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Osteomyelitis

Osteomyelitis is an infection of bone, usually caused by pyogenic bacteria or mycobacteria. It can be usefully subclassifed on the basis of the causative organism, the route, duration and anatomic location of the infection. more...

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Generally microorganisms may be disseminated to bone hematogenously (i.e., via the blood stream), spread contiguously to bone from local areas of infection, such as cellulitis, or be introduced by penetrating trauma including iatrogenic causes such as joint replacements or internal fixation of fractures. Leukocytes then enter the infected area, and in their attempt to engulf the infectious organisms, release enzymes that lyse bone. Pus spreads into the bone's blood vessels, impairing the flow, and areas of devitalized infected bone, known as sequestra, form the basis of a chronic infection. On histologic examination, these areas of necrotic bone are the basis for distinguishing between acute osteomyelitis and chronic osteomyelitis. Osteomyelitis is an infective process which encompasses all of the bone (osseous) components, including the bone marrow. When it is chronic it can lead to bone sclerosis and deformity.

Osteomyelitis often requires prolonged antibiotic therapy, lasting a matter of weeks or months, and may require surgical debridement. Severe cases may lead to the loss of a limb.

Because of the particulars of their blood supply, the tibia, the femur, the humerus, and the vertebral bodies are especially prone to osteomyelitis.

The vast predominance of hematogenously seeded osteomyelitis is caused by Staphylococcus aureus. Escherichia coli, and streptococci are other common pathogens. In some subpopulations, including intravenous drug users and splenectomized patients, Gram negative bacteria, including enteric bacilli, are significant pathogens.

Staphylococcus aureus is also the most common organism seen in osteomyelitis seeded from areas of contiguous infection, but here Gram negative organisms and anaerobes are somewhat more common, and mixed infections may be seen.

In osteomyelitis involving the vertebral bodies, about half the cases are due to Staphylococcus aureus, and the other half are due to tuberculosis (spread hematogenously from the lungs). Tubercular osteomyelitis of the spine was so common before the initiation of effective antitubercular therapy that it acquired a special name, Pott's disease, by which it is sometimes still known.

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Osteomyelitis
From Ear, Nose & Throat Journal, 11/1/05 by Francis H. Gannon

The proper treatment and clinical management of osteomyelitis (bone infection) depend on a successful correlation of its clinical features with radiologic and pathologic findings. Diagnostic difficulties may arise, and the final arbiter is intraoperative culture. The importance of intraoperative culture obtained in a "sterile" environment cannot be overemphasized.

The three general categories of osteomyelitis are acute, chronic, and tuberculous (the latter is not seen in head and neck locations). Most patients with acute osteomyelitis in the head and neck present with mandibular disease. Osteomyelitis is being seen with increasing frequency in patients with chronic diseases such as diabetes and peripheral vascular disease and in patients with poor dental hygiene; it is uncommon in healthy adults. Because adult patients often present with pain and without an associated fever, a high index of suspicion and the appropriate cultures are required to establish the correct diagnosis and appropriate treatment. The histologic features include marrow edema and delicate fibrosis with acute inflammatory cells and bone resorption (figure 1).

[FIGURE 1 OMITTED]

Chronic osteomyelitis is often the result of incomplete treatment of acute osteomyelitis. Approximately 15 to 30% of patients with acute osteomyelitis will develop chronic osteomyelitis. Signs and symptoms of the chronic form are usually less prominent and may fluctuate in severity; they include swelling, pain, sinus formation, sequestration and, in the case of bone loss, pathologic fractures. The histologic features are marrow fibrosis with scattered mononuclear cells (figure 2). Long-standing chronic osteomyelitis is associated with squamous cell carcinoma in approximately 1% of patients.

[FIGURE 2 OMITTED]

The treatment of acute osteomyelitis involves an armamentarium of antibiotic agents in addition to debridement and removal of dead bone. Chronic osteomyelitis is more difficult to manage unless all necrotic bone and organisms are removed. Occasionally, resection of large parts of the mandible is necessary to achieve this goal.