CURRENT CONCEPTS
Review Article
Current Concepts
O STEOMYELITIS
DANIEL P. LEW, M.D., AND FRANCIS A. WALDVOGEL, M.D.
K
NOWN since antiquity,1 osteomyelitis is a dif-
ficult-to-treat infection characterized by the
progressive inflammatory destruction and new
apposition of bone.2-4 This review focuses on current
knowledge of the disease and the progress being
made in understanding its pathogenesis, diagnosis,
and treatment.
PATHOGENESIS
The pathogenesis of osteomyelitis has been ex-
plored in various animal models5; these studies have
found that normal bone is highly resistant to infec-
tion, which can only occur as a result of very large in-
ocula, trauma, or the presence of foreign bodies.6,7
Certain major causes of infection, such as Staphy-
lococcus aureus, adhere to bone by expressing re-
ceptors (adhesins) for components of bone matrix
(fibronectin, laminin, collagen, and bone sialoglyco-
protein)8; the expression of the collagen-binding ad-
hesin permits the attachment of the pathogen to
cartilage.9 The role of the fibronectin-binding ad-
hesins of S. aureus in the attachment of bacteria to
devices surgically implanted in bone has recently
been elucidated (Fig. 1).
S. aureus that has been internalized by cultured
osteoblasts can survive intracellularly.12 The intracel-
lular survival of bacteria (sometimes in a metaboli-
cally altered state, in which they appear as so-called
small-colony variants) may explain the persistence of
bone infections.13 Once the microorganisms adhere
to bone, they express phenotypic resistance to anti-
microbial treatment, which may also explain the high
failure rate of short courses of therapy.14
Normal bone remodeling requires the coordinat-
ed interplay of osteoblasts and osteoclasts.15 Cyto-
kines (such as interleukin-1, interleukin-6, interleu-
From the Division of Infectious Diseases and Medical Clinic II, Depart-
ment of Medicine, Geneva University Hospital, 24 rue Micheli-du-Crest,
1211 Geneva 14, Switzerland, where reprint requests should be addressed
to Dr. Lew.
©1997, Massachusetts Medical Society.
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kin-11, and tumor necrosis factor) generated locally
by inflammatory and bone cells are potent osteolytic
factors. The role of bone growth factors in normal
bone remodeling and their therapeutic usefulness
are still unclear. During infection, phagocytes attempt
to contain invading microorganisms and, in the
process, generate toxic oxygen radicals and release
proteolytic enzymes that lyse surrounding tissues.
Several bacterial components act directly or indirect-
ly as bone-modulating factors.16 The presence of
arachidonic acid metabolites, such as prostaglandin
E2, which is a strong osteoclast agonist generated in
response to fracture, decreases the amount of the
bacterial inoculum needed to produce infection.
Pus spreads into vascular channels, raising the in-
traosseous pressure and impairing blood flow. The
ischemic necrosis of bone results in the separation of
devascularized fragments, which are called sequestra.
Microorganisms, infiltrations of neutrophils, and con-
gested or thrombosed blood vessels are therefore the
principal histologic findings in acute osteomyelitis.
One of the distinguishing features of chronic osteo-
myelitis is necrotic bone, which can be recognized
by the absence of living osteocytes.
CLINICAL FEATURES AND
MICROBIOLOGIC AND RADIOLOGIC
DIAGNOSIS
The term acute osteomyelitis is used clinically to
signify a newly recognized bone infection; the re-
lapse of a previously treated or untreated infection is
considered a sign of chronic disease. Clinical signs
persisting for more than 10 days correlate roughly
with the development of necrotic bone and chronic
osteomyelitis.17 The clinical pattern may evolve over
months or even years and is characterized by low-
grade inflammation; the presence of pus, microorgan-
isms, and sequestra; a compromised soft-tissue enve-
lope; and sometimes a fistula.
The identification of the causative microorganisms
is essential for diagnosis and treatment (Table 1).
Surgical sampling or a needle biopsy of infected tis-
sue provides this indispensable information. Evidence
from swabs of ulcers or fistulae, however, is often
misleading.18 Sometimes only the histopathological
examination of a bone-biopsy specimen with special
staining procedures will permit the accurate diagno-
sis of infection.19,20
The diagnosis of skeletal infection entails a vari-
ety of imaging methods,21,22 but conventional radi-
ography is still necessary at both presentation and
follow-up. For nuclear imaging, technetium Tc 99m
methylene diphosphonate, a technetium phosphate
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 The New England Journal of Medicine

1 cm
A

In vitro Ex vivo

100

No. of Adherent Bacteria (103/plate)

No. of Adherent Bacteria (103/cm2)

Parental strain

80 10

60

40

20 Mutant strain

1
0
0 50 100 150
Parental Mutant
B Amount of Adsorbed Fibronectin (ng/cm2) C strain strain
Figure 1. Fibronectin-Binding Protein and the Degree of Adherence of S. aureus to Bone-Implanted Metallic Devices.
Panel A shows titanium miniplates and miniscrews (left) and a radiograph obtained six weeks after the implantation of these de-
vices in the iliac bone of a guinea pig (right).
Panel B is a plot of the degree of adherence of two strains of S. aureus against the amount of adsorbed fibronectin on artificial
surfaces in vitro. Bacterial attachment is mediated by a specific adhesin exposed on the bacterial surface (fibronectin-binding pro-
tein). A mutant strain10 expressing a markedly reduced amount of fibronectin-binding protein exhibits less attachment than the
parental strain to the fibronectin-coated surfaces.
Panel C shows the degree of bacterial adhesion to miniplates explanted from the iliac bones of guinea pigs. The level of adhesion
of the parental strain was three times as high as that of the adhesin-defective mutant strain. This result indicates that fibronectin
plays an important part in the adhesion of S. aureus to bone-implanted miniplates. Bars indicate medians. (Reprinted from Fischer
et al.11 with the permission of the publisher.)

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 CURRENT CONCEPTS

compound, is still the radiopharmaceutical of choice.23

It binds to sites of increased bone metabolic activ- TABLE 1. MICROORGANISMS ISOLATED FROM PATIENTS
WITH BACTERIAL OSTEOMYELITIS.
ity and is highly sensitive for the early detection
of acute osteomyelitis. Other nuclear imaging tech-
niques, such as those using gallium citrate Ga 67, MICROORGANISM MOST COMMON CLINICAL ASSOCIATION
111In-labeled white cells, 24 and 111In-labeled human
S. aureus (susceptible or resistant to Most frequent microorganism in
polyclonal IgG,25 need further assessment before they methicillin) any type of osteomyelitis
can be recommended. Coagulase-negative staphylococci Foreign-body–associated infection
Both computed tomography (CT) and magnetic or propionibacterium
Enterobacteriaceae or Pseudomonas Common in nosocomial infections
resonance imaging (MRI) have excellent resolution aeruginosa
and can reveal edema and the destruction of medul- Streptococci or anaerobic bacteria Associated with bites, fist injury
la, as well as any periosteal reaction, cortical destruc- caused by contact with another
tion, articular damage, and soft-tissue involvement, person’s mouth, diabetic foot le-
sions, and decubitus ulcers
even when conventional radiographs are still normal. Salmonella or Streptococcus Sickle cell disease
CT is prone to image degradation due to artifacts pneumoniae
caused by the presence of bone or metal, but is nev- Bartonella henselae Human immunodeficiency virus
ertheless extremely useful for guiding needle biopsy. infection
Pasteurella multocida or Eikenella Human or animal bites
At many centers CT has been replaced by MRI for corrodens
the diagnosis and assessment of the extent of dis- Aspergillus, Mycobacterium avium Immunocompromised patients
ease. The presence of a ferromagnetic material in or complex, or Candida albicans
near the examined tissue is, however, a contraindica- Mycobacterium tuberculosis Populations in which tuberculosis is
prevalent
tion to MRI. Fortunately, most materials used in
Brucella, Coxiella burnetii (chronic Populations in which these patho-
orthopedics (such as titanium) do not interfere with Q fever), or other fungi found in gens are endemic
MRI. A diagnosis of osteomyelitis by MRI may some- specific geographic areas
times precede a positive result on scintigraphy, be-
cause of the earlier detection of bone marrow in-
volvement with MRI.
A typical combination of magnetic resonance pulse
sequences includes a T1-weighted spin–echo se- of the patient. S. aureus and streptococci are typical
quence and a T2-weighted spin–echo sequence. In in neonates; S. aureus is found later in life; and gram-
the T1-weighted phase, infectious processes are im- negative rods are found in the elderly. Fungal osteo-
aged as areas of low signal intensity, which appear myelitis is a complication of catheter-related fungemia,
dark on standard films. In the T2-weighted phase, in- the use of illicit drugs contaminated by candida spe-
flammation and infection are seen as areas of ab- cies, and prolonged neutropenia. Pseudomonas aeru-
normally bright signal. Other techniques, including ginosa can be isolated from injection-drug addicts
additional pulse sequences such as the inversion– (often from cervical vertebrae) and from patients with
recovery sequence, fat-suppression techniques,26 and urinary catheters in place for long periods (often
gradient–echo images, are used to decrease the bright from lumbar vertebrae).
signal of fat and increase the detection of water Vertebral infection,27-30 a rare disease in adults, typ-
and thus of early infection. The intravenous contrast ically involves two adjacent vertebrae and the disk
agent gadopentetate di-N-methylglucamine, a para- space between them (Fig. 2B). Neck or back pain
magnetic material, may also be useful in differentiat- and fever are the main symptoms. Blood cultures are
ing vascularized and inflamed tissue from the periph- often negative, so needle biopsy with multiple spec-
eral rim enhancement characteristic of an abscess. imens for microbiologic and pathological examina-
tion is the diagnostic procedure of choice. If the cul-
Hematogenous Osteomyelitis ture from the first biopsy specimen is negative, a
Osteomyelitis develops after bacteremia mostly in second biopsy guided by CT should be performed.
prepubertal children and in elderly patients. In chil- In the event of a second failure to establish the di-
dren, infection is usually located in the metaphyseal agnosis, the alternatives are either empirical therapy
area of long bones (particularly the tibia and femur), or an open surgical biopsy.
usually as a single focus (Fig. 2A). The clinical fea-
tures of this form of osteomyelitis are typically chills, Osteomyelitis Due to a Contiguous Focus of Infection
fever and malaise, local pain, and swelling. Blood cul- Osteomyelitis after injury is the most prevalent
tures are often positive for the infection. Total-body type and is usually associated with an open fracture
scintigraphy is useful in detecting any metastatic sites or occurs after surgery necessary for reconstruction
of infection and should be repeated in case of an early of bone. Infections associated with prostheses are
negative result. also common.31 Between 500,000 and 1 million hip
The infecting organisms differ according to the age replacements per year were performed worldwide

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 CURRENT CONCEPTS

Figure 2. Appearance on MRI of Various Types of Osteomyelitis.

Panel A shows acute osteomyelitis of the right tibia in a four-year-old boy. In a T1-weighted image (left),
a large area of signal hypointensity in bone marrow is seen (arrows). The intravenous injection of gad-
olinium enhances the signal (arrows) and reveals a small abscess (arrowhead).
Panel B shows vertebral osteomyelitis with a soft-tissue abscess one week after an L4–L5 diskectomy.
In a T1-weighted image (left) and after the intravenous injection of gadolinium (right), abnormalities
of bone marrow in the vertebral bodies (arrows) and a posterior fluid collection (arrowheads) are ev-
ident.
Panel C shows three views of acute osteomyelitis of the left big toe in a patient with diabetes mellitus.
Abnormalities of bone marrow (arrows) are seen as an area of signal hypointensity in a T1-weighted
image (right), as an area of enhanced signal after the intravenous injection of gadolinium (center), and
as an area of hyperintensity in an inversion–recovery sequence with fat suppression (left).

during the late 1980s; because the techniques for
other joint replacements (e.g., knee or elbow) have
improved, the annual number of artificial joints in-
serted has become much higher.
Infection associated with a prosthesis may occur
within 12 weeks after surgery (acute infection), with-
in 24 months after surgery (chronic infection, often
with less virulent microorganisms), and in patients
with hematogenous infection, even later. Patients
usually have little or no fever and present with a pain-
ful, unstable joint on physical examination or radiog-
raphy. Because of the difficulty of distinguishing me-
chanical from infectious loosening, a positive culture
of fluid aspirated from the artificial-joint space or of
bone from the bone–cement interface is required for
diagnosis. Gram’s staining and quantitative cultures
of material obtained from deep tissues are useful in
distinguishing colonization from infection. Coagulase-
positive and coagulase-negative staphylococci account
for 75 percent of the bacteria cultured.
Osteomyelitis Due to Vascular Insufficiency
In patients with diabetes or vascular insufficiency,
osteomyelitis is found almost exclusively in the feet.32
The disease starts insidiously in an area of previously
traumatized skin in a patient with claudication. Cel-
lulitis may be minimal as the infection progressively
burrows its way to the underlying bone (e.g., toes,
metatarsal heads, and tarsal bones). Physical exami-
nation elicits either no pain (if there is advanced
neuropathy) or excruciating pain (if the destruction
of bone has been acute). One must carefully assess
the vascular supply to the affected limb and look for
concomitant neuropathy. If one can gently advance a
sterile surgical probe to reach bone, the diagnosis of
osteomyelitis is clearly established.33 In cases of early
bone infection in which the clinical presentation does
not establish the diagnosis and the results of plain-
film radiographs are still normal, MRI may permit the
detection of the early infection (Fig. 2C).34 The ex-
tent of vascular compromise can be assessed by trans-
cutaneous oximetery (once inflammation has been
controlled) and by measurements of pulse pressure
with Doppler ultrasonography. If serious ischemia is
suspected, arteriography, including examination of
the foot vessels, should be performed.
ANTIBIOTIC PROPHYLAXIS IN BONE
SURGERY
In patients undergoing bone surgery, antibiotics
should be administered intravenously 30 minutes
before incision of the skin and for no longer than 24
hours after the operation.35-37 In orthopedic surgery
for closed fractures, antistaphylococcal penicillins and
first-, second-, or third-generation cephalosporins de-
crease the incidence of postoperative infection.38 By
definition, open fractures include those in a large pro-
portion of patients who have contaminated or infect-
ed wounds at the time of surgery.
In patients who can receive antibiotics within six

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 The New England Journal of Medicine

hours after injury and who receive prompt operative
treatment, administration of first-generation (cefaz-
olin) or second-generation (cefamandole and cefur-
oxime) cephalosporins for one day is appropriate.
The drug therapy should be followed by close obser-
vation and treatment with appropriate antibiotics and
surgery if a postoperative infection is diagnosed.37,39
However, the treatment of complex fractures with
extensive soft-tissue damage requires broader antibiot-
ic therapy for longer periods.40
With respect to the insertion of prosthetic devices,
several experimental studies and the early clinical ex-
perience have shown high susceptibility to infection
when only a few microorganisms of low pathogenic-
ity, such as S. epidermidis or propionibacterium spe-
cies, are present.41 In such procedures, good preop-
erative preparation, the use of surgical rooms with
laminar air flow, and prophylactic antibiotic treatment
have decreased the rate of infection to around 0.5 to
2 percent.42-45
TREATMENT
Basic Principles
Early antibiotic treatment, before extensive de-
struction of bone or necrosis, produces the best re-
sults and must be administered parenterally for at
least four — and usually six — weeks to achieve an
acceptable rate of cure (Table 2). To reduce costs,
parenteral administration of antibiotics on an outpa-
tient basis has become widely used. A combined an-
timicrobial and surgical approach should always be
considered. At one end of the spectrum of disease
(e.g., acute hematogenous osteomyelitis), surgery is
usually unnecessary; at the other end (e.g., a consol-
idated infected fracture), cure may be achieved with
antibiotic treatment provided that the foreign mate-
rial is eventually removed.
In treating hematogenous osteomyelitis in chil-
dren, the parenteral administration of antibiotics may
be rapidly followed by several weeks of oral therapy,
provided that the infecting organism has been iden-
tified, clinical signs abate rapidly, and the patient’s
compliance with therapy is good.46 Because of the
limited bioavailability of high-dose oral beta-lactam
antibiotics (cloxacillin and cephalexin) and poor gas-
trointestinal tolerance, early intravenous–oral switch
therapy with these drugs is not used in adults with
acute osteomyelitis.
Long-term oral therapy with quinolones (ciproflox-
acin and ofloxacin) can suppress the symptoms and

TABLE 2. ANTIBIOTIC TREATMENT OF OSTEOMYELITIS IN ADULTS.*

MICROORGANISMS ISOLATED TREATMENT OF CHOICE ALTERNATIVES

S. aureus
Penicillin-sensitive Penicillin G (4 million
units every 6 hr)
Penicillin-resistant Nafcillin (2 g every 6 hr)†
Methicillin-resistant Vancomycin (1 g every
12 hr)
Various streptococci (group A or Penicillin G (4 million
B b-hemolytic or Strepto- units every 6 hr)
coccus pneumoniae)
Enteric gram-negative rods Quinolone (ciprofloxacin,
750 mg every 12 hr
orally)
Serratia or Pseudomonas aerugi- Ceftazidime (2 g every
nosa 8 hr) (with aminogly-
cosides for at least the
first 2 wk)§
Anaerobes Clindamycin (600 mg
every 6 hr intravenous-
ly or orally)
Mixed aerobic and anaerobic Amoxicillin–clavulanic
microorganisms acid (2.0 and 0.2 g,
respectively, every 8 hr)
First-generation cephalosporin (e.g., cefazolin, 2 g
every 6 hr), clindamycin (600 mg every 6 hr),
or vancomycin (1 g every 12 hr)
First-generation cephalosporin, clindamycin (as
above), or vancomycin (as above)
Teicoplanin (400 mg every 24 hr; first day, every
12 hr intravenously or intramuscularly)‡
Clindamycin (as above), erythromycin (500 mg
every 6 hr), vancomycin (as above), or ceftriax-
one (2 g once a day)
Third-generation cephalosporin (e.g., ceftriaxone,
2 g every 24 hr)
Imipenem (500 mg every 6 hr), piperacillin–
tazobactam (4 g and 0.5 g, respectively, every
8 hr), or cefepime (2 g every 12 hr) (with amino-
glycosides for at least the first 2 wk)§
Amoxicillin–clavulanic acid (2.0 and 0.2 g, respec-
tively, every 8 hr) or metronidazole for gram-
negative anaerobes (500 mg every 8 hr)
Imipenem (500 mg every 6 hr)¶

*All antibiotic treatments are given intravenously unless otherwise stated.

†In Europe, flucloxacillin is the treatment of choice.
‡Teicoplanin is currently available only in Europe.
§Aminoglycosides may be given once a day or in multiple doses.
¶Imipenem should be given when infection is due to aerobic gram-negative microorganisms resistant to amoxicillin–
clavulanic acid.

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 CURRENT CONCEPTS
signs of chronic, refractory osteomyelitis.47 Although
the efficacy of quinolones in the treatment of osteo-
myelitis due to Enterobacteriaceae is undisputed, their
advantage over conventional therapy for infections
due to P. aeruginosa, serratia species, and S. aureus
(against S. aureus, these drugs are given alone or in
combination with rifampin) has yet to be shown.48
Nosocomial infections with methicillin-resistant S. au-
reus or multidrug-resistant gram-negative rods require
prolonged intravenous therapy with glycopeptides49,50
or broad-spectrum antibiotics (Table 2).
The local administration of antibiotics, either by
instillation or with gentamicin-impregnated beads,
has its advocates. However, the diffusion of antibiot-
ics given in this way is limited in time and area,51 and
the method has not undergone controlled study.
Surgical Management
Novel surgical approaches to the treatment of os-
teomyelitis can lead to the more rapid formation of
new bone.52 In acute osteomyelitis that is unrespon-
sive to antimicrobial therapy (or is marked by extreme
bone tenderness), surgical decompression may re-
lease intramedullary or subperiosteal pus. Chronic
osteomyelitis requires treatment that is primarily sur-
gical, because the complete débridement of all the
devitalized bone and soft tissue, regardless of the size
of the wound created,53 is essential for cure.
Successful surgical therapy entails both filling the
space created by the loss of tissue due to débride-
ment and revascularization of a poorly perfused re-
gion. After débridement, the classic approach is to
cover the wound with a graft of skin, bone, or mus-
cle. Skin grafting is used to cover wound sites involv-
ing bone that has undergone surgery or to cover
muscle flaps or grafts of cancellous bone. Cancellous
bone grafts can fill the space left after bone débride-
ment with a tissue that can quickly become revascu-
larized. The bone fragments can also become incor-
porated into the final bone structure. In the Papineau
technique, the wound is left open after bone graft-
ing to permit the growth of granulation tissue be-
fore closure.54 All these grafting procedures have a
high failure rate due to resorption of the bone graft
in the presence of persistent local infection.
Revascularization procedures are the best means of
fighting recurrent infection55; those involving local
pedicle muscle flaps and myocutaneous flaps are now
the ones most frequently used to fill the space created
by surgery. Local muscle flaps are limited by the avail-
ability of adjacent muscle, but are very useful because
the vascular supply is kept intact. Myocutaneous flaps
have the advantage of providing vascular supply to
both the muscle and the overlying skin. Increasingly,
microsurgically transplanted (or free-tissue) muscle
flaps are being used in areas such as the distal tibia
where no appropriate muscle exists.56,57
Complex orthopedic techniques are necessary to
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repair very large bone defects that would otherwise
be considered untreatable except by amputation. In
the Ilizarov technique,58 the resection of diseased
tissue and bone creates a gap partially filled by a well-
vascularized bone segment. Transfer of the bone
graft leads to progressive local generation of new
bone. This is a complex and expensive procedure,
more popular in Europe than in the United States.
Alternatively, recent experience with the microvascu-
lar transfer of fibular grafts and composite osteocu-
taneous iliac flaps into infected areas of bone has
shown that massive autogenous bone grafting with
an intact vascular pedicle decreases the time needed
for bone union and shortens the period of immobi-
lization.59
Specific Conditions
The proper treatment of osteomyelitis may depend
on its anatomical location and the type of underlying
disease. In pyogenic vertebral osteomyelitis, surgical
intervention is reserved for the management of com-
plications or for the failure of medical therapy. It is
mainly undertaken either to relieve compression of
the spinal cord or to improve spinal stability and drain
epidural or paravertebral abscesses. In infections asso-
ciated with prosthetic joints the basic rule is to re-
move the device. Exceptions to this rule include situ-
ations involving a stable hip prosthesis infected with
very sensitive microorganisms such as streptococci
(such infections may be cured by prolonged parenter-
al therapy) or the early diagnosis of device-related in-
fections of the hip with S. aureus, which have been
reported to be cured after several months of treat-
ment with oral quinolones and rifampin.60,61
A classic approach to removing prostheses in infec-
tion, the two-stage exchange arthroplasty, entails the
surgical removal of all foreign material, débridement
of the bone and soft tissues, and a minimum of four
weeks of parenteral antimicrobial therapy before re-
construction. In one-stage exchange arthroplasty, a
new prosthesis is immediately inserted. Practitioners
of the one-stage technique always use cement con-
taining an antimicrobial drug, which may contribute
to the high success rate reported with this procedure.
One-stage arthroplasty carries a higher risk of recur-
rent infection than the two-stage procedure, particu-
larly in the presence of more virulent bacteria such as
S. aureus.
In osteomyelitis due to vascular insufficiency in
patients with diabetes, the treatment depends on the
oxygen tension of tissue at the infected site, the po-
tential for revascularization, the extent of local infec-
tion, and the preference of the patient.62 Surgery to
restore vascularization is often useful before ampu-
tation is considered. There is no convincing evi-
dence that hyperbaric oxygen is effective in these pa-
tients. Débridement and a four-to-six-week course
of antimicrobial therapy may benefit a patient who
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 The New England Journal of Medicine
has good oxygen tension at the infected site, partic-
ularly if the identity of the pathogen has been estab-
lished (usually, S. aureus). In the absence of good
oxygen tension and an accurately identified patho-
gen, the wound often fails to heal, and amputation
of the infected extremity is ultimately required. With
digital resection, transmetatarsal amputation, and
disarticulation at the midfoot, however, the patient
can walk without an orthosis.
CONCLUSIONS
With new diagnostic methods and better treat-
ment it can be anticipated that, for those with ready
access to health care, the sequelae of hematogenous
osteomyelitis should become rare. Infection-control
strategies and prophylactic antibiotics will further
decrease the rate of postoperative infection. Howev-
er, the increase in reconstructive orthopedic proce-
dures with prosthetic materials will increase the over-
all number of infections, and it is doubtful whether
any preventive measures can reduce the rate of in-
fection to below 0.5 percent. New materials for
reconstruction should be developed that combine
mechanical with antiadhesive properties and approx-
imate more closely the extracellular matrix. Surgical
approaches that combine the skills of orthopedic, plas-
tic, and vascular surgeons, along with the clinical use
of various factors that promote bone growth, should
allow more rapid growth of new bone and shorten the
period of vulnerability to infection.
Chronic osteomyelitis entails a major financial bur-
den and has a substantial impact on the quality of
life. Collaboration between patient and physician is
essential in the treatment of this disease. A clear un-
derstanding of the risks, costs, and chances of suc-
cess of treatment options should form the basis of
an open dialogue between the physician and the pa-
tient with chronic osteomyelitis.
Supported in part by a grant (32-45810.95) from the Swiss National Sci-
ence Foundation.
We are indebted to Dr. B. Wyssa, Dr. F. Southwick, Dr. W. Zim-
merli, and Mrs. Jean Gunn for their valuable advice; to Dr. J. Gar-
cia for providing magnetic resonance images; and to Dr. P. Vaudaux
and Dr. P. François for providing the image of S. aureus adhesins.
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