Osteomyelitis

1 What Is Osteomyelitis?

Osteomyelitis is a rare, but serious bacterial infection of the bone. There are several ways by which a bone becomes infected. Infection in another part of the body may spread into the bone through the bloodstream or may spread from nearby tissue. 

Infections can also begin in the bone itself if an open fracture or surgery exposes the bone to germs. In children, osteomyelitis commonly occurs in the long bones of the lower limbs and upper arms.

Adults most often develop osteomyelitis in the bones of the spine (vertebrae). 

Individuals with diabetes may develop osteomyelitis in their feet if they have ulcers in the foot. Although it was considered an inalterable condition, osteomyelitis can now be successfully treated.

Most cases require surgery to remove the portion of bone that has died, followed by strong antibiotics that are often delivered intravenously for at least four to six weeks.

2 Symptoms

Sometimes, osteomyelitis produces no signs or symptoms, or may cause symptoms that are difficult to differentiate from other problems. Symptoms usually develop over a period of seven to ten days after infection.

The signs and symptoms of osteomyelitis include the following:

  • Fever accompanied by chills
  • General feeling of discomfort, malaise, or uneasiness
  • Pain in the bone and neighboring area of infection
  • Swelling, warmth, and redness over the area of infection
  • Excessive sweating
  • Swelling in the feet, ankles, and legs
  • Irritability or lethargy in young children

When to See a Doctor

Consult your doctor immediately if you develop extreme bone pain along with fever. If you are at a higher risk of infection due to a medical condition or recent surgery or trauma, see your doctor right away if you develop the signs and symptoms of a bone infection.

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3 Causes

In most cases, osteomyelitis is caused by Staphylococcus aureus bacteria, which normally dwells on the skin and nasal mucosa of healthy individuals. 

Osteomyelitis may also be caused by fungi or other microorganisms. The bacteria may gain entry into a bone in a number of ways, including: 

  • The bloodstream: Bacteria in other parts of the body, for example, in the lungs from pneumonia or in the bladder from a urinary tract infection, may travel through the bloodstream to reach a weakened portion of bone.
  • Infected tissue or prosthetic joint: Severe puncture wounds may deposit bacteria deep inside the body. If such a wound becomes infected, the bacteria can spread to a nearby bone. 
  • Open wounds or surgery: Bacteria may gain entry into a severely broken bone that is exposed through the skin. Direct contamination of bone may also occur during a surgical procedure performed to replace joints, or if metal rods or plates are placed into the bone to repair broken bone.

In children, osteomyelitis most often affects the softer areas, called growth plates, at either end of the long bones of the arms and legs. In adults, the feet, spinal bones (vertebrae), and hip bone (pelvis) are most commonly affected by osteomyelitis.

4 Making a Diagnosis

A diagnosis of osteomyelitis is made by performing several tests and procedures.

After a medical evaluation, you may be referred to a doctor specializing in infectious diseases or an orthopedic surgeon. 

Before your appointment, make sure you are fully prepared to ensure a productive meeting with the doctor.

Always ask about any pre-appointment restrictions, such as dietary modifications. 

Make a list of the following information:

  • All the symptoms you are having, including those that may seem unrelated to the reason for your appointment
  • All your regular medications, vitamins, or supplements 
  • Any questions you may want to ask your doctor

For osteomyelitis, some basic questions to ask your doctor include: 

  • What is the most likely cause of my symptoms?
  • Are there any other possible causes?
  • What kind of diagnostic tests do I need?
  • Do these tests require any special preparation? 
  • What treatments are available, and which one do you suggest for my condition?
  • Is surgery required? 
  • What type of side effects may occur from treatment? 
  • How can I best manage my other health conditions? 
  • Is there a generic alternative available to the medicine you prescribed? 

Your doctor is likely to ask you a number of questions, such as: 

  • When did you first start experiencing your symptoms? 
  • Did you have a fever with chills? 
  • Does any activity make your symptoms better or worse?
  • Have you had any cuts, scrapes, or other injuries recently?
  • Have you recently undergone surgery, such as joint replacement surgery or surgical correction of bone?
  • Are you diabetic?
  • Do you have any foot ulcers? 

During the physical examination, your doctor may touch and feel the area around the affected bone to check for any tenderness, swelling, or warmth. If you have a foot ulcer, your doctor may determine its proximity to the underlying bone using a dull probe. 

Your doctor may order certain diagnostic tests and procedures to diagnose osteomyelitis and to determine which bacteria is causing the infection, such as: 

  • Blood tests: Blood tests may show elevated levels of white blood cells and other factors that indicate the body is fighting against an infection. If your osteomyelitis was caused by an infection in the blood, tests may reveal the causative organisms. Blood tests can help the doctor decide on the further tests and procedures you need. 
  • Imaging tests:
    • X-rays: X-rays can show the amount of damage that has occurred to the bone. However, the damage may not become visible until osteomyelitis has been there for several weeks. More detailed imaging tests are required to diagnose osteomyelitis that has developed recently.
    • Computerized tomography (CT) scan: A CT scan creates a detailed cross-sectional view of a person's internal structures. 
    • Magnetic resonance imaging (MRI): Using radio waves and a strong magnetic field, MRI scans create more detailed images of the bones and soft tissues surrounding them. 
    • Bone biopsy: A bone biopsy is the gold standard for diagnosing osteomyelitis, as it can reveal the particular type of microorganism that has infected the bone. Knowing the causative organism allows the doctor to choose the most appropriate antibiotic for the infection. An open biopsy is done under general anesthesia and involves surgery to gain access to the bone. In some cases, the surgeon inserts a long needle through the skin to reach the affected bone to take a biopsy. This procedure involves administration of local anesthesia to numb the area where the needle is inserted. X-rays or other imaging scans may be used for needle guidance.

5 Treatment

The main objective of treating osteomyelitis is to stop the infection and preserve as much function as possible by reducing the damage to the bone and its surrounding tissues. 

The most common treatment option is surgery to remove portions of bone that are infected or dead, followed by a course of antibiotics. Hospitalization is usually necessary. 

Surgery

Surgery may be required to remove dead bone tissue if the infection does not resolve with antibiotics. Depending on the severity of the infection, osteomyelitis surgery may include one or more of the following procedures: 

  • Draining the infected area: The area around the infected bone is exposed to allow drainage of pus or fluid that has formed and accumulated in response to the infection.
  • Removal of diseased bone and tissue: Through a procedure called debridement, the surgeon will remove as much of the infected bone as possible, as well as excise a small portion of the healthy bone to make sure that all the infected areas have been removed. Surrounding tissues that show signs of infection may be removed. 
  • Restoration of blood flow to the bone: The empty space left after the debridement procedure is filled with a piece of bone or other tissue, such as skin or muscle harvested from another part of the body. Sometimes, temporary fillers may be placed in the empty space until one is healthy and ready to undergo a bone or tissue graft. The graft assists the body in repairing the damaged blood vessels and forming new bone. 
  • Removal of any foreign objects: In some cases, foreign objects, such as surgical plates or screws inserted during a previous surgical procedure, may have to be removed. 
  • Amputation of the limb: This is considered a last resort. The surgeons amputate the affected limb to stop further spread of infection. 
  • Hyperbaric oxygen: This treatment can be used in certain cases as an alternative to surgery. Also, if the patient does not respond to antibiotics, one can try this therapy. As part of this therapy, an individual would be placed in a specially designed chamber. The chamber would be filled with hyperbaric oxygen, making the pressure in such cases higher than the atmospheric ones. Breathing in this oxygen is known to speed up the healing process and simultaneously slow down the spread of infection.

Medications

Antibiotics are infused through a vein in the arm for at least four to six weeks. An additional course of oral antibiotics may be needed to treat more serious infections. The doctor can suggest antibiotics to prevent or help treat the bacterial infection. If it is a fungal infection, the doctors can suggest antifungal medications. Acetaminophen is known to reduce pain and fever. It is a prescription-based medicine, so the doctor would provide details on how much should be taken and how often. Follow the doctor’s directions, or check the medicine label for more details. If the medicine is taken incorrectly or in a larger dose, it can lead to liver damage. One should not take more than four grams of acetaminophen per day.

One can always look to complement the surgical and medical treatment suggested by the doctor. This can be done by trying out a variety of alternative methods or therapies. Many of these therapies or treatments are home-based and mainly focus on increasing the strength of the immune system. A stronger immune system leads to overcoming an infection more quickly. One of the most important methods to strengthen the immune system is to ensure the body gets a well-balanced diet, which should have a combination of all the various nutrients. If there are still any deficiencies, one can take supplements of that particular nutrient, which will make up for any loss in the body. A few of these important nutrient supplements are mentioned below:

  • Vitamin A: Daily intake of vitamin A should be 15,000 IU, however, if one is pregnant, check with the doctor.
  • Vitamin C: Daily intake should be 500mg twice a day at least for a week’s time. However, if you experience any kind of gastrointestinal side effects, stop usage.
  • Vitamin E: Daily intake should be between the range of 400 IU to 800 IU.
  • Selenium: Doses for selenium should be taken only after confirmation from the doctor.
  • Zinc: Daily intake should be 50mg every day.
  • Probiotics: These are available in the form of capsules, hence, one can take up to three capsules per day containing bifidobacteria and acidophilus. Probiotics help replenish the storage of good bacteria in the gut, which tend to get depleted due to the use of antibiotics.

Apart from supplements, there are also several herbs available in day-to-day use which also play an important role in strengthening the immune system. Herbs are available in various forms, such as capsules, powders, dried extracts, and teas. They are also available in the form of tinctures and glycerites or their extracts. Those who are alcoholic or have a past history of drug abuse should avoid the intake of tinctures, since they contain traces of alcohol. Below are herbs which promote the immune system and help fight against infections:

  • Siberian ginseng: This herb is well known to boost the immune system, but one should be careful when taking it, since it should be taken only under strict medical supervision. To properly consume this medicine, take two teaspoons of Siberian ginseng and mix it with a cup of hot water. Steep this mixture for fifteen minutes, then strain and consume it two times a day for stronger immunity.
  • Garlic: Garlic is very commonly used to fight off various kinds of infection in the body. It is loaded with antibacterial properties that help keep infections at bay. Garlic can be eaten raw or slightly cooked in oil. There are also garlic extract capsules available in stores. However, those who are taking blood thinners, such as warfarin or aspirin, should avoid garlic capsules, as it could lead to other conditions.
  • Astragalus: This herb should be taken in doses of 7mg per day and is a great immunity booster. It is also available in powdered roots form. For consumption, take half a teaspoon of the powder and mix it with one cup of water. Boil this mixture for ten minutes. You can drink this herb water mixture three times a day.
  • Goldenseal: This herb should be taken in doses ranging from 500mg to 1,000mg up to three times per day. Goldenseal is known to be loaded with antibacterial properties. There are also powdered roots of this herb available. Take half a teaspoon of goldenseal powder and mix it with a cup of water. Let this mixture boil and simmer it for ten minutes, then drink.
  • Echinacea: This herb is also known to be very good for bone infections. One can also try the powdered roots of Echinacea. Take half a teaspoon of Echinacea and mix it in one cup of water. Let this mixture boil and then simmer for ten to fifteen minutes. This mixture can be taken three times a day.

Apart from conventional medicines, there are also homeopathic medicines available which are used as supportive or alternative treatments. Before starting any treatment, talk to a doctor, since these therapies are essentially complementing treatments to the conventional ones, not replacements.

6 Prevention

If you are at an increased risk of infection, discuss with your doctor methods to prevent osteomyelitis. Reducing your risk of infection will also help you lower your risk of developing osteomyelitis. 

The best possible way to prevent infections is by maintaining cleanliness. If you or your child has a deep wound, wash it thoroughly under running water for about five minutes, then cover it with a sterile dressing. Check for any signs of infection in the wound.

In general, follow precautions to avoid cuts and scrapes, which can give bacteria easy access to the body. If you are diabetic, closely examine your feet regularly, and contact your doctor if there is any sign of infection. 

The outcome of treatment is best if osteomyelitis is recognized and treated early.

To recover more quickly from this medical condition, give the body ample rest so that it helps the bone heal faster. A splint will prevent any movement of the bone. Use crutches, a walker, or a cane, if possible, and try to avoid putting any weight on the feet.

7 Risks and Complications

There are several risks and complications associated with osteomyelitis.

Bones are generally resistant to infection. For osteomyelitis to develop, a condition that makes the bones susceptible to infection must be present. 

The risk factors that increase one’s chance of developing osteomyelitis include:

  • Recent injury or orthopedic surgery: A severe, open fracture of the bone or a deep puncture wound in the skin gives infections access to the bone or nearby tissue. Surgery performed to repair bone fractures or to replace worn out joints can accidentally create an entry path for the bacteria to reach the bone. Orthopedic hardware implants increase the risk of infection. Deep animal bites can also provide a pathway for infection.
  • Circulation disorders: A blockage or damage in the blood vessels causes trouble distributing the blood cells needed to fight infections and prevent small infections from growing larger. A small cut may progress into a deep ulcer that exposes underlying tissue and bone to infection. The diseases that hinder blood circulation include:
    • Poorly controlled diabetes
    • Sickle cell disease
    • Peripheral arterial disease, often related to smoking
  • Problems requiring intravenous lines or catheters: There are several conditions that may require medical tubing. This tubing can serve as a pathway for bacteria to enter the body, increasing one’s risk of an infection, which can lead to osteomyelitis. Examples of conditions in which medical tubing is used include:
    • Hemodialysis machine tubing
    • Urinary catheters
    • Long-term intravenous tubing, sometimes called central lines 
  • Conditions that impair the function of the immune system: If the immune system is compromised by a medical condition or medication, there is a higher risk of developing osteomyelitis. Factors that may suppress the immune system include: 
    • Chemotherapy 
    • Poorly controlled diabetes
    • Being on long-term corticosteroids or drugs called tumor necrosis factor (TNF) inhibitors 
    • Splenectomy procedure
  • Use of injectable illicit drugs: People with an addiction to the intravenous use of illicit drugs are more likely to develop osteomyelitis, as they usually use unsterile needles.

Complications of osteomyelitis include:

  • Bone death (osteonecrosis): A bone infection may cause impairment of blood circulation within the bone, leading to bone death. Healing of bone may begin after surgery is performed to remove small sections of dead bone. If there is a large portion of diseased bone, you may need to have the affected limb surgically amputated to prevent the spread of infection. 
  • Septic arthritis: Sometimes, an infection within the bones may spread to a nearby joint. 
  • Impaired growth: In children, osteomyelitis most commonly occurs in the softer portions called the growth plates, located at either end of the long bones of the arms and legs. In children with such infected bones, normal growth becomes hindered.
  • Skin cancer: If osteomyelitis results in an open skin sore that is draining pus, the surrounding skin is at an increased risk of developing squamous cell carcinoma.
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