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Anthony R. Berendt

and Martin McNally


May 29, 2014: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

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date: 29 April 2017

Bacteria can obtain access to bone from a contiguous focus of infection (e.g. a diabetic foot ulcer) or by haematogenous spread. Osteomyelitis is most commonly caused by Staphylococcus aureus, β‎-haemolytic streptococci, and—in some situations—aerobic Gram-negative rods. An acute inflammatory response causes oedema within bone and soft tissue, and thrombosis in vessels that can result in bone infarction. Pus may form within cancellous bone and beneath the periosteum, stripping it from the bond and leading to extensive necrosis that sometimes involves an entire bone. The process may become chronic and relapsing.

Diagnosis—certain diagnosis of osteomyelitis requires the culture of bacteria from reliably obtained samples of bone, accompanied by histological evidence of inflammation, but this cannot be achieved in many cases and diagnosis is commonly made on the basis of clinical features and imaging. MRI is the standard and best method.

Acute osteomyelitis

Clinical features—the condition predominantly affects the metaphyses adjacent to large weight-bearing joints, presenting as rapid onset of pain and loss of function in the affected limb, usually accompanied by high fever and malaise.

Treatment—acute osteomyelitis is an orthopaedic and medical emergency. Antibiotics (probably for at least 4 weeks) should be initiated on clinical suspicion, with appropriate initial regimens in most cases being a cephalosporin, a β‎-lactam/β‎-lactamase combination, or the combination of an antistaphylococcal penicillin and gentamicin. Vancomycin or an alternative will be necessary if the patient has risk factors for infection with methicillin-resistant S. aureus. Surgery is indicated if abscesses are present, or if the patient is failing to respond to medical measures.

Chronic osteomyelitis

Clinical features—presentation is more variable than acute osteomyelitis, but is typically painful unless there is underlying neuropathy. Wound or sinus tract drainage is usually present when the condition complicates ulceration, instrumentation, or other surgery. Bone may be visible, palpable with a gloved finger, or located with a sterile metal probe in the base of an ulcer or sinus.

Treatment—chronic osteomyelitis usually requires both (1) surgery—to remove dead bone and soft tissue, drain abscesses, eliminate cavities, ensure skeletal stability, and restore soft-tissue cover; and (2) antibiotics—as above, but guided by culture results, for weeks to many months.

Prognosis—a positive and coordinated approach from a multidisciplinary team can produce good results (90% cure rate with acute osteomyelitis and 80 to 90% with chronic osteomyelitis), a fact that stands in contrast to the negative experiences or views of many patients, carers, and health care workers.

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