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Osteomyelitis of the Long Bones
Jason H. Calhoun, M.D., F.A.C.S.,1
M.M. Manring, Ph.D.,
an! Mar" Shirtliff, Ph.D.#
ABS$%AC$
Long &one osteomyelitis 'resents a (ariety of )hallenges to
the 'hysi)ian. $he
se(erity of the !isease is stage! !e'en!ing u'on the infe)tion*s
'arti)ular features,
in)lu!ing its etiology, 'athogenesis, e+tent of &one
in(ol(ement, !uration, an! host fa)tors
'arti)ular to the in!i(i!ual 'atient infant, )hil!, a!ult, or
immuno)om'romise!-. Long
&one osteomye litis may &e either hematogenous or )ause!
&y a )ontiguous s'rea! of
infe)tion. A single 'athogeni) organism is almost al/ays
re)o(ere! from the &one in
hematogenous osteomye litis0 Sta'hylo)o))us aureus is the most
)ommon organism
isolate!. A (ariety of multi!rug resistant organisms of
&a)teria )ontinue to &e a sour)e of
)on)ern in arresting infe)tion. $he'rimary /ea'ons to treat
these infe)tions are )ulture
s'e)ifi) anti&ioti)s, aggressi(e !e&ri!e ment, mus)le
fla's, an! &one grafts. $his arti)le
offers a &asi) re(ie/ of the )lassifi)ation, etiology,
e'i!emiology, 'athogenesis, an!
treatment of long &one osteomyelitis.
234O%DS5 Osteomyelitis, long&ones, anti&ioti)s,
!e&ri!ement
Osteomyelitis in long &ones 'resents a (ariety of)hallenges
!e'en!ing on the infe)tion*s 'arti)ular fea
tures etiology, 'athogenesis, e+tent of &one in(ol(ement,
an! !uration- an! the 'atient infant, )hil!, a!ult,
or immuno)om'romise!-. O(er the 'ast four !e)a!es,
/e ha(e ma!e tremen!ous 'rogress in treating this
!isease as the many fa)tors that a))ount for the o))ur
ren)e an! 'ersisten)e of infe)tion ha(e &een i!entifie!
an! a (ariety of antimi)ro&ials /ith !ifferent s'e)trums
of a)ti(ity against s'e)ifi) 'athogens ha(e &een !e(el
o'e!. Also, ne/ o'erati(e te)hni6ues, su)h as 7li8aro(
fi+ation an! mus)le fla's, an! inno(ati(e !eli(ery sys
tems for anti&ioti)s ha(e &een a!!e! to our arsenal.
7n
s'ite of these a!(an)es, ho/e(er, osteomyelitis remains
!iffi)ult to treat, /ith )onsi!era&le mor&i!ity an!
)osts.$his arti)le offers a &asi) re(ie/ of the
)lassifi)ation,
etiology, e'i!emiology, 'athogenesis, an! treatment of
long &one osteomyelitis.
CLASS7F7CA$7O9
Osteomyelitis )an &e )lassifie! &y !uration a)ute or
)hroni)-, 'athogenesis trauma, )ontiguous s'rea!,hem atogenous,
surgi)al-, site, e+tent, or ty'e of
'atient. Although se(eral )lassifi)ations of
osteomyelitis ha(e &een !es)ri&e! &y !ifferent
authors,
the t/o most /i!ely use! in the me!i)al literature an!
in )lini)al 'ra)ti)e are the )lassifi)ation systems &y
4al!(ogel et al.1
an! Cierny et al.
:n!er the
4al!(ogel system, osteomye litis is first !es)ri&e!
a))or!ing to !uration, either a)ute or )hroni). Se)on!,
the !isease is )lassifie! a))or!ing to sour)e of infe)tion,
as hematogenous /hen it originates from a &a)teremia
or as )ontiguous fo)us /hen it originates from an
infe)tion in a near&y tissue. A final )ategory of the
)lassifi)ation is (as)ular insuffi)ien)y. One of the
limitations of the 4al!(ogel )lassifi)ation system is
that it !oes not )onsi!er infe)tion originating from
!ire)t 'enetration of mi)roorganisms into the
1$he Ohio State :ni(ersity Me!i)al Center, Colum&us,
Ohio0
:ni(ersity of MissouriColum&ia S)hool of Me!i)ine,
Colum&ia,
Missouri0#De'artment of Biome!i)al S)ien)es, :ni(ersity of
Mary
Colum&us, OH ;#1< email5) a lho u n= > o s um ).e !
u-.
Osteomyelitis0 ?uest 2!itors, Christo'her J. Salga!o, M.D.,
an!
La/ren)e B. Colen, M.D.lan! S)hool of Me!i)ine, Baltimore,
Marylan!.
A!!ress for )orres'on!en)e an! re'rint re6uests5 Jason H.
Semin Plast Surg
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of mole)ular &iology in !iagnosis, many other
&a)terial
s'e)ies that /ere (ia&le &ut un)ultura&le may also
&e
'resent. Ho/e(er, the 'athogeni) im'ortan)e of these
s'e)ies has yet to &e !etermine!. 7n infants, the 'atho
gens most fre6uently isolate! from &loo! or &one are
Sta'hylo)o))us aureus, Stre'to)o))us agala)tiae, an!
2s)her i)hia )oli. Ho/e(er, in )hil!ren more than 1
year of age, Sta'hylo)o))us aureus, Stre'to)o))us 'yogenes,
an! Haemo 'hilus influen8ae are most )ommonlyisolate!.
;After age
;, the in)i!en)e of Haemo'hilus influen8ae infe)tion!e)reases,
an! the o(erall in)i!en)e of H. influen8ae as
a )ause of osteomyelitis is !ramati)ally !e)reasing /iththe
e(erin)reasing use of an im'ro(e! H. influen8ae
(a))ine.,G
S"eletal tu&er)ulosis is the result of hematoge
nous s'rea! of My)o&a)terium tu&er)ulosis early in
the
)ourse of a 'rimary infe)tion. On rare o))asions,
s"eletal tu&er)ulosis may &e a )ontiguous infe)tion
from an a!=a)ent )aseating lym'h no!e. Aty'i)al
my)o&a)teria, in)lu!ing My)o&a)terium
marinum,My)o&a)terium a(iumintra)ellulare,
My)o&a)terium
fortuitum, an! My)o&a)terium gor!onae, all ha(e &een
asso)iate! /ith osteoarti)ular infe)tions. 7n a!!ition,
infe)tions may also &e )ause! &y a (ariety of fungal
organisms, in)lu!ing )o))i!ioi!omy)osis,
&lastomy)osis, )ry'to)o))us, an! s'orotri)hosis.
2P7D2M7OLO?3
Perha's the most signifi)ant e'i!emiologi) )hange re
gar!ing long &one osteomyelitis, an! all osteoarti)ular
infe)tions, is the ongoing rise of methi)illinresistant
Sta'hylo)o))us aureus M%SA- an! other multi!rug
resistant organisms MD%Os-. A
