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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
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Chronic Osteomyelitis
Types
A complication of acute Osteomyelitis
Post traumatic
Post operative
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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.
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Chronic Osteomyelitis
Investigation
Lab tests/ culture
Plain X-ray:
Bone rarefaction surrounded by the densesclerosis, sequestration and cavity formation
Sinogram
Bone scan & gallium scan
To detect chronic multifocal osteomyelitis
CT Scan & MRI
Biopsy
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Chronic Osteomyelitis
Complications
Recurrence & Recurrence& Recurrence
Pathological fractures
Growth disturbance
Amyloid disease Epidermoid carcinoma of the fistula
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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
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TREATMENTAntibiotics.
Local treatment.
Operations.
After care.
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TUBERCULOSIS A surgeon could
gain experience in
the management ofTB. Of bone and
joint only if hechoose to work in
econmically lessdeveloped countries.(edit, Br.Med.J>1968)
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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
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TB Cause by Mycobacterium tuberculosis,
occasionally by M.bovis/africanum.
Also known as tubercle bacilli as theyproduce lesion tubercles.
Acid fast bacilli.
Transmission
airborne droplets. Risk- extent of exposure to droplets and
susceptibility to infection.
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TB Primary infection
Exposure to tubercle bacilli
Lungs
multiplication of bacilli in terminalalveoli (Ghon focus) lymphatic drain itto hilar lymph nodes (PRIMARYCOMPLEX) BLOOD SPREAD.
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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
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TB 3 days sputum.
Ziehl-Neelsen stain.
X-ray: cavitation, infilteration,lymphadenopathy.
Full blood count:Relative lymphocytosis,^ESR,Anemia.
Serology. Lymphnode biopsy.
CT/ MRI
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BONE TUBERCULOSIS Spread from primary complex to any
bone/joints.
Can effect any bone but the weightbearing bones are more likely to beaffected.
Spine
commonest, hip, knee , foot.
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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.
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STAGES C/F XRAY PROGNOSIS
1 synovitis ROM>75% SOFT TISSUE SWELLING,OSTEOPOROSIS
NEAR NORMAL
2 earlyarthritis
ROM50-75% JT.SPACE DIMINITION ANDMARGINAL EROSION
RESTORATIONUPTO 75%
3 Adv.arthritis
ROM >75%ALL
DIRECTION
DESTRUCTION OF JT.SURFACE
ANKYLOSIS
4Adv. Arthpath/disln
DO DISORGANISE JT.DIS/SUB.LOCATION
ANKYLOSIS
5
Aftermath
GROSS
DEFORMITY
DEFORMED JT. , OA ANKYLOSIS
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TB - TYPES Caseous exudative-
more destruction,
exudation & abscessformation.Symptoms moremarked.
Onset is lessinsidious.
Granular type lessdestructive. Abscess
formation rare. Drylesion.adults
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TUBERCULOSIS
Spine is the mostcommon site of skeletal
TB
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TUBERCULOSIS
Pathology Blood borne - settles
in vertebral body
anteriorly usually more bone
destruction, moresequestra, larger
abscess, gaseouspus than pyogenicOM
intervertebral discspreserved until late
disease
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TB SPINE -Classification 1- pre-destructive
2- early destructive.
3- mild angular kyphos.
4- moderate angular kyphos.
5- severe kyphos (humpback)
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STAGES
1 & 2 Predestructive
straightening of
curvatures , spasmof perivertebralmuscles, MRI-marrow oedema.
Early destructive Diminished disk
space and paradiscalerosion.MRI-marrowoedema and breakof osseous
margin.CT-marginalerosion /cavitaion
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STAGE 3,4&5 Body
destruction with Kyphos
Mild 2-3 vertebra Kyphosis
10-30*
moderate >3 body 30-60*
severe >3 body >60*
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TB SPINE
D/DAGE- anomalies.
Infection.
Tumour.
Traumma.
Osteoporosis ,Osteochondrosis. Spondylolisthesis.
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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 anterioredges of the superior and inferior boarders of
adjacent vertebral bodies with narrowing ofdisc space.
USG :paravertebral abscess.
Biopsy/ CT scan
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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 thejoint space, later destruction of the joint.
Synovial bioposy.
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TB KNEE / ANKLE.
C/F: pain and synovial swelling, musclewasting., contracture, draining sinuses.
X-ray.
Synovial biopsy.
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PRINCIPLES OF
MANAGEMENT OF TB General.
Rest, mobilization & brace.
Abscess, effusion & sinuses.
Antitubercular drugs.
surgery
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TB PROBLEMS Diagnosis.
Treatment .
Anti tuberculous drugs.
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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.
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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 earlydiagnosis before the development of
radiological evidence of joint destruction. Always keep TB in D?Diagnosis
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Thank you for not sleepingNow you can ask your questions
???
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