Chronic osteomyelitis is a chronic inflammatory process affecting all elements of the bone: bone marrow, periosteum, compact and spongy substance. Usually it becomes the outcome of acute osteomyelitis, less often there is a primary chronic course. Alternation of remissions and exacerbations is characteristic. In the acute phase, symptoms of general intoxication, pain, swelling, hyperemia of the affected area and the formation of fistulas are observed. In the remission phase, the symptoms smooth out or disappear. The diagnosis is made taking into account anamnesis, clinical manifestations, X-ray data and other studies. Treatment is more often operative, sequestrectomy is performed, reconstructive interventions are performed according to indications.
ICD 10
M86.3 M86.4 M86.5 M86.6
Meaning
Chronic osteomyelitis is a chronic inflammation of the bone. Usually occurs after acute osteomyelitis. It can affect any bone, but long tubular bones are more often affected. There is a predominance of patients with lesions of the lower extremities. Chronic osteomyelitis is detected in people of any age and gender. It is characterized by a long course with alternating exacerbations and remissions. The duration of remissions can range from several weeks to several years.
Long-term inflammation has a devastating effect not only on the bone, but also on other organs. The affected segment may be curved or shortened, sometimes a false joint is formed in the area of inflammation. The mobility of adjacent joints is limited, contractures occur. With the localization of the focus in the periarticular zone, the development of purulent arthritis is possible. Fistulas with a permanent purulent discharge cause significant inconvenience to patients, are a source of unpleasant odor, make communication difficult, negatively affect career and personal life. In patients suffering from osteomyelitis for many years, dystrophic changes in internal organs and amyloidosis of the kidneys are often detected.
Chronic osteomyelitis causes
Chronic osteomyelitis can be the outcome of any form of acute osteomyelitis. In children, chronic purulent processes that have arisen against the background of hematogenous osteomyelitis prevail. In adults, the first place in prevalence is occupied by chronic post-traumatic osteomyelitis, which usually develops against the background of open fractures, but can also occur after surgical interventions for closed bone injuries (such osteomyelitis is called postoperative).
Chronic osteomyelitis also often develops after gunshot fractures, accompanied by extensive damage to tissues destroyed as a result of direct impact of the projectile and the formation of a zone of commotion. Healing of such wounds always occurs through suppuration, which contributes to the formation of a chronic purulent focus in the area of the damaged bone. It is relatively rare to find chronic inflammation of the bone caused by the contact spread of infection (from a closely located purulent wound, phlegmon or abscess).
Pathogenesis
Gram-positive pyogenic bacteria (staphylococci, pneumococci or streptococci) usually act primarily in the focus of inflammation. As the process chronicles, gram-positive flora is replaced by gram-negative flora or complements it, forming microbial associations. In crops from foci of chronic osteomyelitis, Klebsiella, vulgar proteus, E. coli, Pseudomonas aeruginosa and other microorganisms can be detected.
The probability of the transition of acute osteomyelitis to chronic depends on many factors, including the general condition of the body, the presence or absence of immune disorders, features of the structure and blood supply of bone tissue, the state of the circulatory system, etc. Chronic osteomyelitis develops more often in patients suffering from severe somatic diseases and combined injuries, as well as in weakened and exhausted patients. The area of damage to the bone and surrounding soft tissues is of great importance.
Acute osteomyelitis turns into chronic after about a month after the first symptoms appear. By this time, sequesters are formed in the bone, the rejection of necrotic tissues begins, fistulas form. In the absence of the effect of therapeutic measures carried out within 1.5 months from the onset of the disease, we can talk about chronic purulent inflammation of the bone. Subsequently, the process proceeds in waves, while the frequency and severity of exacerbations can vary significantly.
Chronic osteomyelitis symptoms
In the remission phase, the patient feels satisfactory. A fistula with a small amount of purulent discharge usually persists in the affected area, but there are no signs of general intoxication. Sometimes the fistula closes. Local inflammation is weakly expressed, signs of a chronic sluggish process prevail. Soft tissues in the zone of osteomyelitis are compacted, the skin is purple, less often – bluish. In chronic osteomyelitis of the limb, the affected segment is usually thickened, swelling of the distal parts may be detected due to disorders of blood and lymph circulation.
The exacerbation resembles an erased picture of acute osteomyelitis. The patient’s temperature rises, weakness, bruising, muscle pain and other symptoms of intoxication appear. The swelling of the affected segment increases. The skin turns red, the pain syndrome becomes more intense. The formation of intermuscular phlegmon is possible, accompanied by a deterioration in the general condition and the appearance of intense bursting or jerking pains that disrupt the patient’s sleep.
The soft tissues in the phlegmon area become tense, the local temperature rises. In some cases, during palpation, it is possible to determine the area of fluctuation. The amount of discharge through the fistula increases. If the fistula has closed during remission, the patient’s condition improves after the formation of a new fistula or several fistulas, which can form both in the immediate vicinity of purulent foci and at a considerable distance.
Diagnostics
The main instrumental method of investigation in chronic osteomyelitis is radiography. Radiographs show signs of bone destruction in combination with elements of proliferation. In the area of the purulent focus, a cavity is visible, sequesters are often detected in the form of dense shadows with uneven contours and a preserved bone pattern. Areas of sclerosis are determined around the inflammation zone. In the acute phase, periostitis occurs, the number and nature of periosteal layers depend on the prescription and severity of the process.
Sometimes, due to significant bone sclerosis, small foci are not detected on radiographs. In addition, radiography does not allow to assess changes in soft tissues, therefore, in doubtful cases, patients are additionally referred for bone CT and MRI. An important part of the preoperative examination is fistulography, the results of which determine the scope and tactics of surgical intervention. Fistulography makes it possible to see the direction of the fistula course, which is often tortuous and has a complex shape. With the help of this study, it is possible to determine the volume of cavities, to identify the connection of the fistula with sequestration, etc.
Chronic osteomyelitis treatment
The treatment is carried out by specialists in the field of traumatology and orthopedics. Therapeutic tactics are determined depending on the patient’s condition, the severity, prevalence and stage of pathological changes, as well as the presence of concomitant complications from the affected segment (false joints, shortening or gross deformity of the limb) and the severity of dystrophic changes in internal organs. During the period of exacerbation, antibiotics and means for stimulating immunity are prescribed, purulent cavities are drained using special needles or catheters.
Cavities and fistulas are washed with solutions of antibiotics. Intermuscular phlegmons are opened and drained. Surgical interventions are performed after the acute inflammatory phenomena subside. Sequestrectomy is performed – the foci of necrosis, granulation and areas of excessive sclerosis are completely removed. Fistula passages are excised based on fistulography data. The surgical wound is washed with antiseptic solutions. After complete cleansing of the wound, the remaining bone walls are perforated, the removed areas are replaced with bone grafts.
In some cases, more complex, multi-stage treatment of chronic osteomyelitis is carried out. With false joints, shortening and severe deformation, osteotomy, resection of a bone area not involved in the pathological process and other therapeutic measures may be required. To correct angular deformations and elongation of the affected limb segment, traumatologists apply Ilizarov devices.
Prognosis and prevention
The prognosis depends on the age of the disease, the extent of the lesion, the patient’s state of health and the radicality of the surgical intervention. With fresh processes and complete excision of small foci, complete recovery is often observed. In case of old osteomyelitis, the prognosis worsens due to trophic changes in soft tissues, extensive dystrophic bone restructuring, deterioration of local blood supply and unfavorable general background caused by a violation of the activity of various organs. Nevertheless, surgical treatment is indicated even in advanced cases, since the chronic purulent process has a negative effect on all organs and can cause serious deterioration of the patient’s health. Prevention includes the prevention and adequate treatment of injuries and diseases that can cause osteomyelitis.
Literature
- Suppurative osteomyelitis of the mandible secondary to fracture. Report of a case. Limongelli WA, Connaughton B, Williams AC. Oral Surg Oral Med Oral Pathol. 1974 Dec;38(6):850-9 link
- Eikenella osteomyelitis of the mandible associated with anemia of chronic disease. Stern K, Nersasian RR, O’Keefe P, Plisner K, Doku HC. J Oral Surg. 1978 Apr;36(4):285-9. link
- Chronic osteomyelitis of the jaws. Shakenovsky BN, Ripamonti U, Lownie JF. Int J Oral Maxillofac Surg. 1986 Jun;15(3):352-6. link
- Facial pressure sore complicated by mandibular osteomyelitis. Taylor J, Obisesan O. Int J Oral Maxillofac Surg. 1999 Oct;28(5):385-6. link
- Chronic recurrent multifocal osteomyelitis involving the mandible: case reports and review of the literature. Monsour PA, Dalton JB. Dentomaxillofac Radiol. 2010 Mar;39(3):184-90. link
