous nafcillin or cefazolin should be done. Methicillin-resistant Staphylococcus aureus should be treated with vancomycin.

Complications

• Acute exacerbation
• Growth disturbances
• Pathological fractures
• Epithelioma

Also Read: Bursitis: Causes, Symptoms, Risk Factors, Diagnosis, Treatment and Prevention

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