From: Karr JC. Diagnosis and management of osteomyelitis. Wound, Ostotomy, Continence Nursing Secrets. Hanley and Belfus Inc. Philadelphia, 2002.
1. What is osteomyelitis?
Osteomyelitis generally defined is an infective inflammatory process of bone involving the cortex and ceancellous portions. Ostitis refers to the cortical involvement only. The source of osteomyelitis is classified as either: 1) spread to the bone from a source through bloodstream (hematogenous), or 2) spread to the bone from a source in nearby tissue (contiguous-focused).
2. Are there different degrees of severity in osteomyelitis?
The Cierny-Madder osteomyelitis classification system takes into consideration the anatomic extent of bone involvement, the quality of the host and treatment factors. (See Table 1) This has been used as a staging system to describe extent and severity of osteomyelitis and compare effectiveness of treatment protocols.
3. What is the mechanism of development of osteomyelitis in the diabetic foot?
Foot osteomyelitis typically develops by spread of infection in the patient with underlying polyneuropathies. The insensate foot receives increased repetitive microtrauma at high axial load areas, such as bony prominences. This leads to localized tissue necrosis and ulcer formation. Diabetic patients usually have some degree of proximal arterial vascular disease. At times this proximal vascular disease can be segmental with high grade stenosis or occlusions which severely impair the bodies’ ability to manage this type of neuropathic ulceration. Uncontrolled hyperglycemia, especially in the brittle diabetic, decreased the immune capacity to fight to infection. Trauma, ulceration, and bacterial invasion therefore precede the development of osteomyelitis. It is this sequela that leads to chronic ulcer formation with a bacterial load that then colonizes and infects the neighboring bone (contiguous-focused). Underlying osteomyelitis is present in as many as 2/3 of patients hospitalized for diabetic foot ulcer.
4. How can osteomyelitis develop in non-healing wounds other than the foot?
In contiguous-focused osteomyelitis any deep soft tissue wound infection adjacent to bone can be the source of osteomyelitis. Bacteria from necrotic tissue as seen with a stage IV pressure ulcer or non-stagable mal perforans ulcer can invade the outer surface of bone. Wound on the pretibial surface of the leg can quickly deep to the bone surface, exposing the bone to the environment, and initiating the osteomyelitis process. The pretibial surface of the leg is rather dysvascular and has a thinner tissue depth than the other leg compartments.
5. What wounds would be suspicious for osteomyelitis?
Suspicious wounds include those that probe to the bone, joint or deep fascial compartments. Generally, any wound in near proximity to bone and over six month’s duration should be suspected for osteomyelitis. When a history of a wound that heals and then opens again preceded by an episode for extreme warmth and abscess formation, osteomyelitis should be suspected.
6. What causes osteomyelitis?
Bacterial, fungal, and mycobacterium are common agents associated with ostemyeilits. The most common bacterial pathogen of osteomyelitis is S. aureus. Other infective bacterial pathogens seen are S. epidermidis, and streptococci. These bacterial pathogens account for up to 73% of the osteomyelitis following musculoskeletal surgery. S. epidermidis has been more frequently the causative pathogen of osteomyelitis after implant arthroplasty. Diabetic patients, especially those with vascular disease, have a mixed polymicrobial infection of gram positive and negative bacteria. Salmonella is seen in a higher incidence with sickle cell disease or other hemoglobinopathies. Pseudomonas and other gram negative bacteria are seen in a higher incidence with drug addicts.
Fungi involved in osteomyelitis are Blastomyces, Cryptococcus, and Coccidiodes. These fungi pathogens usually occur in non-compromised hosts. Fungi pathogens in osteomyelitis that are seen in compromised hosts are Aspergillus and Candida. Fungal osteomyelitis may be rather recalcitrant to therapy and may require amputation of the effected body part.
Tuberculosis osteomyelitis is seen usually in the bacteremic phase of the mycobacterium infection generated by hematogenous spread. This type of osteomyelitis occurs in approximately 1% of tuberculosis patients. Mycobacterium is seen in a higher incidence with renal transplant patients. Even though it may occur at any age, it is seen most frequently in adults. Negative purified protein derivative (PPD) skin tests do not exclude the diagnosis. These patients generally respond well to oral therapy.
7. What are common bacterial pathogens of osteomyelitis from a puncture wound?
P. aeruginosa and then P. multocida and other gram negative rods. P. aeruginosa osteomyelitis secondary to puncture wounds is not uncommon. P. aeruginosa is inoculated 2% in all puncture wounds and is 90% the etiologic agent. The phalanges, metatarsals, and calcaneus are the most commonly involved bones of the feet. Therapy for P. aeruginosa osteomyelitis includes surgical debridement and a minimum of 14 days of appropriate antibiotics.
8. What are the two most common bacterial pathogens of neonatal osteomyelitis from a puncture wound, i.e. repeated heel punctures for phlebotomy.
Staphylococcus aureus and Pseudomonas aeruginosa.
9. What are the clinical findings of soft tissue wound mycetoma and how this condition relates to osteomyelitis treatment outcome.
Mycetoma is a chronic infection of soft tissue structures and bone that is characterized by multiple sinus tracts draining pus containing mycotic granules with indurated swelling of the effected area. Treatment of mycetoma is difficult and medical cure is rarely obtained. Males aged 20-40 are more frequently involved than females. The lower extremities are involved in 56-70% of the patients. The most common site is the dorsum of the forefoot. Treatment with Iatroconazole has been promising. Diagnosis of this condition is made by the clinical triad: mycotic granules, sinus tracts, and appropriate bacterial and fungal cultures. Surgical debridement alone is rarely curative. Treatment of mycetoma is difficult and eventually amputation for mycetoma may be required.
10. What are etiology and clinical findings associated with hematogenous osteomyelitis.
Hematogenous osteomyelitis is the spread of bacterial from an internal source such as an upper respiratory infection, through the circulation, to an osseous location where bacterial reproduction occurs leading to an infective process. Hematogenous osteomyelitis is most commonly a disease of children. Other sources of infection are colonized intravenous devices, dental infection, and urinary tract infections. In the presence of urinary tract infections the, hematogenous osteomyelitis may result in streptococci or gram negative organisms. Hematogenous osteomyelitis of the foot is rather uncommon, compared with other sites. In children 5-11% and in adults 8% have involvement of the foot bones. The most common foot bone affected is the calcaneus, followed by the metatarsal, tarsal bones, talus, and then phalanges. S. aureus is the most common pathogen in children and adults, occurring in 60% of patients. Gram negative rods are seen more commonly in adults. Poly microbial infection is uncommon. Fungi and mycobacterium are also spread by dissemination with hematogenous osteomyelitis.
Classically acute hematogenous osteomyelitis in a child presents as an abrupt onset of high fever, sudden pain, systemic toxicity, and local signs of infection and suppuration along the effected bone. The presentation in adults is less definitive. Leukocytosis and elevated sedimentation rate is common.
11. What are etiology and clinical findings associated with contiguous focus osteomyelitis.
Contiguous focus osteomyelitis is the result of the spread of infection from an adjacent soft tissue focus. Such an adjacent soft tissue focus that would spread infection would be a wound, laceration, abscess, open reduction of a compound fracture, post-operative infection, or a septic joint. Contiguous focus osteomyelitis is usually seen in adults, usually over the age of 50. The phalanges and metatarsals are most commonly involved. The most common pathogen is S. aureus, but frequently a polymicrobial infection is encountered. Pathogens encountered as well are S. epidermidis, gram negative rods, and anaerobes.
Contiguous focus osteomyelitis in this age group demonstrates significant co-morbidities to consider when assessing possible outcomes. Some of the more significant co-morbidities are diabetes, vascular disease, hypertension, coronary vascular disease, hyper lipidemia, renal disease, venous insufficiency, and auto immune disease. Osteomyelitis occurring with vascular insufficiency often occurs with diabetic patients. Patients with tobacco usage alone have higher significant morbidity for wound/bone complications and limb loss.
12. What are the radiographic findings of osteomyelitis.
Soft tissue swelling, subperiosteal elevation and lytic/sclerotic changes of bone are the classic radiographic findings of osteomyelitis. Bone changes are usually not evident for 10 to 14 days or until 35-50% on the bone has been destroyed. Sequestrum is the segmentation of dead bone from living bone, highly suggestive of chronic osteomyelitis. Sequestrum appears on x-ray as more dense in appearance than surrounding bone that may be osteoporotic or hyperemic. Sequetra are usually not present for at least three weeks. Sequestrum findings on x-ray mimic the findings osteoarthropathy (charcot deformity) in the diabetic. Invoucrum or new bone formation at the periosteum is suggestive of osteomyelitis. Cloaca formation is found at the bone-periosteum interface for extrusion of sequestrum and dead bone products.
Initial findings of hematogenous osteomyelitis initially are limited to swelling of the soft tissue over the metatphysis. The first radiographic findings are one or more lytic areas surrounded by a wide area of radiolucency. This is followed by periosteal elevation with cortex taking on a moth eaten appearance. Radiographic evidence of subacute or chronic hematogenous osteomyelitis (i.e., brodie’s abscess) is a radiolucent area in the metaphysic surrounded by sclerotic or hypertrophic bone.
The radiographic features of contiguous focus osteomyelitis are bone destruction and reabsorbtion at the area of adjacent soft tissue focus. Bone involvement begins in the outer bone cortex and periosteum. Cortical and cancellous involvement follows the reverse of hematogenous osteomyelitis. Radiographic findings of an infected arthroplasty are a progressively enlarging radiolucent zone at the bone-prothesis interface, endosteal scalloping, and focal lytic areas. Sequential radiographic studies are always usefull in the evaluation of either type of osteomyelitis.
13. What are the limitation of the radiographic evaluation in osteomyelitis?
Radiographic evaluation for findings consistent with osteomyelitis may not be evident for at least ten days and may lag weeks behind the clinical presentation. This is because 50% of the bone matrix must be destroyed until lytic lesions are seen. Radiographic lytic lesions are seen 3-4 weeks after onset of symptoms in 90% of patients. Initial radiographic findings of osteomyelitis, when present, are often vague and inconclusive. A periosteal elevation of a metatarsal may be the start in the infective process or an old stress fracture with bone exocallous present. Wounds or non-stagable eschar at the posterior and plantar aspect of the heel with suspicious calcaneal cortical bone findings may be misleading. This type of calcaneal finding may represent an early infective process or the normal irregular cortical surface seen with the posterior calcaneus. A periosteal elevation of the tibia or fibula may represent an early infective process or normal findings associated with chronic venous insufficiency. The radiographic findings of osteoarthropathy (charcot deformity) and atrophic or hypertrophic non-unions of the foot, ankle, and knee are usually the same as seen with osteomyelitis. To confuse matters further, magnetic resonance imaging has similar pitfalls between the two pathologies and nuclear imaging is usually required. Reabsorptive or destructive changes to bone may be noted in such disorders as rheumatoid arthritis or gout.
14. What are the advantages and disadvantages of nuclear medicine (bone scan) evaluation of osteomyelitis.
A technetium bone scan is more sensitive than plain film imaging in detecting early infections and may be positive as early as three days. Nuclear imaging (bone scans) can clarify and distinguish osteomyelitis from a healed, old fracture with bone callous, irregular, chronic bone changes, periosteal reactions from venous insufficiency and charcot deformity. Indium-111 white blood cell scanning is useful in the early detection of osteomyelitis. In charcot deformity, a dual nuclear imaging scans are utilized, technetium sulfur colloid and indium-111 labeled white blood cell study.
However, bone scans in general are sensitive for bone turnover, but are generally not specific for osteomyelitis. There is a high incidence of false positive osteomyelitis nuclear medicine studies. These studies are less sensitive when done with contiguous foci or soft tissue infection is present. Galium scans are less sensitive and also lack specificity in the presence of soft tissue infections.
15. What are the four types of osteomyelitis anatomical classification according to the Cierny-Mader classification system.
Type one osteomyelitis is confined to the meduallary canal without cortical involvement. Type two osteomyelitis (ostitis) is confined to the cortical and not meduallary bone. Type three osteomyelitis involves the cortical bone at one cortice and meduallary bone as well. This type is the most commonly encountered osteomyelitis. Type four osteomyelitis involves the cortical bone at multiple cortices and the meduallary bone as well.
11. Describe the clinical staging of osteomyelitis according to the Cierny-Mader classification system.
The A host demonstrates normal systemic defenses, metabolic capacities, and vascularity. The B host demonstrates local, system, or combined deficiencies. The C host demonstrates high treatment morbidity where the treatment poses a greater risk to the patient than the disease process.
Table 1 Cierny-Madder Classification System Anatomic Type Stage 1 Medullary osteomyelitis Confined to medullary canal
No cortical involvement
Results from hematogenous infection
Treated with antibiotics alone (pediatrics)
or cortical unroofing and medullary
Stage 2 Superficial osteomyelitis Exposed, necrotic outer surface of bone
Results from adjacent soft tissue infection
Requires superficial debridement
and coverage with local flap
Stage 3 Localized osteomyelitis Full thickness cortical sequestration
Requires surgical debridement, possibly
Stage 4 Diffuse osteomyelitis Involves cortical bone at multiple cortices
Loss of bony stability
Requires debridement, stabilization, flap
Host A Normal host with normal immunological defenses, metabolic
Host B Host with local compromise
Venous stasis, lymphedema, major vessel compromise
Arteritis, radiation fibrosis, small vessel disease
Host with systemic compromise
Malnutrition, Diabetes, Renal, Liver, Immune disease
Malignancy, Chronic hypoxia
Host C Treatment of bone infection poses a greater risk than the disease
12. Bone ostitis (infection) refers to which of the Cierny-Mader anatomical classification system.
Bone ostitis in an infective process localized to the bone cortex and thus is classified as type two. This infective process does not involve the cancellous or medullary bone. However, this type of infection can quickly progress and soon involve the cancellous bone progressing to a type three osteomyelitis. This type of osteomyelitis is rather amendable to bone debridement and PMMA bead placement with a good outcome and low morbidity for reoccurrence.
13. Which Cierny-Mader anatomical classification type is the most unstable and may require multi-plane external fixation such as the Ilizerov system.
The osteomyelitis that is most unstable is classified as type four. Type four osteomyelitis may present as a chronic osteomyelitis with several draining sinus tract. There may be an axial limb deviation present from previous trauma, such as an open compound fracture. This type of osteomyelitis, once debrided or partially excised, would have a significant morbidity for fracture or dislocation because of the amount of bone substance removed. Once fractured, because of soft diseased bone and gross instability, the bone is usually not amendable to open reduction and internal fixation and requires below or above the knee amputation. Closed treatment, such as casting and immobilization, generally yields poor result with a high incidence of non-union, non functional limb, significant pain, and recurrent osteomyelitis.
14. What are the limitations of blood cultures?
Blood cultures may be positive up to 60% of the acute hematogenous osteomyelitis. Blood cultures are rarely positive in other forms of osteomyelitis. A negative blood culture cannot prove that osteomyelitis is absent. In order to obtain an accurate sampling of the pathogen a bone biopsy or deep aspirate is usually required. Blood cultures may be useful in reflecting the potential source of bone pathogens from origins such as urinary tract or upper respiratory tract infections.
15. Discuss the limitations of basing antibiotic therapy for osteomyelitis on sinus tract or wound culture.
Less than 50% of the sinus tract or wound cultures contain the same pathogen as found in the infected bone. A culture of a sinus tract often provides a polymicrobial list that may not have the true osteomyelitis pathogen identified or also list other pathogens that are localized to the soft tissue and not the bone. If S. aureus is present, it can be usually be assumed to be the causative pathogen of the osteomyelitis. Bone biopsy or aspiration, when indicated, results in a reliable culture of the involved pathogen if properly taken. Different pathogens may be growing in isolated microenviroments within the bone. Therefore, there is a high probability that a needle biopsy will miss some of these microenviroments. The risk of potentially contaminating uninvolved bone must be considered before proceeding with a bone biopsy for pathogen identification.
16. Discuss why, even with appropriate wound care, a wound in an area of osteomyelitis will not heal or stay healed for a prolonged period of time if the osteomyelitis is not directly managed.
The wound continues to be seeded by etiological agents and will not close or stay closed if continually seeded from the neighboring bone. When a sinus tract is present, the pustular product of the deep bone infection maintains this structure. At times the lining of the sinus tract may become epithelized and remain open. Chronic sinus tract may result in malignant neoplasm, which in turn maintain the sinus tract in part.
17. Discuss the benefits of antibiotic impregnated Polymethylmethacrylate ( PMMA) beads.
PMMA beads manage osseous dead space, reduced incidence of secondary infections, and provide high local antibiotic concentration (10 to 100 times higher) without serious systemic effects. Gentamycin and trobramycin are two antibiotics commonly used. Other antibiotic that can be used are clindamycin and vancomycin. The antibiotic is released at bacterialcidal concentrations at the site of infection with only trace amounts detectable in the circulation. The antibiotic has been measured to diffuse up to 2 cm surrounding the area of implantation. In vitro studies demonstrated that fibroblast function is not inhibited with the high concentration of gentamycin from the PMMA beads. Because the local antibiotic concentration is so elevated, the usual classification of pathogens into sensitive or resistant strains may not be appropriate. With levels 10 to 100 times greater, such levels may be bacterialcidal against pathogens that were previously assessed as resistant in the routine antibiogram. The implantation of the beads allows for primary closure when possible.
18. Discuss the advantages of tissue grafting for wound management with osteomyelitis.
The purpose of local muscle and free vascular transfers is to provide a soft tissue envelope, cover large exposed osseous defects, and improves the local biological environment by bring in a new source of blood supply for antibiotic delivery, improved host defense mechanisms, and promoting soft tissue healing.
Skin grafting is advantageous in patients with chronic soft tissue infection with a sinus tract present, that are responsible for recurrent infections. Viable periosteum covering cancellous or cortical bone or granulation tissue is mandatory to ensure graft survivability.
19. Discuss the situation that hyperbaric oxygen therapy would be appropriate adjunctive therapy.
Hyperbaric oxygen treatment is directed at the local hypovascularity and hypoxia associated with chronic bone and joint infections. In situations where there is decreased systemic blood flow such as diabetes or decreased segmental blood flow such as trauma, hyperbaric oxygen therapy may be beneficial. The use of hyperbaric oxygen treatment is controversial because it is administered in conjunction with surgical management and IV antibiotic therapy.
6. How is osteomyelitis treated?
The treatment of osteomyelitis is controversial. Osteomyelitis is most effectively treated by surgical removal of infected bone. Debridement should remove infected bone back to solid bleeding bone. Dead space management is addressed with polymethylmethacrylate ( PMMA) beads. Once the infected bone is removed, antibiotics are required only for control of infection in surrounding soft tissues.
If a patient is not a candidate for surgical bone debrided and/or resection, then prolonged intravenous antibiotic therapy based on reliable culture methods and bone penetration ability of the antibiotic agent is proceeded with. Recent literature has suggested that long term oral therapy with high doses can be as effective as intravenous therapy for diabetic patients with osteomyelitis.
If there is a large dead space resulting from debridement with significant soft tissue deficit, flap or graft placement may be indicated for closure. Patients that do not undergo a strict smoking cessation program have a high morbidity for treatment failure.
After treatment of infection, methods for healing a wound with osteomyelitis follow general wound healing guidelines.
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