Osteomyelitis - Wheeless' Textbook of Orthopaedics

- Discussion:
- predisposing conditions:
- open fracture (traumatic tibia infections)
- sickle cell anemia
- septic arthritis
- in children, distinguishing between metaphyseal osteomyelitis and septic arthritis can be problematic;
- diabetes (see osteomyelitis in the diabetic patient);
- classification:
- hematogenous osteomyelitis;
- cierny classification
- chronic osteomyelitis
            - tibia fracture infection
            - vertebral osteomyelitis
- characteristics based on age:
- osteomyelitis in infants
- osteomyelitis in children
- references:
- Osteomyelitis in infants and children. Dich VQ, Nelson JD, Haltalin KC: Am J Dis Child 1975;129:1273.
- The changing epidemiology of osteomyelitis in children.
- Primary subacute epiphyseal osteomyelitis.
- Diaphyseal primary subacute osteomyelitis in children.
- Osteomyelitis of the calcaneus in children. WR Puffinbarger et al. J. Pediatric Orthopaedics. Vol 16. No 2. 1996. p 225.
                  - Occult epiphyseal bone abscess: lessons for the unwary.

- Labs:
- WBC, ESR, CRP;
- gram stain and culture:
- prior to giving antibiotics, it is essential that a gram stain and culture be collected;
- in hematogenous osteomyelitis, a bone aspirate is required which can usually be performed w/ a 16 or 18 gauge needle;
- in children, consider the need for open biopsy inorder to rule out tumor (such as EOG);
                - need to culture material from sinus track,purulent material, soft tissue, of bone obtained from curettage, andspecimens from the bed of involved bone;
          - gram stain diff dx:
- gram negative bacilli:
- gram negative cocci:
- gram positive bacilli:
- gram positive cocci
- references:
- Quantitative wound cultures in upper extremity trauma.
- Microbiologic flora contaminating open fractures: its significance in the choice of primary antibiotic agents and the likelihood of deep wound infection.
- Comparison of the results of bacterial cultures from multiple sites in ³ chronic osteomyelitis of long bones. A prospective study.
- The significance of perioperative cultures in open pediatric lower-extremity fractures.
- Accuracy of cultures from swabbing of superficial aspect of wound and needle bx in preop assessment of osteomyelitis. CR Perry JBJS Vol 73-A. 1991. p 745-749.
- Laboratory monitoring in pediatric acute osteomyelitis and septic arthritis.
                - Comparison of the results of bacterial cultures from multiple sites in chronic osteomyelitis of long bones. A prospective study
                - The limping child: evaluation and diagnosis.
                - Does aspiration of bones and joints affect results of later bone scanning?

- Radiographic Studies:
- x-ray manifestations
- MRI for osteomyelitis
- radioisotope scanning
- will be positive after 3 days of symptoms;
- never delay a bone aspirate inorder to avoid artifacts on bone scan;
- fluorine-18 fluorodeoxyglucose-positron emission tomography:
- FFPET is an accurate imaging technique which is more accurate than the combination of a bone scan and a white blood-cell scan for the diagnosis of
chronic infection of the spine;
- in the report by F. De Winter et al, the authors evaluated the value of fluorine-18 fluorodeoxyglucose-positron
emission tomography in the diagnosis of osteomyelitis;
- 60 patients with a suspected chronic musculoskeletal infection involving the central skeleton (33 patients) or the peripheral skeleton (27 patients) were studied;
- 35 patients had had surgery within the previous two years;
- 25 patients had infection and thirty-five did not - all 25 infections were correctly identified by both readers;
- 4 false-positive findings; in two of these cases, surgery had been performed less than 6 months prior to the study;
- sensitivity, specificity, and accuracy were 100%, 88%, and 93% for the whole group;
- 100%, 90%, and 94% for the subgroup of patients with a suspected infection of the central skeleton;
and 100%, 86%, and 93% for the subgroup of patients with a suspected infection of the peripheral skeleton;
- ref: Fluorine-18 Fluorodeoxyglucose-Positron Emission Tomography: A Highly Accurate Imaging Modality for the Diagnosis of Chronic Musculoskeletal Infections
F. De Winter, MD. JBJS (Am) 83:651-660 (2001)
- references:
- Does aspiration of bones and joints affect results of later bone scanning. Canale ST, Harkness RM, Thomas PA, et al: J Pediatr Orthop 1985;5:23.
- Diagnosis of infection in ununited fractures. Combined imaging with indium-111-labeled leukocytes and technetium-99m methylene diphosphonate.

- Traumatic Osteomyelitis:
- antibiotic beads:
- medications for osteomyelits
- criteria for oral antibiotics
- ATB treatment based on organism:
- references:
- Antimicrobial treatment of osteomyelitis.
- Long-term intravenous therapy with use of peripherally inserted silicone-elastomer catheters in orthopaedic patients.
- The penetration characteristics of cefazolin, cephalothin, and cephradine into bone in patients undergoing total hip replacement.
- Concentration of antibiotics in normal bone after intravenous injection. Benefits and risks of sequential parenteral--oral cephalosporin therapy
- Benefits and risks of sequential parenteral--oral cephalosporin therapy for suppurative bone and joint infections.
- Oral ciprofloxacin compared with parenteral antibiotics in the treatment of osteomyelitis.
- Oral ciprofloxacin treatment of Pseudomonas aeruginosa osteomyelitis.
- The transcapillary passage and interstitial fluid concentration of penicillin in canine bone.
- Penetration of cephalosporins into bone.
- Penetration of cefazolin into normal and osteomyelitic canine cortical bone.
- treatment based on location:
- spinal osteomyelitis;
- tibial osteomyelitis;
- femoral osteomyelitis following IM nailing:
- osteomyelitis of the foot
- debridement of sequestra:
- soft tissue coverage:
- The Muscle Flap in the Treatment of Chronic Lower Extremity Osteomyelitis: Results in Patients Over 5 Years After Treatment.
- The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment.
- Local muscle flaps in the treatment of chronic osteomyelitis.

- References for Osteomyelitis::

Osteomyelitis - Review - NEJM

Intracellular Staphylococcus aureus. A mechanism for the indolence of osteomyelitis.

In vivo internalization of Staphylococcus aureus by embryonic chick osteoblasts.

Internalization of Bacteria by Osteoblasts in a Patient with Recurrent, Long-Term Osteomyelitis.

Osteomyelitis and Intraosteoblastic. Staphylococcus aureus

Hematogenous osteomyelitis of the wrist in children.