1. CURRENT CONCEPTS REVIEW OSTEOMYELITIS IN LONG BONE BY LUCA LAZZARINI,MD ET ALL THE JOURNAL OF BONE AND JOINT SURGERY, 2004 PAGE 2305 -2318

2. Osteomyelitis is defined as infection in bone The clinical state in which bone is infected with microorganisms. Main treatment  antimicrobial agents and operative (muscle flap, Ilizarov technic,antibiotics loaded beads)

3. Classification According to : Duration of disease (acute and chronic) The source of infection (hematogenous, contagious focus, vascular insufficiency) Cierny-Mader classification ( anatomic type and Physiologic class)

4. Cierny – Mader Staging System Anatomic type Stage 1  Medullary (confined to the medullary cavity) Stage 2  Superficial (involves only the cortical bone) Stage 3  Localized (involves both cortical and medullary bone) Stage 4  Diffuse (involves the entire thickness of the bone, loss of instability, infected nonunion) Physiologic class A. Host Normal B. Host Bs Systemic Compromise BI Local Compromise Bls Systemic and local Compromise C. Host Treatment worse than the disease

5. Etiology Hematogenous  single pathogenic organism : In infants  S. Aureus, Str. Agalactiae, E.Coli In children over 1 year of age  S. Aureus, Str.pyogenes, H.Influenzae In adult  S.Aureus Direct inoculation / contiguous focus  multiple organisms ( S.Aureus, gram Negative bacilli, anaerob microorganism) Tuberculosis  Primary infection (hematogenous) Fungal infection  (Coccidioidomycosis, Blastomycosis, Cryptococcosis, Sporotrichosis)

6. Pathogenesis 1. Source of infection : Hematogenous (metaphysis a long bone in children and vertebral bodies in adult) Direct inoculation  penetrating injury and surgical contamination) Contiguous focus  severe vascular disease

7. 2. Host factors May predispose individuals to the development of Osteomyelitis Host deficiencies Patient with sickle cell anemia, chronic granulomatous disease, Diabetes Melitus.

8. Pathology 1. Acute Osteomyelitis  Early  suppurative, edema,vascular congestion, thrombosis.  Promptly and aggressive treatment can arrest before the dead bone process  Infection  fibrous tissue and inflammatory cells form arround the granulation tissue and dead bone  Decrease in vascular supply  necrotic bone, resorbed by the enzym,bone destroyed  separation (sequestration)

9. 2. Chronic Osteomyelitis  Presence of necrotic bone  Formation of new bone  Exudation PMN, lymphocytes, Plasma cell, histiocytes  Presence of involucrum  Cavity  form the sinus tract with skin

10. Clinical Manifestation Signs and Symptoms :  In children : fever, lethargy, vague symptom, irritability and local sign of inflamation  In adult : vague symptom; non spesific pain and low grade of fever, bone and joint pain, swelling, drainage around the area, chills.  Chronic condition : local bone loss, sequestrum formation, bone sclerosis

11. Laboratories Studies The Leucocytes count may be elevated, but in chronic condition is often normal The erythrocyte sedimentation is usually elevated in both acute and chonic The C-reactive protein is rises in acute and chronic, decreases faster than the erythrocytes sedimentation in succesfully treatment

12. Microbiology The etiology depend on the isolation of the pathogen microorganism in cultures of specimens from the bone lesion, blood or joint fluid

13. Radiologic Findings Radiographic changes usually reflect the destructive process (infection process) Axial CT  increased bone marrow density and intramedullary gas, identify areas of necrotic bone and involvement of surrounding soft tissues MRI  useful to differentiating between bone and soft tissue infection

14. Treatment Appropriate therapy includes ; adequate drainage, extensive debridement, obliteration of dead space, wound protection and specific antimicrobial coverage Improve the nutritional, medica; and vascular status of the patient

15. Operative Treatment Bone debridement : the goal is to leave healthy, viable tissue ; all necrotic tissues must be debrided Reconstruction of Bone Defects and Management of Dead space ; the goal is to replace the dead bone and the scar tissue with durable vascularized tissue (living or non living bone graft,AB-impregnated beads,AB- impregnated cancelous bone graft)

16. Bone Stabilization ; external fixation is preferred over the internal fixation (Ilizarov external fixation) Soft Tissue Coverage  Split Thickness skin graft if the defect is small, muscle flaps if large defect present ; improve the biological environment by bringing in blood supply that important for host defense mechanisms, AB delivery and osseus and soft tissue healing