Etiologic Osteomyelitis (osteo- derived from the Greek word osteon, meaning bone, myelo- meaning marrow, and

-itis meaning inflammation) simply means an infection of the bone or bone marrow. It can be usefully subclassified on the basis of the causative organism (pyogenic bacteria or mycobacteria), the route, duration and anatomic location of the infection. Bone infection can be caused by bacteria (more common) or fungi (less common).

Infection may spread to a bone from infected skin, muscles, or tendons next to the bone, as in osteomyelitis that occurs under a chronic skin ulcer (sore).

The infection that causes osteomyelitis can also start in another part of the body and spread to the bone through the blood.

A current or past injury may have made the affected bone more likely to develop the infection. A bone infection can also start after bone surgery, especially if the surgery is done after an injury or if metal rods or plates are placed in the bone.

Risk factors are:

Diabetes Hemodialysis Injected drug use Poor blood supply Recent trauma

People who have had their spleen removed are also at higher risk for osteomyelitis. Symptoms

Bone pain Fever General discomfort, uneasiness, or ill-feeling (malaise) Local swelling, redness, and warmth

Pathophysiology Acute osteomyelitis presents as a suppurative infection accompanied by oedema, vascular congestion, and small-vessel thrombosis. In early acute disease, the vascular supply to the bone is decreased by infection extending into the surrounding soft tissue. Large areas of dead bone (sequestra) may be formed when the medullary and periosteal blood supplies are compromised. Acute osteomyelitis can be arrested before dead bone develops if treated promptly and aggressively with antibiotics and surgery (if necessary). In an established infection, fibrous tissue and chronic inflammatory cells form around the granulation tissue and dead bone. Pathological features of chronic osteomyelitis are the presence of necrotic bone, the formation of new bone, and the exudation of polymorphonuclear leukocytes. New bone forms from the surviving fragments of periosteum and endosteum in the region of the infection. An encasing sheath of live bone, an involucrum, surrounds the dead bone under the periosteum. The involucrum is irregular and is often perforated by openings through which purulence may track into the surrounding soft tissue and eventually drain to the skin surface, forming a chronic sinus. Most infections in orthopaedics, including osteomyelitis, are caused by biofilm-forming bacteria. A biofilm is a highly structured community of bacterial cells that adopt a distinct phenotype, communicate through cell-cell signals, and adhere to an inert or living surface. Biofilm-forming bacteria exist in 1 of 2 states - the planktonic state or the stationary state. Planktonic bacteria are free-floating; the bodys host defences can easily eradicate the organism through the usual immunological mechanisms. In contrast, stationary bacteria within the biofilm appear to be phenotypically different from their planktonic types. They have a slower rate of growth and are less metabolically active, and are thereby less susceptible to the effects of chemotherapeutic agents. In chronic osteomyelitis and implantassociated infections, bacteria grow within biofilms attached to the surface of the dead bone or foreign material. This protective mode of growth shields bacteria from antibiotic agents and host defence mechanisms, and enables the infection to persist. The concept of biofilm science must be applied to the diagnosis, treatment, and prevention of chronic orthopaedic infection.

Diagnosis A physical examination shows bone tenderness and possibly swelling and redness. Tests may include:

Blood cultures Bone biopsy (which is then cultured) Bone scan Bone x-ray Complete blood count (CBC) C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) MRI of the bone Needle aspiration of the area around affected bones

Management Treatment-The goal of treatment is to get rid of the infection and reduce damage to the bone and surrounding tissues. Antibiotics are given to destroy the bacteria causing the infection. You may receive more than one antibiotic at a time. Often, the antibiotics are given through an IV (intravenously) rather than by mouth. Antibiotics are taken for at least 4 - 6 weeks, or longer. Surgery may be needed to remove dead bone tissue if you have an infection that does not go away. If there are metal plates near the infection, they may need to be removed. The open space left by the removed bone tissue may be filled with bone graft or packing material that promotes the growth of new bone tissue. Infection of an orthopedic prosthesis, such as an artificial joint, may need surgery to remove the prosthesis and infected tissue around the area. A new prosthesis may be implanted in the same operation. More often, doctors wait to implant the prosthesis until the infection has gone away.

If you have diabetes, it will need to be well controlled. If there are problems with blood supply to the infected area, such as the foot, surgery to improve blood flow may be needed. Prevention-Prompt and complete treatment of infections is helpful. People who are at high risk or who have a compromised immune system should see a health care provider promptly if they have signs of an infection anywhere in the body. Complications When the bone is infected, pus is produced in the bone, which may result in an abscess. The abscess steals the bone's blood supply. The lost blood supply can result in a complication called chronic osteomyelitis. This chronic infection can cause symptoms that come and go for years. Other complications include:

Need for amputation Reduced limb or joint function Spread of infection to surrounding tissues or the bloodstream