Reey8t.b. Osteomyelitis

8/13/2019 Reey8t.b. Osteomyelitis

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Chronic Osteomyelitis

Factors responsible for chronicity Local factors: Cavity, Sequestrum, Sinus,

Foreign body, Degree of bone necrosis General:Nutritional status of the involved

tissues, vascular disease, DM, low immunity

Organism:Virulence Treatment:Appropriateness and compliance

Risk factors:Penetrating trauma, prosthesis,

Animal bite


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Types

A complication of acute Osteomyelitis

Post traumatic

Post operative


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Clinical picture

Continuous or intermittent suppuration and

sinus formation with acute exacerbations.

Pain, fever, redness, and tenderness

during acute exacerbations.

Discharging sinus with +ve/-ve culture.

Pathological fracture.


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Investigation

Lab tests/ culture

Plain X-ray:

Bone rarefaction surrounded by the densesclerosis, sequestration and cavity formation

Sinogram

Bone scan & gallium scan

To detect chronic multifocal osteomyelitis

CT Scan & MRI

Biopsy


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Complications

Recurrence & Recurrence& Recurrence

Pathological fractures

Growth disturbance

Amyloid disease Epidermoid carcinoma of the fistula


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CHRONIC OSTEOMYELITIS Sequel of acute/open fracture/opt.

C/F: pain, discharging sinus, scars

Xray- bone resorption, sequestra,

CT/MRI: extent of bone loss, oedema,hidden abscess

Lab-raised ESR pus-cs


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TREATMENTAntibiotics.

Local treatment.

Operations.

After care.


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TUBERCULOSIS A surgeon could

gain experience in

the management ofTB. Of bone and

joint only if hechoose to work in

econmically lessdeveloped countries.(edit, Br.Med.J>1968)


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T.B. OSTEOMYELITIS 1/3 population infected.

Over 80,000 people in Nepal have TB.

22,000 develop Pul. TB every year.

Total 50,000.

10,000 die of TB. LEADING CAUSE OF DEATH.

1 3% skeletal TB


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TB Cause by Mycobacterium tuberculosis,

occasionally by M.bovis/africanum.

Also known as tubercle bacilli as theyproduce lesion tubercles.

Acid fast bacilli.

Transmission

airborne droplets. Risk- extent of exposure to droplets and

susceptibility to infection.


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TB Primary infection

Exposure to tubercle bacilli

Lungs

multiplication of bacilli in terminalalveoli (Ghon focus) lymphatic drain itto hilar lymph nodes (PRIMARYCOMPLEX) BLOOD SPREAD.


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TB C/F:Cough >3wks.,sputum production,

weight loss, monoarticular.

Respiratory

haemoptysis, chest pain,breathlesness.

Constitutional:fever/night sweat ,

tiredness , loss of appetite. Physical sign: non specific,muscle

wasting, loss of ROM


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TB 3 days sputum.

Ziehl-Neelsen stain.

X-ray: cavitation, infilteration,lymphadenopathy.

Full blood count:Relative lymphocytosis,^ESR,Anemia.

Serology. Lymphnode biopsy.

CT/ MRI


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BONE TUBERCULOSIS Spread from primary complex to any

bone/joints.

Can effect any bone but the weightbearing bones are more likely to beaffected.

Spine

commonest, hip, knee , foot.


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STAGES OF ARTICULAR TB 1 SYNOVITIS. 2 EARLY ARTHRITIS.

3 ADVANCED ARTHRITIS.

4 ADV.ART. PATHOLOGICAL DISLOCATION /SUBLUXATION.

5 AFTER MATH TERMINAL OF GROSS ARTHRITIS.


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STAGES C/F XRAY PROGNOSIS

1 synovitis ROM>75% SOFT TISSUE SWELLING,OSTEOPOROSIS

NEAR NORMAL

2 earlyarthritis

ROM50-75% JT.SPACE DIMINITION ANDMARGINAL EROSION

RESTORATIONUPTO 75%

3 Adv.arthritis

ROM >75%ALL

DIRECTION

DESTRUCTION OF JT.SURFACE

ANKYLOSIS

4Adv. Arthpath/disln

DO DISORGANISE JT.DIS/SUB.LOCATION

ANKYLOSIS

5

Aftermath

GROSS

DEFORMITY

DEFORMED JT. , OA ANKYLOSIS


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TB - TYPES Caseous exudative-

more destruction,

exudation & abscessformation.Symptoms moremarked.

Onset is lessinsidious.

Granular type lessdestructive. Abscess

formation rare. Drylesion.adults


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TUBERCULOSIS

Spine is the mostcommon site of skeletal

TB


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TUBERCULOSIS

Pathology Blood borne - settles

in vertebral body

anteriorly usually more bone

destruction, moresequestra, larger

abscess, gaseouspus than pyogenicOM

intervertebral discspreserved until late

disease


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TB SPINE -Classification 1- pre-destructive

2- early destructive.

3- mild angular kyphos.

4- moderate angular kyphos.

5- severe kyphos (humpback)


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STAGES

1 & 2 Predestructive

straightening of

curvatures , spasmof perivertebralmuscles, MRI-marrow oedema.

Early destructive Diminished disk

space and paradiscalerosion.MRI-marrowoedema and breakof osseous

margin.CT-marginalerosion /cavitaion


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STAGE 3,4&5 Body

destruction with Kyphos

Mild 2-3 vertebra Kyphosis

10-30*

moderate >3 body 30-60*

severe >3 body >60*


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TB SPINE

D/DAGE- anomalies.

Infection.

Tumour.

Traumma.

Osteoporosis ,Osteochondrosis. Spondylolisthesis.


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TB SPINE C/F:Back pain of variable duration, fever and

weight loss.

O/E: local tenderness, spasm, mild kyphosis-late Gibbus, cold abscess and paraparesis.

DIAGNOSIS: XRAY-erosion of the anterioredges of the superior and inferior boarders of

adjacent vertebral bodies with narrowing ofdisc space.

USG :paravertebral abscess.

Biopsy/ CT scan


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TB HIP C/F: pain/limping, irritable hip child. Gradual

loss of range of movement, flexion deformity,

wasting of thigh muscles. Xray: both hip to compare.Early changes

rarefaction of the bone and widening of thejoint space, later destruction of the joint.

Synovial bioposy.


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TB KNEE / ANKLE.

C/F: pain and synovial swelling, musclewasting., contracture, draining sinuses.

X-ray.

Synovial biopsy.


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PRINCIPLES OF

MANAGEMENT OF TB General.

Rest, mobilization & brace.

Abscess, effusion & sinuses.

Antitubercular drugs.

surgery


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TB PROBLEMS Diagnosis.

Treatment .

Anti tuberculous drugs.


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Tuberculous lesion Resolve completely.

Complete healing with varying degree of

deformity / loss of function. Lesion may be complete walled off and the

caseous tissue may calcified.

Persist as a low grade ch.fibromatous

granulating & caseating lesion. Infection may spread.

Damage growth centre with shortening.


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CONCLUSION Slow progressive course of clinical symptoms

and radiological signs of tuberculosis creates

difficulty in early diagnosis. Anti tuberculous treatment is effective but the

functional outcome depends on earlydiagnosis before the development of

radiological evidence of joint destruction. Always keep TB in D?Diagnosis


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Thank you for not sleepingNow you can ask your questions

???


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Reey8t.b. Osteomyelitis

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