What is the difference between osteitis and osteomyelitis

In later stages, a sequestrum may be identified. Due to the high dose of radiation, this method is no longer a standard procedure. Specific scintigraphic methods have the same problems as the bone scan [ 20 ]. They are not reliable in the detection of acute exogenous osteomyelitis as, after trauma, there is always the scintigraphic presence of a lesion and it is not possible to differentiate between fracture and bone infection.

Specific monoclonal antibodies may provide additional information about inflammatory changes but it is difficult to distinguish between bone and soft tissues [ 21 , 22 ].

Positron emission tomography PET scans are highly specific and can be very useful in the detection of osteomyelitic foci and the presence of chronic osteomyelitis [ 23 , 24 ]. CT-scans are helpful in the detection of sequestra and abscesses. Ultrasonography is a standard examination technique for the localisation of pockets of liquid material in soft tissues. It also provides information on the size of the collection and its possible contents [ 26 ].

Aspiration of these liquid areas or biopsies may lead to the first diagnosis. Gram-staining may provide results after 45 min but definitive microbiological examination takes about 48 h. Since then various means of the management have evolved and been reported in the medical literature. As with the treatment of malignant tumours, one has to distinguish between specific local and systemic therapies [ 27 ]. Together they should lead to:. Local and systemic eradication of the infection or at least to an enduring non-symptomatic stage ;.

What is to be done the type of surgery if needed; the use of antibiotics; and the method of antibiotic delivery? If there is a slightest suspicion of an infection after surgery for trauma, it is important that the wound should be dealt with surgically as soon as possible.

The earlier revision surgery is performed, the greater the likelihood of eradication of the infection. Postoperative or posttraumatic wounds that are clinically and symptomatically suspicious should be surgically explored and revised early, especially if an osteosynthesis was performed and the implant may be involved in the infection.

Additionally, the use of antibiotics in this instance is not prophylaxis but treatment of a surmised infection [ 28 ]. Local surgical treatment is based on five principles Figs.

Fifty-six-year-old male patient with chronic osteitis and fistula from a lower leg fracture. Osteosynthesis was performed in The preoperative X-ray shows the bone lesion under the osteosynthesis material and also a sequestrum a , b. Exposure and removal of the osteosynthesis material.

The stabilising external fixator is already partially installed. It shows the transport corticotomy. It shows the bone defect after tibial segment resection. Local treatment with repetitive debridement, lavage and vacuum sealing. Continuation of the transport as an open transport. Continuation of the transport. Coverage with mesh graft. Transport completed. The transport is finished and the external fixator is removed. Good callus formation in the transport zone.

It shows almost complete consolidation. Owing to the soft tissue conditions, the docking manoeuvre was carried out as a compression docking without additional plating or cancellous bone graft. Suspicion is important, especially in post-operative bone infections, where clinical examination combined with suggestive results of investigations either a rising of the CRP and white blood count, or an inadequate decrease of either should lead to immediate revision of the wound [ 26 ] and radical removal of affected tissue.

With bone tissue, possible treatment extends from local debridement to resection of the infected area. Only if the diagnosis is made very early, the local infection not very extended and titanium implants were used, can the osteosynthesis material be left in situ [ 3 ] see Fig.

Clinical examination after 9 months. The soft tissue is consolidated and full weight-bearing of the right leg. No further signs of bone or soft tissue infection. If intramedullary nailing was performed to stabilise the fracture, the nail must be removed, the medullary canal reamed and the reaming material examined microbiologically and histologically. Plates must also be removed and the area debrided. After surgical debridement of the osteomyelitic focus, extended irrigation with a pulsatile delivery system 3—5 l NaCl 0.

Primary wound closure is not essential. Although coverage with intact soft tissues is a prerequisite for bone healing, it may be better to leave the wound open but covered by vacuum sealing techniques than to force a primary wound closure and so inflict damage to the local vascularity and produce further damage to the tissue. It is also possible to shorten the bone after resection of the osteomyelitic focus in order to protect the soft tissues and minimise the influence of tension on the vascular situation.

This debridement technique is repeated every 48 h until the samples taken from the wound during operation do not show further bacterial growth and the clinical findings and the blood count CRP, white cell count, etc.

Bone stabilisation is usually accomplished by external fixators. The original osteosynthesis material is left in situ only in exceptional circumstances. The use of an external fixator has many advantages: it is relatively simple to apply; it provides good stability; and it does not produce further alteration of the soft tissues.

The type of external fixator chosen monolateral, circular, hybrid, etc. In his study Schmidt recommended a ring fixator the Ilizarov-fixator as the appropriate tool for bone stabilisation especially if reconstruction was planned for acute purulent bone infections, extended bone defects or a combination of these problems [ 29 ]. The main advantage of a ring fixator is the ability to perform three-dimensional reconstruction.

We support its use for the stabilisation of the lower leg tibia and the forearm. In general it may also be utilised for the treatment of the thigh femur , but due to the discomfort to the patient, most circular fixators in the thigh are modified to a hybrid fixator. For the upper arm a unilateral fixator will usually be sufficient. However, the rate of Gentamycin resistant microorganisms isolated from osteomyelitic foci has been rising and the use of these supplements is not viewed in a positive light today [ 30 ].

Korkusuz et al. The evidence for use of local antibiotics is not strong. We recommend their use when. Supportive systemic antibiotics may be helpful. To establish optimal efficiency, antibiotic treatment should depend on the results of microbiological investigation of material from the infected focus.

Systemic antibiotic treatment is also only necessary in the acute purulent, septic stage of the disease. The long-term application of antibiotics should be considered very critical, not the least because of well-known side effects e. Soft tissue and bone reconstruction should not be looked at as separate procedures.

Only complete and good quality soft tissue coverage ensures the survival of newly formed callus. The treatment of the soft tissue must always be considered when planning the first surgical steps to eradicate an osteomyelitic focus. Depending on the size of the soft tissue defect, the spectrum of treatment options ranges from mesh-split skin graft to free vascularised myocutaneous flaps. According to Heppert, soft tissue coverage options will depend on the following criteria [ 32 ]:.

It is important to plan the reconstruction of soft tissue and skin at an early stage of the treatment so that there is a coordinated strategy with subsequent surgical procedures. For example, a misplaced ring fixator may make satisfactory closure of a soft tissue defect impossible through having the fixator wires exactly in the position where the anastomosis of a free myocutaneous flap has to be located.

Many different techniques are available for the bridging of osseous defects. Two of them are well established:. The metaphyseal—epiphyseal vessels occlude with increasing age. Dilated vascular loops are present in the metaphysis, favoring pathogen colonization.

This is the reason why the focus of inflammation initially develops in the metaphysis. Rapid penetration of the thin cortical bone ensues, with subsequent subperiosteal spread of the infection. The periosteum is elevated. The infection can then spread to the adjacent joint, especially if the metaphysis is located within the joint capsule, as with the hip and knee joints.

Acute osteomyelitis of adulthood. Acute osteomyelitis at this age is being increasingly diagnosed, affecting primarily the vertebrae Chapter 3. Clinical presentation. Acute hematogenous osteomyelitis is a systemic disorder. Early symptoms include fever, chills and localized pain with focal swelling, erythema, and increased skin temperature. CRP and white blood cell count are elevated. A number of findings should be looked for on the radiographs:.

A wide spectrum is possible, ranging from diffuse reduction of density, via solitary radiolucency, irregular multiple radiolucencies moth-eaten or mottled pattern to an extensive permeative pattern.

The dense calcaneal apophysis is normal. The skeletal alterations require at least 7 to 10 days before they become radiographically evident. The laminated periosteal reactions are sometimes recognized before bone destruction.

A late sign in this age group is swelling of the metaphysis, sometimes also involving the epiphysis. During the late phase of the disease, the extensive periosteal reaction can appear as periosteal ossification.

Nowadays, patients with acute osteomyelitis during the neonatal period, and above all in childhood, commonly present at such an early stage of the disease that only subtle radiographic findings, or even none at all, are present cf.

Imaging conditions are particularly favorable during the neonatal period. The first sign, evident even before any periosteal reaction, is the hypoechoic, or even hyperechoic, edematous soft tissue swelling.

Then a thin, hypoechoic fluid layer develops, elevating the periosteum Fig. This can go on to form a space-occupying abscess with an anechoic to hypoechoic intralesional structure and hyperechoic wall Fig. With good imaging conditions, destruction of the cortex can be well visualized as disruption or distortion of the contour Fig.

The diagnostic value of ultrasound decreases with increasing age of the patient. In osteomyelitis, its indication is essentially restricted to providing additional diagnostic soft tissue information. Abscesses, cysts, and hematomas are excellently visualized as anechoic or hypoechoic lesions and are therefore amenable to ultrasound-guided aspiration.

Examination technique. Fluid-sensitive fat saturated sequences STIR, PDW or T2W serve as sequences for screening; the T1W sequence demonstrates the anatomy and provides characteristic findings within the bone marrow, while the T1W sequence with fat saturation after administration of contrast agent is of help with reliably diagnosing abscesses and sequestrum formation, although it is not generally required for routine diagnostics.

Morphology and signal behavior. This usually involves circumscribed, very signal-intense areas on fluid-sensitive sequences. Intramedullary lesions are hypointense on T1W images Figs. An edematous halo forms around the focal lesion, extending as an irregular and ill-defined manifestation of normal bone marrow. Instead of small circumscribed lesions, large diffuse areas of increased signal intensity are also possible Fig. With hematogenous osteomyelitis, an area of low signal intensity is always evident in the bone marrow on the T1W image, clearly marking the extent of the inflammatory lesion Fig.

The rule is that periosteal edema should always be identifiable Figs. The periosteal areas of edema can be very subtle in early cases. Longitudinal section. Cortical penetration arrow and concomitant involvement of the soft tissue deep to the Achilles tendon, especially the bursa. Differentiation between osteomyelitis and arthritis can be problematic.

Septic arthritis may result in concomitant completely unspecific edematous involvement of the epiphysis and metaphysis, without any pathogen-induced osteomyelitis having to be present. On the other hand, juxta-articular osteomyelitis often results in a reactive joint effusion Figs.

Chapter 3. The diagnosis of concomitant osteomyelitis in association with septic arthritis should only be made if the cortical bone is clearly disrupted clarification is best obtained on T1W or T2W sequences without fat saturation. Intraosseous abscesses tend to be small in size in acute osteomyelitis 0. Additional confirmation of an abscess is the marked marginal enhancement with no, or distinctly less, contrast enhancement in the center of the lesion corresponding to the abscess Fig. Bone-seeking tracers are used for acute osteomyelitis.

Multiphase bone scintigraphy using technetium 99mTc -labeled diphosphonates is primarily used. Here, fully developed osteomyelitis will display a marked focal accumulation of the radionuclide in all three phases. Increased uptake in the blood-pool phase, without accumulation in the bone phase, is regarded as being indicative of an inflammation of only the soft tissue. Because of its radiation exposure, the use of multiphase bone scintigraphy has been reduced in favor of ultrasound and MRI, especially in children.

Nor have other nuclear medicine imaging procedures leukocyte scintigraphy, PET, and hybrid procedures such as PET-CT been able to assert themselves as diagnostic modalities of choice for acute osteomyelitis. Signs of healing of acute osteomyelitis. The first sign of healing to appear on the radiograph is progressive sclerosis, beginning at the periphery.

The bone scan displays a reduction in activity, the MRI scan a resolution of the edematous changes and the soft tissue swelling with the development of contrast-enhanced fibrovascular granulation tissue. Contrast agent uptake becomes less and less over the course of time months. In the ideal case, complete resolution occurs Fig. Many cases, however, end up with an incomplete recovery. We list the most important complications. The selection is not exhaustive.

Expand all sections Register Log in. Trusted medical expertise in seconds. Find answers fast with the high-powered search feature and clinical tools. Try free for 5 days Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer. Summary Osteitis and osteomyelitis are infections of the bone and bone marrow , respectively. Etiology Routes of infection Hematogenous osteomyelitis Most commonly due to a single pathogen Hematogenous dissemination of pathogen Exogenous osteomyelitis : usually due to multiple pathogens Posttraumatic: infection following deep injury penetrating injury, open fractures , severe soft tissue injury Contiguous: spread of infection from adjacent tissue Secondary to infected foot ulcer in diabetic patients Iatrogenic e.

Pasteurella multocida Bites from dogs and cats Fungi e. References Gutierrez K. Bone and joint infections in children.. Pediatr Clin North Am. Clinical Infectious Diseases. BMC Infect Dis. Microbiology of bone and joint infections in injecting drug abusers..