Osteomyelitis Holly Schlicht April 22,2014 What is Osteomyelitis? Infection of the bone
Often confused with septic arthritis Can occur in infants, children, and adults Most commonly occurs: Children ends of long bones in arms and legs Adults spine, feet, or pelvis Two classifications used: Waldvogel Classification best for clinicalapplication Cierny and Mader Classification best forsurgical treatment proposals Only 2 out of 10,000 people get osteomyelitis Adults and children are affected in different ways Waldvogel Classification of Osteomyelitis
Hematogenous Secondary to bacterialtransport through the blood.Majority of infections inchildren Contiguous Bacterial inoculation from anadjacent focus. E.g.:Posttraumatic Osteomyelitis,infections from prostheticdevices Associated with vascularinsufficiency Infections in patients withdiabetes affecting the feet,hanseniasis, or peripheralvascular insufficiency Acute Osteomyelitis initial episodes of osteomyelitis Edema, formation of pus,vascular congestion,thrombosis of small vessels Chronic Osteomyelitis recurrence of acute cases Large areas of ischemia,necrosis, and bonesequestra Acute osteomyelitis can lead to chronic osteomyelitis because without treatment, the infection and inflammation block the blood vessels and causes the bone to die. Chronic osteomyelitis is harder to treat Sequestra= a fragment of dead bone attached to healthy bone Duration of Infection Mechanism of BoneInfection Cierny and Mader Classification of Osteomyelitis
Host healthy Patient without comorbidities Local Compromise Smoking, chroniclymphedema, venous stasis,arthritis, large scars, fibrosisby radiotherapy Systemic Compromise Diabetes mellitus,malnutrition, renal or hepaticfailure, chronic hypoxia,extremes of age Poor clinical conditions Surgical treatment will havehigher risk than theosteomyelitis itself Medullary Infection restricted to the bonemarrow. Superficial Infection restricted to corticalbone Localized Infection with clearly definededges and bone stabilitypreserved Diffuse Infection spread to the entirebone circumference, withinstability before or afterdebridement Anatomical Stage Host Classification Pathology of Osteomyelitis
Staphylococcus bacteria most common bacteriato cause Osteomyelitis Bacteria enters bone causing an infection. Bacteria can enter bone via bloodstream, from anearby infection, or direct contamination Risk factors include: Open wound over a bone Open fracture Recent surgery Injection around bone Medications that weaken immune system Pre-morbid conditions (diabetes) When I say risk factors, these are events that can cause osteomyelitis. Pre-morbid conditions include diabetes (the most common), cancer, sickle cell anemia, high blood cholesterol, immune system deficiencies, and peripheral vascular disease Signs and Symptoms Fever or chills Irritability or lethargy Fatigue
Pain in the area of infection Swelling, warmth, redness, & possibly pus overthe area of infection Nausea Unexplained weight loss Excessive sweating Stiffness Decreased ROM Ways to diagnose Physical Examination Medical History X-rays
Blood Tests Bone Scans Computed Tomography (CT) Scan Magnetic Resonance Imaging (MRI) **Bone Tissue Biopsy** Bone tissue biopsy is important because it allows the physician to know exactly which bacteria has caused the infection MRI is most useful in the diagnosing of acute osteomyelitis X Rays MRI Treatment Antibiotics Lifestyle changes (i.e. quitting smoking)
Treatment of underlying cause (i.e diabetes) Surgery May include one or more of the followingprocedures: Drainage of the infected area Removal of diseased bone and tissue Restoration of blood flow to bone Removal of any foreign objects Amputation of the limb Prognosis If caught early on then prognosis is very good
Delay of diagnosis can lead to permanentdeficits 31% of Osteomyelitis recurrence happenswithin 1 year of diagnosis Suspected Functional Losses
**Depends where the Osteomyelitis is located and theseverity of the condition** *WALKING* Decreased strength, ROM, and endurance Decreased ADL (bathing, dressing, sleeping, etc.) Decreased IADL (driving, cleaning, running errands, etc.) Decreased performance of social activities Psychological changes Lifestyle/role changes Loss of limb(s) OT Implications **PSYCHOSOCIAL** **Pain Reduction**
Teach and educate clients to fully participate in: Self care Work or school Play or leisure IADL Patient positioning Example: We need to educate staff, patient, and caregivers that staticpositioning of a limb can cause other problems like DVTs. OT Implications Cont. Patient education: Strengthening and ROM
Energy conservation Work simplification Home modifications *Patient can be in a wheelchair permanently after having osteomyelitis sofurniture, doorways, cabinets, etc. will need to be modified for the patientto function independently in his/her new lifestyle* Medication management Strengthening and ROM Vocational rehabilitation Leisure exploration Adaptive equipment Prosthetic training Provide resources (i.e. support groups, books, blogs,etc.) Model Model of Human Occupation (MOHO)
Based on three subsystems: volition, habituation,and performance capacity. Learning how the impairment has affected thepersons life and using the persons interests togain full participation in functional activities Theories Biomechanical Rehabilitation
Intervention approach aimed at increasing ROM,strength, and endurance to improve functionaloutcomes Rehabilitation Intervention approach that focuses on the clientsability to return to the fullest physical, mental,social, vocational, and economic functioning as ispossible while using compensation and adaptation Focus on the clients abilities instead of disabilities Treatment Session Session 2:
17 year old female who is a senior in high school and hasdiabetes Acquired Staphylococcus bacteria (staph infection) from thelocker room at school through an open abrasion on her thighthat she got while playing softball Staph infection spread to the bone resulting in acute osteomyelitis of thefemur On antibiotics to fight off infection and decrease the chances of surgery Pain and constant fatigue make it difficult to participate in socialand leisure activities Problem: Decreased participation in social and leisure activitiesdue to pain and constant fatigue Goal: Patient will utilize energy conservation/work simplificationtechniques independently during all functional and socialactivities by discharge Treatment Session Cont.
Introduction, Homework Review, & Pain level- 10 min. Activity- 40 min.* *OT learned that prom is coming up and it is important to the patientto attend it* Patient will utilize energy conservation techniques while shopping andgetting ready for prom Dresses will be hanging around the clinic area like a store and thepatient will go pick a dress out to wear to prom Client will walk for as long as she can and practice using her wheelchairand walker provided by the OT whenever she feels tired or increased painlevels Patient will apply makeup at the dresser and will be reminded, if needed,of techniques to use to decrease fatigue OT will cue patient to utilize her energy conservation techniquesthroughout the activity (taking breaks, laying makeup out before applyingit, sitting down to get ready, etc.) and offer new strategies if needed Having the client walk as long as she can works on strengthening as well as endurance Treatment Session Cont.
End of Activity and Reflection- 10 minutes Therapist will get patients feedback about the session and willremind her of the importance of the energy conservationtechniques Introduction of pain management techniques andexercises to look at for next session Patient should continue to utilize energyconservation and work simplification techniquesduring all activities End of Session Two groups of children with Osteomyelitis:
Article 1 The impact of evidence-based clinical practice guidelines applied by a multidisciplinary team for the care of children with osteomyelitis Purpose to evaluate the impact ofevidence-based clinical practice guidelines asapplied by a multidisciplinary team throughdaily surveillance and management Two groups of children with Osteomyelitis: Group 1 consisted of 210 children who had beentreated before implementation of guideline-driventreatment Group 2 consisted of 61 children who had beentreated using guidelines applied by themultidisciplinary team Two groups were compared with respect to:
patient demographics length of hospital stay contagious infection the percentage of patients who had blood and tissuecultures the rates of positive cultures causative organism MRI utilization and timing surgical procedures initial antibiotic utilization antibiotic changes duration of intravenous and/or oral antibiotic use the rate of readmission Results Group 2 had better outcomes in almost allsignificant differences found between twogroups including: Shorter delay time of MRI after admission Higher Percentage of patients who had had a bloodculture before antibiotic & higher percentage ofpatients who had had a culture of tissue from theinfection site Higher percentage of patients in whom the infectingorganism was identified on tissue or blood culture Fewer number of antibiotic changes Shorter length of stay in hospital and fewerreadmissions Take home message! A guideline-driven treatment applied througha multidisciplinary approach resulted in amore efficient diagnostic workup, a higherrate of identifying the causative organism,improved adherence to initial antibioticrecommendations with fewer antibiotic changes, and shorter hospital stays withfewer readmissions Diagnosis of DFO confirmed by probe-to-bone test and X-ray
Article 2 Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: A randomized comparative trial Purpose to compare the outcomes of treatment ofdiabetic foot osteomyelitis (DFO) in patients treatedexclusively with antibiotics versus patients treatedexclusively with conservative surgery and short termpostoperative antibiotics 2 groups: 24 in Antibiotic Group (AG) 22 in Surgery Group (SG) Diagnosis of DFO confirmed by probe-to-bone test andX-ray Inflammatory markers measurements taken atbeginning and end of study Antibiotics for 90 days and conventional surgeryimmediately with postoperative antibiotics for 10 days 12 week follow up of both groups Probe-to-bone test determined osteomyelitis if the bone felt hard and gritty when touched with the probe Results Eighteen patients in the AG and 19 patients inthe SG achieved primary healing healing from either only antibiotics or only surgerydepending on which group the individual was in Majority of the inflammatory markers wentdown in both groups The primary wound healing andnormalization of inflammatory markers fromboth treatments shows that DFO can bereduced after both antibiotic treatment andconservative surgery. 70 patients identified for this study
Article 3 Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children Hypothesis majority of children with acute septicarthritis and acute osteomyelitis could be managed by 3full days of intravenous antibiotics followed by 3 weeksof oral therapy 70 patients identified for this study 34 from Birmingham Childrens Hospital 36 from The Royal Childrens Hospital in Melbourne Septic arthritis (SA)= 33 Acute osteomyelitis (OM)= 37 Diagnosis of septic arthritis positive blood or aspiratecultures or a large number of joint aspirate white blood cellcount Diagnosis of osteomyelitis based on clinical findings(pain and fever) and positive culture and/or imaging (i.e.MRI). All patients were assessed clinically for limb functionincluding pain, swelling, range of motion of affectedjoints, and ability to weight bear for lower limb problems Temperature and inflammatory marker measurementswere taken Patients began high dosage of intravenous antibioticafter evaluation for 3 days After 3 days patients were reevaluated to determinewhether or not they were ready to switch to low dosageoral medication for 3 weeks 59% of patients were able to switch to oral medicationsafter 3 days and 86% by day 5 with the average inpatientcare duration being five days. Patients were followed up 3 weeks, 6 weeks, 3 months, 6months, and one year Results 58 patients (28 patients with osteomyelitis and 30patients with septic arthritis) were clinically andhematologically normal at three week follow up andremained normal through discharge Some patients were recommended to continue oralmedication, some readmitted to hospital for IVantibiotics, and some had complications thatcorrected themselves without extra treatment. By year follow up all patients were clinically andhematologically normal Take home message children with acute septicarthritis and acute osteomyelitis can be treated with 3days of high dose IV antibiotic and three weeks oforal medication instead of the usual prolonged use ofantibiotics References eomyelitis treatment-diagnosis-symptoms conditions/osteomyelitis/basics/causes/con litis and_Septic_Arthritis/ Lima, A. L. L., Oliveria, P. R., Carvalho, V. C., & Cimmerman, S.(2014). Recommendations for the treatment of osteomyelitis. TheBrazilian Journal of Infectious Diseases, References cont. (Articles)
Copley, L. A. B., Kinsler, M.A., Gheen, T., Shar, A., Sun, D., &Browne, R. (2013). The impact of evidence-based clinical practiceguidelines applied by a multidisciplinary team for the care ofchildren with osteomyelitis. The Journal of Bone and JointSurgery, 95 (8), doi: /JBJS.L.00037 Lazaro-Martinez, J. L., Aragon-Sanchez, J., & Garica-Morales, E.(2014). Antibiotics versus conservation surgery for treatingdiabetic foot osteomyelitis: A randomized comparative trial.Diabetes Care, 37 (4), doi: /dc Jagodzinski, N. A., Kanwar, R., Graham, K., & Bache, C. E. (2009). Prospective evaluation of a shortened regimen oftreatment for acute osteomyelitis and septic arthritis in children.Journal of Pediatric Orthopedics, 29 (5), doi: /BPO.0b013e3181ab472d. References cont. Resources
therapy.advanceweb.com/sharedresources/AdvanceforOT/Resource s/DownloadableResources/OT_051503_energy_patient.pdf https://patienteducation.osumc.edu/Documents/sav-eng.pdf %20Health%20Information/Alternative%20Ways%20to%20Control%20 Pain.pdf FAF DDC/$file/Osteomyelitis.pdf Questions anyone?