Chronic osteomyelitis of the right. Osteomyelitis of the bone: symptoms, treatment and causes of the disease, photo

Inside the bones is the marrow. When it becomes inflamed, osteomyelitis develops. The disease spreads to compact and spongy bone, and then to the periosteum.

What it is

Osteomyelitis is an infectious disease that affects the bone marrow and bone. The causative agents of the disease penetrate the bone tissue through the bloodstream or from neighboring organs. The infectious process can primarily occur in the bone when it is damaged due to a gunshot wound or.

In pediatric patients, the disease mainly affects the long bones of the upper or lower extremities. In adult patients, the frequency of the osteomyelitic process of the spine increases. In people with diabetes, the disease can affect the bones in the foot.

This pathology before the invention of antibiotics was considered incurable. modern medicine copes with it quite effectively, using surgical removal of the necrotic part of the bone and a long course of potent antimicrobial agents.

There are several theories for the development of the disease. According to one of them, proposed by A. Bobrov and E. Lexer, an accumulation of microbes (embolus) is formed in a distant focus of inflammation. Through the blood vessels, it enters the narrow terminal arteries of the bones, where the blood flow slows down. Microorganisms settled in this place cause inflammation.

It is also assumed that the basis of the disease is the allergization of the body in response to a bacterial infection.

If microbial agents are weakened, and the body's immune response is strong enough, osteomyelitis can take on a primary chronic character without suppuration and bone destruction.

The development of inflammation in the bone substance causes the formation of a sequester - a specific sign of osteomyelitis. This is a dead part that is spontaneously rejected. Around the sequester, vascular thrombosis occurs, blood circulation and bone nutrition are disturbed.

Around the sequester accumulate immune cells forming a granulation shaft. It is manifested by thickening of the periosteum (periostitis). The granulation shaft well delimits dead tissue from healthy. Periostitis along with sequesters is a specific sign of osteomyelitis.

Classification

Clinical classification of osteomyelitis is carried out according to many criteria. The more precise the formulation of the diagnosis, the clearer becomes the tactics of treatment.

Types of disease depending on the pathogen:

• caused by nonspecific microflora (gram-positive or gram-negative): staphylococcus aureus, pneumococcus, streptococcus, proteus, Escherichia coli and Pseudomonas aeruginosa, less often anaerobes:
• caused by one type of microbe (monoculture);
• associated with association 2 or 3 different types microorganisms.
• specific for infectious pathology:
• syphilitic;
• leprous;
• tuberculosis;
• brucellosis;
• other.
• the pathogen was not found.

There are clinical forms of the disease:

• hematogenous:
• after an infection of another organ;
• post-vaccination;
• other.
• post-traumatic:
• after fractures;
• after operation;
• when using spoke devices.
• gunshot;
• radiation;
• atypical (primary chronic):
• abscess Brody;
• osteomyelitis Ollie and Garre;
• tumor-like.

Flow options:

• generalized:
• septicotoxic;
• septicopyemic;
• isolated toxic.
• focal:
• fistulous;
• fistulous.

The nature of the flow:

• acute (in particular, fulminant);
• subacute;
• primary chronic;
• chronic.

There are such stages of the osteomyelitic process:

• acute;
• subacute;
• ongoing inflammation;
• remission;
• exacerbation;
• recovery;
• convalescence.

Phases of defeat:

• intramedullary (only the bone marrow suffers);
• extramedullary.

By localization, osteomyelitis of tubular and flat bones is distinguished. In long tubular bones, different departments can be affected: epiphysis, diaphysis, metaphysis. Among the flat bones, the skull, vertebrae, shoulder blades, ischial bones, and ribs are affected.

Local complications of osteomyelitis:

• sequestration;
• fracture;
• bone, paraossal or soft tissue phlegmon;
• pathological dislocation;
• the formation of a false joint;
• ankylosis;
• articular contractures;
• violation of the shape and development of the bone;
• bleeding;
• fistulas;
• vascular complications;
• neurological complications;
• muscle and skin disorders;
• gangrene;
• malignancy.

Variants of the disease with common complications:

• amyloid damage to the kidneys and heart;
• severe pneumonia with lung collapse;
• inflammation of the pericardium;
• sepsis;
• other.

The most common variants of the disease are acute hematogenous (in childhood) and chronic post-traumatic (in adult patients).

The disease often affects certain bones of the human body.

Osteomyelitis of the hip

It is observed in people at any age, is more often of hematogenous origin, but often develops after surgery on the bones. Accompanied by swelling of the thigh, fever and impaired mobility of adjacent joints. A large fistula forms on the skin, through which pus is separated.

Osteomyelitis of the bones of the leg

It is observed more often in adolescents and adults, often complicating the course of leg fractures. Accompanied by redness and swelling of the lower leg, severe pain, the formation of fistulous passages with purulent discharge. First, the tibia is affected, but then the fibula always becomes inflamed. The patient cannot step on the foot.

Osteomyelitis of the calcaneus

Unlike the forms described above, it usually has a long course and often complicates infectious diseases feet, for example, in diabetes. The main symptoms are soreness and swelling in the heel, redness of the skin, the formation of an ulcer with the release of purulent contents. The patient can hardly move, relying on the front of the foot.

shoulder osteomyelitis

Often occurs in childhood, has an acute course, accompanied by fever, swelling, pain in the arm. With the progression of the disease, pathological fractures are possible.

Metatarsal osteomyelitis

It develops with insufficiently thorough surgical treatment of a wound resulting from a foot injury. It can also complicate the course of diabetes. Accompanied by soreness and swelling of the foot, difficulty walking.

Vertebral osteomyelitis

It develops mainly in adults against the background of immunodeficiency or a septic condition. Accompanied by back pain, headache, palpitations, weakness, fever.

The reasons

The vast majority of cases are caused by staphylococci.

These microorganisms are widely distributed in the environment. They are found on the surface of the skin and in the nasal cavity in many healthy people.

Microbial agents can penetrate the bone substance in different ways:

1. Through blood vessels. Bacteria that cause inflammation in other organs, such as pneumonia or pyelonephritis, can spread through the vessels into the bone tissue. In children, the infection often penetrates into the growth area - the cartilage plates at the ends of the tubular bones - the shoulder or femur.
2. Infected wounds, endoprostheses. Microorganisms from stab, cut and other wounds enter the muscle tissue, and from there spread to the bone substance.
3. Fractures or operations, when infectious agents enter directly into the bone substance.

Bones healthy person resistant to the development of osteomyelitis. Factors that increase the likelihood of pathology:

• recent trauma or surgery to the bones or joints, including hip or knee arthroplasty;
• implantation of a metal bracket or wires during osteosynthesis;
• animal bite;
• diabetes with high blood sugar;
• disease peripheral arteries often associated with atherosclerosis and smoking, for example, atherosclerosis or endarteritis obliterans;
• having intravenous or urinary catheter, frequent intravenous injections;
• hemodialysis;
• chemotherapy for cancer;
• long-term use of glucocorticoid hormones;
• injection drug addiction.

Diagnostics

The doctor examines the area around the affected bone to determine redness and tenderness of the tissues. A blunt probe is used to examine fistulas.

Blood tests reveal signs of inflammation - an increase in ESR and the number of leukocytes. Blood and fistulous discharge are subjected to microbiological examination to recognize the type of microorganism and determine antibacterial agents that effectively destroy it.

The main diagnostic procedures for osteomyelitis are imaging tests.

X-ray of bones is used to detect necrotic areas of the bone - sequesters. Fistulography - the introduction of a radiopaque substance into the fistulous tract - is used to study internal structure fistula. In the early stages of the disease, radiographic examination provides little information.

A CT scan is a series of x-rays taken from different positions. When they are analyzed, a detailed three-dimensional picture of the affected bone is formed.

Magnetic resonance imaging - safe method research, which allows to recreate in detail the image not only of the bone, but also of the soft tissues surrounding it.

A bone biopsy is performed to confirm the diagnosis. It can be performed in the operating room general anesthesia. In this case, the surgeon cuts through the tissue and takes a piece of the inflamed material. Then a microbiological study is carried out to identify the pathogen.

In some cases, a biopsy is taken under local anesthesia with a long, strong needle passed to the site of inflammation under x-ray control.

Symptoms of osteomyelitis of the bone

Signs of osteomyelitis:

• fever and chills;
• bone pain
• swelling of the affected area;
• impaired function of the affected limb - the inability to raise the arm or step on the affected leg;
• the formation of fistulas - holes in the skin through which pus is released;
• feeling unwell, in children - irritability or drowsiness.

Sometimes the disease proceeds almost without external manifestations.

Seek medical attention if you have a combination of fever and pain in one or more bones.

The physician must differential diagnosis with the following diseases:

• infectious arthritis;
• intermuscular hematoma, including festering;
• bone fracture.

Chronic osteomyelitis of the bone

This form most often serves as the outcome of an acute process. A sequester cavity is formed in the bone substance. It contains loose pieces of dead bone tissue and a liquid purulent discharge. The contents of the sequester box is released through the fistulas to the surface of the skin.

The development of the disease is undulating: the closure of fistulas is replaced by a new phase of inflammation and pus. When the exacerbation subsides, the patient's condition improves. The skin temperature returns to normal, the pain disappears. Blood counts are close to normal. At this time, new sequesters are gradually formed in the bone substance, which begin to be rejected and cause exacerbation. The duration of remission can be several years.

Signs of recurrence resemble acute osteomyelitis. There is inflammation and pain in the affected area, a fistula opens, and soft tissue phlegmon may develop. The duration of relapse is determined by many conditions, primarily the effectiveness of treatment.

Primary chronic forms occur without signs of an acute stage. Brodie's abscess is a single cavity of a round shape in the bone substance, surrounded by a capsule and located in the bones of the lower leg. The abscess contains pus. Severe symptoms inflammatory process No, the disease is sluggish. With exacerbation, pain in the leg occurs, especially at night. Fistulas are not formed.

Sclerosing osteomyelitis is accompanied by an increase in bone density, layers of the periosteum. The bone thickens and takes the form of a spindle. The medullary canal narrows. This form is difficult to treat.

Acute osteomyelitis

The most common variant of this process is hematogenous. It is seen mainly in boys. Phlegmonous inflammation of the bone marrow canal develops.

The toxic variant proceeds at lightning speed and can lead to the death of the patient within a few days. The septicopyemic variant is characterized by the presence of abscesses not only in the bone substance, but also in the internal organs.

Most patients have a local form of the disease. The illness starts suddenly. There is a feeling of fullness and intense pain in the limb, more often near the knee, shoulder or elbow joints. It intensifies with movement. The body temperature rises.

Pallor is noted skin, rapid breathing and pulse, lethargy and drowsiness. The limb is in a bent position, movements in it are limited. Above the area of ​​inflammation, swelling and redness of the skin occurs. There is severe pain when tapping in the affected area or in the direction along the bone axis.

X-ray changes appear only 2 weeks after the onset of the disease.

Treatment of osteomyelitis of the bone

In an acute process, urgent hospitalization is required. Treatment is through surgery and medicines.

The operation includes osteoperforation - the formation of a hole in the bone, cleansing and drainage of the cavity. In severe cases, purulent streaks in the muscles are opened and bone trepanation is performed. After cleansing the bone from pus, intraosseous lavage begins - the introduction into the cavity through plastic catheters of antimicrobial substances - antibiotics, chlorhexidine, rivanol, as well as enzymes.

Comprehensive conservative treatment includes:

• antibiotics in high doses;
• detoxification (introduction of plasma solutions, albumin, hemodez, reopoliglyukin into a vein), forced diuresis;
• correction of violations of the acid-base state with the help of intravenous infusion of sodium bicarbonate;
• stimulation of tissue repair (methyluracil);
• immunomodulating agents and vitamins.

If the disease is caused by staphylococcus, specific immunotherapy methods can be used to treat it - staphylococcal toxoid, staphylococcal vaccine, gamma globulin or hyperimmune plasma with a high content of antimicrobial antibodies.

Mandatory immobilization of the limb with a splint. After the subsidence acute inflammation physiotherapy is prescribed - UHF, magnetic field and others. Hyperbaric oxygen therapy is one of the effective procedures for osteomyelitis. It involves the inhalation of an air-oxygen mixture in a special chamber under pressure. This helps not only to improve the blood supply to all tissues, but also to speed up the healing process of the purulent focus.

The prognosis of the disease is usually favorable, it ends with recovery. However, in some cases, the disease becomes chronic.

The basis of the treatment of the chronic variant is sequesternecrectomy. During this operation, bone sequesters are removed, the bone cavity is cleaned, fistulas are excised. The resulting cavity is drained. You can close them with special plastic materials.

In case of pathological fractures, long-term osteomyelitic process, limb shortening, the method of compression-distraction osteosynthesis using the Ilizarov apparatus is used. Surgeons first perform a sequestrectomy and process the edges of the bone, removing all foci of infection. Then several wires are passed through the bone above and below the pathological focus. The spokes are secured with metal rings that surround the leg or arm. Between adjacent rings, metal rods are held parallel to the axis of the limb.

With the help of pins and rods, bone fragments are pressed against each other. At their junction, an accretion is gradually formed - a callus. Her cells are actively dividing. After the fusion of fragments, surgeons begin to gradually remove the rings from each other, increasing the length of the rods. Stretching of the callus leads to the growth of new bone and restoration of the length of the limb. The treatment process is quite lengthy, but this method has many advantages compared to other types of surgery:

• low trauma;
• lack of plaster immobilization;
• the patient's ability to move;
• the ability for the patient to independently carry out distraction (stretching) after a little training;
• restoration of healthy bone tissue, completely replacing the osteomyelitic defect.

In extreme cases, amputation of the limb is performed. It is indicated in the development of extensive phlegmon, especially caused by anaerobes, or gangrene of the limb.

After the operation, conservative treatment is prescribed. It includes the same drugs as in the acute form.

With proper treatment, the prognosis is favorable. However, recurrence of the disease is not ruled out. Persistent osteomyelitis can lead to renal amyloidosis and other complications.

Antibiotics for osteomyelitis

The problem of adequate antibiotic therapy is the need to quickly select effective drug, acting on the maximum possible number of alleged pathogens, as well as creating a high concentration in the bone tissue.

Osteomyelitis is most often caused by staphylococci. The most severe course of the disease is associated with infection with Pseudomonas aeruginosa. In conditions of a long course of osteomyelitis, surgical operations, concomitant diseases, microorganisms often acquire insensitivity to a broad-spectrum antibiotic, for example, to cephalosporins and fluoroquinolones.

Therefore, it is preferable to prescribe linezolid for empirical therapy. Vancomycin is a lesser choice, as many bacteria become resistant to it over time.

Linezolid is administered by intravenous drip. It is well tolerated. From side effects Nausea, loose stools, and headache are more common. The medicine can be used in children of any age, it has almost no contraindications. It is produced under the trade names Zenix, Zyvox, Linezolid. In forms for oral administration, Amizolid and Rowling-Routek are available.

Vancomycin is administered intravenously. It is contraindicated in the first trimester of pregnancy and during breastfeeding, with neuritis auditory nerve, renal failure, individual intolerance. The drug is produced under trade names Vancomabol, Vancomycin, Vankorus, Vankotsin, Vero-Vancomycin, Edicin.

In severe cases, the most modern antibiotics- Tienam or Meropenem. If anaerobic microorganisms are present in the microbial association that caused the disease, metronidazole is added to therapy.

Before prescribing antibiotics, it is necessary to obtain material for microbiological examination. After receiving the results of the sensitivity of microorganisms, the drug can be replaced with a more effective one.

The duration of the course of antibiotics is up to 6 weeks.

Sometimes treatment begins with broad-spectrum antibiotics that affect staphylococci:

• protected penicillins;
• cephalosporins;
• fluoroquinolones;
• clindamycin and others.

However, such treatment must necessarily be supported by data on the sensitivity of isolated microorganisms.

Simultaneously with long-term antibiotic therapy, it is necessary to prevent intestinal dysbiosis with the help of such agents as Linex, Acipol, fermented milk products with live bacteria. Assigned if necessary antifungal drugs(nystatin).

Folk remedies for osteomyelitis of the bone

After treating osteomyelitis in a hospital and discharging the patient home, some folk recipes can be used to prevent the transition to a chronic form or the development of an exacerbation:

• make a decoction of oat grass (in extreme cases, oat bran is suitable) and make compresses from it on a sore limb;
• do alcohol tincture lilacs: pour a full three-liter jar of flowers or buds with vodka and insist in a dark place for a week, use for compresses;
• take 3 kg of walnuts, remove partitions from them and pour vodka over these jumpers, insist in a dark place for 2 weeks; take a tablespoon three times a day for 20 days;
• lubricate the affected area with aloe juice or make a compress from crushed leaves;
• grate a large onion, mix with 100 g laundry soap; apply the mixture to the skin near the fistula at night.

Complications

Osteomyelitis can cause complications from surrounding tissues or the whole body. They are associated with the direct spread of infection, circulatory disorders, intoxication, changes in metabolism.

A pathological fracture occurs at the site of a sequester with minor trauma. In this case, the patient cannot step on the foot, abnormal mobility of bone fragments appears, pain and swelling are possible.

Phlegmon is a diffuse purulent inflammation that can capture the bone, periosteum or surrounding muscles. The disease is accompanied by fever, intoxication, pain and swelling of the limb. Without treatment, it can lead to blood poisoning - sepsis.

With the destruction of the ends of the bones, pathological dislocation is possible in the hip, knee, shoulder, elbow and other joints. It is accompanied by a violation of the shape of the limb, pain, inability to move the arm or leg.

One of frequent complications osteomyelitis - a false joint. The free edges of the bone, formed after the operation to remove the purulent focus, do not grow together, but only touch each other. In this place, the bone remains mobile. There is a violation of the function of the limb, pain in it, sometimes swelling. There is muscle weakness and atrophy. Treatment of a false joint is quite long. Often it is necessary to use the Ilizarov apparatus.

Ankylosis occurs when the fusion of the articular surfaces of bones affected by osteomyelitis, for example, due to long-term immobility of the limb. It is accompanied by a lack of movement in the joint.

As a result of excision of fistulas, compaction of surrounding tissues, articular contracture may develop - a decrease in its mobility.

Pathological fractures, false joints, ankylosis, contractures lead to limb deformity, inability to walk or work with hands.

Arrosive bleeding may occur, accompanied by constant blood loss and the formation of an interstitial hematoma. Suppuration of the surrounding soft tissues leads to the development of diffuse purulent inflammation - phlegmon. it dangerous complication in some cases requires amputation of the limb.

In chronic osteomyelitis, the vessels and nerves passing near the bone are significantly affected. The blood supply to the final (distal) part of the leg or arm worsens, the tissues swell, lack oxygen. There are prolonged pains in the limbs, numbness and a feeling of tingling of the skin are possible. Irritation with purulent discharge from the fistula leads to the development of dermatitis and eczema. The code becomes excessively dry, flaky, itching occurs. If the patient begins to scratch the skin, secondary infection and suppuration often appear in the wounds.

In some cases, against the background of osteomyelitis develops malignant tumor bones - osteosarcoma, which has a high degree of malignancy and is growing rapidly.

With a long course of osteomyelitis, metabolic processes in the body are disrupted. The tension of compensatory mechanisms leads to an increase in the production of a protein necessary for bone tissue healing. At the same time, pathological protein formations may appear that are deposited in the kidneys and other organs. This is how a common complication of chronic osteomyelitis develops - amyloidosis. It is manifested mainly by symptoms of renal failure - edema, increased blood pressure, violation of the process of urination.

Pathogenic microorganisms from a purulent focus through the blood vessels can enter any organ, causing inflammation. One of the most common complications is pneumonia. The outer heart sac, the pericardium, is also affected. Often there is a blood poisoning - sepsis.

Prevention

If the patient has risk factors for osteomyelitis, he should be aware of them. It is necessary to take all measures to prevent various infections, avoid cuts, scratches, treat skin damage in time. People with diabetes need to constantly monitor the condition of their feet to prevent the appearance of skin ulcers.

Dental caries, chronic tonsillitis, cholecystitis, pyelonephritis should be treated in time. To increase the nonspecific defense of the body, it is necessary to monitor nutrition and physical activity, healthy lifestyle life.

Osteomyelitis is an inflammatory process in the bone marrow that spreads to the surrounding bone substance. It can have an acute or chronic course and is manifested by bone pain, fever, intoxication, the formation of cavities and fistulas with purulent discharge. Treatment includes surgery and massive antibiotic therapy.

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- This is a chronic inflammatory process that affects 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. The alternation of remissions and exacerbations is characteristic. In the exacerbation 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. Diagnosis is based on history, clinical manifestations, X-ray data and other studies. Treatment is often surgical, sequestrectomy is performed, and according to indications, reconstructive interventions are performed.

General information

Chronic osteomyelitis is a chronic inflammation of the bone. Usually occurs after acute osteomyelitis. It can affect any bone, but long bones are more commonly affected. There is a predominance of patients with lesions of the lower extremities. Chronic osteomyelitis occurs in people of any age and gender. It is characterized by a long course with alternating exacerbations and remissions. The duration of remissions can vary from a few 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 bent 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 persistent purulent discharge cause significant inconvenience to patients, are a source of unpleasant odor, make communication difficult, and negatively affect career and personal life. In patients suffering from osteomyelitis for many years, dystrophic changes in internal organs and kidney amyloidosis are often detected.

The reasons

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 predominate. In adults, chronic post-traumatic osteomyelitis occupies the first place in prevalence, 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 tissue damage, destroyed as a result of the direct impact of the projectile and the formation of a commotion zone. The 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. Relatively rare chronic bone inflammation due to 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 becomes more chronic, the gram-positive flora is replaced by the gram-negative one or supplements it, forming microbial associations. In crops from foci of chronic osteomyelitis, Klebsiella, Proteus vulgaris, coli, Pseudomonas aeruginosa and other microorganisms.

The likelihood of transition from acute osteomyelitis to chronic depends on many factors, including general state organism, the presence or absence of immune disorders, structural features and blood supply of bone tissue, the state of the circulatory system, etc. Chronic osteomyelitis often develops in patients suffering from severe somatic diseases and concomitant injuries, as well as in debilitated and malnourished patients. Great importance has an area of ​​damage to the bone and surrounding soft tissues.

Acute osteomyelitis becomes chronic after about a month after the onset of the first symptoms. By this time, sequesters are formed in the bone, rejection of necrotic tissues begins, and fistulas form. In the absence of the effect of therapeutic measures carried out within 1.5 months from the onset of the disease, one can speak of chronic purulent inflammation of the bone. Subsequently, the process proceeds in waves, while the frequency and severity of exacerbations can vary significantly.

Symptoms of chronic osteomyelitis

In the remission phase, the patient feels well. In the affected area, a fistula usually remains with a small amount of purulent discharge, but there are no signs of general intoxication. Sometimes the fistula closes. Local inflammation is poorly expressed, signs of a chronic sluggish process predominate. Soft tissues in the area of ​​the osteomyelitic focus are thickened, the skin is purple, less often cyanotic. In chronic osteomyelitis of the extremity, the affected segment is usually thickened, swelling of the distal sections may be detected due to impaired blood and lymph circulation.

The exacerbation resembles an erased picture of acute osteomyelitis. The patient's temperature rises, weakness, weakness, 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. Perhaps the formation of intermuscular phlegmon, accompanied by a deterioration in the general condition and the appearance of intense arching or jerking pains that disturb the patient's sleep.

Soft tissues in the area of ​​phlegmon become tense, the local temperature rises. In some cases, palpation can determine the site of fluctuation. The amount of discharge through the fistula increases. If the fistula closed during the period of 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 the purulent foci, and at a considerable distance.

Diagnostics

Main instrumental method research in chronic osteomyelitis is radiography. On radiographs, signs of bone destruction are determined 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 zone of inflammation. In the acute phase, periostitis occurs, the number and nature of periosteal layers depend on the duration and severity of the process.

Sometimes, due to significant bone sclerosis, small foci are not detected on radiographs. In addition, radiography does not allow assessing soft tissue changes, therefore, in doubtful cases, patients are additionally referred for bone CT and MRI. An important part of the preoperative study is fistulography, the results of which determine the volume and tactics of surgical intervention. Fistulography makes it possible to see the direction of the fistulous tract, 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 between a fistula and a sequester, etc.

Treatment of chronic osteomyelitis

Treatment is carried out by specialists in the field of traumatology and orthopedics. Therapeutic tactics is determined depending on the patient's condition, severity, prevalence and stage. 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 dystrophic changes internal organs. During the period of exacerbation, antibiotics and means to stimulate the immune system are prescribed, purulent cavities are drained using special needles or catheters.

Cavities and fistulas are washed with antibiotic solutions. Intermuscular phlegmons are opened and drained. Surgical interventions are performed after the subsidence of acute inflammatory phenomena. Sequestrectomy is performed - foci of necrosis, granulation and areas of excessive sclerosis are completely removed. Fistulous tracts are excised based on fistulography data. The operating 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, a more complex, multi-stage treatment of chronic osteomyelitis is carried out. With false joints, shortening and severe deformity, osteotomy, resection of a bone area not involved in the pathological process, and other therapeutic measures may be required. To correct angular deformities and lengthen the affected limb segment, traumatologists apply Ilizarov devices.

Forecast and prevention

The prognosis depends on the duration of the disease, the extent of the lesion, the patient's health status and the radicalness of the surgical intervention. With fresh processes and complete excision of small lesions, complete recovery is often observed. With chronic osteomyelitis, the prognosis worsens due to trophic changes in soft tissues, extensive dystrophic bone remodeling, deterioration of local blood supply and an unfavorable general background due to impaired activity of various organs. However, surgical treatment is indicated even in advanced cases, since chronic purulent process has a negative effect on all organs and can cause a serious deterioration in the health of the patient. Prevention includes the prevention and adequate treatment of injuries and diseases that can cause osteomyelitis.

Osteomyelitis- This is a disease whose name comes from the Greek language and literally means "inflammation of the bone marrow." It is characterized by a varied course - from asymptomatic and sluggish to fulminant. For this reason, a patient with suspected osteomyelitis should be carefully examined, receive timely appropriate treatment and be under the vigilant supervision of medical personnel.


Osteomyelitis can affect any bone in the body, but statistically, osteomyelitis occurs most frequently in the femur, tibia, and humerus. Men are most predisposed to this disease.

The treatment of osteomyelitis is a complex and not always successful process, since it includes several components, which are based on surgical intervention. The prognosis largely depends on the condition of the patient's body and the quality of medical care provided. According to statistics, the percentage of complete recovery without subsequent relapses ( repeated exacerbations) is 64%. Relapses in the next 5 years occur in another 27% of patients. 6% fail treatment and the remaining 3% develop fulminant osteomyelitis and die.

Bone Anatomy

The bones of the skeleton are classified according to their shape into the following types:

• long and short tubular ( femurs, humerus, phalanges of fingers);
• flat ( scapula, bones of the cranial vault);
• mixed ( sternum, vertebrae, etc.)

Bone consists of two thirds of inorganic minerals and one third of organic matter. The main inorganic substance is calcium hydroxyapatite. Among organic substances, various proteins, carbohydrates and not a large number of fats. In addition, the bone in small quantities contains almost all the elements of the periodic table of chemical elements. Water is an integral component of the bone and to a certain extent determines its flexibility. Children have a higher water content, so their bones are more elastic than those of adults and, especially, the elderly. Also of some importance is the balance between calcium and phosphorus ions. Compliance with this balance is maintained by a constant balance of the hormonal influence of parathyroid hormone and somatostatin. The more parathyroid hormone enters the bloodstream, the more calcium is washed out of the bones. The resulting gaps are filled with phosphorus ions. As a result, the bone loses strength, but gains some flexibility.

Different types of bones have different structures. Osteomyelitis can develop in any bone, but according to statistics, in more than two-thirds of cases it develops in long bones. This is facilitated by certain features of vascularization ( provision of blood vessels) bones of this type, which will be described in the section "mechanism of development of osteomyelitis". Based on this, the closest attention should be paid to the structure of the long tubular bones.

The tubular bone consists of the body ( diaphysis) and two ends ( epiphyses). A small strip of tissue up to 2–3 centimeters wide, which is located between the diaphysis and epiphyses, is called the metaphysis. The metaphysis is responsible for the growth of the bone in length.

On a cut, the bone looks like this: In the center of the diaphysis is a cavity - the medullary canal, in which the red bone marrow is located. The amount of red bone marrow can vary significantly depending on the intensity of hematopoietic processes. Around the medullary canal is directly bone substance, which is divided into two types - spongy and compact substance. Closer to the center and at the ends of the bone is a spongy substance. According to the name, its structure contains a large number of interconnected cavities in which yellow bone marrow is located. It is believed that he does not special functions, but is a precursor of red bone marrow and is converted into it when there is a need to increase hematopoiesis. The main supporting function of the bone is performed by a compact substance. It is located around the spongy substance, mainly in the diaphysis. In the region of the epiphyses and metaphyses, the spongy substance is organized in the form of septa ( partitions). These partitions are located parallel to the vector of the greatest constant load on the bone and are able to be rebuilt depending on the need to strengthen or weaken the bone.

The shell of the bone consists of the periosteum in the area of ​​the diaphysis and articular cartilage in the area of ​​the epiphyses. The periosteum is a thin plastic capable of producing young bone cells - osteoblasts. It is she who ensures the growth of bones in thickness and actively regenerates ( recovering) at fractures. There are several holes in the periosteum through which blood vessels enter the bone. Under the periosteum, these vessels form an extensive network, one part of the branches of which feeds the periosteum itself, and the second penetrates deep into the bone and, in the form of tiny capillaries, penetrates both bone marrows, and also enters the spongy and compact bone substance, providing them with nutrition. Vessels passing through the bone marrow are fenestrated, that is, there are holes in their wall. Through these openings, newly formed erythrocytes in the bone marrow enter the bloodstream.

To further describe the mechanism of development of hematogenous osteomyelitis, it is necessary to pay attention to the metaphysis, which in most cases is the place from which inflammation begins. As mentioned earlier, the metaphysis is the area that provides the growth of the bone in length. Growth implies a high metabolic activity of this zone, which is unimaginable without proper nutrition. It is for this reason that the most extensive capillary network is located in the metaphyses, providing the necessary blood supply to this area of ​​​​the bone.

The articular surfaces located along the edges of the bone are covered with hyaline cartilage. Cartilage is nourished both by intraosseous blood vessels and by synovial fluid located in the joint cavity. The functional integrity of the cartilage lies in its cushioning function. In other words, cartilage softens the natural vibrations and tremors of the body, thus preventing damage to bone tissue.

Causes of osteomyelitis

According to the number of types of pathogens that caused osteomyelitis, there are:

• monoculture;
• mixed culture;
• no growth of the pathogen on nutrient media.

Predisposing factors for the development of osteomyelitis are:

• foci of latent infection tonsils, caries, adenoids, boils, etc.);
• increased allergic background of the body;
• weak immunity ;
• physical exhaustion;
• prolonged fasting.

• injury;
• respiratory viral infection (SARS);
• weight lifting;
• acute reaction to stress, etc.

The mechanism of development of osteomyelitis

• vascular ( embolic);
• allergic;
• neuro-reflex.

Vascular ( embolic) theory

Allergic theory

In addition to an attempt to describe the mechanism of development of osteomyelitis, this theory provided the fulfillment of another important task. Thanks to her, the key role of increasing intraosseous pressure in the maintenance and progression of inflammation has been proven. Thus, the main therapeutic measures should primarily be aimed at reducing intraosseous pressure through puncture of the medullary canal or bone trepanation.

Neuro-reflex theory

The explanation for this regularity is as follows. Any adverse effect on the body, such as stress, illness or injury, causes a reflex spasm of blood vessels, including those in bone tissue. According to the mechanism described above, vasospasm leads to bone necrosis. However, if the reflex spasm is eliminated with medication, then there will be no deterioration in blood supply and, as a result, osteomyelitis will not develop, even with a slight bacteremia.

All of the above theories are different options for describing the initial mechanisms of the onset of inflammation. In the future, there is an active development of pathogenic microflora in the bone marrow canal, accompanied by an increase in intraosseous pressure. When certain critical pressure values ​​are reached, pus corrodes the bone tissue along the path of least resistance. When pus spreads towards the epiphysis, it breaks into the articular cavity with the development of purulent arthritis. The spread of pus towards the periosteum is accompanied by severe pain. The pain is caused by the accumulation of pus under the periosteum with its gradual detachment. After a certain time, the pus melts the periosteum, breaking through into the soft tissues around it with the formation of intermuscular phlegmon. The final stage is the release of pus to the skin with the formation of a fistulous tract. At the same time, pain and temperature are on the decline, and acute osteomyelitis becomes chronic. This option of self-resolution of osteomyelitis is the most favorable for the patient.

Less successful resolution of osteomyelitis occurs when purulent inflammation spreads to the entire bone. In this case, melting of bone tissue and periosteum is observed in several places. As a result, an extensive periosseous phlegmon is formed, which opens on the skin in several places. The outcome of such phlegmon is a pronounced destruction of muscle tissue with massive adhesions and contractures.

The most dramatic outcome of the disease occurs when the infection is generalized from the focus to the entire body. At the same time, a huge number of pathogenic microorganisms penetrate into the blood. They spread throughout the body, forming metastatic foci of infection in other bones and internal organs. The consequence of this is the development of osteomyelitis of the corresponding bones and the insufficiency of the function of the affected organs. Some of the microbes are destroyed immune system. When destroyed, the microbes secrete into the blood a substance called endotoxin, which in small amounts causes an increase in body temperature, and in extreme amounts leads to a sharp drop in blood pressure and the development of state of shock. Unlike other types of shock, septic shock is the most irreversible, since it is practically not amenable to treatment prescribed for given state medicines. In most cases, septic shock is fatal.

The process of formation of sequesters deserves special attention. A sequester is a piece of bone that freely floats in the cavity of the medullary canal, torn away from a compact or spongy substance due to purulent fusion. It is one of the signs, when determining which, it can be said with certainty that the patient has osteomyelitis. With the formed fistulous course, the sequester can be released from it along with pus. The sizes of sequesters can be different depending on the depth of the lesion of the bone tissue. Resorption may occur in children ( resorption) formed sequester in the acute phase of the disease. During the transition to a chronic course, a protective capsule is formed around it, which prevents both resorption and its attachment to a healthy bone. With age, the ability of sequesters to self-resorption decreases. Thus, in adults, resorption occurs extremely rarely and only small sequesters, and in the elderly and people old age doesn't happen at all.

Sequestration is detected by X-ray or computed tomography of the affected bone. Its detection is a direct indication for the surgical treatment of osteomyelitis with the removal of the sequester itself. Removal of the sequester is necessary because it contributes to the maintenance of the inflammatory process in the bone.

By size and origin, sequesters are divided into the following types:

• cortical;
• central ( intracavitary);
• penetrating;
• total ( segmental, tubular).

cortical sequestration develops from the outer layer of the bone, often includes a portion of the periosteum. The separation of such a sequester occurs outside the bone.

Central sequester develops from the inner layer of the bone. Often the necrosis is located circularly. The sizes of such sequesters rarely reach 2 cm in longitudinal section. The separation of such sequesters occurs only towards the medullary canal.

penetrating sequestration it is considered as such when the zone of necrosis extends to the entire thickness of the bone, while only in one semicircle. In other words, at least a small isthmus of healthy tissue must be present. Such sequesters can be quite large. Their separation takes place both inside and outside the bone.

Total sequestration - complete defeat of the entire thickness of the bone at a certain level. Such a lesion in osteomyelitis often leads to the formation of pathological fractures and false joints. The sizes of such sequesters are the largest and depend on the thickness of the bone. Their separation occurs either by disintegration into smaller areas, or by complete displacement away from the bone.

Clinical forms and stages of osteomyelitis

There are the following clinical forms of osteomyelitis:

• acute hematogenous osteomyelitis;
• post-traumatic osteomyelitis;
• primary chronic osteomyelitis.

• abscess Brody;
• albuminous osteomyelitis;
• antibiotic osteomyelitis;
• sclerosing osteomyelitis of Garre.

Acute hematogenous osteomyelitis

The most common pathogen sown from the bottom bone cavity with hematogenous osteomyelitis, is Staphylococcus aureus. Rarely detected Proteus, hemolytic streptococcus, Pseudomonas aeruginosa and Escherichia coli. Most frequent localization with this clinical form of osteomyelitis are femoral, then tibial and humerus. Thus, there is a certain pattern between the length of the bone and the likelihood of developing osteomyelitis.

There are the following variants of the course of hematogenous osteomyelitis:

• break;
• protracted;
• fulminant;
• chronic.

Protracted option
This variant is characterized by a subacute long-term course of the disease. Despite the weakness of the recovery processes and the low immune status of the body, recovery still occurs after 6-8 months of treatment.

Lightning option
This is the most rapid and deplorable outcome of the disease, in which there is a massive release of bacteria into the blood. More often this form is characteristic of hematogenous osteomyelitis of staphylococcal etiology. This microbe does not release exotoxins, but is easily destroyed. Being destroyed, an extremely aggressive endotoxin is released from it, causing a drop in blood pressure to zero values. With such pressure, without the provision of massive medical care, brain death occurs in 6 minutes.

Chronic variant
With this option, the course of the disease is long - more than 6 - 8 months with periods of remission and relapse. Characterized by the formation of sequesters ( areas of dead tissue) that maintain inflammation for a long time. Fistulas open and close according to the phases of exacerbation and chronicity. In addition, often being tortuous, the fistulas themselves provoke the resumption of the inflammatory process. With a long course of inflammation, connective tissue forms around the fistulas, which can lead to cicatricial degeneration of muscles and their gradual atrophy. chronic inflammation is at risk of developing amyloidosis ( violation of protein metabolism) with damage to the corresponding target organs in this disease.

Post-traumatic osteomyelitis

According to the reasons, the following types of post-traumatic osteomyelitis are distinguished:

• gunshot;
• postoperative;
• after an open fracture, etc.

Primary chronic osteomyelitis

Abscess Brodie
This is an intraosseous abscess with a sluggish course and poor symptoms, which develops when a weak pathogen interacts with a strong immune system. Such an abscess is soon encapsulated and stored in this form for more than one year. A certain soreness can be when exerting a slight pressure on the bone and with a slight tapping on it over the site of the abscess. Radiologically, a cavity in the bone is determined, in which sequesters are never found. Periosteal reaction ( periosteum response to irritation) is weakly expressed.

Albuminous osteomyelitis
This type of osteomyelitis develops when an initially weak microorganism is unable to transform aseptic transudate into pus. A distinctive feature of this form is a pronounced infiltration of the periosseous tissues. Despite the pronounced swelling, the pain is low. The x-ray shows a mild periosteal reaction with superficial fibrous overlays.

Antibiotic osteomyelitis
Antibiotic osteomyelitis develops due to the unjustified use of antibiotics. In the presence of a certain constant concentration of antibiotic in the blood, the pathogen that enters the bone will not be destroyed, since the concentration of antibiotic in the bone is low. Instead, the microbe slowly multiplies and encapsulates. Clinical and paraclinical data are extremely scarce.

Sclerosing osteomyelitis
This rare type of osteomyelitis is characterized by a subacute onset, dull night pains in the area of ​​the affected bone, body temperature is not more than 38 degrees. Periods of subsidence of the clinic alternate with relapses. The formation of small sequesters is typical. X-ray reaction of the periosteum is manifested only at the beginning of the disease, then it disappears. When performing surgery for this disease, pronounced sclerosis of the bone marrow canal is revealed.

Symptoms of osteomyelitis

• local form;
• generalized form.

Local osteomyelitis

By location, the following types of local osteomyelitis are distinguished:

• osteomyelitis of tubular bones ( femur, tibia, humerus, etc.);
• osteomyelitis of flat bones pelvic bones, calvarium and scapula);
• osteomyelitis of mixed bones ( patella, vertebrae, jaw, etc.)

Osteomyelitis of tubular bones, in turn, is divided into:

• epiphyseal;
• metaphyseal;
• diaphyseal;
• total.

Generalized osteomyelitis ( toxic, septicopyemic)

The onset of the disease is identical to the local form, however, at a certain point in time, symptoms of intoxication appear. Body temperature rises to 39 - 40 degrees and is accompanied by chills and profuse cold sticky sweat. Multiple metastatic foci of infection in various organs manifest themselves accordingly. Purulent lung disease presents a picture of pneumonia with severe shortness of breath, pale complexion, cough with purulent bloody sputum. Kidney damage is manifested by severe pain from the corresponding side with irradiation to the groin, pain during urination, frequent trips to the toilet in small portions, etc. When purulent metastases enter the coronary vessels purulent pericarditis, myocarditis, or endocarditis develops with symptoms of acute heart failure.

In addition, a small petechial rash is often observed, which tends to merge. Brain damage is predominantly toxic in nature, but inflammation of the meninges, manifested by neck stiffness and severe headaches, is not excluded. Neurological lesions occur in two stages. Productive first appear mental symptoms such as convulsions, delirium. As brain damage progresses, symptoms of depression of consciousness occur, such as stupor, stupor, precoma, and coma.

The general condition of such patients is extremely severe. Symptoms of local osteomyelitis recede into the background. In the vast majority of cases, the patient dies either from collapse at the beginning of the generalization of the infection, or from multiple organ failure in the next few hours, less often a day.

Diagnosis of osteomyelitis

General blood analysis

The total blood protein in the local form is within 70 g / l, in the generalized form - less than 50 g / l. Albumins less than 35 g/l. Increase C-reactive protein up to 6 - 8 mg / l.

Infectious-inflammatory lesions of bone tissue do not always have an acute course. Often, with improper treatment, the disease progresses to chronic stage. In this case, the symptoms subside, but the process of bone destruction continues. Chronic osteomyelitis is characterized by alternating relapses and remissions, the formation of sequesters and bone deformity. Despite the improvement in the patient's condition, the transition to the chronic form of the disease has serious consequences. It is more difficult to cure it, since often the process of bone tissue destruction becomes irreversible.

The chronic course of the disease greatly undermines the health of the patient. It can last from 3 months to several years. Due to the constant purulent process, a violation of the functions of the liver and kidneys, a decrease in efficiency begins.

Although chronic osteomyelitis has many characteristics, the main symptoms and treatments are almost the same as in the acute form. Therefore, according to international classification diseases they belong to the same group. ICD code 10 different types of chronic osteomyelitis has from 86.3 to 86.6.

Features of chronic osteomyelitis

About transition acute form diseases in chronic can be said when there is no effect of treatment within 1-1.5 months. The patient's condition may improve, but radiological signs indicate an ongoing process of bone destruction. In children, most often the chronic form develops after hematogenous osteomyelitis, as well as infection of the jaw bones. Adults mainly suffer from the post-traumatic form on the background of severe fractures, gunshot wounds or surgical interventions.

This course of the inflammatory process is the same for different types of disease. Chronic osteomyelitis is characterized by the presence of purulent fistulas, bone sequesters, as well as alternating phases of exacerbation and remission. If inflammation has developed after an injury or surgery, usually purulent fistulas and other signs are localized in the area of ​​​​damage. Hematogenous osteomyelitis causes the spread of pus and damage to the bone throughout its entire length. Often inflammation also affects soft tissues and joints.

feature chronic course disease is the alternation of periods of remission, when the patient feels well, and exacerbations. Such a change in the phases of the inflammatory process can continue many times.

Relapses of the disease

The often relapsing course of the disease lasts for many years. An exacerbation can occur at any time against the background of relative well-being. It is provoked by hypothermia, viral diseases, decreased immunity, bad habits, injuries and increased physical activity on the affected limbs. The fistula closes and pus accumulates in the bone cavity.

Relapse begins abruptly: the temperature rises, symptoms of intoxication increase, the patient feels weakness, headache, chills. The affected area swells and turns red due to the accumulation of pus, severe pain appears. The exacerbation subsides only when the purulent contents of the fistulas come out.

Serious deformity of the limb can occur due to untimely treatment.

Complications

As a result of the constant presence of infection, poisoning occurs with metabolic products of microorganisms. This often causes degeneration of the liver and kidneys, disruption of the heart and endocrine system. The inflammatory process attracts a large number of leukocytes and phagocytes to the site of infection. They produce enzymes to kill bacteria. But it also leads to the destruction of the bone. Sequesters are formed, consisting of dead pieces of bone tissue, purulent fistulas.

The affected bone is severely deformed, movement in nearby joints is disturbed, a false joint or muscle contractures may form. The purulent process leads to the development of infectious arthritis, and the likelihood of sepsis is also high. Due to bone destruction in chronic osteomyelitis, pathological fractures often occur. In some cases, it even becomes necessary to amputate the limb.

Causes

Most often, chronic osteomyelitis develops after the acute stage. The reasons for this are simple: weakened immunity of the patient and improper treatment of the disease. It usually occurs 3-6 weeks after the onset of the inflammatory process. The patient's condition improves, but the infection in the bone remains. This happens for the following reasons:

• late treatment;
• incorrectly selected antibiotics;
• non-compliance by the patient with all the prescriptions of the doctor;
• errors during the operation;
• insufficient cleaning of the purulent focus.

Most often, osteomyelitis becomes chronic in children, elderly patients, people weakened by other diseases. This is approximately 20-30% of patients. In other cases, even with the formation of sequesters and bone necrosis, the damaged areas are gradually replaced by healthy tissue.

Even with an external improvement in the condition, the purulent process in the bone continues

Symptoms of the chronic form of the disease

Usually secondary chronic osteomyelitis is characterized by a special course. It can be divided into three stages. First, a subacute form is isolated, when the symptoms of the disease gradually subside. The temperature drops, intoxication passes. Somewhere in 2-3 months after infection, remission occurs. At this time, the patient's condition improves, the pain completely disappears, the patient can lead a normal life. This state continues for several months. Sequestration processes take place in the bone, and very little pus is released from the fistulas. Outwardly, only a slight increase in the volume of the affected area is noticeable.

During a relapse, the symptoms of osteomyelitis resemble the acute course of the disease, but the temperature is not so high, the pain is not very strong, and there may be no intoxication of the body at all. Sometimes at this stage, the fistulous tract closes, and pus accumulates in the osteomyelitic cavity. This can cause complications such as the development of cellulitis or soft tissue abscess. In this case, there are severe pain, the temperature rises and the symptoms of intoxication increase. This continues until the purulent focus breaks through and the pus comes out.

At the initial stage of primary chronic osteomyelitis, minor pains are observed, which can be mistaken for symptoms of other diseases.

Unlike secondary, primary chronic osteomyelitis begins immediately after infection. Its symptoms are blurred, there may be a slight pain of indefinite localization, a slight increase in temperature. The patient usually sees a doctor when the fistulous form is already developing and pus is released.

characteristic symptom chronic course of the disease is a severe deformation of the bone. Changes in volume and appearance. The bone becomes thinner, may be bent. Because of this, the affected limb is shortened, depressions or thickenings are noticeable on it. If this condition is observed in children, their bone growth and skeletal formation are disturbed.

Types of chronic osteomyelitis

The classification of the disease occurs depending on the severity of the inflammatory process, the reasons for its transition to the chronic stage and features. Most often, secondary chronic osteomyelitis and its primary form are distinguished. According to the severity and characteristics of the course, there is a toxic form, septic-pyemic and pathological.

Primary chronic form

This course of the disease occurs quite rarely, mainly in patients with strong immunity - most often in children and healthy young people, as well as in those who often use antibiotics irrationally. Because of this, the infectious-inflammatory process proceeds sluggishly, the symptoms are mild, pus does not spread. This makes it difficult to make a correct diagnosis.

Primary chronic osteomyelitis is most often localized in one place, usually in the long tubular bone legs. X-ray diagnostics shows a single focus of destruction with clear edges. In such cases, the development atypical forms osteomyelitis.

• Brodie's abscess is localized in the spongy substance of long bones, most often the tibia or femur. Caused by inflammation Staphylococcus aureus, but the purulent process develops very sluggishly. The disease can last for many years and is characterized by a mild course with rare exacerbations after physical activity or hypothermia.
• Olier's albuminous osteomyelitis develops in femur. This is a very rare disease that affects children and adolescents. In this case, the affected area thickens, the limb increases in size.
• Antibiotic osteomyelitis often occurs in children and debilitated patients. They develop a bacterial flora that is insensitive to antibiotics. This happens when these drugs are used incorrectly.
• Sclerosing osteomyelitis of Garre most often affects one bone of the thigh or lower leg. In this case, its thickening and deformation are observed. Signs of this form of osteomyelitis are detected only during MRI.

Sometimes the presence of a purulent process does not appear outwardly

Secondary chronic osteomyelitis

If 3-4 weeks after the onset of the inflammatory process, it was not possible to cope with the infection, acute osteomyelitis passes into the chronic stage. This can be hematogenous, post-traumatic, contact and other forms of the disease. At the same time, patients initially feel a significant improvement in their condition. Then vague pains in the limbs may appear, slight temperature, decreased performance. The disease proceeds with long periods of remission, alternating with exacerbations.

Post-traumatic osteomyelitis

This type of disease has recently become a problem in traumatology. It usually affects middle-aged people. Chronic osteomyelitis develops most often after a fracture, especially the bones of the foot and lower leg. This happens due to a weakened immune system, after severe injuries or due to errors in treatment. After open fractures, the risk of developing chronic osteomyelitis is almost 25%. It also occurs after closed fractures, but less often, mainly due to poor-quality surgery to combine the bones.

Children often develop chronic odontogenic osteomyelitis.

With this form of the disease, fistulas are most often formed around the wound. There may be a shortening or impaired mobility of the limb, inflammatory processes in the nearest joints.

To prevent post-traumatic osteomyelitis, it is necessary to seek medical help in a timely manner in case of an injury. It is very important to prevent infection from penetrating the wound; for this, it is superimposed sterile dressing. Fractures also require timely debridement with the removal of bone fragments and foreign objects, as well as the correct immobilization of the limb.

Infectious-inflammatory lesions of the jaw bones very often affect children during tooth growth. The rudiments of molars are involved in the purulent process, maintaining and intensifying inflammation. In children, the diffuse nature of the inflammatory process is often observed, spreading to different parts of the jaw. Destruction can even affect the chin or the lower edge of the orbit. This process can continue for years, leading to significant deformation of the face.

Chronic odontogenic osteomyelitis develops most often with untimely or incorrect treatment of the acute stage. In this case, large areas of the bone are affected, tooth decay occurs. Single or multiple fistulas are formed, often in the oral cavity. In children, there may be a violation of the formation of the jaws, their strong deformation. At the age of 7 years, pathological fractures of the condylar process sometimes occur. But most often, with timely treatment, the course of the disease is favorable. In children and young people, bone regeneration after infection is cleared is fast.

Timely diagnosis helps prevent complications and cure the disease faster

Diagnosis of the disease

For the correct treatment of chronic osteomyelitis, it is very important to identify the transition of inflammation to this stage in time. When the patient's condition improves, therapy does not stop, hardware diagnostics are carried out. The most informative ways to correctly diagnose are magnetic resonance or CT scan. They allow to detect violations not only in the bones, but also in soft tissues. Do also scintography, ultrasound, thermography, tissue biopsy.

But most often with this disease, x-rays are performed. It helps to identify the number and location of sequesters, the degree of destruction of bone tissue. In the presence of fistulous passages, fistulography is performed. At the same time, a contrast agent is injected into its cavity and an x-ray is taken. On the pictures you can determine the length of the fistulous passages. This is a very important examination before the operation. Based on the collected information about the patient's condition and the course of the inflammatory process, osteomyelitis treatment is prescribed.

Features of the treatment of chronic osteomyelitis

The complexity of the treatment of this condition is that the inflammation proceeds almost without external signs, but the process of bone destruction leads over time to severe complications. Therefore, the treatment of chronic osteomyelitis should be comprehensive. First of all, this drug therapy, then draining the wound, surgery and physiotherapy methods.

Antibiotics are required. The most sensitive microorganisms that cause osteomyelitis are Ciprofloxacin, Gentamicin, Amikacin, Ceftriaxone, Lincomycin, Metronidazole. Antibiotic therapy is carried out during the period of exacerbation, and drugs are prescribed not only orally or in the form of injections, but also necessarily for washing purulent cavities. Relapse also requires non-steroidal anti-inflammatory and analgesic drugs, sometimes corticosteroid hormones are required.

In addition to local treatment, supportive therapy is very important to strengthen the immune system and improve the patient's condition.

In the treatment of chronic osteomyelitis, it is very important to maintain the patient's immunity. For this, metabolic and immunomodulatory agents, vitamins and biologically active additives are prescribed. At the initial stages, the introduction of immunoglobulin, autovaccine or staphylococcal toxoid is effective. Stimulants of the body's defenses also help - Levamisole, Pentoxyl or Methyluracil. With a generalized form of the inflammatory process, ultraviolet or laser blood purification, detoxification with saline is carried out.

But even with the correct appointment of all therapeutic methods in the treatment of chronic osteomyelitis, one cannot do without surgical intervention, which is carried out after the exacerbation subsides. Be sure to need aspiration-washing drainage of the purulent focus, removal of necrotic areas of the bone and sequesters. Sequestrectomy is the complete cleansing of osteomyelitic cavities. With a pronounced deformation of the limb with the loss of its functions, bone grafting is performed with the replacement of the lost bone tissue with grafts. Sometimes osteotomy, bone resection, or the use of the Ilizarov apparatus may be necessary.

Surgery especially important in the presence of a large number of sequesters and purulent fistulas, frequent exacerbations with severe pain, impaired limb mobility. Regular washing of foci of infection with antiseptic solutions, for example, Furacilin, Dioxidine or Chlorhexidine, significantly increases the possibility of a favorable outcome of the disease.

After surgical treatment, therapy is required aimed at suppressing the residual microflora and restoring limb mobility. In addition to antibiotics, medicinal electrophoresis, ultrasound or UHF therapy, mud or paraffin applications.

Chronic osteomyelitis is very serious disease leading to damage to all organs of the patient. Therefore, it is very important for such patients to follow all the doctor's prescriptions and treat treatment responsibly. In order to prevent the transition of the disease to the chronic stage, it is necessary to correctly prescribe antibiotics and timely removal of pus from the bone cavity.

Chronic osteomyelitis is an infectious and inflammatory process in bone tissues. The symptoms of the disease in this form are mild, the destruction proceeds slowly. Chronic osteomyelitis is characterized by a change in periods of exacerbation and remission. Despite the temporary normalization of the patient's condition during the transition of the pathology to a sluggish form, it has consequences that are hazardous to health. Bone destruction often becomes irreversible. Symptoms of the disease may be present for 3 or more years. Due to the constant presence of the inflammatory process, the functions of internal organs are disrupted.

Causes and development of the disease

The transition of acute osteomyelitis to chronic is evidenced by the lack of effectiveness of therapy within 30–45 days. The patient's condition may improve, but the results diagnostic procedures indicate the further development of destructive processes. In children, the chronic form of the pathology usually has a hematogenous character. It often occurs against the background of infection of the jaw bones. In adults, post-traumatic forms of osteomyelitis are diagnosed, which develop after complex fractures, injuries or surgical interventions.

The slow nature of the development of the inflammatory process is characteristic of various forms pathology. The disease is accompanied by the formation of fistulas and voids in the bones. If the destruction of bones began against the background postoperative complications, purulent fistulas are formed in the area of ​​\u200b\u200bthe seams.

Promotes the spread of exudate with damage to the entire bone. Often, inflammation covers the connective and cartilaginous tissues. This phase sequence can take quite a long time. An outbreak can happen at any time. It can be provoked by:

• infectious and colds;
• excessive physical activity;
• weakening of the body's defenses.

The fistula closes and pus begins to accumulate in the bone cavity.

The exacerbation begins abruptly: the temperature rises, signs of intoxication intensify. The patient complains of general weakness, headaches, fever. In the affected area, redness and swelling occur, a pronounced pain syndrome is observed. These symptoms disappear when the fistulas open and the purulent masses come out.

With incorrect or late treatment, it is possible serious complications in the form of bone deformity or sepsis.

Effects

Osteomyelitis of the femur can lead to a leg fracture, which makes a person unable to work on long months. The constant activity of the infection contributes to the intoxication of the body with the products of the vital activity of microorganisms. In the focus of inflammation there is a large number of phagocytes and leukocytes. They secrete substances that destroy bacteria. At the same time, these enzymes break down bones. Cavities are formed containing tissue decay products and purulent masses. The structure of the affected bone changes, the mobility of nearby joints is impaired, and muscle adhesions may form.

The destruction of cartilage and bone tissue contributes to the development of arthritis. The risk of blood poisoning increases. Bone damage in osteomyelitis contributes to the appearance of pathological fractures. In some cases, the affected limb has to be amputated.

The primary chronic form of osteomyelitis develops after the acute phase. Weakened immunity of the patient is not able to cope with pathogenic microorganisms. The first signs of the disease appear 4-6 weeks after the onset of inflammation. The human condition is normalized, but the pathogenic bacteria in the bone tissues remain. This may be due to:

• untimely start of therapy;
• improper selection of antibacterial drugs;
• non-compliance with the doctor's recommendations;
• complications of surgical interventions;
• insufficient sanitation of purulent foci.

Most often, osteomyelitis flows into a sluggish form in children, the elderly and those with concomitant diseases. In other cases, destroyed bone tissues are gradually renewed.

Characteristic symptoms

Secondary osteomyelitis of the lower leg has both specific and general signs. The pathological process proceeds in 3 stages:

1. At the first, the symptoms of the acute form subside, the temperature reaches normal values, intoxication subsides. After some time after the onset of the inflammatory process, there is a lull. Pain disappears, and the patient can lead a normal life. The remission lasts for several weeks. Cavities form in the bone, and pus practically does not come out of the fistulas. Outwardly, only a slight swelling of the affected area is visible.
2. The clinical picture of recurrence is similar to the manifestations of the acute form. However, the temperature does not rise above 38 ° C, the pain is mild, and signs of poisoning of the body may be completely absent. The fistula closes at this stage, the pus spreads through the bone and soft tissues. At this time, complications such as an abscess or phlegmon may occur. The patient experiences severe pain, a febrile syndrome develops. It lasts until the pus comes out.
3. Exacerbation of chronic osteomyelitis is accompanied by deformation of the affected bones. Its size and appearance change. The limb is shortened and bent. The development of such conditions in children contributes to the incorrect formation of the skeleton.

Identification and methods of treatment

Osteomyelitis can be quickly cured and complications can be avoided only if it is detected in time. After the patient's condition improves, it is not recommended to stop therapy, it is necessary to conduct a diagnosis. CT and MRI are the most accurate ways to detect diseases of the musculoskeletal system. They allow to detect violations not only in bone, but also in soft tissues. However, most often with osteomyelitis, an X-ray examination is used. With its help, the number of foci of destruction and the severity of pathological changes are determined. A contrast agent is injected into the cavity of the fistula, after which an x-ray is taken.

Treatment of chronic osteomyelitis can be complicated by the absence of obvious signs of inflammation. The therapeutic regimen includes:

• taking medications;
• wound sanitation;
• restoration of bone integrity;
• physiotherapy procedures.

Antibiotics are an essential part of the treatment of osteomyelitis. They are prescribed during an exacerbation, they are administered intramuscularly and are used to cleanse purulent cavities. Additionally, painkillers and anti-inflammatory drugs are used.

Basic therapy should be combined with taking drugs that improve the general condition of the body.

It is very important to strengthen the patient's immunity. For this, immunostimulants and vitamins are used.

On the early stages recovery is facilitated by the introduction of immunoglobulin or bacterial toxoid.

Even the use of all these drugs does not allow avoiding the operation, which is carried out during the period of remission. Mandatory are the aspiration of purulent contents and drainage of the cavity. Affected tissues are completely removed. With a significant deformation of the bone, it is replaced with an implant. After the operation, the patient is given antibiotics.

Osteomyelitis of bones - dangerous disease, capable of hitting not only musculoskeletal system, but also internal organs. Therefore, it is very important to start treatment in a timely manner and follow all the instructions of the attending physician.