Surgery

TREATMENT

Differential Diagnoses

Cellulitis, subcutaneous abscess, fractures, and bone tumors should be considered in the differential diagnosis. In newborns and infants in whom osteomyelitis may present as a pseudoparalysis, also consider CNS disease (eg, poliomyelitis), cerebral hemorrhage, trauma, scurvy, and child abuse.

Deep Venous Thrombosis and Thrombophlebitis, Gas Gangrene, Gout and Pseudogout, Juvenile Rheumatoid Arthritis, Lumbar (Intervertebral) Disk Disorders, Sickle Cell Disease, Septic Arthritis, Spinal Cord Infections, Transient Synovitis.

Diagnosis requires 2 of the 4 following criteria:

Ø Purulent material on aspiration of affected bone

Ø Positive findings of bone tissue or blood culture

Ø Localized classic physical findings of bony tenderness, with overlying soft-tissue erythema or edema

Ø Positive radiological imaging study

It has been well established that sequestered abscesses demand surgical drainage. However, areas of simple inflammation without abscess formation can be treated with antibiotics alone.

In 1983 Nade (Australia) proposed five principles for the treatment of acute hematogenous osteomyelitis that are still applicable today: (1) an appropriate antibiotic will be effective before pus formation; (2) antibiotics will not sterilize avascular tissues or abscesses and such areas require surgical removal; (3) if such removal is effective, antibiotics should prevent their reformation and therefore primary wound closure should be safe; (4) surgery should not further damage already ischemic bone and soft tissue; and (5) antibiotics should be continued after surgery.

The patient should receive general supportive care consisting of intravenous fluids, appropriate analgesics, and comfortable positioning of the affected limb.

Empirical antibiotic coverage for the most likely infecting organism should be started if gram stain is negative, and the patient then should be carefully monitored. The CRP should be checked every 2 to 3 days after the initiation of antibiotic therapy.

If no appreciable clinical response to antibiotic treatment is noted within 24 to 48 hours, then occult abscesses must be sought and surgical drainage considered.

The two main indications for surgery in acute hematogenous osteomyelitis are (1) the presence of an abscess requiring drainage and (2) failure of the patient to improve despite appropriate intravenous antibiotic treatment.

The objective of surgery is to drain any abscess cavity and remove all nonviable or necrotic tissue. When a subperiosteal abscess is found in an infant, several small holes should be drilled through the cortex into the medullary canal. If intramedullary pus is found, then a small window of bone is removed. The skin is then closed loosely over drains, and the limb is splinted. The limb is protected for several weeks to prevent pathological fracture.

Intravenous antibiotics should be continued postoperatively. The duration of antibiotic therapy is controversial; however, the current trend is toward a shorter course of intravenous antibiotics (2 weeks), followed by oral antibiotics (4 weeks). The entire duration of treatment remains between 4-6 weeks until normalization of the C-reactive protein level.