Pathophysiology

Acute osteomyelitis presents as a suppurative infection accompanied by oedema, vascular congestion, and small-vessel thrombosis. In early acute disease, the vascular supply to the bone is decreased by infection extending into the surrounding soft tissue. Large areas of dead bone (sequestra) may be formed when the medullary and periosteal blood supplies are compromised. [8] Acute osteomyelitis can be arrested before dead bone develops if treated promptly and aggressively with antibiotics and surgery (if necessary). In an established infection, fibrous tissue and chronic inflammatory cells form around the granulation tissue and dead bone. [9] Pathological features of chronic osteomyelitis are the presence of necrotic bone, the formation of new bone, and the exudation of polymorphonuclear leukocytes. New bone forms from the surviving fragments of periosteum and endosteum in the region of the infection. An encasing sheath of live bone, an involucrum, surrounds the dead bone under the periosteum. The involucrum is irregular and is often perforated by openings through which purulence may track into the surrounding soft tissue and eventually drain to the skin surface, forming a chronic sinus. [9] Most infections in orthopaedics, including osteomyelitis, are caused by biofilm-forming bacteria. A biofilm is a highly structured community of bacterial cells that adopt a distinct phenotype, communicate through cell-cell signals, and adhere to an inert or living surface. Biofilm-forming bacteria exist in 1 of 2 states - the planktonic state or the stationary state. Planktonic bacteria are free-floating; the bodys host defences can easily eradicate the organism through the usual immunological mechanisms. In contrast, stationary bacteria within the biofilm appear to be phenotypically different from their planktonic types. They have a slower rate of growth and are less metabolically active, and are thereby less susceptible to the effects of chemotherapeutic agents. In chronic osteomyelitis and implantassociated infections, bacteria grow within biofilms attached to the surface of the dead bone or foreign material. This protective mode of growth shields bacteria from antibiotic agents and host defence mechanisms, and enables the infection to persist. The concept of biofilm science must be applied to the diagnosis, treatment, and prevention of chronic orthopaedic infection. [10] [11][12] [13] [14]