Osteomyelitis Disease

BASICS

DESCRIPTION

Osteomyelitis is an acute or chronic infection of the bone and its structures caused most commonly by bacteria and rarely by other microorganisms. This infection may be acquired either by hematogenous, contiguous, or direct inoculation such as trauma or surgery.

System(s) affected: Musculoskeletal
Genetics: There is no genetic predisposition known in this disease
Incidence/Prevalence in USA: Uncommon
Predominant age: This infection is commonly seen in older adults; hematogenous is bimodal, also seen in infants and children
Predominant sex: Males > Females

SIGNS AND SYMPTOMS

Hematogenous long bone infection (in children with hematogenous osteomyelitis)
- Abrupt onset of high fever
- Irritability
- Malaise
- Restriction of movement of the involved extremity
- Signs of localized inflammation
Hematogenous vertebral infection (in adults with vertebral osteomyelitis)
- Illness is insidious and behaves more like a chronic infection
- History of an acute bacteremic episode associated with infection of a specific organ may be found in some patients
Contiguous and vascular insufficiency associated infection
- Acute constitutional manifestations are seldom seen
- Localized signs and symptoms of inflammation with or without drainage frequently found
Chronic osteomyelitis
- Non-healing ulcer or draining sinus
- Constitutional symptoms, when present, indicate acute suppurative condition in the bone or surrounding tissues
Prosthetic device associated infection
- Infection may be acquired either by hematogenous route, or by contiguous foci such as local infection, operative contamination, or postoperative infection
- Acute postoperative infection may present as fever, localized swelling, tenderness, and drainage
- Chronic infection is characterized by joint discomfort, swelling, erythema, and joint dysfunction

CAUSES

Acute hematogenous osteomyelitis
- Staphylococcus aureus (most common)
- Streptococcus, coagulase negative Staphylococcus, Haemophilus influenzae, and gram negative organisms (less common)
Vertebral osteomyelitis
- Staphylococcus aureus and gram negative enteric organisms (common)
- Other microorganisms to consider include Mycobacterium tuberculosis, and fungi
Contiguous focus osteomyelitis and vascular insufficiency osteomyelitis
- Mixed aerobic/anaerobic microorganisms are frequently found
Prosthetic device infection
- Coagulase negative Staphylococcus, and S. aureus (most common)
- Diphtheroids, and gram negative bacteria (less common)

RISK FACTORS

Sickle cell disease
Other conditions which predispose to bone infarcts
IV drug use
Hemodialysis
Local trauma
Open fractures
Presence of prosthetic orthopedic implant
Vascular insufficiency
Neuropathy
Diabetes mellitus

DIAGNOSIS

LABORATORY

Definitive diagnosis is made by needle aspiration or bone biopsy and demonstration of the microorganism by culture or histology
Blood culture may be positive in about 50% of younger patients with acute hematogenous disease
Leukocyte count is usually elevated in the acute cases, but not in the chronic cases
Sedimentation rate or C-reactive protein is usually elevated, but non-specific

Drugs that may alter lab results: Antimicrobial agents given before bone culture
Disorders that may alter lab results:

Cultures from the sinus tract are unreliable because of frequent contamination
Superficial cultures only helpful in identifying methicillin-resistant S. aureus

PATHOLOGICAL FINDINGS

Inflammatory process of the bone with pyogenic bacteria

SPECIAL TESTS

N/A

IMAGING

No technique can absolutely confirm or exclude osteomyelitis
Radiographic - routine X-ray (findings on plain X-ray often delayed for 10-14 days in acute infection)
Radionuclide (technetium, indium, or gallium) are also useful, but limited by low specificity
CT with good resolution, artifact may decrease specificity
MRI excellent, but limited by costs

DIAGNOSTIC PROCEDURES

Needle biopsy or open bone biopsy for bacterial culture (which is the "gold standard")

TREATMENT

APPROPRIATE HEALTH CARE

Hospitalize the patient with suspected acute osteomyelitis for diagnostic work-up and initial treatment

GENERAL MEASURES

Symptomatic treatment of pain

SURGICAL MEASURES

Surgical drainage and removal of necrotic tissues are of utmost importance to effect cure
In patients with vascular insufficiency or severe gangrenous infection, amputation may be the only effective treatment

ACTIVITY

Bedrest and immobilization of the involved bone and joint

DIET

No restriction

PATIENT EDUCATION

Stress need for long-term treatment and follow up

FOLLOW UP

PREVENTION/AVOIDANCE

Avoid further stress and weight bearing until healing

POSSIBLE COMPLICATIONS

Abscess formation
Bacteremia
Fracture
Loosening of the prosthetic implant
Postoperative infection

EXPECTED COURSE AND PROGNOSIS

Cure of osteomyelitis with medical treatment is notoriously unpredictable especially when not accompanied by surgical debridement
In patients with acute hematogenous osteomyelitis, the prognosis is usually good even without surgery. Cure takes about 6 weeks
The prognosis is improved if all infected bone has been removed

MISCELLANEOUS

ASSOCIATED CONDITIONS

Listed with Causes

AGE-RELATED FACTORS

Pediatric: Occurs most often in 5-14 age group and more frequently in boys
Geriatric:

Vertebral osteomyelitis more common
Contiguous focus of infection more common
Vascular insufficiency is the most common cause of osteomyelitis in 50–70 age group (usually due to presence of associated conditions)

Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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