| Osteomyelitis | |
|---|---|
| Other names | Bone infection |
 | |
| Osteomyelitis of the 1st toe | |
| Specialty | Infectious disease,orthopedics |
| Symptoms | Pain in a specific bone, overlying redness,fever, weakness[1] |
| Complications | Amputation[2] |
| Usual onset | Young or old[1] |
| Duration | Short or long term[2] |
| Causes | Bacterial, fungal[2] |
| Risk factors | Diabetes,intravenous drug use, priorremoval of the spleen, trauma to the area[1] |
| Diagnostic method | Blood tests,medical imaging, bonebiopsy[2] |
| Differential diagnosis | Charcot's joint,rheumatoid arthritis,infectious arthritis,giant cell tumor,cellulitis[1][3] |
| Treatment | Antimicrobials, surgery[4] |
| Prognosis | Low risk of death with treatment[5] |
| Frequency | 2.4 per 100,000 per year[6] |
Osteomyelitis (OM) is theinfectiousinflammation ofbone marrow.[1] Symptoms may include pain in a specific bone with overlying redness,fever, and weakness.[1] The feet, spine, and hips are the most commonly involved bones in adults.[2]
The cause is usually abacterial infection,[1][7][2] but rarely can be afungal infection.[8] It may occur by spread from the blood or from surrounding tissue.[4] Risks for developing osteomyelitis includediabetes,intravenous drug use, priorremoval of the spleen, and trauma to the area.[1] Diagnosis is typically suspected based on symptoms and basic laboratory tests asC-reactive protein anderythrocyte sedimentation rate. This is because plainradiographs are unremarkable in the first few days following acute infection.[7][2] Diagnosis is further confirmed byblood tests,medical imaging, orbone biopsy.[2]
Treatment of bacterial osteomyelitis often involves bothantimicrobials and surgery.[7][4] Treatment outcomes of bacterial osteomyelitis are generally good when the condition has only been present a short time.[7][2] In people with poor blood flow,amputation may be required.[2] Treatment of the relatively rare fungal osteomyelitis asmycetoma infection entails the use of antifungal medications.[9] In contrast to bacterial osteomyelitis, amputation or large bony resections is more common in neglected fungal osteomyelitis (mycetoma) where infections of the foot account for the majority of cases.[8][9] About 2.4 per 100,000 people are affected by osteomyelitis each year.[6] The young and old are more commonly affected.[7][1] Males are more commonly affected than females.[3] The condition was described at least as early as the 300s BC byHippocrates.[4] Prior to the availability of antibiotics, the risk of death was significant.[10]
Symptoms may include pain in a specific bone with overlying redness,fever, and weakness and inability to walk especially in children with acute bacterial osteomyelitis.[7][1] Onset may be sudden or gradual.[1]Enlarged lymph nodes may be present.[11]In fungal osteomyelitis, there is usually a history of walking bare-footed, especially in rural and farming areas. Contrary to the mode of infection in bacterial osteomyelitis, which is primarilyblood-borne, fungal osteomyelitis starts as a skin infection, then invades deeper tissues until it reaches bone.[8]
| Age group | Most common organisms |
|---|---|
| Newborns (younger than 4 mo) | Staphylococcus aureus,Enterobacter species, andgroup A andBStreptococcus species |
| Children (aged 4 mo to 4 y) | S. aureus, group AStreptococcus species,Haemophilus influenzae, andEnterobacter species |
| Children, adolescents (aged 4 y to adult) | S. aureus (80%), group AStreptococcus species,H. influenzae, andEnterobacter species |
| Adult | S. aureus and occasionallyEnterobacter orStreptococcus species |
| Sickle cell anemia patients | Salmonella species are most common in patients with sickle cell disease.[12] |
Acute osteomyelitis almost invariably occurs in children who are otherwise healthy, because of rich blood supply to the growing bones. When adults are affected, it may be because of compromised host resistance due to debilitation,intravenous drug abuse, infectious root-canaled teeth, or other disease or drugs (e.g.,immunosuppressive therapy).[7] The most commonly affected areas for children are thelong bones,[7][failed verification] and for adults, the feet, spine, and hips.[2]
Osteomyelitis is a secondarycomplication in 1–3% of patients with pulmonarytuberculosis.[13] In this case, the bacteria, in general, spread to the bone through thecirculatory system, first infecting thesynovium (due to its higheroxygen concentration) before spreading to the adjacent bone.[13] In tubercular osteomyelitis, the long bones and vertebrae are the ones that tend to be affected.[13]
Staphylococcus aureus is the organism most commonly isolated from all forms of osteomyelitis.[13]
Osteomyelitis is often caused byStaphylococcus aureus.[14] In infants,S. aureus,Group B streptococci andEscherichia coli are commonly isolated; in children from one to 16 years of age,S. aureus,Streptococcus pyogenes, andHaemophilus influenzae are common. In some subpopulations, including intravenous drug users andsplenectomized patients,Gram-negative bacteria, includingenteric bacteria, are significant pathogens.[15]
The most common form of the disease in adults is caused by injury exposing the bone to local infection.[14]Staphylococcus aureus is the most common organism seen in osteomyelitis, seeded from areas of contiguous infection. Butanaerobes and Gram-negative organisms, includingPseudomonas aeruginosa,E. coli, andSerratia marcescens, are also common. Mixed infections are the rule rather than the exception.[15]
Systemicmycotic infections may also cause osteomyelitis. The two most common areBlastomyces dermatitidis andCoccidioides immitis.[citation needed]
In osteomyelitis involving the vertebral bodies, about half the cases are due toS. aureus, and the other half are due totuberculosis (spread hematogenously from thelungs). Tubercular osteomyelitis of thespine was so common before the initiation of effective antitubercular therapy, it acquired a special name,Pott's disease.[citation needed]
TheBurkholderia cepacia complex has been implicated in vertebral osteomyelitis in intravenous drug users.[16]
In general, microorganisms may infect bone through one or more of three basic methods
The area usually affected when the infection is contracted through the bloodstream is themetaphysis of the bone.[17] Once the bone is infected,leukocytes enter the infected area, and, in their attempt toengulf the infectious organisms, releaseenzymes thatlyse the bone.Pus spreads into the bone's blood vessels, impairing their flow, and areas of devitalized infected bone, known assequestra, form the basis of a chronic infection.[13] Often, the body will try to create new bone around the area ofnecrosis. The resulting new bone is often called aninvolucrum.[13] Onhistologic examination, these areas of necrotic bone are the basis for distinguishing betweenacute osteomyelitis and chronic osteomyelitis. Osteomyelitis is an infective process that encompasses all of the bone (osseous) components, including the bone marrow. When it is chronic, it can lead to bonesclerosis and deformity.[citation needed]
Chronic osteomyelitis may be due to the presence ofintracellular bacteria.[19] Once intracellular, the bacteria are able to spread to adjacent bone cells.[20] At this point, the bacteria may be resistant to certain antibiotics.[21] In chronic osteomyelitis, Staphylococcus aureus can persist by forming biofilms and invading the osteocyte lacuno‑canalicular network, which contributes to antibiotic tolerance and difficulty eradicating infection[22].
In infants, the infection can spread to a joint and causearthritis. In children, largesubperiostealabscesses can form because theperiosteum is loosely attached to the surface of the bone.[13]
Because of the particulars of their blood supply, thetibia,femur,humerus,vertebrae,maxilla and themandibular bodies are especially susceptible to osteomyelitis.[23] Abscesses ofany bone, however, may be precipitated by trauma to the affected area. Many infections are caused byStaphylococcus aureus, a member of the normalflora found on theskin andmucous membranes. In patients withsickle cell disease, the most common causative agent isSalmonella, with a relative incidence more than twice that of S. aureus.[12]
The diagnosis of osteomyelitis is complex and relies on a combination of clinical suspicion and indirect laboratory markers such as a high white blood cell count and fever, although confirmation of clinical and laboratory suspicion with imaging is usually necessary.[24]
Radiographs and CT are the initial method of diagnosis, but are notsensitive and only moderatelyspecific for the diagnosis. They can show thecortical destruction of advanced osteomyelitis, but can miss nascent or indolent diagnoses.[24]
Confirmation is most often byMRI.[25] The presence ofedema, diagnosed as increased signal on T2 sequences, is sensitive, but not specific, as edema can occur in reaction to adjacentcellulitis. Confirmation of bony marrow and cortical destruction by viewing the T1 sequences significantly increases specificity. The administration of intravenousgadolinium-based contrast enhances specificity further. In certain situations, such as severeCharcot arthropathy, diagnosis with MRI is still difficult.[24] Similarly, it is limited in distinguishingavascular necrosis from osteomyelitis insickle cell anemia.[26]
Nuclear medicine scans can be a helpful adjunct to MRI in patients who have metallic hardware that limits or prevents effective magnetic resonance. Generally a triple phasetechnetium 99 based scan will show increased uptake on all three phases.Gallium scans are 100% sensitive for osteomyelitis but not specific, and may be helpful in patients with metallic prostheses. Combined WBC imaging with marrow studies has 90% accuracy in diagnosing osteomyelitis.[27]
Diagnosis of osteomyelitis is often based onradiologic results showing alytic center with a ring ofsclerosis.[13]Culture of material taken from a bone biopsy is needed to identify the specific pathogen;[28] alternative sampling methods such as needle puncture or surface swabs are easier to perform, but cannot be trusted to produce reliable results.[29][30]
Factors that may commonly complicate osteomyelitis are fractures of the bone,amyloidosis,endocarditis, orsepsis.[13]
The definition of osteomyelitis (OM) is broad, and encompasses a wide variety of conditions. Traditionally, the length of time the infection has been present and whether there issuppuration (pus formation) orosteosclerosis (pathological increaseddensity of bone) are used to arbitrarily classify OM. Chronic OM is often defined as OM that has been present for more than one month. In reality, there are no distinct subtypes; instead, there is a spectrum of pathologic features that reflects a balance between the type and severity of the cause of the inflammation, the immune system, and local and systemic predisposing factors.[citation needed]
OM can also be typed according to the area of the skeleton in which it is present. For example,osteomyelitis of the jaws is different in several respects from osteomyelitis present in a long bone.Vertebral osteomyelitis is another possible presentation.[citation needed]
Osteomyelitis often requires prolongedantibiotic therapy for weeks or months. APICC line orcentral venous catheter can be placed for long-termintravenous medication administration. Some studies of children with acute osteomyelitis report that antibiotic by mouth may be justified due to PICC-related complications.[31][32] It may require surgicaldebridement in severe cases, or even amputation. Antibiotics by mouth and by intravenous appear similar.[33][34]
Due to insufficient evidence it is unclear what the best antibiotic treatment is for osteomyelitis in people with sickle cell disease as of 2019.[35]
Initial first-line antibiotic choice is determined by the patient's history and regional differences in common infective organisms. A treatment lasting 42 days is practiced in a number of facilities.[36] Local and sustained availability of drugs have proven to be more effective in achieving prophylactic and therapeutic outcomes.[37] Open surgery is needed for chronic osteomyelitis, whereby the involucrum is opened and the sequestrum is removed or sometimes saucerization[38] can be done.Hyperbaric oxygen therapy has been shown to be a useful adjunct to the treatment of refractory osteomyelitis.[39]
Before the widespread availability and use of antibiotics,blow fly larvae were sometimesdeliberately introduced to the wounds to feed on the infected material, effectively scouring them clean.[40][41]
There is tentative evidence thatbioactive glass may also be useful in long bone infections.[42] Support fromrandomized controlled trials, however, was not available as of 2015.[43]
Hemicorporectomy is performed in severe cases of Terminal Osteomyelitis in the Pelvis if further treatment won't stop the infection.[44]
The word is from Greek words ὀστέονosteon, meaning bone, μυελόςmyelos meaning marrow, and -ῖτις-itis meaning inflammation.
In 1875, American artistThomas Eakins depicted a surgical procedure for osteomyelitis atJefferson Medical College, in anoil painting titledThe Gross Clinic.[45]
Canadian politician andpremier of SaskatchewanTommy Douglas suffered from osteomyelitis as a child, and in 1910, underwent several surgeries, which the surgeon performed for free in exchange for allowing his medical students to observe the procedures (which Douglas's parents could not have otherwise afforded). This experience convinced him that medical care should be free for everyone.[46] Douglas became known as the Canadian "Father of Medicare".[47]
Evidence for osteomyelitis found in the fossil record is studied bypaleopathologists, specialists in ancient disease and injury. It has been reported in fossils of the large carnivorous dinosaurAllosaurus fragilis.[48] Osteomyelitis has been also associated with the first evidence of parasites in dinosaur bones.[49]
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