Elsevier

The Lancet

Volume 364, Issue 9431, 24–30 July 2004, Pages 369-379
The Lancet

Seminar
Osteomyelitis

https://doi.org/10.1016/S0140-6736(04)16727-5Get rights and content

Summary

Bone and joint infections are painful for patients and frustrating for both them and their doctors. The high success rates of antimicrobial therapy in most infectious diseases have not yet been achieved in bone and joint infections owing to the physiological and anatomical characteristics of bone. The key to successful management is early diagnosis, including bone sampling for microbiological and pathological examination to allow targeted and long-lasting antimicrobial therapy. The various types of osteomyelitis require differing medical and surgical therapeutic strategies. These types include, in order of decreasing frequency: osteomyelitis secondary to a contiguous focus of infection (after trauma, surgery, or insertion of a joint prosthesis); that secondary to vascular insufficiency (in diabetic foot infections); or that of haematogenous origin. Chronic osteomyelitis is associated with avascular necrosis of bone and formation of sequestrum (dead bone), and surgical debridement is necessary for cure in addition to antibiotic therapy. By contrast, acute osteomyelitis can respond to antibiotics alone. Generally, a multidisciplinary approach is required for success, involving expertise in orthopaedic surgery, infectious diseases, and plastic surgery, as well as vascular surgery, particularly for complex cases with soft-tissue loss.

Section snippets

Mechanisms of disease: the bone

Examination of the area of acute osteomyelitis by microscopy reveals an acute suppurative inflammation in which bacteria or other microorganisms are embedded. Various inflammatory factors, and leucocytes themselves, contribute to tissue necrosis and the destruction of bone trabeculae and bone matrix. Vascular channels are compressed and obliterated by the inflammatory process, and the resulting ischaemia also contributes to bone necrosis. Segments of bone devoid of blood supply can become

Pathogenesis: host and microorganisms

The development of osteomyelitis is related to microbial (table 1) and host factors. Among pathogenic microorganisms, Staphylococcus aureus is by far the most commonly involved (figure 2). This organism elaborates a range of extracellular and cell-associated factors contributing to its virulence. First are factors promoting attachment to extracellular matrix proteins, called bacterial adhesins. The ability of Staph aureus to adhere is thought to be crucial for the early colonisation of host

Diagnostic procedures

Patients can present with a variety of symptoms ranging from an open wound exposing fractured bone, an indolent draining fistula, to no skin lesion, but local swelling and bone pain tenderness on clinical examination. Confirmation of osteomyelitis requires several diagnostic procedures as described below.

Osteomyelitis secondary to a contiguous infection

Chronic osteomyelitis, characterised by infected dead bone and in most cases poor local vascularisation within a compromised soft-tissue envelope, is difficult to eradicate. Systemic symptoms generally subside, but one or more foci in the bone still contain infected tissue, or a sequestrum. The infected foci within the bone are surrounded by sclerotic, avascular bone covered by a thickened periosteum and scarred muscle and subcutaneous tissue. This avascular envelope makes systemic antibiotics

Osteomyelitis secondary to vascular insufficiency and diabetic foot infection

An estimated 15% or more of patients with diabetes will have a foot problem during their lifetime, and in a small but important proportion limb amputation will eventually be necessary.6 The suspicion of osteomyelitis should be raised in diabetic patients with soft-tissue inflammation or skin ulcerations in the feet present for a week or longer, especially if the lesions are on bony prominences. Generally, patients have no fever and few signs of inflammation. Physical examination should include

Osteomyelitis associated with an infected prosthesis

Because of the increasing numbers of implantations, infections associated with prostheses have become more common. More than a million hip replacements are done each year worldwide, and the number of other artificial joints (knees, elbows) inserted is also rising. Several experimental studies and early clinical experience have shown the high susceptibility to infection after insertion of prosthetic devices, even when microorganisms of low pathogenicity, such as Staph epidermidis or

Other types of osteomyelitis

The diagnosis of underlying bone infection in a pressure sore should be considered whenever it does not heal with conventional local treatment or after removal of pressure.49, 50 However, clinical assessment of the depth of the sore or its duration is not helpful in decisions on whether bone infection is present. Bone scintigraphy is generally useful because of its high negative predictive value (>90%), although the positive predictive value is only around 80%.42, 43 Gram-negative bacilli,

Haematogenous osteomyelitis

Historically, haematogenous osteomyelitis has been described in prepubertal children. It involves mostly the metaphysis of long bones (particularly tibia and femur), in most cases as a single focus. Although rare in adults, it most frequently involves the vertebral bodies.

Bacteria causing this form of osteomyelitis (figure 2) reflect essentially their frequency in blood as a function of age.52, 53 Thus, organisms most commonly encountered in neonates and infants include Staph aureus, group-B

Vertebral osteomyelitis

Vertebral osteomyelitis is most frequently of the haematogenous type and generally involves the lower dorsal or lumbar spine; involvement of the cervical spine is a rare, but well-described, clinical entity.59 The disease mostly presents in adults as a febrile lumbago or torticollis. An arterial route5 is believed to be the most likely route of infection: since the segmental arteries supplying the vertebrae generally bifurcate to supply both adjacent bony segments, the disease involves two

General principles in prevention and treatment of osteomyelitis

Antibiotic prophylaxis has been used successfully to prevent wound infections after surgery for non-compound hip fractures63, 64 and in the placement of total hip and knee prostheses. Standard preoperative preparations (including antimicrobial shower, shaving, and soap-disinfectants),65 the use of surgical rooms with laminar air flow,66, 67 and prophylactic antibiotic treatment have decreased the infection rate after the placement of prostheses to 0·5–2·0% depending on the type of joint

Chronic osteomyelitis

Chronic osteomyelitis generally cannot be eradicated without surgical treatment. The goal of surgery is to achieve a viable vascularised environment and eliminate dead bone, which acts as foreign material. Radical debridement down to living bone is required to achieve this aim in many cases. Inadequate debridement is one cause of high recurrence rates in chronic osteomyelitis. Surgery for chronic osteomyelitis consists therefore of removal of sequestra and resection of scarred and infected bone

Conclusions

Greater awareness, new diagnostic methods, and better treatment for people with ready access to modern health care have led to a decrease in the rate of treatment failure in acute osteomyelitis. Sequelae have become less frequent. Infection control strategies and prophylactic antibiotics have further lowered the rate of postoperative infection. However, the large increase in reconstructive orthopaedic procedures with prosthetic materials will increase the overall number of infections, because

Search strategy and selection criteria

We searched the The Cochrane Library and MEDLINE (1966 to 2004) to identify studies on the pathogenesis, microbiology, and treatment of osteomyelitis; many articles were identified through searches of the extensive files of the two authors. The main search term was “osteomyelitis” alone and in combination with “vascular insufficiency”, “haematogenous”, “vertebral”, “biofilm”, “imaging”, “diabetic foot”, “prosthetic infections”, “trauma”, and “surgery”. Papers published in English, French,

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