1. 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

2. Chronic Osteomyelitis
Types
A complication of acute Osteomyelitis
Post traumatic
Post operative

3. Chronic Osteomyelitis
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.

4. Chronic Osteomyelitis
Investigation
Lab tests/ culture
Plain X-ray:
Bone rarefaction surrounded by the dense sclerosis, sequestration and cavity formation
Sinogram
Bone scan & gallium scan
To detect chronic multifocal osteomyelitis
CT Scan & MRI
Biopsy

11. Chronic Osteomyelitis
Complications
Recurrence & Recurrence & Recurrence
Pathological fractures
Growth disturbance
Amyloid disease
Epidermoid carcinoma of the fistula

12. 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

13. TREATMENT
Antibiotics.
Local treatment.
Operations.
After care.

14. TUBERCULOSIS
A surgeon could gain experience in the management of TB. Of bone and joint only if he choose to work in econmically less developed countries. (edit, Br.Med.J>1968)

15. 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

16. TB
Cause by Mycobacterium tuberculosis, occasionally by M.bovis/africanum.
Also known as tubercle bacilli as they produce lesion – tubercles.
Acid fast bacilli.
Transmission – airborne droplets.
Risk- extent of exposure to droplets and susceptibility to infection.

17. TB Primary infection
Exposure to tubercle bacilli – Lungs – multiplication of bacilli in terminal alveoli (Ghon focus) – lymphatic drain it to hilar lymph nodes – (PRIMARY COMPLEX) – BLOOD – SPREAD.

18. 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

19. TB 3 days sputum. Ziehl-Neelsen stain.
X-ray: cavitation, infilteration, lymphadenopathy.
Full blood count:Relative lymphocytosis,^ ESR,Anemia.
Serology.
Lymphnode biopsy.
CT/ MRI

20. BONE TUBERCULOSIS Spread from primary complex to any bone/joints.
Can effect any bone but the weight bearing bones are more likely to be affected.
Spine –commonest, hip, knee , foot.

21. 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.

22. STAGES
C/F
XRAY
PROGNOSIS
1 synovitis
ROM>75%
SOFT TISSUE SWELLING, OSTEOPOROSIS
NEAR NORMAL
2 early arthritis
ROM50-75%
JT.SPACE DIMINITION AND MARGINAL EROSION
RESTORATION UPTO 75%
3 Adv. arthritis
ROM >75% ALL DIRECTION
DESTRUCTION OF JT. SURFACE
ANKYLOSIS
4Adv. Arth path/disln DO
DISORGANISE JT. DIS/SUB.LOCATION
5 Aftermath
GROSS DEFORMITY
DEFORMED JT. , OA

23. TB - TYPES
Caseous exudative- more destruction, exudation & abscess formation. Symptoms more marked Onset is less insidious.
Granular type – less destructive. Abscess formation rare. Dry lesion. adults

24. TUBERCULOSIS
Spine is the most common site of skeletal TB

25. TUBERCULOSIS Pathology
Blood borne - settles in vertebral body anteriorly
usually more bone destruction, more sequestra, larger abscess, gaseous pus than pyogenic OM
intervertebral discs preserved until late disease

26. TB SPINE -Classification
1- pre-destructive
2- early destructive.
3- mild angular kyphos.
4- moderate angular kyphos.
5- severe kyphos (humpback)

27. STAGES –1 & 2
Predestructive –straightening of curvatures , spasm of perivertebral muscles, MRI-marrow oedema.
Early destructive – Diminished disk space and paradiscal erosion.MRI-marrow oedema and break of osseous margin.CT-marginal erosion /cavitaion

28. STAGE 3,4&5 –Body destruction with Kyphos
Mild
2-3 vertebra
Kyphosis –
10-30*
moderate
>3 body
30-60*
severe
>60*

29. TB SPINE –D/D AGE- anomalies. Infection. Tumour. Traumma.
Osteoporosis ,Osteochondrosis.
Spondylolisthesis.

30. 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 anterior edges of the superior and inferior boarders of adjacent vertebral bodies with narrowing of disc space.
USG :paravertebral abscess.
Biopsy/ CT scan

31. 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 the joint space, later destruction of the joint.
Synovial bioposy.

32. TB KNEE / ANKLE.
C/F: pain and synovial swelling, muscle wasting., contracture, draining sinuses.
X-ray.
Synovial biopsy.

33. PRINCIPLES OF MANAGEMENT OF TB
General.
Rest, mobilization & brace.
Abscess, effusion & sinuses.
Antitubercular drugs.
surgery

34. TB PROBLEMS
Diagnosis.
Treatment .
Anti tuberculous drugs.

35. 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.

36. 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 early diagnosis before the development of radiological evidence of joint destruction.
Always keep TB in D?Diagnosis

37. Thank you for not sleeping
Now you can ask your questions ???

38. THANK YOU