Infectious agents, penetrating from the external environment or a chronic focus within the body, can affect any tissue. Purulent melts form in the bones with the formation of sequesters – new altered fragments due to the work of osteoclasts. These cells try to resist microbial aggression by restoring bone structures. However, the effect of their activity is insufficient, because against the background of reduced immunity and high invasive ability of bacterial pathogens, purulent fusion continues. This is how osteomyelitis is formed – the focus of infection of the bone tissue.
The standard of therapeutic measures includes conservative care for the patient, surgical methods of influencing the bacterial process. Acute inflammation involves a small intervention, limited to local trepanation and the establishment of an outflow of purulent contents. The protocol of surgery for chronic osteomyelitis may include various techniques, up to partial bone resection and application of the Ilizarov apparatus. Reviews of patients undergoing radical intervention indicate that the duration of the rehabilitation period is quite high. However, subsequently, complete recovery is often observed, freeing patients from prolonged painful manifestations of the disease.
The disease occurs in children and adults – from birth to late old age. The main cause of osteomyelitis is bacteria that penetrate the bone tissue by contact or hematogenous route. Among microorganisms, the etiological basis is:
- staphylococci, especially golden;
- blue pus bacillus;
- spore-forming bacteria;
- Klebsiella, Legionella and rarer infectious agents.
More than 90% of all osteomyelitis is caused by staphylococci and streptococci. After surgical interventions on the bone tissue to replace the prosthesis in the absence of a proper antiseptic, conditionally pathogenic microorganisms enter the wound. This complicates the identification of the etiological factor, affects the choice of antibiotic, since such a flora is extremely insensitive.
The reasons for the decrease in local immunological protection are known – these are factors that contribute to the penetration of bacteria into bone tissue:
- foci of bacterial inflammation in the body – caries, gallstone disease, infections of the genitourinary tract, tonsillitis;
- prolonged acute respiratory diseases that reduce cellular and humoral immunity;
- HIV infection;
- alcoholism, drug addiction;
- bone injury;
- operations – tooth extraction, endoprosthetics.
Against the background of weakening of the body’s defense, bacteria penetrate and multiply in bone tissue. As a result, a focus of purulent fusion appears.
The main manifestations of osteomyelitis:
- temperature increase;
- edema and hyperemia on the skin around the local area of damaged bone tissue;
- asymmetry of limbs or face;
- worsening of general well-being – intoxication, weakness, sweating.
The specific manifestations of osteomyelitis and its diagnosis depend on the location of the pain and the inflammatory process. The following bones are most susceptible to destruction:
In children, the process can spread to the joints due to the weakness of the synovial membrane. Pain and intoxication take pronounced features, which aggravates the course of the disease in minors.
The basic principles of treatment of osteomyelitis:
- prescribing antibiotics;
- surgical debridement of the site of infection;
- restorative therapy;
- recovery and rehabilitation.
Treatment after osteomyelitis includes vitamin therapy, stimulation of the immune system, preventive courses of antibacterial effects, exercise therapy, massage and symptomatic relief.
Antibacterial therapy is prescribed before and after surgical debridement. The main task of antibiotics is to suppress the active reproduction of microorganisms. Regardless of the localization of the infectious focus, parenteral intravenous agents combined with those taken orally are most widely used. For antibiotic therapy, groups of drugs are used:
- cephalosporins – cefuroxime, ceftazidime, ceftriaxone;
- glycopeptides – vancomycin;
- semi-synthetic penicillins – Amoxicillin in combination with clavulanic acid, Ticarcillin;
- aminoglycosides – Tobramycin, Amikacin, Netilmicin;
- fluoroquinolones – Levofloxacin, Ciprofloxacin;
- imidazole derivatives – metronidazole;
- antibiotics of other groups in certain categories of patients.
The choice of a specific drug depends on the severity of the patient’s condition, the characteristics of infection. Below is a table of options for antibacterial combinations in various categories of patients.
|Children||Weakened persons of any age, elderly people||Addicts and HIV-infected||Ordinary patients|
|Acute osteomyelitis||Amoxicillin + clavulanic acid in combination with cefuroxime or cefotaxime||3-4 generation cephalosporins in combination with fluoroquinolones and metronidazole||Vancomycin, Rifampicin, Biseptol in combination with cephalosporins 2-3 generations||Ceftriaxone plus aminoglycosides|
|Postoperative process||Imipenem or previous combination||Vancomycin||Same combination||Fluoroquinolone, Cephalosporins, Metronidazole|
|Chronic osteomyelitis||Amoxicillin + clavulanic acid, Vancomycin, Cefepime||Ceftazidime, Aminoglycosides, Metronidazole||Vancomycin, metronidazole, fluoroquinolones in large doses||Cephalosporins, aminoglycosides, ticarcillin|
|Diffuse lesion with numerous foci in the bones||Parenteral Macrolides, Cephalosporins, Vancomycin||Same combination||Same combination||Metronidazole plus vancomycin in combination with cephalosporins|
|Concomitant Mix Infection||Imipenem, Vancomycin||Cephalosporins 4-5 generations, Netilmicin, Metronidazole, fluoroquinolones||Biseptolum, Vancomycin, Imipenem||Same combination|
|Sustainable forms of the disease||Vancomycin||Vancomycin, Imipenem||Same combination||Vancomycin or Imipenem|
Medication along with antibiotics should include detoxification by the introduction of plasma-replacement fluids, vitamin therapy, specific drugs for certain categories of patients. In case of HIV infection, parallel antiretroviral therapy (antiviral effect) is mandatory. In the absence of an effect on the retrovirus, the effect of antibiotic therapy will be negligible even with the use of all groups of antibiotics.
With multifocal diffuse osteomyelitis, which spreads by the hematogenous route, only intravenous and intra-arterial administration of antibiotics is indicated. For children, the suppression of inflammation plays a role, so you can neglect some adverse reactions of drugs and expand the range of antibacterial effects. Initially, empirical therapy is prescribed to all categories of patients to suppress the most likely pathogens. Further correction is carried out by identifying a specific microorganism that has caused a focus of acute or chronic inflammation. In addition to medicines and surgical care, physiotherapy with a laser, UHF or diadynamic currents is used.
To alleviate the suffering of the patient, folk remedies can be used. They are not basic, since without full medical care the patient will die, but they can accelerate the healing process. For local exposure, healers recommend the following herbs to help with osteomyelitis:
These plants have a wound healing, absorbable, anti-inflammatory effect. Decoctions and tinctures are made of them, and then compresses are applied to the affected area of the bone tissue. Removing pus with aloe juice in osteomyelitis has been practiced in folk medicine for many years. Comfrey therapy is just as popular as a plant with pronounced analgesic properties. Against caries, chamomile or calendula in the form of a decoction is used as a means to rinse the oral cavity. However, with all the advantages of alternative methods of treatment, their effectiveness in severe osteomyelitis is insufficient, so the help of a surgeon is necessary.
Osteomyelitis is a purulent process of bone tissue with the formation of sequesters and abscesses, so therapeutic measures can not do without surgical intervention. At home, the disease is not treated, therefore, to ensure full assistance to the patient, hospitalization in a purulent surgical department is necessary.
The main modern methods of surgical correction include:
- local trepanation by applying milling holes with drainage;
- opening an abscess;
- sequestrectomy and open debridement of the site of infection;
- bone resection with the application of the Ilizarov apparatus;
- open osteosynthesis using metal plates;
- replacing a bone site with artificial material.
Which surgical treatment to choose, the specialist decides, based on the characteristics of the disease. Acute cases often end happily after a simple trepanation, but the chronic process needs radical surgical care.
Infection after tooth extraction
One of the varieties of the disease is osteomyelitis of the jaw. It occurs when an infection occurs by contact after tooth extraction, accompanied by severe pain syndrome with the inability to perform chewing functions. The problem requires immediate treatment, as the quality of life of the patient is sharply impaired.
The basic principles of therapy include:
- surgical debridement of the lesion in the jaw;
- the use of antibiotics;
- immobilization by applying a tire;
- sparing diet;
Even “neglected” joint problems can be cured at home! Just remember to smear it once a day.
The sequence of treatment measures begins with surgical care, then immobilization is applied, and conservative measures are prescribed in parallel. After removing the tires, the treatment changes: the dose of antibacterial drugs decreases, the local antiseptic effect ceases, the diet is expanded, physiotherapeutic help joins. Within two weeks, complete recovery occurs.
Foci of chronic infection are often located in the oral cavity: poorly healed carious teeth, tonsillitis, sinusitis cause microorganisms to enter the region of the upper or lower jaw. This is how osteomyelitis develops, which is facilitated by facial injuries, complicated by maxillary sinus puncture or tooth extraction. The clinic of odontogenic osteomyelitis includes the following symptoms:
- severe pain in the affected area;
- sharp swelling of the oral mucosa and skin over the affected jaw;
- temperature increase;
- facial asymmetry;
- weakness, severe fatigue.
The patient has a mastication function, as it is often difficult to open his mouth. Speech changes, headaches join. Intoxication is increasing, and the process is prone to spread rapidly in the absence of help. Therefore, the dentist evaluates the symptoms and treatment in order to decide on the management of the patient.
The defeat of the bone requires surgical debridement of the jaw, which is performed by open access through the oral cavity. Further tactics are tire immobilization followed by x-ray control of changes in bone tissue. Conservative antibiotic therapy with an extended spectrum of action is prescribed. Metronidazole is especially often used in combination with cephalosporins of 3-4 generations. Additionally, fluoroquinolones or rifampicin are prescribed. You can help the patient and folk remedies. To do this, rinse with phyto-antiseptics, which are part of chamomile, calendula or eucalyptus, is used. The composition can be prepared independently, but it is preferable to use ready-made pharmacy tinctures of these plants in breeding.
Osteomyelitis in Dentistry
Damage to the jaw plays a leading role in the genesis of osteomyelitis after tooth extraction. Infection occurs in the dental office or at home due to improper care of the postoperative wound. The main symptoms are associated with damage to the oral cavity:
- strong pain;
- sharp swelling;
- inability to eat;
- difficulty speaking;
- manifestations of intoxication.
Therapeutic measures boil down to the rehabilitation of the osteomyelitis foci with the subsequent prescription of antibiotics. Surgical measures are carried out in the hospital, and with a favorable course of the disease in the next 3-4 days, the patient is discharged for observation in the surgical room of the dental clinic. Antibiotics are changed to oral ones while maintaining the dosage, and X-ray control and removal of immobilization is carried out on an outpatient basis. This approach is needed for the convenience of the patient and accelerate the rehabilitation period.
Symptoms and treatment of bone lesions depend on the localization of the inflammatory process. Calcaneus osteomyelitis most easily proceeds. The affected area is localized only by a small area of the limb. Therefore, edema and impaired leg function, although there are, but easy access for drainage and powerful antibiotic therapy provide a quick result.
The defeat of the lower leg captures the process in the tibia, which proceeds with sharp violations of limb function:
- acute pain;
- swelling of the leg;
- inability to walk;
- increased intoxication;
- hectic fever.
With inflammation of only the tibia, the strength of the pain decreases. However, quick access to it is difficult, and with the joined violation of blood supply in the lower extremities, the disease is often delayed.
The defeat of the femur passes with severe intoxication and often with immobilization of the patient. The usual trepanation is not enough, because the muscle mass around is great. Therefore, an open operation is performed, which delays the rehabilitation and complete recovery of the patient. Sciatic osteomyelitis leads to sharp lower back pain. Sometimes paresis of a limb reaches such a force that completely complicates the movement of the patient. Open surgery is rarely performed, trepanation and conservative therapy are more often used.
If you damage any bone in the legs, you can help with folk remedies. Herbs in the form of decoctions or tinctures, applied in the form of a compress to the inflamed area, accelerate the removal of edema and enhance the effect of antibiotics. However, their use in open drainage is futile, since the ingestion of foreign bodies of plant origin enhances bacterial growth in the wound.
With inadequate treatment of the acute process, a prolonged inflammatory focus in the bone tissue is formed. Part of it is sclerosed, which causes Garre disease, the treatment of which is carried out for years in periods of exacerbation. But sclerodegenerative osteomyelitis is treated only conservatively, the basis of therapy is physiotherapy and exercise therapy. Limited Brody abscess arising from the formation of a cavity in the bone tissue is filled with purulent masses. Here, an expanded rehabilitation is required, followed by immobilization of the limb.
After post-traumatic osteomyelitis, rehabilitation is always delayed. This is due to the involvement of soft tissues in inflammation. A purulent fistula is formed, the course of which continues deep into the bone tissue. Radical treatment will be required, with resection of the affected area and replacement with artificial materials. In case of damage to the metatarsal bone or little toe, which is quite rare, treatment is limited to closed debridement with antibacterial therapy. The same approach is used for inflammation of the rib or sternum. Severely occurring hip osteomyelitis requires serious measures – endoprosthetics or the installation of an Ilizarov apparatus.
Damage to the vertebrae leads not only to pain, but also to neurological deficiency in the lower extremities. This is manifested by difficulty walking, impaired function of the pelvic organs, the development of flaccid paresis of the legs. Symptoms and treatment are evaluated by a neurosurgeon, which often changes the tactics of standard therapy.
- surgical debridement;
- with the location of the osteomyelitis lesion in the closure plastic, it is completely removed;
- conservative treatment – physiotherapy, antibiotics;
- symptomatic assistance – removal of intoxication, anesthesia, improvement of blood flow in the limbs;
- wearing an immobilizing corset.
In case of damage to the lumbar spine, treatment is aimed at stabilizing neurological disorders. In addition to laminectomy, wound drainage is carried out, followed by powerful antibiotic therapy.
Pathology of the big toe is rare. It provokes the process of gout, traumatic damage to this zone. Osteomyelitis proceeds as a chronic lesion with periodic exacerbations and the formation of a purulent fistula. This is due to insufficient blood supply to the zone, especially in people of an older age group.
In order to prevent the spread of infection, one of the treatment methods is the radical removal of the affected phalanx. This approach is due to the low effect of antibiotic therapy even against the background of the use of drugs that improve blood supply to the limb. The overlying sections of the leg are characterized by better blood flow, so treatment is prescribed according to the standard protocol for managing patients.
The spread of infection through the blood always presents a danger in terms of the development of septic complications. One of these foci is hematogenous osteomyelitis, which is more common in children and debilitated patients. The most important condition for the speedy recovery of patients with sepsis is the combination of prompt surgical assistance and conservative therapy.
The main method of surgical treatment of acute hematogenous osteomyelitis is local milling trepanation with the addition of active drainage. The principle of help is simple – the outflow of pus is quickly established, and then empirical antibiotic therapy is added. To clarify the causative agent, not only purulent discharge of the wound is taken for examination, but also the blood of the patient.
Any leg bone can be affected by infectious agents. Most often, inflammation is localized in the lower leg or thigh. With shin damage, symptoms and treatment are evaluated by a traumatologist. The following antibiotics are used as conservative help:
- in severe cases, vancomycin.
One antibiotic does not treat the lower extremities. Usually an effective combination is used depending on the sensitivity of the isolated pathogen. Symptoms, treatment, rehabilitation are under the supervision of a specialist until the patient recovers completely.
Where is osteomyelitis treated? This question is asked by each patient, as well as his relatives. Neither in Russia, nor abroad does a special center that deals only with osteomyelitis therapy exist. Large trauma clinics are involved in medical measures. In Russia, treatment is carried out free of charge in full at the patient’s place of residence or in central hospitals with a quota.
In Germany and Israel, as well as in other countries, most orthopedic centers have departments where they help patients with osteomyelitis. Treatment takes place exclusively on a reimbursable basis, including not only payment for the work of surgeons, but also hospital stay. The cost of assistance in Israel is disproportionately higher than in any European country.
Shishkevich Vladimir, orthopedic and traumatologist, project editor-in-chief ExpertNews.
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