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Pathophysiology:

The two primary categories of acute osteomyelitis are hematogenous osteomyelitis


and contiguous osteomyelitis. Hematogenous osteomyelitis is an infection caused by
bacterial seeding from the blood from a remote source. This condition occurs
primarily in children. The most common site is the rapidly growing and highly
vascular metaphysis of growing bones. The apparent slowing or sludging of blood
flow as the vessels make sharp angles at the distal metaphysis predisposes the
vessels to thrombosis and the bone itself to localized necrosis and bacterial seeding.
This condition generally has a slow clinical development and insidious onset.

Contiguous osteomyelitis is an infection in the bone secondary to the inoculation of


organisms from direct trauma, spread from a contiguous focus of infection, or sepsis
after a surgical procedure. Clinical manifestations of direct inoculation osteomyelitis
are more localized than those of hematogenous osteomyelitis and tend to involve
multiple organisms.

Disease states known to predispose patients to osteomyelitis include diabetes


mellitus, sickle cell disease, acquired immune deficiency syndrome (AIDS), IV drug
abuse, alcoholism, chronic steroid use, immunosuppression, and chronic joint
disease. In addition the presence of a prosthetic orthopedic device is an independent
risk factor as is any recent orthopedic surgery or open fracture.

A single pathogenic organism is almost always recovered from the bone. The most
common bone isolates are Staphylococcus species, the most common gram-negative
organism is Pseudomonas aeruginosa, and the most common anaerobes are
Peptostreptococcus species. However, in immunocompromised patients, other
organisms, including fungi and mycobacteria, also must be considered.

Pathogenesis
In general, microorganisms may infect bone through one or more of three basic methods:
via the bloodstream, contiguously from local areas of infection (as in cellulitis), or
penetrating trauma, including iatrogenic causes such as joint replacements or internal
fixation of fractures or root-canaled teeth.[1] Once the bone is infected, leukocytes enter
the infected area, and, in their attempt to engulf the infectious organisms, release
enzymes that lyse the bone. Pus spreads into the bone's blood vessels, impairing their
flow, and areas of devitalized infected bone, known as sequestra, form the basis of a
chronic infection.[1] Often, the body will try to create new bone around the area of
necrosis. The resulting new bone is often called an involucrum.[1] On histologic
examination, these areas of necrotic bone are the basis for distinguishing between acute
osteomyelitis and chronic osteomyelitis. Osteomyelitis is an infective process which
encompasses all of the bone (osseous) components, including the bone marrow. When it
is chronic it can lead to bone sclerosis and deformity.

Chronic osteomyelitis may be due to the presence of intracellular bacteria (inside bone
cells)[2]. Also, once intracellular, the bacteria are able to escape and invade other bone
cells[3]. In addition, once intracellular, the bacteria becomes resistant to antibiotics[4].
These combined facts may explain the chronicity and difficult eradication of this disease.
This results in significant costs and disability and may even lead to amputation.
Intracellular existence of bacteria in osteomyelitis is likely an unrecognized contributing
factor to its chronic form.

In infants, the infection can spread to the joint and cause arthritis. In children, large
subperiosteal abscesses can form because the periosteum is loosely attached to the
surface of the bone.[1]

Because of the particulars of their blood supply, the tibia, femur, humerus, vertebra, the
maxilla, and the mandibular bodies are especially susceptible to osteomyelitis.[5]
Abscesses of any bone, however, may be precipitated by trauma to the affected area.
Many infections are caused by Staphylococcus aureus, a member of the normal flora
found on the skin and mucous membranes. In sickle cell the causative agent is normally
from the Salmonella species.

It has been noted that baseball Hall-of-Famer Mickey Mantle had osteomyelitis, as well
as British Singer/Songwriter Imogen Heap. During her tour in 2010 she devised an
improvised track with the key and tempo voted on by the audience. All proceeds went to
the Great Ormond Street hospital, where a surgeon had successfully performed an
operation to save her leg.[6]

Pathophysiology:
First the pathogen provokes an intense inflammatory response. This
inflammation of the bone is characterized by vascular engorgement, edema,
leukocyte activity, and abscess formation. The small terminal vessels thrombose
and seal the bone's canaliculi. The inflammation then spreads into the marrow
cavity and through the metaphyseal openings into the cortex.

Osteoblasts lay down new bone that can partially or completely surround the
infected bone.

In adults the infection disrupts and weakens the cortex which predisposes the
bone to pathologic fractures.