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Semin Plast Surg 2009; 23(2): 059-072
DOI: 10.1055/s-0029-1214158
© Thieme Medical Publishers

Osteomyelitis of the Long Bones

Jason H. Calhoun1 , M.M. Manring2 , Mark Shirtliff3
  • 1The Ohio State University Medical Center, Columbus, Ohio
  • 2University of Missouri-Columbia School of Medicine, Columbia, Missouri
  • 3Department of Biomedical Sciences, University of Maryland School of Medicine, Baltimore, Maryland
Further Information

Publication History

Publication Date:
30 April 2009 (online)

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ABSTRACT

Long bone osteomyelitis presents a variety of challenges to the physician. The severity of the disease is staged depending upon the infection's particular features, including its etiology, pathogenesis, extent of bone involvement, duration, and host factors particular to the individual patient (infant, child, adult, or immunocompromised). Long bone osteomyelitis may be either hematogenous or caused by a contiguous spread of infection. A single pathogenic organism is almost always recovered from the bone in hematogenous osteomyelitis; Staphylococcus aureus is the most common organism isolated. A variety of multidrug-resistant organisms of bacteria continue to be a source of concern in arresting infection. The primary weapons to treat these infections are culture-specific antibiotics, aggressive debridement, muscle flaps, and bone grafts. This article offers a basic review of the classification, etiology, epidemiology, pathogenesis, and treatment of long bone osteomyelitis.

KEYWORDS

Osteomyelitis - long bones - antibiotics - debridement

REFERENCES

  • 1 Waldvogel F A, Medoff G, Swartz M N. Osteomyelitis—a review of clinical features, therapeutic considerations and unusual aspects. 3: osteomyelitis associated with vascular insufficiency.  N Engl J Med. 1970;  282 316-322
    PubMedGoogle Scholar
  • 2 Cierny III G, Mader J T, Penninck J J. A clinical staging system for adult osteomyelitis.  Clin Orthop Relat Res. 2003;  414 7-24
    PubMedGoogle Scholar
  • 3 Lew D P, Waldvogel F A. Osteomyelitis.  N Engl J Med. 1997;  336 999-1007
    CrossrefPubMedGoogle Scholar
  • 4 Song K M, Sloboda J F. Acute hematogenous osteomyelitis in children.  J Am Acad Orthop Surg. 2001;  9 166-175
    PubMedGoogle Scholar
  • 5 De Jonghe M, Glaesener G. Type B Haemophilus influenzae infections. Experience at the Pediatric Hospital of Luxembourg.  Bull Soc Sci Med Grand Duche Luxemb. 1995;  132 17-20
    PubMedGoogle Scholar
  • 6 Blyth M J, Kincaid R, Craigen M A, Bennet G C. The changing epidemiology of acute and subacute haematogenous osteomyelitis in children.  J Bone Joint Surg Br. 2001;  83 99-102
    CrossrefPubMedGoogle Scholar
  • 7 Meier J L, Beekmann S E. Mycobacterial and fungal infections of bone and joints.  Curr Opin Rheumatol. 1995;  7 329-336
    PubMedGoogle Scholar
  • 8 Arnold S R, Elias D, Buckingham S C et al.. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus.  J Pediatr Orthop. 2006;  26 703-708
    PubMedGoogle Scholar
  • 9 Gardam M, Lim S. Mycobacterial osteomyelitis and arthritis.  Infect Dis Clin North Am. 2005;  19 819-830
    CrossrefPubMedGoogle Scholar
  • 10 Murray C K, Roop S A, Hospenthal D R et al.. Bacteriology of war wounds at the time of injury.  Mil Med. 2006;  171 826-829
    PubMedGoogle Scholar
  • 11 Hawley J S, Murray C K, Griffith M E et al.. Susceptibility of Acinetobacter strains isolated from deployed U.S. military personnel.  Antimicrob Agents Chemother. 2007;  51 376-378
    PubMedGoogle Scholar
  • 12 Yun H C, Murray C K, Roop S A, Hospenthal D R, Gourdine E, Dooley D P. Bacteria recovered from patients admitted to a deployed U.S. military hospital in Baghdad, Iraq.  Mil Med. 2006;  171 821-825
    PubMedGoogle Scholar
  • 13 Pollak A N, Calhoun J H. Introduction.  J Am Acad Orthop Surg. 2006;  14(10, Suppl) viii-ix
    PubMedGoogle Scholar
  • 14 Beronius M, Bergman B, Anderson R. Vertebral osteomyelitis in Goteborg, Sweden: a retrospective study of patients during 1990–95.  Scand J Infect Dis. 2001;  33 527-532
    CrossrefPubMedGoogle Scholar
  • 15 Dahl L B, Hoyland A L, Dramsdahl H, Kaaresen P I. Acute osteomyelitis in children: a population-based retrospective study 1965 to 1994.  Scand J Infect Dis. 1998;  30 573-577
    CrossrefPubMedGoogle Scholar
  • 16 Trobs R, Moritz R, Buhligen U et al.. Changing pattern of osteomyelitis in infants and children.  Pediatr Surg Int. 1999;  15 363-372
    CrossrefPubMedGoogle Scholar
  • 17 Epps Jr C H, Bryant III D D, Coles M J, Castro O. Osteomyelitis in patients who have sickle-cell disease. Diagnosis and management.  J Bone Joint Surg Am. 1991;  73 1281-1294
    PubMedGoogle Scholar
  • 18 Moutschen M P, Scheen A J, Lefebvre P J. Impaired immune responses in diabetes mellitus: analysis of the factors and mechanisms involved. Relevance to the increased susceptibility of diabetic patients to specific infections.  Diabete Metab. 1992;  18 187-201
    PubMedGoogle Scholar
  • 19 Emslie K R, Ozanne N R, Nade S M. Acute haematogenous osteomyelitis: an experimental model.  J Pathol. 1983;  141 157-167
    PubMedGoogle Scholar
  • 20 Ciampolini J, Harding K G. Pathophysiology of chronic bacterial osteomyelitis. Why do antibiotics fail so often?.  Postgrad Med J. 2000;  76 479-483
    CrossrefPubMedGoogle Scholar
  • 21 Gristina A G, Oga M, Webb L X, Hobgood C D. Adherent bacterial colonization in the pathogenesis of osteomyelitis.  Science. 1985;  228 990-993
    PubMedGoogle Scholar
  • 22 Nickel J C, Ruseska I, Wright J B, Costerton J W. Tobramycin resistance of Pseudomonas aeruginosa cells growing as a biofilm on urinary catheter material.  Antimicrob Agents Chemother. 1985;  27 619-624
    CrossrefPubMedGoogle Scholar
  • 23 Anwar H, Dasgupta M K, Costerton J W. Testing the susceptibility of bacteria in biofilms to antibacterial agents.  Antimicrob Agents Chemother. 1990;  34 2043-2046
    PubMedGoogle Scholar
  • 24 Wong A L, Sakamoto K M, Johnson E E. Differentiating osteomyelitis from bone infarction in sickle cell disease.  Pediatr Emerg Care. 2001;  17 60-63; , quiz 64
    CrossrefPubMedGoogle Scholar
  • 25 Treves S, Khettry J, Broker F H, Wilkinson R H, Watts H. Osteomyelitis: early scintigraphic detection in children.  Pediatrics. 1976;  57 173-186
    PubMedGoogle Scholar
  • 26 Russin L D, Staab E V. Unusual bone-scan findings in acute osteomyelitis: case report.  J Nucl Med. 1976;  17 617-619
    PubMedGoogle Scholar
  • 27 Trainor V C, Udy R K, Bremer P J, Cook G M. Survival of Streptococcus pyogenes under stress and starvation.  FEMS Microbiol Lett. 1999;  176 421-428
    CrossrefPubMedGoogle Scholar
  • 28 Barer M R, Harwood C R. Bacterial viability and culturability.  Adv Microb Physiol. 1999;  41 93-137
    PubMedGoogle Scholar
  • 29 Lleò Mdel M, Benedetti D, Tafi M C, Signoretto C, Canepari P. Inhibition of the resuscitation from the viable but non-culturable state in Enterococcus faecalis.  Environ Microbiol. 2007;  9 2313-2320
    CrossrefPubMedGoogle Scholar
  • 30 Ericsson H M, Sherris J C. Antibiotic sensitivity testing. Report of an international collaborative study.  Acta Pathol Microbiol Scand [B] Microbiol Immunol. 1971;  217(Suppl 217)
    PubMedGoogle Scholar
  • 31 Turnidge J D, Ferraro M J, Jorgensen J H. Susceptibility test methods: general considerations. In: Murray PR, Baron EJ, Jorgensen JH Manual of Clinical Microbiology. 8th ed. Washington, DC; ASM Press 2003: 1102-1107
    Google Scholar
  • 32 Menozzi M G, Eigner U, Covan S et al.. Two-center collaborative evaluation of performance of the BD phoenix automated microbiology system for identification and antimicrobial susceptibility testing of gram-negative bacteria.  J Clin Microbiol. 2006;  44 4085-4094
    CrossrefPubMedGoogle Scholar
  • 33 O'Hara C M. Evaluation of the Phoenix 100 ID/AST system and NID panel for identification of Enterobacteriaceae, Vibrionaceae, and commonly isolated nonenteric gram-negative bacilli.  J Clin Microbiol. 2006;  44 928-933
    CrossrefPubMedGoogle Scholar
  • 34 Roveta S, Marchese A, Debbia E A. Antibiotic susceptibility tests directly on urine samples using Uro-Quick, a rapid automated system.  J Chemother. 2006;  18 12-19
    PubMedGoogle Scholar
  • 35 Itani L Y, Cherry M A, Araj G F. Efficacy of BACTEC TB in the rapid confirmatory diagnosis of mycobacterial infections. A Lebanese tertiary care center experience.  J Med Liban. 2005;  53 208-212
    PubMedGoogle Scholar
  • 36 Sader H S, Fritsche T R, Jones R N. Accuracy of three automated systems (MicroScan WalkAway, VITEK, and VITEK 2) for susceptibility testing of Pseudomonas aeruginosa against five broad-spectrum beta-lactam agents.  J Clin Microbiol. 2006;  44 1101-1104
    CrossrefPubMedGoogle Scholar
  • 37 Biedenbach D J, Jones R N. Interpretive errors using an automated system for the susceptibility testing of imipenem and aztreonam.  Diagn Microbiol Infect Dis. 1995;  21 57-60
    CrossrefPubMedGoogle Scholar
  • 38 Biedenbach D J, Marshall S A, Jones R N. Accuracy of cefepime antimicrobial susceptibility testing results for Pseudomonas aeruginosa tested on the MicroScan WalkAway System.  Diagn Microbiol Infect Dis. 1999;  33 305-307
    CrossrefPubMedGoogle Scholar
  • 39 Jones R N, Biedenbach D J, Marshall S A, Pfaller M A, Doern G V. Evaluation of the Vitek system to accurately test the susceptibility of Pseudomonas aeruginosa clinical isolates against cefepime.  Diagn Microbiol Infect Dis. 1998;  32 107-110
    CrossrefPubMedGoogle Scholar
  • 40 Saegeman V, Huynen P, Colaert J, Melin P, Verhaegen J. Susceptibility testing of Pseudomonas aeruginosa by the Vitek 2 system: a comparison with Etest results.  Acta Clin Belg. 2005;  60 3-9
    PubMedGoogle Scholar
  • 41 Reller L B, Stratton C W. Serum dilution test for bactericidal activity. II. Standardization and correlation with antimicrobial assays and susceptibility tests.  J Infect Dis. 1977;  136 196-204
    PubMedGoogle Scholar
  • 42 Stein A, Raoult D. Colistin: an antimicrobial for the 21st century?.  Clin Infect Dis. 2002;  35 901-902
    CrossrefPubMedGoogle Scholar
  • 43 Jones R N, Anderegg T R, Swenson J M. Quality control guidelines for testing gram-negative control strains with polymyxin B and colistin (polymyxin E) by standardized methods.  J Clin Microbiol. 2005;  43 925-927
    CrossrefPubMedGoogle Scholar
  • 44 Butt W P. The radiology of infection.  Clin Orthop Relat Res. 1973;  96 20-30
    PubMedGoogle Scholar
  • 45 Jones A G, Francis M D, Davis M A. Bone scanning: radionuclidic reaction mechanisms.  Semin Nucl Med. 1976;  6 3-18
    CrossrefPubMedGoogle Scholar
  • 46 Kuhn J P, Berger P E. Computed tomographic diagnosis of osteomyelitis.  Radiology. 1979;  130 503-506
    PubMedGoogle Scholar
  • 47 Propst-Proctor S L, Dillingham M F, McDougall I R, Goodwin D. The white blood cell scan in orthopedics.  Clin Orthop Relat Res. 1982;  168 157-165
    PubMedGoogle Scholar
  • 48 Pineda C, Vargas A, Rodriguez A V. Imaging of osteomyelitis: current concepts.  Infect Dis Clin North Am. 2006;  20 789-825
    CrossrefPubMedGoogle Scholar
  • 49 Merkel K D, Brown M L, Dewanjee M K, Fitzgerald Jr R H. Comparison of indium-labeled-leukocyte imaging with sequential technetium-gallium scanning in the diagnosis of low-grade musculoskeletal sepsis. A prospective study.  J Bone Joint Surg Am. 1985;  67 465-476
    PubMedGoogle Scholar
  • 50 Al-Sheikh W, Sfakianakis G N, Mnaymneh W et al.. Subacute and chronic bone infections: diagnosis using In-111, Ga-67 and Tc-99m MDP bone scintigraphy, and radiography.  Radiology. 1985;  155 501-506
    PubMedGoogle Scholar
  • 51 Termaat M F, Raijmakers P G, Scholten H J, Bakker F C, Patka P, Haarman H J. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis.  J Bone Joint Surg Am. 2005;  87 2464-2471
    CrossrefPubMedGoogle Scholar
  • 52 Singh B, Mittal B R, Bhattacharya A, Aggarwal A, Nagi O N, Singh A K. Technetium-99m ciprofloxacin imaging in the diagnosis of postsurgical bony infection and evaluation of the response to antibiotic therapy: a case report.  J Orthop Surg (Hong Kong). 2005;  13 190-194
    PubMedGoogle Scholar
  • 53 Britton K E, Wareham D W, Das S S et al.. Imaging bacterial infection with (99m)Tc-ciprofloxacin (infecton).  J Clin Pathol. 2002;  55 817-823
    CrossrefPubMedGoogle Scholar
  • 54 Zhuang H, Duarte P S, Pourdehand M, Shnier D, Alavi A. Exclusion of chronic osteomyelitis with F-18 fluorodeoxyglucose positron emission tomographic imaging.  Clin Nucl Med. 2000;  25 281-284
    CrossrefPubMedGoogle Scholar
  • 55 Kalicke T, Schmitz A, Risse J H et al.. Fluorine-18 fluorodeoxyglucose PET in infectious bone diseases: results of histologically confirmed cases.  Eur J Nucl Med. 2000;  27 524-528
    CrossrefPubMedGoogle Scholar
  • 56 Jones-Jackson L, Walker R, Purnell G et al.. Early detection of bone infection and differentiation from post-surgical inflammation using 2-deoxy-2-[18F]-fluoro-D-glucose positron emission tomography (FDG-PET) in an animal model.  J Orthop Res. 2005;  23 1484-1489
    PubMedGoogle Scholar
  • 57 Meller J, Koster G, Liersch T et al.. Chronic bacterial osteomyelitis: prospective comparison of (18)F-FDG imaging with a dual-head coincidence camera and (111)In-labelled autologous leucocyte scintigraphy.  Eur J Nucl Med Mol Imaging. 2002;  29 53-60
    CrossrefPubMedGoogle Scholar
  • 58 de Winter F, van de Wiele C, Vogelaers D, de Smet K, Verdonk R, Dierckx R A. Fluorine-18 fluorodeoxyglucose-position emission tomography: a highly accurate imaging modality for the diagnosis of chronic musculoskeletal infections.  J Bone Joint Surg Am. 2001;  83 651-660
    PubMedGoogle Scholar
  • 59 El-Haddad G, Zhuang H, Gupta N, Alavi A. Evolving role of positron emission tomography in the management of patients with inflammatory and other benign disorders.  Semin Nucl Med. 2004;  34 313-329
    CrossrefPubMedGoogle Scholar
  • 60 Love C, Tomas M B, Tronco G G, Palestro C J. FDG PET of infection and inflammation.  Radiographics. 2005;  25 1357-1368
    CrossrefPubMedGoogle Scholar
  • 61 Basu S, Chryssikos T, Houseni M et al.. Potential role of FDG PET in the setting of diabetic neuro-osteoarthropathy: can it differentiate uncomplicated Charcot's neuroarthropathy from osteomyelitis and soft-tissue infection?.  Nucl Med Commun. 2007;  28 465-472
    CrossrefPubMedGoogle Scholar
  • 62 Fukuda Y, Ando K, Ishikura R et al.. Superparamagnetic iron oxide (SPIO) MRI contrast agent for bone marrow imaging: differentiating bone metastasis and osteomyelitis.  Magn Reson Med Sci. 2006;  5 191-196
    CrossrefPubMedGoogle Scholar
  • 63 Greenberg R N, Newman M T, Shariaty S, Pectol R W. Ciprofloxacin, lomefloxacin, or levofloxacin as treatment for chronic osteomyelitis.  Antimicrob Agents Chemother. 2000;  44 164-166
    CrossrefPubMedGoogle Scholar
  • 64 Shirtliff M E, Calhoun J H, Mader J T. Comparative evaluation of oral levofloxacin and parenteral nafcillin in the treatment of experimental methicillin-susceptible Staphylococcus aureus osteomyelitis in rabbits.  J Antimicrob Chemother. 2001;  48 253-258
    CrossrefPubMedGoogle Scholar
  • 65 Cierny III G, Mader J T. The surgical treatment of adult osteomyelitis. In: Evarts CMC Surgery of the Musculoskeletal System. New York, NY; Churchill Livingstone 1983: 15-35
    Google Scholar
  • 66 Mader J T, Ortiz M, Calhoun J H. Update on the diagnosis and management of osteomyelitis.  Clin Podiatr Med Surg. 1996;  13 701-724
    PubMedGoogle Scholar
  • 67 May Jr J W, Jupiter J B, Gallico III G G, Rothkopf D M, Zingarelli P. Treatment of chronic traumatic bone wounds. Microvascular free tissue transfer: a 13-year experience in 96 patients.  Ann Surg. 1991;  214 241-250
    CrossrefPubMedGoogle Scholar
  • 68 Papagelopoulos P J, Mavrogenis A F, Tsiodras S, Vlastou C, Giamarellou H, Soucacos P N. Calcium sulphate delivery system with tobramycin for the treatment of chronic calcaneal osteomyelitis.  J Int Med Res. 2006;  34 704-712
    PubMedGoogle Scholar
  • 69 Kent M E, Rapp R P, Smith K M. Antibiotic beads and osteomyelitis: here today, what's coming tomorrow?.  Orthopedics. 2006;  29 599-603
    PubMedGoogle Scholar
  • 70 Diefenbeck M, Muckley T, Hofmann G O. Prophylaxis and treatment of implant-related infections by local application of antibiotics.  Injury. 2006;  37(Suppl 2) S95-S104
    CrossrefPubMedGoogle Scholar
  • 71 Mader J T, Calhoun J H. Adult long bone osteomyelitis. In: Mader JT, Calhoun JH Musculoskeletal Infections. New York, NY; Marcel Dekker 2003: 149-182
    Google Scholar
  • 72 Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects.  J Orthop Trauma. 2007;  21 258-268
    CrossrefPubMedGoogle Scholar
  • 73 Ohtsuka H, Yokoyama K, Higashi K et al.. Use of antibiotic-impregnated bone cement nail to treat septic nonunion after open tibial fracture.  J Trauma. 2002;  52 364-366
    PubMedGoogle Scholar
  • 74 Paley D, Herzenberg J E. Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases.  J Orthop Trauma. 2002;  16 723-729
    CrossrefPubMedGoogle Scholar
  • 75 Anthony J P, Mathes S J, Alpert B S. The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment.  Plast Reconstr Surg. 1991;  88 311-318
    CrossrefPubMedGoogle Scholar
  • 76 Evans R P, Nelson C L, Harrison B H. The effect of wound environment on the incidence of acute osteomyelitis.  Clin Orthop Relat Res. 1993;  286 289-297
    PubMedGoogle Scholar
  • 77 Calhoun J H, Cantrell J, Cobos J et al.. Treatment of diabetic foot infections: Wagner classification, therapy, and outcome.  Foot Ankle. 1988;  9 101-106
    CrossrefPubMedGoogle Scholar
  • 78 Webb L X, Wagner W, Carroll D, Tyler H, Coldren F, Martin E. Osteomyelitis and intraosteoblastic Staphylococcus aureus.  J Surg Orthop Adv. 2007;  16 73-78
    PubMedGoogle Scholar
  • 79 Ellington J K, Harris M, Hudson M C, Vishin S, Webb L X, Sherertz R. Intracellular Staphylococcus aureus and antibiotic resistance: implications for treatment of staphylococcal osteomyelitis.  J Orthop Res. 2006;  24 87-93
    CrossrefPubMedGoogle Scholar

Jason H CalhounM.D. F.A.C.S. 

Frank J. Kloenne Chair in Orthopaedic Surgery, Professor and Chair, Department of Orthopaedics N-1043 Doan Hall

410 West 10th Ave, The Ohio State Medical Center, Columbus, OH 43210

Email: calhounj@osumc.edu

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