General Information
• Osteomyelitis is an infection of the bone tissue.
• It can develop primarily as a result of direct inoculation of microorganisms into the bone as a result of trauma or surgical procedure, or as a secondary hematogenous route through direct spread from the surrounding soft tissues and joints.
• Acute hematogenous osteomyelitis is the most common form and usually affects children.
• It can be classified as acute-subacute-chronic.
Classification
Usually no leukocytosis
Erythrocyte sedimentation rate and C-reactive protein levels increased.
Soft tissue swelling occurs after 1-3 days on direct radiographs, but bone or periosteal damage may not be detected before 10-12 days. Septic arthritis, Ewing's sarcoma, osteosarcoma, juvenile arthritis, sickle cell crisis, Gaucher's disease and pathological fractures are included in the differential diagnosis.
Magnetic resonance imaging shows early inflammatory changes in bone marrow and soft tissue.
Technetium-99m bone scintigraphy is positive in 90-95% of patients. Being negative is used to exclude the diagnosis of acute osteomyelitis.
Subacute osteomyelitis:
The most common form of subacute hematogenous osteomyelitis is Brodie's abscess (Picture 9).
Sclerotic appearance surrounding the lytic bone tissue is observed.
It develops after bacteremia from an infection focus in the body.
It is a localized form of osteomyelitis involving the long bones of the lower extremities, more commonly in young adults.
It can be confused with tumor radiologically. A biopsy may be required for definitive diagnosis.
Chronic osteomyelitis
Clinically It is characterized by infected dead bone tissue (sequestrum) and surrounding soft tissue (involucrum). There is sclerotic avascular bone tissue and scarred muscle and subcutaneous tissue around the infected focus.
Pathological feature of chronic osteomyelitis; In the necrotic bone area, it is in the form of new bone formation and mononuclear cell infiltration consisting mainly of lymphocytes, histiocytes and plasma cells.
Over time, it can perforate the soft tissue and open to the skin surface and create a sinus tract.
Chronic osteomyelitis of long bones can occur due to open and comminuted fractures, inadequately treated fractures and internal fixator devices.
Systemic symptoms such as fever and pain are often absent.
The gold standard is obtained by histological examination with biopsy and microbiological examination by culture.
Increase in C-reactive protein and sedimentation can be seen. Leukocytosis was detected in only 35% of the cases. There is no technique that can fully demonstrate the presence or absence of chronic osteomyelitis. Direct radiographs should be the first examination to be requested.
Computed tomography gives very good results on cortical bone, but its efficiency decreases in soft tissue. Magnetic resonance imaging gives better results in soft tissue.
Although the treatment varies according to each patient, surgical debridement and then antibiotic treatment are recommended. Classically, 6 weeks of antibiotic therapy is recommended.
Garre's sclerosing osteomyelitis; A chronic form of osteomyelitis in which the bone appears thick and enlarged without abscess or sequestration:
- It is more common in children and young adults.
- The main complaint is temporary, but long-lasting and moderate pain. Swelling and tenderness may be detected.
- Radiologically, bone enlargement and an increase in sclerosis are seen.
- In the differential diagnosis, osteoid osteoma and Paget's disease should be considered.
Clinic
• Pain, fever, weakness and limitation of movement may be observed in the bone and adjacent joint.
• Osteomyelitis in adults is usually subacute or chronic, with vague symptoms.
• Complications that can be seen in osteomyelitis: Septic arthritis (most often in the hip joint) Sarcoma in the infected bone (osteosarcoma and malignant fibrosis histiocytoma may develop) Squamous cell carcinoma in the sinus tract Sepsis, bacteremia Reactive amyloidosis Short growth, deformity, pathological fracture Endocarditis
Diagnosis
Lab
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are generally increased.
Microbiology
S. aureus is the most isolated microorganism, especially in acute hematogenous osteomyelitis.
Patients with sickle cell anemia have an increase in Salmonella osteomyelitis; however, the most common agent is again S. aureus.
Pseudomonas aeruginosa is the most common cause of intravenous drug users.
Group B streptococci are the most frequently isolated organisms in infants aged 2-4 weeks without any other health problems.
Treatment
• Cleaning of necrotic tissues
• Filling dead spaces
• Long-term effective antibiotic therapy
• Hyperbaric oxygen therapy