History

Fact Explanation
Localized tenderness. [3],[6] Due to on going Inflammation. [3] Pain is due to the action of bradykinin and prostaglandins on local nerves. [5]
Pyrexia. [3],[6] It occurs during disease flare ups due to on going Inflammation. [3] The temperature set point of the hypothalamus is raised by the action of cytokines. [5]
Localized swelling. [3],[6] It occurs during disease flare ups due to on going Inflammation[3] as a result of increased capillary permeability [4], vasodilation [4] and accumulation of fluid in the tissue. [5]
Seropurulent discharge. [3],[6] Pus consists of necrotic tissue, dead neutrophils, dead macrophages and tissue fluid[2] and is discharged by perforation of the involucrum, thus leading to the formation of a sinus.[6]
Bony deformity. [3],[6] Due to prior trauma that may lead to post-traumatic osteomyelitis. [6]
Exposed bone. [3] Due to an open fracture resulting in inoculation by pathogenic organisms. [6]
Chronic wound. [3] May be due to an immunocompromised state, diabetic neuropathy [1] or peripheral vascular disease [6]. The wound may even be due to a squamous cell carcinoma at the discharging site of a sinus tract which may actually be a complication of chronic osteomyelitis. [6]
Discolored skin (necrotic tissue). [3] May be due to diabetic foot infection, peripheral vascular disease. [6]
Back pain. [3] Due to underlying medical conditions (eg.; diabetes mellitus, cancer, chronic renal disease, tuberculosis) or a history of intravenous drug use [7] leading to vertebral osteomyelitis. [3]
Joint pain (commonly of the hip and knee). [3],[6] May be due to septic arthritis (may be a complication of chronic osteomyelitis). [6]
Reduced range of movements in effected joint. [6] Due to pain and spasm of muscles surrounding the joint. [6]
Previous prosthetic implant. The prosthesis acts as a nidus for the growth of pathogenic organisms which may have been inoculated during the initial surgical procedure.
References
  1. ABDULRAZK ,Adel, et al. Bacteriological study of diabetic foot infections. Journal of Diabetes and its Complications[online]. May 2005.vol19(3).138–141[viewed 19 March 2014].Available from;http://www.jdcjournal.com/article/S1056-8727(04)00073-X/abstract
  2. GUYTON,Arthus C,John E HALL.Textbook of Medical Physiology.11th edi.Philodelphia.Elsevier;2006.
  3. HATZENBUEHLER,John,Thomas J PULLING.Diagnosis and managment of osteomyelitis;American family physician[online].American academy of family physicians.November 2011.vol.84(9).1027-1033[viewed 19 March 2014].Available from;http://www.aafp.org/afp/2011/1101/p1027.html
  4. KUMAR,Vinay,et al.Robbinand Cotran Pathological Basis of disease.7th ed.Philadelphia;Elsevier.2005
  5. MACCANCE,Kathryn E,et al.Pathophysiology The Biologic basis for disease in Adults andChildren.6th ed.New York;Elsevier.2009.
  6. SOLOMON,Louis,David WARWICK,Salvadurai NAYAGAM.Apley's system of Orthopaedics and Fractures.9th ed.London;Holder Arnold,2010.
  7.  ZIMMERLI, Werner. Vertebral osteomyelitis. N Engl J Med[online].Massachusetts Medical Society. March 2010.vol.362(11),1022–1029[viewed 19 March 2014]. Available from; http://www.nejm.org/doi/full/10.1056/NEJMcp0910753

Examination

Fact Explanation
Localized tenderness. [1],[5] During disease flare ups due to Inflammation and tissue injury. [1],[2]
Pyrexia. [1],[5] During disease flare ups due to inflammation. [1],[2] The temperature set point of the hypothalamus is raised by the action of cytokines.
Swelling in affected region. [1],[5] During disease flare ups due to ongoing inflammation [1],[2] as a result of increased capillary permeability, vasodilation and accumulation of fluid in the tissue.
Erythema in effected region. [1],[5] During disease flare ups due to inflammation. It is due to increased blood flow to the affected region. [1],[2]
Seropurulent discharge.[1],[3],[5] Due to infection and sinus formation. [5]
Reduced movements of the affected joint. [1],[3],[5] Mainly due to pain. [1],[3],[5]
Presence of ulcer. [1],[3] The ulcer may be due to an immunocompromised state, diabetic neuropathy or peripheral vascular disease. The wound may even be due to a squamous cell carcinoma at the discharging site of a sinus tract which may actually be a complication of chronic osteomyelitis.[1],[5] 1). Ischemic ulcer - Regular outline. Punched out clean edges. Bone may be exposed with no granulation tissue in the base. [4] 2). Neuropathic ulcer - Regular outline which follows the skin contour. Consists of clean edges, often with exposed bone at the base.[4] 3). Squamous cell carcinoma - rapid growth. Edges are raised and everted. May show the presence of local lymph node involvement. [4]
Gangrene. [1] 1).Wet gangrene - acute ischemia, local trauma or maybe complicated by infection. [4] 2).Dry gangrene- commonly see in diabetic patients. [4]
Absent peripheral pulses and cold limbs. [1] Due to peripheral vascular disease. [1]
Surgical scars. [1],[5] Due to previous surgery (prosthetic implantation). [1],[5]
Bone deformity. [1],[3],[5] Due to malunion, nonunion of old fractures. [1],[5]
Spinal deformity. [1] Gibbus formation in tuberculosis. [5]
References
  1. HATZENBUEHLER,John,Thomas J PULLING.Diagnosis and managment of osteomyelitis;American family physician[online].American academy of family physicians.November 2011.vol.84(9)1027-1033[viewed 19 March 2014].Available from;http://www.aafp.org/afp/2011/1101/p1027.html
  2. MACCANCE,Kathryn E,et al.Pathophysiology The Biologic basis for disease in Adults andChildren.6th ed.New York;Elsevier.2009.
  3. OBI,Ebube E,et al.Rapid Surgery.1st ed.Oxford;Blackwell Publishing Ltd.2005.
  4. RAMACHANDRAN,Manoj,Marc A GLADMAN,Clinical cases and OSCES in surgery,2nd ed,Edinburgh;Elsevier limited,2010.
  5. SOLOMON,Louis,David WARWICK,Salvadurai NAYAGAM.Apley's system of Orthopaedics and Fractures.9th ed.London;Holder Arnold,2010.
  6. ZIMMERLI, Werner. Vertebral osteomyelitis. N Engl J Med[online].Massachusetts Medical Society. March 2010.vol.362(11),1022–1029[viewed 19 March 2014]. Available from; http://www.nejm.org/doi/full/10.1056/NEJMcp0910753

Differential Diagnoses

Fact Explanation
Osteosarcoma. [1],[4] It will cause pain, swelling and reduced range of movements of the joint. Most commonly occurring in the region of the metaphysis of a long bone. [2],[4] X-ray findings - Codman's triangle and sunray appearance. [2],[4]
Ewing's sarcoma. [1],[4] It will cause pain, swelling, reduced range of movements of the joint and a raised Erythrocyte Sedimentation rate (ESR). [4] X-ray finding - onion peel appearance. [4]
Gout. [1],[4] Signs of inflammation will be present. [3],[4] It will cause hyperuricemia resulting in deposition of monosodium urate crystals in synovial fluid. [3],[4]
Inflammatory arthritis. [1] It will cause pain, swelling and reduced range of movements of the joint. [1]
Mycetoma. [5] It will cause localised swelling, ulceration, sinus formation and pus discharge. Cytology of fine needle aspirate or pus from the lesion and tissue biopsy will help to diagnose Mycetoma. [5]
References
  1. Osteomyelitis;Staford University Medical Media and Information Technologies,2003[ viewed 19 March 2014]available from;http://osteomyelitis.stanford.edu/pages/main.html
  2. OBI,Ebube E(et al).Rapid Surgery.1st ed.Oxford;Blackwell Publishing Ltd.2005.
  3. PITMAN,Joel R,et al.Diagnosis and managment of Gout;American family physician[online].American academy of family physicians.April 1999.vol.59(7).1799-1806[viewed 19 March].Available from; http://www.aafp.org/afp/1999/0401/p1799.html
  4. SOLOMON,Louis,David WARWICK,Salvadurai NAYAGAM.Apley's system of Orthopaedics and Fractures.9th ed.London;Holder Arnold,2010.
  5. WENDY W, J.,Van De SANDE.Global Burden of Human Mycetoma: A Systematic Review and Meta-analysis;PLoS Negl Trop Dis[online]. November 2013.vol7(11): e2550.[viewed 21 March].Available from;http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3820768/

Investigations - for Diagnosis

Fact Explanation
X-ray. [1],[3] Bone resorption either as a patchy loss of density or as frank excavation around an implant with thickening and sclerosis of the surrounding bone. [3]
Sinogram. [2] Useful in localising the site of infection. [3]
Radioisotope scintigraphy. [2] May detect increased activity in both the perfusion phase and the bone phase, Also useful to detect hidden foci of infection. [3]
Swabs from the wound discharge. [1],[2],[3] For organism culture and to check for antibiotic sensitivity. [2],[3]
Bone biopsy. [2] For organism culture and histopathology (will consist of necrotic tissue). [2]
Blood culture. [1],[2],[3] For the evidence of disseminated systemic infection. [2],[3]
Molecular techniques (Polymerase Chain Reaction). [3] It will increase the sensitivity of organism detection. [3]
References
  1. CIERNY,Gorge,et al,A clinical staging system for adult osteomyelitis,The Classic,Lippincott Williams and Wilkins,September 2003 vol,414,7-24.
  2. HATZENBUEHLER,John,Thomas J PULLING.Diagnosis and managment of osteomyelitis;American family physician[online].American academy of family physicians.November 2011.vol.84(9)1027-1033[ viewed 19 March 2014].Available from;http://www.aafp.org/afp/2011/1101/p1027.html
  3. SOLOMON,Louis,David WARWICK,Salvadurai NAYAGAM.Apley's system of Orthopaedics and Fractures.9th ed.London;Holder Arnold,2010.

Investigations - Fitness for Management

Fact Explanation
Full blood count. [1] Assessment of anemic status. (due to anemia of chronic disease , sickle cell anemia etc which may give rise to non-healing ulcers.)
Erythrocyte sedimentation rate (ESR). [1],[2],[3] It may be elevated in non-infectious forms of inflammation ( arthritis etc.). [3]
Serum protein electrophoresis. [1],[3] Useful to detect immunocompromised disease status. [1]
Total iron binding capacity. [1] To detect iron deficiency anemia. [1]
Liver function tests. [1] To detect liver disease. [1]
Fasting blood sugar level,Post prandial blood sugar level. [1] To detect Diabetes Mellitus. [1]
References
  1. CIERNY,Gorge,et al,A clinical staging system for adult osteomyelitis,The Classic,Lippincott Williams and Wilkins,September 2003 vol,414,7-24.
  2. HATZENBUEHLER,John,Thomas J PULLING.Diagnosis and managment of osteomyelitis;American family physician[online].American academy of family physicians.November 2011.vol.84(9)1027-1033[ viewed 19 March 2014].Available from;http://www.aafp.org/afp/2011/1101/p1027.html
  3. SOLOMON,Louis,David WARWICK,Salvadurai NAYAGAM.Apley's system of Orthopaedics and Fractures.9th ed.London;Holder Arnold,2010.

Investigations - Followup

Fact Explanation
Full blood count. [1],[2] To detect acute flares and to assess the progress of the disease. [2]
Erythrocyte sedimentation rate, C reactive protein. [1],[2] To detect acute flares and to assess the progression of the disease. [2]
X-ray. [1],[2] Assess the union and graft incorporation. [1]
Swab culture from the discharging sinus. [2] To check antibiotic sensitivity (organisms often change their characteristics). [2]
Fasting blood glucose level, Post prandial blood sugar level, HbA1C level. [2] Monitor control of diabetes melitus. [2]
Blood picture. [2],[3] To identify the etiology of the anemia (sickle cell, iron deficiency). [2],[3]
References
  1. HATZENBUEHLER,John,Thomas J PULLING.Diagnosis and managment of osteomyelitis;American family physician[online].American academy of family physicians.November 2011.vol.84(9)1027-1033[viewed 19 March 2014].Available from;http://www.aafp.org/afp/2011/1101/p1027.html
  2. SOLOMON,Louis,David WARWICK,Salvadurai NAYAGAM.Apley's system of Orthopaedics and Fractures.9th ed.London;Holder Arnold,2010.
  3. CIERNY,Gorge,et al,A clinical staging system for adult osteomyelitis,The Classic,Lippincott Williams and Wilkins,September 2003 vol,414,7-24.

Investigations - Screening/Staging

Fact Explanation
X-rays, Computerized Tomography (CT) scans (if indicated). [1],[2],[3] Useful in disease assessment in clinical staging. [1],[2],[3]
Arteriograms. [1] Useful in determining the exact anatomy and if microvascular reconstruction is planned. [1]
Technetium 99 (99mTc) bone scan and indium-111 chloride scan12 (whole body and pinhole analysis). [1] Useful to detect hidden foci of infection. [1],[3]
References
  1. CIERNY,Gorge,et al,A clinical staging system for adult osteomyelitis,The Classic,Lippincott Williams and Wilkins,September 2003 vol,414,7-24.
  2. HATZENBUEHLER,John,Thomas J PULLING.Diagnosis and managment of osteomyelitis;American family physician(online).American academy of family physicians.November 2011.vol.84(9)1027-1033( viewed 19 March 2014).Available from;http://www.aafp.org/afp/2011/1101/p1027.html
  3. SOLOMON,Louis,David WARWICK,Salvadurai NAYAGAM.Apley's system of Orthopaedics and Fractures.9th ed.London;Holder Arnold,2010.

Management - General Measures

Fact Explanation
Patient education [1] Cessation of smoking improves the outcome of treatment. Smoking constricts the blood vessels and reduces the available oxygen supply. [5]
Nutritional supplementation [1] : 1) Malnutrition 2) Alcohol use 3)Immune compromise 4) Renal/liver failure 5)Diabetes. Optimize the condition of the patient and improve the outcome of treatment.
Hyperbaric oxygen: used in advanced age, chronic hypoxia, arteritis, major vessel disease, extensive scarring, radiation fibrosis, extensive granulation beds. [1] It increases the oxygen transport capacity of the blood. Recent evidence notes that exposure to hyperbaric oxygen mobilizes stem/progenitor cells from the bone marrow by a nitric oxide (·NO)-dependent mechanism. This mechanism may support the recovery of damaged organs and tissues with hyperbaric oxygen. [2]
Methods of force distribution-physiotherapy. [1] To reduce the incidence of pressure sores in debilitated patients. [1]
Blood glucose control. [1],[4] Optimize the health status of diabetic patients. (Uncontrolled diabetes is a risk factor for peripheral vascular disease and complications such as gangrene, neuropathy etc.). [4]
Gamma-globulin therapy. [1] Optimize the health status of immunocompromized patients. [1],[3] (to maintain adequate antibody levels to prevent infections and confers a passive immunity [3])
Arterial bypass surgery. [1] Treatment for major vessel disease. [1],[4]
References
  1. CIERNY,Gorge,et al,A clinical staging system for adult osteomyelitis,The Classic,Lippincott Williams and Wilkins,September 2003 vol,414,7-24.
  2. ESKES,Anne M,et al.Hyperbaric Oxygen Therapy;Solution for difficult to heal acute wounds?Systemic review,World Journal of Surgery.[online].Springer.March 2011.vol35(3).535-542.[viewed 19 March 2014]Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3032900/
  3. HEMMING,Val G.Use of Intravenous Immunoglobulins for Prophylaxis or Treatment of Infectious Diseases.[online].Clinical and Diagnostic Lab Immunology. September 2001.vol8(5): 859–863[viewed 21 March2014]Available from;http://www.ncbi.nlm.nih.gov/pmc/articles/PMC96160/
  4. SOLOMON,Louis,David WARWICK,Salvadurai NAYAGAM.Apley's system of Orthopaedics and Fractures.9th ed.London;Holder Arnold,2010.
  5. THEADOM,Alice,Marck CROPLEY.Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review[online].Tob Control. Octomber 2006.vol 15(5). 352–358.[viewed 20 March 2014];Available from;http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563647/

Management - Specific Treatments

Fact Explanation
Antibiotic therapy. [3],[6],[7] Important in suppressing the infection and preventing its spread to healthy bone [7] and in controlling acute flares. [3],[7] Unless the patient is seriously ill, antibiotics are not started until the arrival of culture and antibiogram results. In the event of a severely compromised host, Ticarcillin, Cefazolin and Gentamicin are administered empirically . [3] This antibiotics regime is administered intravenously for 4-6 weeks and covers the most common isolates (Staphylococcus aureus, Pseudomonas aeruginosa and anaerobes). The antibiotics are modified by culture and antibiogram results. [3] Antibiotics are always administered in parallel to surgical management. [3] Long-term oral therapy with quinolones (ciprofloxacin and ofloxacin) can suppress the symptoms and signs of chronic refractory osteomyelitis. [5] Local administration of gentamicin in a collagen fleece following marginal surgical resection is a useful component in the management of chronic osteomyelitis.[4]
Local treatment. [3],[7] A sinus may need dressing to protect the clothing. [7] Colostomy paste may be used to prevent excoriation of the skin. [7] An acute abscess may need urgent incision and drainage. [7]
Surgical managment. [3],[6],[7] Indications for surgery are chronic hematogenous infections, failure of adequate antibiotic treatment, presence of foreign implant(s), clear evidence of a sequestrum or dead bone etc. [7] Steps of surgery 1) Debridement - the approach is direct and atraumatic. [3] 2) Wound is left open [3] (stent dressing) Exceptions: compromised hosts (Systemic); ankle, hand, spine; Type II lesions (primary soft tissue reconstruction and/or host alteration); minimal necrosis osteomyelitis 3) In second look: Dead space management [3],[7] : a. Open cancellous grafting (Papineau technique) - useful when a free tissue transfer is not a treatment option and local tissue flaps are inadequate. b.Primary closure with local tissue. c. Primary closure with transferred tissues. (An alternative technique is to place cancellous bone grafts beneath local or transferred tissues where structural augmentation is necessary.[1]) d. Primary closure over antibiotic impregnated beads-may be used to sterilize and temporarily maintain dead space.[2] The beads are usually removed within 3–4 weeks and replaced with a cancellous bone graft.[2] 4) Antibiotics are adjusted according to the culture reports if needed. [3]
References
  1. ANTHONY, JP, Mathes SJ, Alpert BS: The muscle flap in the treatment of chronic lower extremity osteomyelitis: Results in patients over 5 years after treatment. Plast Reconstr Surg[online].Augest 1991,vol,88(2).311–318.[viewed 24 March 2014].Available from;http://www.ncbi.nlm.nih.gov/pubmed/1852825
  2. Calhoun JH, Mader JT: Antibiotic beads in the management of surgical infections. Am J Surg[online],April 1989,vol,157(4).443–449.[veiwed 21March 2014].Available from;http://www.ncbi.nlm.nih.gov/pubmed/2648886
  3. CIERNY,Gorge,et al,A clinical staging system for adult osteomyelitis,The Classic,Lippincott Williams and Wilkins,September 2003.vol,414,7-24.
  4. LEUNG,H.A,B.R. HAWTHORN,A.H.R.W. SIMPSON. Effectiveness of local antibiotics for treating chronic osteomyelitis.Journal of Bone Joint Surgery,British volume[online]. 2012. vol. 94-B no. SUPP XXVIII. 22[viewed 25 March 2014].Available from;http://www.bjjprocs.boneandjoint.org.uk/content/94-B/SUPP_XXVIII/22.abstract
  5. LEW,Daniel P., Francis A. WALDVOGEL.Osteomyelitis.The New England Journal of Medicine[online].Massachusetts Medical Society.April 1997.vol.336.999-1007[viewed 25 March 2014].Available from;http://www.nejm.org/doi/full/10.1056/NEJM199704033361406#t=article
  6. HATZENBUEHLER,John,Thomas J PULLING.Diagnosis and managment of osteomyelitis;American family physician[online].American academy of family physicians.November 2011.vol.84(9).1027-1033[ viewed 19 March 2014].Available from;http://www.aafp.org/afp/2011/1101/p1027.html
  7. SOLOMON,Louis,David WARWICK,Salvadurai NAYAGAM.Apley's system of Orthopaedics and Fractures.9th ed.London;Holder Arnold,2010.