Infection

Chronic osteomyelitis - clinical case approach

Case-based chronic bone infection: sequestrum, sinus tract, imaging and surgery.

12 questions 2 source pages

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Q1Describe the X-ray findings in this case of subacute osteomyelitis.▸

Q2What is the differential diagnosis of this diaphyseal lytic lesion?▸

Tumour: Ewing sarcoma in the diaphysis, osteosarcoma in the metaphysis, chondroblastoma in the epiphysis
Infection: Brodie's abscess

Q3What is a Brodie's abscess and how does it arise?▸

Chronic abscess surrounded by sclerotic bone and fibrous tissue
Results from partially treated acute osteomyelitis or decreased virulence of bacteria

Q4What are the clinical and investigation findings in subacute osteomyelitis?▸

Q5What is the management principle for subacute/chronic osteomyelitis?▸

Eradicate infection, reconstruct bone and soft tissue defects, minimise complications and hospital stay
Debridement: saucerization and sequestrectomy until healthy bleeding (paprika sign)
Dead space management: antibiotic-loaded cement spacer, gentamicin beads, VAC dressing
Local and systemic antibiotics
+/- skeletal stabilisation depending on Cierny staging

Q6List the stages of acute osteomyelitis.▸

Q7What are the aims of managing chronic osteomyelitis and how is it assessed?▸

Aims: control infection, look for complications, skeletal stabilisation if pathological fracture
PE: skin and soft tissue condition
Blood: WBC, CRP, ESR; CT to look for collection
Common bacteria: S aureus, polybacteria

Q8Describe the X-ray and clinical findings in chronic osteomyelitis.▸

Bone destruction at the proximal shaft involving half of the diameter on both AP and lateral
Clinically a discharging sinus over the arm
History of previous acute osteomyelitis

Q9Describe the Cierny classification and its management.▸

I intramedullary -> deroof bone for IM debridement
II superficial (bone surface) -> debride cortex till paprika sign, may need soft tissue coverage
III localized (cortex + medullary) -> saucerization, debridement, antibiotic bead +/- ex fix and flap
IV diffuse -> ex fix, debridement, flap
Host A/B/C = host immunity

Q10How is a bone defect after debridement managed?▸

Initially: ex fix + antibiotic-loaded beads, repeated debridement till clean
Small <4cm: Papineau or bypass graft (cross union of tibia/fibula)
Large >6cm: Masquelet technique, vascularized bone graft, bone transport / distraction osteogenesis
Bi/trifocal (2 osteotomy sites) bone transport to reduce time to distraction and consolidation, but bone maturation time is longer

Q11Describe the Papineau technique.▸

Bed free of infection with healthy granulation tissue (blood supply)
Lay morselized bone graft on the defect, not thicker than 2cm
As it is taken up and forms granulation tissue, add another layer of bone graft
Continue till dead space obliterated, then VAC +/- split thickness skin graft

Q12What are the uses of VAC and what is needed for final soft tissue coverage?▸

Removes chronic oedema, enhances blood flow, promotes granulation tissue at the floor
Final coverage by the soft tissue reconstruction ladder
May need a local or distant muscle flap
Adequate vascularised soft tissue coverage helps resolution of osteomyelitis

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