By: León Mora H. MD

CORA Group Director.

Center of Excellence in Reconstructive Orthopedic Surgery and Bone Lengthening

International Limb Lengthening and Reconstruction Center

Frequently asked questions to be answered:

• Is there a cure for osteomyelitis? Yes! It can be cured.
• Are there alternative and different treatments to antibiotics? Yes! Learn about them.
• Are there specialized centers for the treatment? Yes! Consult us at www.doctorleonmora.com, www.coragroup.com.co
• Does it repeat once the treatment is finished? No! The cause of recurrences or relapses is due to incomplete or inadequate treatments.
• If I have a short bone due to the infection, can it be lengthened? Yes, it is part of the treatment (Limb Lengthening).

Osteomyelitis is an acute or chronic infection of the bone or bone marrow, normally caused by a pyogenic bacterium or mycobacterium and fungi. Risk factors are recent trauma in open fractures or infected hematomas, immunosuppressed patients with diabetes, hemodialysis, and intravenous drug use. It can also occur in childhood via the bloodstream (hematogenously), causing damage to bones and growth plates.

Etiology

Staphylococcus aureus is the most commonly isolated organism from all forms of osteomyelitis. Hematogenously initiated osteomyelitis is frequently seen in children, and almost 90% of cases are caused by Staphylococcus aureus. It is an inflammation or swelling of the bone tissue that is usually the result of an infection.

Acute osteomyelitis almost always occurs in children. When it appears in adults, it is usually due to a compromise in the subject’s resistance due to weakness, drug addiction, dental root canal infections, or the use of immunosuppressive medications.

Osteomyelitis is also a secondary complication in trauma from accidents. In these cases, the bacteria usually spread through the bloodstream, infecting locally before reaching the underlying bone.

In most post-traumatic cases, they are associated with complications of osteosynthesis (Application of plates or intramedullary nails) for the treatment of fractures.

The biggest problem is caused by the abandonment of these cases by specialists, allowing the infection to advance and become chronic, without performing effective procedures to achieve bone healing. Many patients consult years after its appearance because they have been told that it has NO cure and this is not true. Currently, with the right treatment, it can be cured permanently.

Pathogenesis

Generally, microorganisms have disseminated to the bone hematogenously, for example, through the bloodstream. They also spread contagiously to the bone from local areas of infection, such as cellulitis or from penetrating trauma, including iatrogenic causes such as joint replacements or the internal fixation of fractures or root canalizations (Endodontics, Root Canal Treatments) of teeth. Once the bone is infected, leukocytes enter the infected area, and in their attempt to eliminate the infectious organisms, they release enzymes that corrode the bone. The pus spreads through the blood vessels of the bone, occluding them and forming abscesses which deprives the bone of blood flow. Areas of devitalized infected bone are formed in the infection area, known as bone sequestration, which forms the basis of a chronic infection. Often, the body will try to create new bone around the necrosis area. The resulting new bone is called an involucrum. In the histological examination, these areas of bone necrosis are the basis for distinguishing between acute and chronic osteomyelitis. Osteomyelitis is an infectious process that covers the entirety of the bones and their components, including the bone marrow and the periosteum. When it is chronic, it can lead to bone sclerosis and deformity.

In children, long bones are usually affected, while in adults, the vertebrae and pelvis are more commonly affected.

It is classified according to the site of bone involvement and the patient’s general condition. This allows for planning the type of treatment, whether it requires segmental bone resection, bone lengthening (Limb Lengthening), or bone transport. This is defined according to the state of the soft tissues (muscle and skin) at the infection site.

A diagram of the Osteomyelitis classification is placed here.

Clinical picture

Osteomyelitis often occurs during childhood, with an average age of 6 years. It is exceptional in the neonatal period. It is found preferentially in the most fertile metaphyses: near the knee, below the elbow. In 30 to 40% of cases, the appearance of a minor lesion is observed in the days before the onset of the infection. In the typical case, it is a male (3/1 preference) who complains of pain at the end of a long bone. The pain has a sudden onset, occasionally accompanied by a fracture and a functional deficiency of the affected limb. Gentle mobilization of the adjacent joint is possible. The infectious syndrome is marked by a fever above 38°, general deterioration, chills, and sweating. In the initial phase, local signs are non-specific. Later in the course of the infection, there is an increase in volume and localized inflammation. Generally, lymphadenopathies (lymph nodes) are not palpable. Other events that can be found in a patient with osteomyelitis, particularly in a febrile context, include:

• a state of agitation or prostration;
• pseudoparalysis of a limb in a baby or newborn;
• seizures;
• limping.

In the case of active chronic osteomyelitis or post-traumatic bone infection, it presents with the appearance of redness in the surgical area, discharge of purulent material, exposure of the osteosynthesis material or bone, appearance of intense local pain and functional limitation, and lack of consolidation of fractures. This infection causes irreparable damage to the bone that compromises its circulation and integrity and requires specialized treatment.

Treatment

Osteomyelitis requires prolonged antibiotic therapy, lasting from weeks to months. For this purpose, a central intravenous line is often placed. Osteomyelitis may also require surgical debridement (Resection of a segment of infected bone). Severe cases can lead to the loss of a limb if the appropriate measures are not taken or if treatment is received in centers NOT specialized in the management of infections, bone lengthenings (Limb Lengthening), skin coverage care, and management of non-union of fractures. The first-line antibiotics of choice are generally glycopeptides such as vancomycin, determined by the patient’s history and the culture of the germ causing the bone infection, with respect to the infectious organisms. Different antibiotic therapy regimens can also be used according to the resistance of the bacterium or the tolerance of the antibiotic by the patient. The most important thing is the culture and antibiogram.

Acute and chronic Osteomyelitis Have a Cure, meaning the disease can be eradicated definitively if treated integrally and effectively. Therefore, it is not only the management with antibiotics that is required. In many cases, it is necessary to resect segments of bone, eliminate the dead bone-sequestra or the exposed dry bone, as it is the only way to eradicate Osteomyelitis.

It is a false statement to say that bone infection-osteomyelitis has No cure. This is a common statement by many specialists who do not have the sufficient experience or knowledge to completely eradicate the disease, because they do not have the means and knowledge about the comprehensive treatment which is not only the use of antibiotics. They must have the surgical means to eliminate the infected bone segments and reconstruct them with distraction osteogenesis or bone lengthening techniques (limb lengthening). Circular or monolateral external fixators will be applied for a period that varies between 2 to 6 months. This, associated with novel and revolutionary techniques (Distraction Osteogenesis, deformity correction and Limb Lengthening), and techniques of bone stabilization and reconstruction of soft tissues, will allow the complete recovery of the limb, its function, elimination of chronic and bad-smelling wounds, and chronic pain, allowing the patient to return to their work activities and move without major problems.

Keywords (Osteomyelitis, Ostheomyelitis, Limb Lengthening, Bone Infection, bone infection, bone lengthening and transport)

• Are there specialized centers for the treatment? Yes! Consult us at www.doctorleonmora.com, www.coragroup.com.co