Orthopedics - Oleksa A.P. 2006

Osteomyelitis
Hematogenous osteomyelitis

Hematogenous Osteomyelitis is a severe acute pyogenic-septic infection of the Bone Marrow that subsequently affects all bone elements and surrounding soft Tissues. It most frequently occurs (in 85% of cases) in infants and children with lowered immune reactivity.

According to Vernyhora I.P., Hayko H.V., Hrytsay M.P., et al. (1995), children in their first year of life are most commonly affected (54.3%), with older children being somewhat less frequently diagnosed, although Hrytsay M.P. and Polyachenko Y.V. (1999) indicate that 60–65% of cases occur between the ages of 8 and 14 years.

The CAUSATIVE AGENT OF hematogenous osteomyelitis can be any microorganism (monoculture of Staphylococcus aureus, streptococcus, Escherichia coli, etc.) that reaches the bone hematogenously from a primary purulent focus (via the umbilical wound, Skin pustules, abscess, acute tonsillitis, measles, scarlet fever, etc.). However, the underlying Prerequisites for the development of osteomyelitis are sensitization and reduced immunoreactivity of the child's body, and sometimes other factors (trauma, hypothermia, overfatigue, etc.).

In terms of localization frequency, the Femur ranks first, followed by the Tibia, accounting for 2/3 of all cases (Hrytsay M.P., Polyachenko Y.V., 1999), while the remaining cases involve other sites.

According to Krasnobayev, There is a fulminant toxic form of osteomyelitis, which can lead to a child's death within a few days; a septicopyemic form, in which the inflammatory process simultaneously appears in multiple bones; and a localized form.

Diagnosing acute hematogenous osteomyelitis can be challenging on the first day of the child's illness. Based on an acute onset with very high body Temperature, district pediatricians may miss the signs of osteomyelitis and restrict the Diagnosis to another inflammatory process. Such diagnostic errors lead to delayed admission of children to surgical hospitals for Treatment. As Vernyhora and co-authors (1995) point out, clinical symptoms develop progressively over several days: Swelling of the affected limb segment appears, along with local hyperthermia and protective antalgic contracture. Leukocytosis increases sharply with a shift of the leukocyte formula to the left, as well as an elevated ERYTHROCYTE SEDIMENTATION RATE. Plain radiographs show no pathological Changes in the bone During the first two weeks. After the eighth to tenth day of illness, computed tomography can identify enlarged foci based on relative Bone tissue density. The localization of the focus can also be determined using ultrasonic echolocating, local electrothermometry, or remote thermodiagnostics (thermography). Figure 391 illustrates a diagram of the potential stages in the progression of hematogenous osteomyelitis.

Without intensive treatment, the condition progresses: the focus enlarges, spreading lengthwise and laterally along the bone, leading to vascular thrombosis and bone necrosis. Clinically, local hyperemia develops against the Background of edema and tissue infiltration, pain and fever do not subside, the child becomes exhausted, and their general condition becomes critical. Only after spontaneous bone decompression (rupture of the abscess beneath the periosteum) does the child finally fall into a deep Sleep. With the rupture of the abscess, acute symptoms gradually subside, and the process transitions into a chronic form. At this point, local fluctuation can be detected. If the subperiosteal abscess is not promptly incised, it can detach the thick periosteum over a significant length of the bone, rupture into the soft tissues to form an intermuscular Phlegmon, and eventually break through the skin surface as a fistula. Simultaneously, bone-producing processes begin to predominate. Periosteal layering appears, and boundaries between healthy and necrotic bone become clearly demarcated. Resorption occurs in areas where Blood Vessels remained unthrombosed during the inflammation and blood supply was preserved, forming a cellular granulation wall and bone sequestra. Radiographs reveal signs of periostitis, bone tissue defects surrounded by a zone of sclerosis, sequestra, etc. (Fig. 392). The dissolution of free sequestra under METABOLISM/18.html">The Influence of lysosomal Enzymes and the functioning of the fistula can continue indefinitely. Fistulae close and reopen, and the inflammatory process may recur.

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Fig. 391. Schematic diagram illustrating the course of hematogenous osteomyelitis.

If the fistula fails to close for a prolonged period, secondary microflora is introduced, which complicates the treatment process.

Depending on the child's age, metaepiphyseal osteomyelitis has its own specific features.

If pus from an epiphyseal focus ruptures into a joint (most commonly the hip or knee), acute Purulent Arthritis develops with severe clinical manifestations. The child's general condition is extremely critical. Without radical surgical intervention, this can lead to generalized infection, Sepsis, and even death. Due to improved Diagnostics and timely initiated complex treatment involving Antibiotics, mortality has been reduced from 20–25% to 1–2% (Bidnenko S.I., 1998).

Treatment. When hematogenous osteomyelitis is suspected, the child must be urgently hospitalized in a surgical unit for diagnosis confirmation and immediate comprehensive treatment.

Fig. 392. Radiograph of the right humerus affected by hematogenous osteomyelitis with periosteal reaction.

Once the localization of the acute inflammatory process in the bone is established, the patient is prescribed broad-spectrum osteotropic antibiotics, as the specific pathogen is initially unknown, although treatment should target Staphylococcus aureus or hemolytic streptococcus.

Given the presence of pain and intoxication, analgesics must be administered, along with detoxification therapy and Homeostasis correction. Passive immunization (gamma globulin, antistaphylococcal plasma, etc.) is performed if necessary, followed later by active immunization (prodigiosan, Lysozyme, methyluracil). The limb is immobilized with a plaster splint, ensuring that the affected area remains accessible for monitoring.

On the day of hospital admission, swabs are also taken from the Pharynx, skin pustules, or unhealed umbilicus for Bacteriological examination and to determine the antibiotic sensitivity of the microflora.

In some cases, intensive conservative treatment initiated within the first 24 hours of illness leads to the resolution of the acute bone inflammation, a rapid improvement in the patient's general condition, and recovery within 10–14 days.

Unfortunately, practicing pediatricians very often fail to diagnose acute hematogenous osteomyelitis during the first day of a child's illness—especially in infants under one year of age, whereas diagnosis is significantly easier in older children.

According to Vernyhora I.P., Hayko H.V., Hrytsay M.P., et al. (1995), pathogenetic treatment in 63.8% of sick children was initiated seven days after the onset of the disease. Such children are admitted to the hospital severely weakened and exhausted by pain and intoxication.

As already noted, every day the inflammatory focus in the bone progresses, leading to abscess formation and destructive changes. To prevent this, an emergency operation under anesthesia must be performed on the day of admission: 2–3 holes are drilled into the bone in the suspected area of osteomyelitis down to the medullary cavity.

Burr holes create intraosseous decompression, which reduces local pain and prevents the lengthwise progression of bone destruction. The exudate or pus obtained through the holes is sampled for bacteriological culture to determine The Nature of the microflora and its antibiotic sensitivity.

If no pus is found—which occurs in the Cytology/cytology/16.html">Early stages of myelitis before an abscess has formed or when the holes miss the purulent focus—one hole is drained for outflow, while a thin tube is inserted through another and connected to an infusion system (for blood transfusion, etc.) for continuous irrigation of the focus with antibacterial solutions according to Vernyhora I.P. (1995) (Fig. 393).

If a pus-filled focus is identified, it is rinsed under pressure through a syringe needle, and a corresponding continuous irrigation-suction system is established. The wound is then closed in layers.

More extensive interventions in the acute stage are generally avoided in severely ill children. Treatment is continued using antibiotics to which the microflora is sensitive. Bacterial cultures are performed every 5-7 days. Once the acute phase subsides and the patient's general condition improves, radiological examination or computed tomography is carried out to determine the precise localization and extent of bone destruction, in order to decide on the necessity and scope of elective surgery, as the condition becomes chronic.

Fig. 393. Schematic drawing of suction drainage (Vernyhora I.P., 1995).

There are cases when a child is admitted to the hospital so late that perforation of the softened bone and breakthrough of the abscess beneath the periosteum have already occurred. Since the periosteum in children is thick and dense, pus strips it away from the bone, forming a subperiosteal phlegmon that can be detected by Palpation and puncture. In such instances, the degree of destructive bone involvement is determined radiologically or tomographically, and a surgical plan is formulated.

If radiographs reveal no significant destruction, it is sufficient on the same day, under anesthesia, to widely open the subperiosteal phlegmon, irrigate its cavity and the purulent focus with a pulsating jet under pressure after enlarging the perforation opening. Whenever possible, ultrasonic cavitation using a solution of dioxidine and antibiotics is advisable. Given the patient's severe condition, the operation is concluded by Setting up an irrigation system, while the wound is drained and closed. Comprehensive postoperative management is the same as described above.

If radiographs show substantial bone destruction, occasionally with the presence of sequestra, the subperiosteal phlegmon is immediately punctured and the cavity is irrigated; comprehensive treatment is prescribed, and the patient is prepared for a scheduled yet urgent operation.

The surgery is performed under anesthesia and tourniquet control with appropriate anesthetic support. Soft tissue dissection is carried out along the entire length of the bone lesion, guided by the radiograph. Using a sharp osteotome, the bone is trephined, removing the site of perforation along with all necrotic foci and sequestra. The bone cavity is irrigated, and the degree of bone destruction is visually assessed, as it may not be visible on a plain radiograph.

It is crucial to remove all affected and sclerotic areas within healthy bone tissue. To achieve this in metaphyseal-diaphyseal lesions, the bone must be trephined over the necessary extent. Following radical necrectomy, the bone cavity is intensively irrigated with antiseptic solutions using a pulsating jet, subjected to ultrasonic cavitation with antibacterial solutions, and dried.

Following a radical operation, Structure/149.html">The problem of filling the bone cavity arises, as it cannot be left empty to prevent recurrence. We will not dwell on the numerous Methods used in the past (such as boiled plaster, foam rubber, Cartilage, egg yolk, cattle bone flour, adhesive compositions, etc.) which proved clinically unjustified as they were ineffective.

However, surgeons still widely employ the old, effective method of closing bone cavities using a flap of adjacent Muscle on a wide vascular pedicle. It is vital that the transposed muscle flap does not undergo necrosis; therefore, it is secured in the cavity with two or three sutures to the periosteum without compromising its blood supply.

The most effective method for closing bone cavities is bone grafting, which is universally recognized by surgeons and widely applied provided the operation has been performed radically. The surgeon must be certain that the cavity walls are healthy and that microbial contamination is below the critical level. Pieces of cancellous bone, harvested from the iliac crest, are gently pressed into the cavity. It is essential that the graft fits the cavity walls ideally, without gaps and without being excessively compressed.

Subsequently, the graft is infiltrated with an antibiotic solution by inserting the needle to the bottom of the cavity. The wound is closed in layers, and a Redon suction drainage is applied, as an irrigation system negatively affects healing.

The limb is immobilized with a gypsum splint. The drainage tube is removed once wound discharge ceases.

If the surgeon is uncertain about the radicality of the performed surgery, the bone cavity is treated in a similar manner following sequestrenecrectomy. In such cases,

it is inappropriate to close the metaepiphyseal cavity with adhesive composites or fast-setting Amino Acids, as this leads to osteomyelitis recurrence.

Clinical observations have established the efficacy of sorption preparations saturated with antibiotics (Septopal—polymethylmethacrylate beads saturated with gentamicin, hemostatic sponge, etc.). In Ukraine, Imosgent—gentamicin immobilized on polymethylsiloxane—is also utilized.

Kostrub O.O., Havretskyi A.I., Skrypniuk P.O. (1998) indicate that Imosgent sorbs remnants of necrotic elements following surgery, Proteins, and Bacteria, while gentamicin is released for over six days, maintaining its concentration within the wound and the adjacent lymphovenous network. The authors observed favorable outcomes when using Imosgent combined with a cancellous bone graft.

Once the wound has healed and under favorable conditions, once the patient's general condition improves, bone autoplasty can be performed as a Second Stage.

If a significant, sometimes circumferential, bone defect forms after a radical operation, performing a transverse resection of the affected bone segment and applying the Ilizarov compression-distraction apparatus is justified.

Fig. 394. Destruction of the proximal end of the femur resulting from acute hematogenous osteomyelitis associated with umbilical sepsis.

Following the healing of the surgical wound and a significant improvement in the patient's general condition, a staged reoperation is performed: an oblique osteotomy is executed to transport the middle fragment according to Ilizarov's method, thereby filling the defect until the transversely resected ends make contact.

It is important that a cellular infiltrate forms after the osteotomy; therefore, distraction of the intermediate fragment by 1 mm per day (in 2-3 sessions) is initiated on the fifth to seventh day post-osteotomy. The docked bone ends are slightly compressed to induce necrobiosis of the scar tissue formed between them, and are stabilized in the apparatus until bone union is achieved. During treatment, it is crucial to manage the apparatus to prevent any loss of wire tension and fixation. This method is highly effective in treating bone defects arising from various causes.

The elimination of bone defects following osteomyelitis using the Ilizarov distraction regenerate is now widely applied worldwide.

In cases of circumferential diaphyseal defects, particularly after traumatic osteomyelitis, some surgeons employ Fibula pro tibiae transposition (according to Hahn) or its transfer with a tissue complex using microsurgical techniques. However, this method has not gained support in Ukraine because the Procedure is quite complex and unsatisfactory results reach nearly 20%.

The treatment of purulent arthritis complicated by the rupture of an abscess, particularly into the hip joint, is extremely complex and demanding. This frequently occurs As a result of delayed diagnosis of osteomyelitis in umbilical sepsis. It leads to significant destructive changes in the proximal femur, resulting in ankylosis at best, or more commonly, a bone defect (Fig. 394). Diagnosing purulent arthritis in other locations is more straightforward, as the joints are more accessible for examination.

Therefore, to prevent an abscess from rupturing into the joint, timely diagnosis and intensive therapy of epiphyseal osteomyelitis are of paramount importance.

In cases of purulent arthritis, emergency arthrotomy with counter-incisions in dependent areas must be performed without delay. The joint cavity should be intensively lavaged with antiseptic solutions, and a continuous irrigation system established for the administration of antibacterial drugs. Postoperatively, it is crucial to immobilize the limb in a functionally advantageous position using a plaster cast, as the restoration of joint mobility cannot be expected. With comprehensive and timely treatment aimed at enhancing immunoreactive processes, it is possible to subdue the purulent inflammation within the joint. In favorable cases, treatment in the vast majority of patients culminates in ankylosis (Fig. 395), and occasionally in a deformity of the proximal femur that requires elective revisional stabilizing surgery (one to two years later or even later).

The dynamics of the osteomyelitic process and arthritis are monitored radiographically.

If the chronic osteomyelitic process fails to subside and persistent purulent sinuses develop, fistulography must be performed. To prevent the contrast agent from leaking out of the sinus, an injection needle is used to puncture an elastic rubber stopper held tightly against the skin around the sinus opening. By comparing plain radiographs with the fistulogram, the further treatment strategy is determined (Fig. 396).

When a sinus tract and a sequestrum are present, the patient is prepared for elective surgery, which should be performed during the remission phase of the inflammation. The operation must be radical, involving the excision of the sinus tract, all granulation tissue, and the surrounding pathologically altered soft tissues. To help the surgeon navigate the tissues and identify potential ramifications of the abscess, a 2% brilliant green solution or a 2% methylene blue solution (optionally mixed with hydrogen peroxide) should be injected under pressure into the sinus prior to surgery. Surgical access to the purulent focus must not only be anatomically sound and minimally traumatic, but also provide adequate exposure for a radical procedure.

Fig. 395. Ankylosis of the left hip joint following hematogenous osteomyelitis of the femoral neck complicated by purulent coxitis.

The Use of antibacterial agents, particularly osteotropic drugs, combined with surgical interventions, has revolutionized the treatment of hematogenous osteomyelitis. Identifying the causative pathogen of the osteomyelitic process and its antibiotic susceptibility as quickly as possible is critically important.

When prescribing chemotherapeutic agents, standard guidelines regarding dosages, intervals, administration routes, drug compatibility, and side effects must be strictly observed. To achieve a maximum antibiotic concentration within the inflammatory focus, direct intraosseous or regional intra-arterial administration in adults is optimal (Fig. 397).

Since Staphylococcus aureus is cultured in the vast majority of patients with hematogenous osteomyelitis, it should be noted that it is typically susceptible (90% or more) to fusidic acid, nitrofuran derivatives, oxacillin-class drugs, rifampicin, lincomycin, oxacillin, Aminoglycosides, and the latest generation of Cephalosporins.

Fig. 396. Fistulogram of a purulent sinus in the distal metaphysis of the femur.

Fig. 397. Diagram of femoral artery catheterization: a - skin incision projection and arterial puncture, b - guidewire insertion, c - removal of the guidewire after catheter placement, d - sealing the catheter lumen with a plug.

Staphylococcus aureus exhibits susceptibility to ampicillin in only about 10% of cultures. Even if in vitro testing reveals such susceptibility, ampicillin or benzylpenicillin should be avoided, as their therapeutic effect is short-lived.

More effective alternatives include unasyn or suldomicelin (administered per os), which are combinations of ampicillin and sulbactam. Erythromycin, oleandomycin, clarithromycin, dirithromycin, rokitamycin, and amoxiclav are particularly valuable in treating septicemia and septic arthritis. Doxycycline (tetradox), which lacks the Adverse effects of traditional Tetracyclines, exerts a bacteriostatic effect in osteomyelitis, while other tetracycline derivatives (morphocycline, doxycycline (vibramycin), rondomycin) are prescribed exclusively to adult patients.

Hemolytic streptococcus is highly susceptible to numerous antibiotics, with the exception of aminoglycosides, whereas enterobacteria (Proteus, Escherichia) are notably sensitive to claforan, longacef, nitroxoline, nitrofurans, and amikacin. Notably, enterobacteria demonstrate significant resistance even to third-generation cephalosporins.

Non-fermenting bacteria (such as Acinetobacter) are susceptible to nitroxoline, whereas high susceptibility to claforan is observed in only 30% of cultures.

It is worth noting that gentamicin, to which many Gram-negative bacteria retain susceptibility, is not osteotropic; therefore, in hematogenous osteomyelitis, it is effective only when administered intraosseously, endolymphatically, or via regional intra-arterial infusion (Fig. 397).

Rifampicin possesses significant osteotropic properties, but its minimum inhibitory concentration for Gram-negative bacteria ranges from 1-10 mcg/mL, compared to 0.2 mcg/mL for staphylococci and streptococci. Consequently, Vernyhora et al. recommend rifampicin when the process involves parenchymal Organs, and it has proven effective against 61.3% of Pseudomonas aeruginosa cultures. Pseudomonas aeruginosa has also shown pronounced susceptibility to claforan, longacef, azlocillin, and, notably, ceftazidime.

Regarding activity against obligate anaerobic bacteria, the most effective agents are metronidazole, levomycetin, lincomycin, clindamycin, penicillin, carbenicillin, oxacillin, cefoxitin, cephaloridine, cefazolin, and cefotaxime.

All anaerobes, including clostridia, are resistant to aminoglycosides (gentamicin, amikacin, etc.). Bacteroides fragilis group organisms are resistant to benzylpenicillin, oxacillin, and lincomycin, yet exhibit high susceptibility to antibiotics such as cifran, ciprobay, ofloxacin, enoxacin, and temafloxacin.

Tinidazole, nimorazole, and other nitroimidazole derivatives exhibit high activity against non-clostridial anaerobes.

Notably, recent years have seen the successful Integration of the newest broad-spectrum osteotropic antibiotics into the management of purulent bone pathology. These include ceftazidime, longacef, ofloxacin (tarivid), ciprofloxacin (ciprobay), enoxacin, norfloxacin, and pefloxacin. These agents demonstrate high efficacy against the majority of purulent infection pathogens, including staphylococci and enterobacteria that are resistant to many standard antibiotics.

Since in chronic hematogenous osteomyelitis after surgery, bone-suppurative infection is often caused by two or more types of microorganisms with varying antibiotic sensitivities, it is necessary to use targeted combination antibiotic therapy.

As S. I. Bidnenko notes, the use of two or more antimicrobial agents leads to a broader antimicrobial spectrum, reduces the risk of selecting resistant microbial strains, and enhances antimicrobial efficacy.

Combining antibiotics is appropriate at the onset of treatment for acute hematogenous osteomyelitis in severe septic patients, even before the specific causative agent of the infection has been identified.

Once the bone pathogen and its antibiotic susceptibility have been identified, treatment should be continued with a single, most effective agent. A course of monotherapy with one antibiotic may last from 5-10 days to 4 weeks or longer, depending on the drug type and clinical indications. Antibiotics should not be switched every 7-8 days. The criterion for changing a drug is its lack of efficacy, which in acute hematogenous osteomyelitis can typically be observed clinically within 2-3 days. In chronic osteomyelitis, prolonged courses of antibiotic therapy can be administered taking into account the sensitivity of the isolated microbes. For instance, fluoroquinolones may be used for 10-12 weeks, Other Antibiotics for up to 5-6 weeks, with the exception of aminoglycosides, which should not be administered for longer than 2-3 weeks.

It is advisable to avoid using exclusively broad-spectrum antibiotics via a single route of administration; rather, it is crucial that they act synergistically, remain compatible, and exert no adverse systemic effects (such as ototoxicity, nephrotoxicity, or hepatotoxicity).

Complications of antibiotic therapy. According to S. I. Bidnenko, Hearing impairment may be caused by aminoglycosides, vancomycin, and ristomycin, while both hearing and Vision impairments can be caused by streptomycin.

Renal function impairment (nephrotoxicity) may be induced by aminoglycosides, sulfonamides, tetracyclines (except doxycycline), as well as vancomycin, carbenicillin, nitrofurans, and occasionally rifampin, azlocillin (mezlocillin), carbenicillin, and piperacillin.

Hepatotoxic effects can be caused by tetracyclines, chloramphenicol, and sulfonamides, and rarely by erythromycin, methicillin, rifampin, fluoroquinolones, amoxicillin, and macrolides.

Sulfonamides can cause leukopenia, erythrocyte hemolysis, and methemoglobinemia.

The aforementioned drugs should be used with caution in patients with renal and hepatic disorders.

Prescribing Chemotherapy to pregnant women and infants requires extreme caution. Fluoroquinolones (such as norfloxacin, cifran, ciprobay, phloxacin [zanocin, tarivid], enoxacin, and temafloxacin) are contraindicated throughout the entire Pregnancy. Furthermore, In the second and third trimesters, tetracyclines adversely affect the fetus and newborns by inhibiting bone growth, while aminoglycosides exhibit ototoxic effects.

Chloramphenicol causes "gray baby" syndrome in newborns, whereas nitrofurans and sulfonamides may induce hemolytic anemia and jaundice.

S. I. Bidnenko believes that the treatment of infants should involve benzylpenicillin, methicillin, oxacillin, unasyn, first-generation cephalosporins, imipenem, and nystatin. Gentamicin and amikacin should be used with caution; lincomycin and clindamycin are permitted up to one month of age; and vancomycin, third-generation cephalosporins, azlocillin, and aztreonam should be reserved for life-threatening indications. Tetracycline, kanamycin, monomycin, fluoroquinolones, and sulfonamides must not be used.

Step-down (sequential) antimicrobial therapy is gaining increasing popularity. Transitioning a patient from parenteral to oral antibiotic administration is based on clinical criteria (normalization of body temperature below 38°C for 48 hours, improvement in blood test parameters and general condition), bacteriological findings (Isolation of the pathogen and determination of its antibiotic susceptibility), and the decision regarding The Need for mono- versus combination antibiotic therapy.

For oral monotherapy, the most accessible options (80-100%) include ciprofloxacin (cifran), ofloxacin (zanocin), clindamycin, doxycycline, amoxicillin, cephalexin, and trimethoprim.

According to S. I. Bidnenko, the ideal scenario for step-down chemotherapy is administering the same high-bioavailability antibiotic both parenterally and orally, though different high-bioavailability oral formulations are more commonly used. Hospital departments should maintain tables listing antibiotics along with their dosages for adults and children, drug compatibility profiles, spectrum of activity, and potential adverse reactions.

When using antibiotics to treat patients with hematogenous osteomyelitis (regardless of age), complications such as candidiasis, aspergillosis, geotrichosis, and others may occasionally arise. These are treated with nystatin, levorin, amphotericin B, nizoral, miconazole, diflucan, intraconazole, and other agents with corresponding antifungal activity.

Alongside antibiotic therapy, detoxification infusion therapy plays a vital role in treating hematogenous osteomyelitis, particularly for critically ill patients during preoperative preparation and the postoperative period.

In acute hematogenous osteomyelitis, patients—especially children—often present as debilitated and dehydrated because pain and intoxication prevent them from sleeping and cause them to refuse food.

Upon hospital admission, the patient's general condition is evaluated, and infusion therapy is initiated as an essential component of comprehensive treatment to correct disrupted body homeostasis. Patients are transfused with detoxification agents (such as hemodez, polydez, neocompensan, etc.). These are alternated with crystalloid regulators of Water-electrolyte and acid-base imbalances (normal saline, Ringer-Locke solution, Lactosol and Acesol preparations, trisamine, mannitol, etc.). It is advisable to combine these solutions with albumin, albuminag, protein, transfusions of type-specific native plasma, glucose, and Vitamins.

Infusion solutions integrated into the comprehensive treatment plan significantly reduce bodily intoxication and improve the patient's overall condition.

Chronic osteogenous osteomyelitis leads to profound disruptions in homeostasis and the functional activity of all bodily systems. The definitive treatment for these patients is radical surgery, for which the patient must be prepared following a comprehensive evaluation. It is particularly important to assess renal and hepatic function, as well as hematological parameters.

Chronic suppurative processes frequently result in anemia, hypoproteinemia, and hypoalbuminemia, which must also be corrected preoperatively through the infusion of blood components and plasma substitutes. For anemia, washed red Blood Cells are transfused, and erythropoiesis stimulants are sometimes employed alongside the administration of Ringer's solution, Acesol, rheopolyglucukin, hemodez, or polypher, which potentiates hematopoiesis.

Infusion therapy is maintained intraoperatively under appropriate Anesthetic Management and is continued throughout the postoperative period.

It is well established that childhood and immunodeficiency contribute to The Development of hematogenous osteomyelitis. Therefore, improving the immunological status of the Organism during the postoperative period is crucial, as adaptive and compensatory capabilities depend on it, making it a key determinant of the subsequent disease course.

To evaluate the status of The Immune System, it is necessary to determine the absolute lymphocyte count in the blood, the relative and absolute number of T-lymphocytes (spontaneous rosette formation test), the subpopulation profile of T-lymphocytes, and the level of circulating immune complexes. The degree of immunodeficiency depends on the duration of hematogenous osteomyelitis. In the early Stages of the disease, there are moderate decreases in the number of T-lymphocytes, The ratio of active helper to suppressor T-cells, the serum levels of IgA, IgM, and IgG, circulating immune complexes, and the phagocytic activity of neutrophils.

According to I.P. Vernygora, G.V. Hayko, M.P. Hrytsay et al. (1995), when chronic osteomyelitis lasts for more than one year, significant alterations occur in both cellular and humoral Immunity indicators. Lymphopenia, a decreased count of T-lymphocytes with a predominance of T-suppressors, reduced levels of IgM and antistaphylotoxin, and an elevated content of circulating immune complexes were observed. In more than half of the patients, low levels of IgG and Complement, as well as reduced neutrophil phagocytic activity, were detected.

To stimulate cellular and humoral immunity and, consequently, regenerative processes, clinical practice most commonly employs a combination of anabolic Hormones (retabolil, silabolin intramuscularly once a week) with sodium nucleinate (0.2 g per day) and decaris (75 mg twice a week for three months). T-activin, vilozen, lysozyme, prodigiosan, and methyluracil are occasionally used. Favorable effects are also achieved with Mumie-Vitas (200 mg per day for 2–3 weeks), transfusions of plasma expanders and small doses of type-matched blood (2–3 times every two weeks), and a balanced, vitamin-rich diet.

Vernygora et al. (1999) propose the following provisional regimens for immunocorrective therapy in osteomyelitis (Tables 13 and 14).

The Implementation of comprehensive treatment for patients with osteomyelitis, including radical surgical interventions, ensures patient recovery and prevents disease relapse and disability.