m.d. Shydlovscky. A.V.

Acute purulent Acute purulent infections of serous infections of serous

cavities, blood cavities, blood vessels, bones, jointsvessels, bones, joints

Osteomyelitis

Among purulent diseases of bones and joints :

1)The severity of duration

2)The difficulty of diagnosis

3)Bad results

highlights acute hematogenous osteomyelitis

The term hematogenous osteomyelitis introduced in 1831 Reynaud.

T.P. Krasnobaev (1925) proposed classification :

1) toxic form 2) septic 3) locally lobular form.

According to the international classification of diseases, injuries and causes of

death osteomyelitis classified :

1. For reasons (for agents):

a)monoculture (staph, strep);

b)mixed, or associated culture (double, triple association);

c)the agent was not found;

2. Clinical forms of osteomyelitis

1) acute hematogenous osteomyelitis :

a)The generalized form (septykotoxyc, septykopiyemic);

b)local (focal) form;

2) post-traumatic osteomyelitis :

a)after fracture;

b)firearm;

c)post operation;

d)post X-Ray.

3) atypical forms of osteomyelitis :

a)Brodie abscess (abscess intrabone);

b)Harry sclerosing osteomyelitis;

c)albumine Ollye osteomyelitis;

d)antibiotic osteomyelitis.

3. Localization Process :osteomyelitis of long bones :a)epiphyseal;b)metaphyseal;c)diaphyseal;d)total.osteomyelitis of the flat bones :a)Pelvic;b)blades;c)iliac;d)the skull.

4. Stages and phases of hematogenous osteomyelitis:

1) acute phase :

a)Intramedullary phase;

b)extramedullary phase;

2) subacute stage :

a)phase of healing;

b)phase extension process.

3) chronic stage:

a)acute phase;

b)the phase of remission;

c)phase of healing.

5. Morphological forms

a)diffuse;b)focal;c)diffuse focal.

6. Complication:

1) locala)pathological fractureb)pathological dislocationc)false jointsd)contraction;e)ankylosis

2) general :a)Amyloidosisb)destructive pneumonia

Theories of pathogenesis

1. Vascular (embolic) founder A.A.Bobrov (1888). Bone vessels ending blindly in the metaphysis forming an extensive network (E. lexers, 1884). This structure takes place mainly at a young age (children).

2. Allergic theory (S.M.Derizhanov, 1940). On the basis of sensitization of the organism occurs in the bone fire aseptic inflammation that leads to vasoconstriction of the blood supply to the bone violation.

3. Neuro-reflex theory (N.N.Yelanskyy, 1954). Reflex spasm of blood vessels with blood circulation due to various external stimuli. Nor is the role of sensitization and the presence of covert infection.

4.M.V.Hrynov (80 years of the twentieth century.) At the heart of osteonecrosis is not intravascular circulatory disorders (embolism) and external compression of vascular inflammatory infiltrate.

Osteomyelitis begins from:

1) inflammatory foci in the metaphysis

2) reactive inflammation of the bone marrow

3) disturbance of microcirculation, increase perfusion of vessels with the release of cellular elements of blood

4) leukocyte infiltration of the bone marrow

5) raising the pressure in the bone marrow canal

6) compression of veins in cavern channels

7) blood stasis, thrombophlebitis shallow vessels bone

8) necrosis

9) Intramedullary, subperiosteum, intramuscular, subcutaneous cellulitis 10) Breakthrough pus through the skin 11) manure spread on the epiphysis with the metaphysis 12) into a joint breakout manure 13) spread manure on neighboring bone

1. Intramedullary lesion in metaphysis

2. Subperiosteum abscess

3. Intramuscular abscess

4. Subcutaneous abscess

sequestration of bone.

sequestration :

1) Cortical 2) central

3) penetrating (in a sector in a circle) 4) Total (segmental or tubular).

The formation of sequestration - from 4 weeks to 4 monthsThe formation of sequestration - from 4 weeks to 4 months..

Types of sequestration in damaged bone osteomyelitis

1) Cortical 2) central

3) penetrating (in a sector in a circle) 4) Total (segmental or tubular)

On the verge of healthy bone tissue formed :

1)demarcation line

2) proliferating granulation, forming pyogenic membrane and prevent the spread of the pathological process in the periphery.     

Sequestration is located in a cavity filled with pus.     

The cavity is covered sequestration capsule (box) of dice.     

On radiographs capsule can be seen after 4-6 weeks of onset.

Osteomyelitis of the tubular bones1. Subperiosteal abscess 2. metaphyseal focus 3. Purulent fistula 4. diaphyseal abscess 5. Epiphyseal abscess 6. sequestration

prevent sequestration :

1) healing of osteomielitic pockets 2) non-absorbable 3) not

healing.

clinic

Semiotics is diverse and depends on:

1) the virulence of microbes 2) reactivity 3) localization process 4) the patient's age 5) presence of complications.

The local (focal) form

The most common and is characterized by local suppurative inflammatory changes.

Begins suddenly, acutely, often after trauma, hypothermia.

Prodromal period of 1-2 days :

1)Weakness

2)Flabbiness, ailments

3)Light Fever

4)The temperature to 400C

5)Pain in the injured limb, intense, arching, ongoing

6)In the affected area 2-3 days edema of soft tissue.

1. Swelling of the thigh

2. Marked tenderness to percussion bones

3. flexion contracture

2

3

1

Generalized form.

a) toxic (lightning) – extremely difficult. Complicated by septic shock.

Begins : 1) hyperthermia with fever 2) excitation 3) delirium 4) cramps 5) symptoms of severe intoxication 6) collaptoid status 7) oliguria.

Diagnosed extremely difficult against the background of the critical condition of the patient.Patients often die in the next few hours or days.

b) septycopyemic form.

Beginning sharp, rapid, severe intoxication. Complication as other purulent lesions (multiple osteomyelitis) and organs (lungs, kidneys, liver). Vomiting, diarrhea.

The emergence of abscesses in other organs caused by bacterial dissemination.

Locally-focal form

Survey methods.

Ultrasonic echolocation - confirms osteomiyelityc focus and its limits.

Skin thermometry - over the fire skin temperature at 2-40C higher.

Color contact thermography - Registration of thermal energy in the form of infrared radiation. Accuracy ± 0,10 C method.

Thermography - determines the temperature of the body surface relief. Temperature difference of the inflammation is from +0.2 to + 0.4 0C.

Puncture bone – 1) promote timely diagnosis verification (search manure)

2) is a medical procedure (evacuation of pus).

Intraosseous thermometry.

Measurement of pressure intrabone – higher pressure (400 mm H2O), the more the transition to chronic.

Cytological method.

2

1

1. Detachment of the periosteum periostitis

2. OsteoporosisDensitometry - the degree of bone demineralization.

Osteomedulography - normal contrast resolves after 10-30 min. In contrast osteomyelitis delayed for longer.

Radioisotope scan (radioactive gold) - observed in the acute phase of his greatest accumulation.

X-ray methods (12-15 days). allows you to:1)confirm or reject the diagnosis2)to detect foci3)the degree of severity4)changes in the prevalence of.most early the X-ray changes of soft tissue (edema) Changes in bone : 1)the disappearance of trabecular structure and cortex2)the emergence of foci of osteoporosis and destruction.Pathognomonic signs :1) peryostytis 2) sequesters. CT scan - the possibility of serial sections with a minimum distance between them (up to 0.5 cm).

Treatment

1) Complex

2) 2) etiopathogenetic

Effects of treatment depend on: 1) the timeliness 2) the adequacy of.

Most effective when it begins in the first 24 hours.

The treatment program based on the principles T.P.Krasnobayeva :

1) Impact on macroorganism

2) the microorganism

3) treatment of the local focus.

Intensive care : 1) correction of homeostasis : a)water-electrolyte balance b) hypovolemiac) intoxication d) disturbance of microcirculation2 ) Therapy dysfunction of vital organs

3) maintenance of energy balance and increase

Imunorhesistency of organism body.

Effects on microorganisms.It is commonly applied antibiotics in the first hours of the disease.

Sensitivity of bacteria to antibiotics is a major consideration for its purpose.

The need for long-term antibiotic treatment (6 weeks) caused by:

1)poor diffusion of drugs in bone

2)the risk of early relapse

3)the transition to the chronic phase.

Support of optimal concentrations of antibiotics .

Indications for discontinuation of antibiotics is: 1) satisfying the patient 2) stable normalization of temperature within 10-14 days 3) leukocyte reaction 4) regression ESR.

Premature cancellation of antibiotics - 1) relapse 2) transition in chronic.

Local treatment.

Local complications (semimuscular cellulitis, abscesses subperiosteal) - additional cuts to their drainage.

Bone trepanation (now used more sparing treatments)

Osteoperforation

Bone marrow puncture channe :

1)Measuring intraosseous pressure

2)Constant washing antiseptic

3)The introduction of antibiotics fire.

This treatment appropriate for children up to 6 years.

The concept of local treatment T.Zh.Sultanbayevym (1979).

Laser osteoperforation.

Ultrasonic treatment of wounds. The effect is achieved by:

1)separation of necrotic tissue

2)penetration of drugs in inflammatory

3)inhibition of microbial flora by increasing its sensitivity to antibiotics.

The use of pulsating jet antiseptic liquid.

In the treatment of local focus obligatory is:

1)washing the bone marrow canal until his cleansing

2)adequate drainage

1) radical manure and products of inflammation foci (constantly)2) the decompression bone marrow canal3) the introduction of antibiotics in the center4) removal of abnormal impulses from the lesion5) Creation of favorable conditions to accelerate bone repair.

Chronic osteomyelitis. 1) Secondary chronic osteomyelitis as a result of acute hematogenous osteomyelitis

2) chronic osteomyelitis that develops after traumatic injury

3) atypical forms of chronic osteomyelitis (cause of these forms is the low virulence of bacteria with high reactivity)

Treatment of chronic osteomyelitis.

The method of choice is surgery.

Indications for conservative treatment.

1) diffuse form of chronic osteomyelitis;

2) Intraosteal small cavities without the express sclerosis;

3) the presence of complications that do not allow to perform radical surgery;

4) difficult access to the focus and connected with the trauma of surgery in the treatment of debilitated patients;

5) the effectiveness of conservative treatment, which was applied to preoperative.

Surgical treatment

Efficiency is measured at : 1) results 2) the frequency of relapses

With the improvement in technology operations, expanding the boundaries of treatment foci of recurrence decreased to 2%.

Most scientists recommend surgery on the bones of conduct with regard to the formation sekvestralnoyi capsule and explicit demarcation sequestration. (2 to 6 months of onset)

Indications for operation:

1)repeated relapses

2)Long-term existing fistula

3)cavity with marked surrounding sclerosis

4)formed sequesters

5)focal necrotic forms (Brodie abscess, osteomyelitis antibiotic cystic form).

Operative intervention.1. Palliative : а) Easy sequestrectomy as an independent operation are rare b) Disclosure subperiosteal, paraostal and semymuscular abscesses c) excision of the fistula.2. Radical :

1) sequestrnecrectomy includes:a)removal of necrotic foci osteomielityc tissue sequestration, pus, granulation, capsules sclerotic wallb)Disclosure bone marrow canal and extending it) adequate treatment of oral bone grafting m "yazevym flap

2) bone resection within healthy tissue:a)subperiostealcircular resection (high risk of trauma and the formation of false joints - not widely used)b)longitudinal resection - remove all damaged and not viable sclerotic area, almost three retractable wall

3) amputation - forced operation

Methods of closure of residual bone cavity.

1)blood clot - hemoplomb (Shede (1886).

2)antibiotic hemoplomb (V.S.Kononov (1974), K.S.Ternovyy (1978) - permanent irrigation (7-10 days) antibiotic solution marrow cavity filled hemoplomboyu.

3)muscular flap on the leg (M.V.Shulten (1897). Contribute :

a) purification of bone wound    

b) accelerates the regeneration process. M.V.Hrynov (1979) considers myoplastyc method of choice. Healing in 94% of cases

4) skin-periosteal-bone or skin-periosteal patches (on the tibia bone – healing in 96%. )

5) free microsurgical transplantation of muscles

6) bone grafting (narrow indications)

a)a large defect in the bone after total sequestration with low bone regeneration, no periosteal reaction.

b)pathological fracture.

c)destruction of bone at the joint of the threat to the tool joint.

e) used autobone, alobone, xenobone, sequestration deleted after processing by boiling.

7) compression and distraction Ilizarov method. (outside the focal compression osteosynthesis)often used in the treatment of complications of osteomyelitis (pathological fracture, nonunion fragments, pseudarthrosis, large bone defects).

Brodie abscess in 1928р.

No specific complaint and features of the disease. The disease begins in early childhood and is manifested in many years. Appearance - slight tenderness to percussion bones.

Noticeable changes in the blood were detected.

On radiographs is a hotbed of enlightenment in the metaphysis or epiphysis femoral, tibial.

Form foci rounded, clear sclerotic border, empty cavity, bone tissue along is not changed, no periosteal reaction.

Treatment - Surgery : trepanation bone dissection of inner wall of the cavity, with muscular plastic.Chronic bone Brodie abscess

in the lower meta-epiphysis of the tibia

Atypical forms of osteomyelitis

A typical picture of sclerosing osteo-myelities Gare. Shaken mid-diaphysis of the femur

Sclerosing osteomyelitis Harry (1893 р.)

Begins subacute, with pain in extremity, there is a dysfunction, mild fever.

General effects quickly pass and prevailing local signs : 1) edema 2) infiltration of soft tissue 3) sometimes intramuscular phlegmon, fistula.

Course with long-term remissions and exacerbations.

X-rays pronounced fusiform thickening of the diaphysis with areas of liquefaction and fractional sequestration. Bone marrow canal completely obliteruyetsya (hard bone, with small cavities and sequestration).

Treatment : 1) Conservative – antibiotic

2) surgery - removal of small lesions osteomiyelityc focuses

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