Osteomyelitis

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The osteomyelitis (plurality osteomyelitis ; of ancient Greek ὀστέον , osteon , plurality ὀστέα ostéa , " bone " [see Latin-anatomical os, ossis ] Greek μυελός , myelós , "mark" and -itis ) or osteomyelitis is an infectious inflammation of the bone marrow . The term osteomyelitis is increasingly being replaced by the term osteitis or ostitis ( inflammation of the bone ), since in the majority of cases it is not just an inflammation of the bone marrow but of all parts of the bone.

causes

In most cases, the causes are open bone fractures and operations on the skeleton , which lead to contamination with bacteria . The infiltration of pathogens via the bloodstream or the forwarding of a neighboring focus of infection are the main causes of acute osteomyelitis in childhood due to the particular blood flow situation in the not yet closed growth plate. In addition to bacterial osteomyelitis, in rare cases those caused by fungi and viruses also occur. If the therapy is inadequate, the acute illness can become chronic and lead to very protracted courses. The therapy is almost always surgical .

Pathogen

Differential diagnosis

The Ewing's sarcoma can be expressed similar to osteomyelitis in his early symptoms. Pain, local tenderness, signs of inflammation in the laboratory findings and rather indistinct changes in the internal bone structure on the X-ray. The differential diagnosis can usually only be made with an MRI . The resulting surgical procedure is significantly different from that of osteomyelitis.

The Charcot foot or diabetic osteoarthropathy has an impact in the acute stage similar to osteomyelitis. The affected foot is overheated and deformed, but almost painless. Sometimes there are open, purulent, but almost painless wounds. Typical bone changes may be conspicuous in imaging diagnostics. Magnetic resonance imaging shows typical medullary edema . White blood cell scintigraphy can rule out osteomyelitis. In the anamnesis and examination, diabetes mellitus and the lack of pain or pain as well as the lack of adequate trauma are indicative .

A distinction must be made between the chronic recurrent multifocal osteomyelitis (CRMO) , which basically has no detectable pathogen and occurs almost exclusively in childhood .

Classification of osteomyelitis by course

Acute osteomyelitis

Postoperatively, one also speaks of an early infection . There is not always an acute clinical event. There are then, for example, local signs of inflammation in the surgical area (reddening, swelling, pain, warming). In the laboratory, the inflammation parameters are increased, the body temperature rises.

In children there is also a creeping form, the Brodie abscess .

For acute hematogenous osteomyelitis and Brodie's abscess, see below.

Chronic osteomyelitis

In contrast to acute osteomyelitis, chronic osteomyelitis lasts for more than months. The body responds to the infection by trying to seal off the diseased, infected area. A kind of capsule made of hard material (the so-called "death drawer") forms around the dead bone. The bacteria live on within this, inaccessible to any drug. Depending on the course of the disease, such a region can be quiet for a long time, but it can also repeatedly break through to the outside and drain the pus through a fistula . The x-ray shows typical changes in the bone structure; it is generally described as "coarse honeycomb". The laboratory parameters of the inflammation are often less pronounced than in the acute form. The patients complain of persistent pain and loss of function in the affected body parts. Chronic infections of the bone are generally considered to be very difficult to treat and can only be cured with great effort. The main reason why conventional antimicrobial therapies usually fail is the formation of so-called biofilms on the surfaces of dead bone parts or foreign implants. Numerous bacteria are able to develop such biofilms. If such germs come into contact with poorly perfused bones or foreign bodies, they usually only need hours to convert from the free (planktonic) to the adherent (sessile) form with the formation of a kind of mucous membrane. Within this envelope, they slow their growth and are largely sealed off from most environmental influences, including the effects of immune cells and antibiotics.

Free living (planktonic) germs can be killed by antibiotics and the immune system. However, adhering germs survive within the biofilm, since they can only be attacked with extremely high doses of antibiotics, which cannot be achieved with systemic administration.

The germs recovered in the microfilm often develop no or only minor symptoms for years, but then become active again for unforeseeable reasons.

In several studies it has meanwhile been proven that film colonization is much more frequent than previously assumed and can be the cause of many "aseptic" loosening of implants, but also of complaints that cannot be clearly assigned (Culture Negative Orthopedic Biofilm Infections).

Classification of osteomyelitis according to etiology

Post-traumatic and post-operative osteomyelitis

Post-traumatic osteomyelitis that occurs after an injury is caused by broken bones. Fractures in which the bone penetrates the skin are called "open fractures", which - according to Gustilo, for example - are divided into different degrees of severity. Depending on where and how the accident happened, the wound can be contaminated or infected. Bacteria penetrate the bones and find almost ideal conditions. If a bone fracture is treated osteosynthetically , this means that foreign material is introduced into the body. In the immediate vicinity of this foreign material there are niches in which the body's defense mechanisms are not sufficiently effective. Here, too, bacteria find the best conditions for colonization once they have penetrated.

Osteomyelitis after an operation due to fractures or accidents is called postoperative osteomyelitis .

Hematogenous or endogenous osteomyelitis

In endogenous osteomyelitis , also known as hematogenous osteomyelitis , the germs are removed from a focus of infection outside the bone, e.g. B. from the maxillary sinuses, carried by the bloodstream into the bone marrow and settle there. The acute hematogenous osteomyelitis with a disease duration of less than six months usually occurs in children of all ages (each with a different spectrum of pathogens) and occasionally in adults. Endogenous osteomyelitis is particularly feared in babies and toddlers up to the age of two, as it can spread unhindered to neighboring joints due to the special blood circulation in the bones.

Transmitted osteomyelitis

During the surgical treatment of broken bones (according to the specifications of the Osteosynthesis Working Group , AO / AO-ASIF), foreign material is introduced into the body. These are perforated plates and screws on the one hand, nails and drill wires or a combination of both types on the other. In the immediate vicinity of this foreign material there are zones in which the body's immune defenses have no way of doing anything against invading germs. Under unfavorable circumstances, this infection can spread along the plate that is screwed to the bone over the entire area affected by the injury and the subsequent operation. A completely comparable process can also occur on joint prostheses ( endoprostheses ); Here, too, the germs spread like along a guardrail and one speaks of a so-called prosthesis infection, whereby a distinction is made between early, delayed and late occurring infections.

Specific osteomyelitis

From the pathologists of the early years were tuberculosis , syphilis and cancer combined into the "specific inflammation." What these diseases have in common: In principle, they were incurable and microscopic examination revealed a certain - “specific” - image in the tissue .

Fortunately, syphilis with its long-term effects is only of historical interest in western countries. The tabetic arthropathy is a very severe joint change occurring as a result of syphilis in the third stage (L III). Research over the past decades has broken down “cancer” into a myriad of different diseases, so that it is forbidden to summarize all these diseases nowadays. What remains is tuberculosis (TB). TB continues to be a fairly common disease; Some studies indicate that 50% of people over the age of 60 have had tuberculosis. The pathogen also reaches the skeletal system via the bloodstream and can settle there. Often this happens in the spine and one speaks of vertebral osteomyelitis or spondylodiscitis . The treatment procedures do not differ fundamentally from the procedures for "normal" osteomyelitis, only the material removed during surgery is treated as highly infectious and dangerous.

Odontogenic osteomyelitis

Starting from the dental system, periapical ostitis ( inflammation of the bones ) can develop into osteomyelitis. Other possible causes are periodontal infections or ostitis after tooth extraction (tooth removal). An upper as well as a lower jaw fracture can be the cause of osteomyelitis. One of the symptoms is the Vincent symptom , a sensory disorder in the supply area of ​​the inferior alveolar nerve .

Special forms

The Brodie's abscess is a special form of "hematogenous osteomyelitis" in childhood. The symptoms are rather mild; The laboratory results also show no severe changes as would otherwise be expected in osteomyelitis. What is noticeable is a circumscribed swelling that is painful to pressure, mostly in the shaft area of ​​a long tubular bone. The diagnosis causes problems here. Children often injure themselves - the shin in particular is often affected - and using every bump as an opportunity for a comprehensive X-ray diagnosis is certainly to be viewed critically. In the X-ray, if one was made, the periosteum in the affected area is raised; the bone has an additional seam here. Further diagnostics should then be carried out using magnetic resonance imaging (MRT), since changes in bone metabolism can be clearly seen very early.

treatment

An early start of therapy (initially calculated) is crucial for the prognosis of infections of bones and joints. Treatment for osteomyelitis is usually lengthy. In the case of early infections, the rehabilitation of a possible wound and osteosynthesis are in the foreground. The stability test is an important part of the treatment; it may be necessary to switch to alternative methods of stabilizing a broken bone. In its 2008 AWMF guideline, the German Society for Oral and Maxillofacial Surgery examined both surgical and conservative treatment methods. In addition to wound care and antibiotic therapy with antibiotics with good tissue penetration, this also includes hyperbaric oxygen therapy and irrigation and suction drainage.

In the case of chronic disease, any existing fistulas must be cut out and scar tissue and bones removed from the blood supply. After the infected bone has been removed, antibiotic carriers are usually inserted. While chains made of gentamicin- containing plastic beads were used in the past , the current trend is towards absorbable (dissolvable) antibiotic carriers (sponges, etc.), which do not have to be removed and locally cause fewer mechanical complications. The advantage of the antibiotic carrier lies in the locally high effective levels of the antibiotic. Bone transplants may need to be performed to fill a defect in the bone. Multiple revisions are often necessary.

New treatment methods are based on the use of antibiotic-impregnated bone grafts. This achieves even higher local effective levels and all cavities can be filled immediately and completely. Since the bone grafts are gradually being replaced by your own, healthy bones, the removal of chains and subsequent reconstruction are unnecessary, which saves at least one operation. The high local effective levels also enable the simultaneous use of metallic implants to stabilize or replace a joint, which enables rapid rehabilitation. Improved long-term results also appear possible with the new technologies.

literature

  • EF Berbasi, JM Steckelberg, DR Osmon: Osteomyelitis. In: Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases. 6th edition. 2005.
  • C. Burri: Post-Traumatic Osteitis. 2nd Edition. Huber, Bern / Stuttgart / Vienna 1979, ISBN 3-456-80644-2 .
  • JR Döhler , M.-L. Hansmann: Plasma cellular and sclerosing osteomyelitis. A follow-up examination of 21 patients. In: The surgeon . 64: 190-194 (1993).
  • L. Kinzl, G. Bauer, W. Fleischmann (eds.): Diagnosis and therapy of post-traumatic osteitis. (= Booklets for The Trauma Surgeon. Volume 255). Springer-Verlag, Berlin / Heidelberg / New York 1995, ISBN 3-540-60123-6 .
  • Gerhard Walter among others: Treatment algorithms for chronic osteomyelitis . In: Dtsch Arztebl Int . No. 109 (14) , 2012, p. 257-264 ( review ).

Guidelines

Individual evidence

  1. ↑ U. Schneider, G. Hierholzer, HJ. Böhm: bone and joint infections. In: trauma surgeon. 1996 Oct; 99 (10), pp. 789-800 PMID 9005569
  2. ^ Franz X. Koeck, Bernhard Koester: Diabetic foot syndrome. 1st edition. Thieme, Stuttgart 2007, ISBN 978-3-13-140821-1 .
  3. ↑ a b Marianne Abele-Horn (2009), p. 161.
  4. ^ GD Ehrlich, PJ DeMeo, JW Costerton, H. Winkler (eds.): Culture Negative Orthopedic Biofilm Infections. (= Springer Series on Biofilms. Vol. 7). 2012, ISBN 978-3-642-29553-9 . [1]
  5. ↑ Marianne Abele-Horn (2009), pp. 161 and 166.
  6. ^ Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , pp. 161-165.
  7. ↑ Marianne Abele-Horn (2009), pp. 174–178 ( prosthetic infections ).
  8. ↑ Marianne Abele-Horn (2009), p. 161 (quoted).
  9. ↑ H. Winkler et al: In vitro release of vancomycin and tobramycin from impregnated human and bovine bone grafts. In: Journal of Antimicrobial Chemotherapy . (2000); 46, pp. 423-428. PMID 10980169
  10. ↑ MA Buttaro, R. Pusso, F. Piccaluga: vancomycin-supplemented impacted bone allografts in infected hip arthroplasty. Two-stage revision results. In: J Bone Joint Surg Br. 2005 Mar; 87 (3), pp. 314-319. PMID 15773637
  11. ↑ H. Winkler, A. Stoiber, K. Kaudela, F. Winter, F. Menschik: One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics. In: J Bone Joint Surg Br. 2008 Dec; 90 (12), pp. 1580-1584. doi: 10.1302 / 0301-620X.90B12.20742 . PMID 19043128