OSTEOMYELITIS

An infection of the bone, bone marrow, and surrounding tissues

Results in inflammation, necrosis, and formation of new bone
Commonly affects the cortex and medullary portion
Causative agent: Staphylococcus Aureus
May be acute or chronic
Osteomyelitis occur in different ways:
1. Hematogenous (indirect) spread from other sites of infection
Ex: infected tonsils, boils, infected teeth, upper respiratory infection
2. Direct extension of soft tissue infection
Ex: infected pressure or vascular ulcer, incisional infection
3. Direct bone contamination from bone surgery, open fracture, or traumatic
injury
Ex: gunshot wound, implants, prosthetic devices
At high risk:
Poorly nourished
Elderly
Obese (because of poor blood circulation)
With impaired immune system
Those with chronic illnesses (e.g. diabetes, rheumatoid arthritis)
Those receiving long-term corticosteroid therapy / immunosuppresants
 PATHOPHYSIOLOGY OF CHRONIC OSTEOMYELITIS

Microorganism lodges in the bone

Inflammatory response is triggered

After 2-3 days, blood clot forms in the vessels

Ischemia (restricted blood supply) with bone necrosis occurs

Infection extends

Medullary cavity Under the periosteum Adjacent soft tissues & joints

If not treated, bone abscess forms

Abscess cavity contains dead bone tissue (sequestrum)

Sequestrum (dead bone tissue) does not easily liquefy and drain and abscess
cavity does not collapse and heal

New bone (involucrum) forms and surrounds the sequestrum

Chronically infected sequestrum remains and produces recurring abscesses

CHRONIC OSTEOMYELITIS
(Healing can still happen however, infected sequestrum remains)
 Sequestrum (dead bone tissue)
surrounded by pus and is difficult to reach by blood borne antibiotics and WBCs
can enlarge and serve as sites for microbial growth
can be removed through sequestrectomy

ASSESSMENT
Acute osteomyelitis
Infection lasts usually less than a month
Systemic signs: fever, night sweats, chills, restlessness, nausea, and malaise (body
weakness)
Local signs: swelling and constant bone pain unrelieved by rest and worsens w/
activity
Diagnostic findings:
Xray: Tissue edema
CBC: Elevated leukocyte levels and elevated ESR, normal Hgb (no anemia)
Chronic osteomyelitis
A persistent problem as a result of inadequate treatment or process of exacerbation
& remission
Over time, scar tissue forms and this becomes an ideal site for microorganism
growth
Presents with non-healing ulcer w/ sinus tract that intermittently drains pus
Bone infection that lasts longer than a month / fails to initial antibiotic therapy
Diagnostic findings:
X-ray: large, irregular cavities, raised periosteum, sequestra (dead bone tissue)
present
CBC: ESR & WBC levels are normal, low Hgb (anemia)
PREVENTION
Elective orthopedic surgery should be postponed if the patient has a current
infection (like UTI, sore throat) or a recent history of infection
During orthopedic surgery, careful attention is paid to the surgical environment
to decrease direct bone contamination
Prophylactic antibiotics administered to achieve adequate tissue levels at the
time of surgery and for 24 hours after surgery
Urinary catheters and drains are removed as soon as possible to decrease the
incidence of hematogenous spread of infection
Aseptic postoperative wound care

MANAGEMENT
Acute osteomyelitis
Hydration, diet high in vitamins and CHON
IV antibiotics (4 weeks to 3 mos.) as long as bone ischemia has not yet occurred
o penicillin, nafcillin, neomycin, cephalexin, cefazolin, gentamicin
Surgical debridement & decompression
If not yet better in 2 days, affected areas should be exposed and drilled to release
pus
Immobilization to decrease discomfort and prevent pathologic fracture
Chronic osteomyelitis
Oral antibiotic therapy (Ciprofloxacin) for 6-8 weeks or after IV therapy is started
Hydration and diet (rich in CHON and vitamins)
Sequestrectomy (removal of dead bone tissue)
Saucerization (surgical excavation of tissue to form a shallow depression to facilitate
drainage from infected areas of a wound)
Closed suction irrigation to remove debris
Correct anemia (diet with green, leafy veggies, red meat, iron supplements)
Bone grafting to remove dead bone and replace it with healthy, viable, vascularized
bone; cancellous bone may be used