Osteomyelitis surgery

2021-05-13 12:15 PM

Osteomyelitis-osteomyelitis disease can be divided into 3 stages of continuous progression and gradual transition without clear boundaries: acute, subacute and chronic.

Osteomyelitis is less common than soft tissue inflammation because the bone is shielded, never exposed to the outside environment unless an open fracture or surgery occurs. Pathogenic microorganisms can only reach a bone by blood sugar (very rarely by lymphatic route). This article only covers osteomyelitis-myelitis.

Purulent inflammation of the bone marrow

Before the antibiotic era, osteoarthritis most commonly caused by staph, had a very severe and massive clinical presentation, had a high mortality rate (20-30% according to Pyrah, Pain, Crossan) and caused death. break a lot. Today, the decrease in staph toxicity can be attributed to the use of many modern antibiotics. There are transient episodes of bacteria in the blood but usually, they are destroyed, so the disease is rare in normal, healthy people. When the body's resistance is poor or the local resistance is weakened, the pathogenic bacteria have a chance to reproduce and create a bone-marrow inflammation. Therefore, the disease has a very high rate in people suffering from chronic disease depletion, opium addiction (due to Pseudomonas), immunosuppressed or traumatic bone areas (possibly due to small haemorrhagic foci that reduce local resistance and thrombosis that allows bacteria to follow blood pathways to assemble and grow). Bones with reduced pO2 oxygen fraction pressure, as seen in sickle cell anaemia, are susceptible to inflammation (Pseudomonas). Osteomyelitis-spinal cord infections are more common in elderly patients suffering from urinary tract infections (E. coli). In elderly people with peripheral vascular failure such as in diabetes, the bones are inflamed by anaerobic bacteria or more at the same time. Gaucher diseases and petrified bones are susceptible to bacterial complications. Bones with reduced pO2 oxygen fraction pressure, as seen in sickle cell anaemia, are susceptible to inflammation (Pseudomonas). Osteomyelitis-spinal cord infections are more common in elderly patients suffering from urinary tract infections (E. coli). In elderly people with peripheral vascular failure such as in diabetes, the bones are inflamed by anaerobic bacteria or more at the same time. Gaucher diseases and petrified bones are susceptible to bacterial complications. Bones with reduced pO2 oxygen fraction pressure, as seen in sickle cell anaemia, are susceptible to inflammation (Pseudomonas). Osteomyelitis-spinal cord infections are more common in elderly patients suffering from urinary tract infections (E. coli). In elderly people with peripheral vascular failure such as in diabetes, the bones are inflamed by anaerobic bacteria or more at the same time. Gaucher diseases and petrified bones are susceptible to bacterial complications.

The proper diagnosis and treatment of osteomyelitis is based on the clinical-imaging-disease-anatomy correlation. A differential diagnosis is always required with osteosarcoma, round cell melanoma and eosinophilic granuloma. Osteomyelitis can give an x-ray image that resembles any type of tumours.

Osteomyelitis-bone marrow inflammation is a secondary disease, 1/3 of the primary infection is pimples, skin abscesses, inflammation around the nail ..., in addition, abscesses of internal organs, plasma membrane, lobar pneumonia, typhoid disease, urinary tract infections ... The main pathogens are Staphylococcus aureus coagulase (+) (90%), streptococcal type b- hemolysis (5%), E. coli, S. Typhi, gonorrhoea ... In new-borns, infections from the umbilical cord and vagina of pregnant women, 40% have many bones, the rate of men and women is equal. Bacteria that cause disease in infants and infants are often E. coli, streptococci, and staphylococcus aureus. The most common disease at the age of 3-15, is the most active stage of bone growth and is caused by staph. Men are 4 times more common than women, possibly because boys are more injured. The most common bones are long bones of the limbs in the order: femur, tibia, arm bones, rotational bones ... in the head of the body, which is strongly grown (near the knee - far from the elbow).

Osteomyelitis-osteomyelitis disease can be divided into 3 stages of continuous progression and gradual transition without clear boundaries: acute, subacute and chronic.

Acute inflammatory stage: The disease starts suddenly with pain, a throbbing pressure on the inflamed bone, then the surrounding soft red and hot swelling. Systemic symptoms include high fever, fatigue, poor appetite, and an infected expression. Infectious foci originating from bone marrow in primary spongiotic just below synaptic cartilage provokes an acute inflammatory response with congestive phenomena, increased vascular permeability, oedema, haemorrhage and lymphatic permeability. multi-core bridge. The white blood cells phagocytic bacteria, destroying and releasing enzymes that destroy protein. Tissue necrosis, bacteria, leukocytes die, fragments of tissue and cells mix to form pus. The progression of the disease depends on many factors: bacterial toxicity, body resistance,

From the tip of the skeletal body, the foci of infection along the veins of the spongy bone, the Volkman canal and the Havers canal spread to the marrow (1) and the cortical cortex (2), spreading easily under the periosteal because of the dense crust in the This bone is very thin (3), creating an abscess in the soft tissue (4), detecting the skin (5), to the tip of the bone and joints (6, 7) (in children).

So the entire skeleton is surrounded by pus on both sides. Initial congestion causes bone absorption. The pressure in the bone increases due to oedema and the drainage of the vessels compresses the blood vessels. If the blood supply is reduced but enough to feed the bones, the osteoblasts will react to form many bone-like substances. If the cultured blood is greatly reduced or completely lost, the bone cells will die to form "prison bones" surrounded by inflammatory granular tissue. Dead bone tissue allows bacteria to multiply and hide to avoid the effects of antibiotics and body resistance. Around the abscess and dead bones, the body creates reactive tissue covering proliferating mesenchymal cells, capillaries and inflammatory cells. The reactive tissue is usually very strong in the periosteum of children.

Conventional radiographs

No change was seen in the early stages; 1-2 weeks later, there are less luminous areas, not clear in the inflamed area and increased soft shading due to oedema, can see supernal and pushed periosteal ghosting.

Blinking map

At first, the "cold" corresponds to the hemodynamic-blood phase, then replace it with a "hot spot" reflecting the generated reactive bone.

Image of magnetic resonance:

Shows the earliest presence of osteomyelitis. Within a few days after the adipose tissue was replaced by an inflammatory cell, the high signal intensity of the fatwas seen on the T1 image. Once an abscess was established, both T1 and T2 images showed the high intensity of fluid.

Subacute inflammatory phase: Fluid oedema and polymorphonuclear leukocytes decreased, replaced by inflammatory granular tissue with many cytoplasms, lymphocytes and monocytes. Dead bones are absorbed by osteoclasts. Bone-forming substances are produced in reactive tissue and mineralized to form a ring of bone along with the fibrous tissue covering the inflammatory drive.

X-ray

Seeing many areas of bone that have been dissipated, starting to see dead bones in the marrow and bone marrow. The skeletal membrane reacts like an onion shell, a Codman triangle, and sometimes images of the sun's rays. Images of synaptic cartilage, sub-cartilage and joint cartilage damage can be seen.

Blinking map

 "Hot spots" increase with the amount of new bone. Flicker is no longer required when a change is seen on the radiograph.

Chronic inflammatory stage: Inflammation spreads in diseased bones with mixed images: bone destruction, dead bones, reactive bones ... clearly seen on radiographs as well as macroscopic and microscopic Bone marrow has regions of bone destruction, fibrosis, new bone areas, dense bones with unclear boundaries; many lymph cells, cytoplasm, macrophages. The bone shell has enlarged Havers, many areas are diluted, destroyed, and dead bones are mixed with new bones, making the bone's thickness change, uneven. Dead bones can be small pieces or whole segments of the body. The multi-reactive periosteal sometimes forms a new cortical canal around the old one that has died. The periosteal reactive bone is often irregular, is not smooth and has optical-penetrating lines. It can be seen that the bridge connects to the next bone (2 bones of the forearm, leg ...), destroys joint cartilage, bone head or solder joints (if accompanied by purulent inflammation). In young children, bones can be deformed.

X-ray computed tomography: helps detect dead bone fragments not seen on conventional radiographs and helps clarify the spread of reactive bone tissue.

Prognosis

The disease usually progresses chronically and the disability rate remains high. So early diagnosis and treatment determine the success of treatment. To avoid relapse, it is necessary to have a complete diet, play a joyful and healthy life to improve the body's resistance, prevent injury.

Tuberculosis of the bone

Bone tuberculosis is a common non-purulent osteomyelitis disease in our country, caused by the bacillus Koch which is an aerobic bacterium. The disease is mostly secondary to pulmonary tuberculosis, sometimes after tuberculosis of the gastrointestinal tract, urinary tract ... The disease can occur at any age, mostly before puberty. The bones often suffer in order: spine, femur, other large long bones.

Tuberculosis of the spine

First described by Percival Pott in 1779. Bacteria follow the incoming bloodstream, especially the valveless Batson vein system. Lesions are common in the lower thoracic vertebrae and the abdominal vertebrae, sometimes in many distant vertebrae. Infection slow progression slows bone destruction, cartilage destruction, atelectasis and spinal disc. The anterior part of the living stem, where the pO2 is high, is often collapsed, causing humpback deformation. The first symptom is that the muscles next to the spine are stiff and weak. Later, the infection spreads to the software that creates cold abscesses that run along the diaphragm to detect the skin next to the spine or along the hip lobe muscles to find the groin area or the inner thigh is very difficult to heal.

A possible complication is tuberculosis meningitis that causes high death, paralysis of limbs, urinary retention due to compression of the spinal cord because the spine is hunched, angled, rotated ...

Long-bone tuberculosis

Long bone tuberculosis is usually at the head-to-head of the body and is mostly accompanied by tuberculosis. It is not known whether the infection originated in the joint or the bone. The hip and knee joint areas are most commonly affected, often with muscle atrophy, so clinically there are signs of "sheep's thigh", walking.

The joint is destroyed, the synovial membrane is replaced by the granulation tissue, the cartilage of the joints is destroyed. Tuberculous abscesses form at the head-tip of the body and detect the skin that is difficult to heal, with few dead bones.

Long skeletal tuberculosis is rarer, more easily healed, and is usually caused by "atypical" tuberculosis bacteria.

X-ray images

It is an image of gradual bone destruction, few new bone formation reactions, less bone death, and an image of osteoporosis.

Spinal tuberculosis: Destruction of one or more vertebral bodies, sharp hunched image. Rarely cancel posterior joint osteoarthritis. Destroy one or more live discs, adjacent living bodies close together. Surrounding soft swollen, pear-shaped cold abscess ball.

Long bone tuberculosis: Often there is very much osteoporosis with very little reactive bone contour. Destroy bone into each socket, each cavity, destroy bone under joint cartilage. No or little periosteal reaction. Narrow joint joints, irregular margins.

Pathology

The microscopic lesions of osteoarthritis resemble tuberculosis of other organs, typically with tuberculosis cysts. Accurate diagnosis is based on bacterial culture (+) and observations of tuberculosis bacteria by acid-alcohol resistant staining of pathological specimens (AFB staining: fast bacilli acid) or fresh specimen smear. However, less than 50% of TB cases have positive diagnostic tests. Moreover, tuberculosis progresses slowly, lasting for many years, so many biopsy tissue samples only see fibrous tissue and lymphocytes. In these cases, it is necessary to coordinate with clinical data - X-rays - tests (PCR, IDR, VS ...) to diagnose, treat and monitor the patient.