Osteomyelitis is an infection of bone or bone marrow, usually caused by

pyogenic bacteria or mycobacteria . It can be usefully subclassified on

the basis of the causative organism, the route, duration and anatomic
location of the infection.

Treatment

Osteomyelitis often requires prolonged antibiotic therapy, with a course

lasting a matter of weeks or months. A PICC line or central venous
catheter is often placed for this purpose. Osteomyelitis also may require
surgical debridement. Severe cases may lead to the loss of a limb. Initial
first line antibiotic choice is determined by the patient's history and
regional differences in common infective organisms.

American artist Thomas Eakins in 1875 depicted a surgical procedure for

osteomyelitis in a famous oil painting titled "The Gross Clinic", now part
of Jefferson Medical College.

Prior to the widespread availability and use of antibiotics, blow fly larvae
were sometimes deliberately introduced to the wounds to feed on the
infected material, effectively scouring clean.

Hyperbaric oxygen therapy has been shown to be a useful adjunct to the

treatment of refractory osteomyelitis. A treatment lasting 42 days is
practiced in a number of facilities

Causes

Staphylococcus aureus is the organism most commonly isolated from all

forms of osteomyelitis.

Hematogenously seeded osteomyelitis is seen most frequently in children,

and nearly 90% of cases are caused by Staphylococcus aureus. In infants,
S. aureus, Group B streptococci (most common) and Escherichia coli are
commonly isolated; in children from 1 to 16 years of age, S. aureus,
Streptococcus pyogenes, and Haemophilus influenzae are common. In
some subpopulations, including intravenous drug users and splenectomized
patients, Gram negative bacteria, including enteric bacilli, are significant
pathogens.
Osteoarthritis (OA, also known as degenerative arthritis, degenerative
joint disease), is a clinical syndrome in which low-grade inflammation
results in pain in the joints, caused by abnormal wearing of the cartilage
that covers and acts as a cushion inside joints and destruction or
decrease of synovial fluid that lubricates those joints. As the bone
surfaces become less well protected by cartilage, the patient experiences
pain upon weight bearing, including walking and standing. Due to decreased
movement because of the pain, regional muscles may atrophy, and
ligaments may become more lax. OA is the most common form of arthritis
and the leading cause of chronic disability in the United States.

Types:
Primary
This type of OA is a chronic degenerative disorder related to but not
caused by aging, as there are people well into their nineties who have no
clinical or functional signs of the disease. As a person ages, the water
content of the cartilage decreases due to a reduced proteoglycan
content, thus causing the cartilage to be less resilient. Without the
protective effects of the proteoglycans, the collagen fibers of the
cartilage can become susceptible to degradation and thus exacerbate the
degeneration. Inflammation of the surrounding joint capsule can also
occur, though often mild (compared to that which occurs in rheumatoid
arthritis). This can happen as breakdown products from the cartilage are
released into the synovial space, and the cells lining the joint attempt to
remove them. New bone outgrowths, called "spurs" or osteophytes, can
form on the margins of the joints, possibly in an attempt to improve the
congruence of the articular cartilage surfaces. These bone changes,
together with the inflammation, can be both painful and debilitating.

Secondary:
This type of OA is caused by other factors or diseases but the resulting
pathology is the same as for primary OA:

Signs and symptoms

The main symptom is acute pain, causing loss of ability and often
stiffness. "Pain" is generally described as a sharp ache, or a burning
sensation in the associated muscles and tendons. OA can cause a crackling
noise (called "crepitus") when the affected joint is moved or touched, and
patients may experience muscle spasm and contractions in the tendons.
Occasionally, the joints may also be filled with fluid. Humid weather
increases the pain in many patients.
Causes
Although it commonly arises from trauma, osteoarthritis often affects
multiple members of the same family, suggesting that there is hereditary
susceptibility to this condition. A number of studies have shown that
there is a greater prevalence of the disease between siblings and
especially identical twins, indicating a hereditary basis[citation needed].
Up to 60% of OA cases are thought to result from genetic factors.
Researchers are also investigating the possibility of allergies, infections,
or fungi as a cause. There is some evidence that allergies, whether fungal,
infectious or systemically induced, may be a significant contributing
factor to the appearance of osteoarthritis in a synovial sac.

Diagnosis
Diagnosis is normally done through x-rays. This is possible because loss of
cartilage, subchondral ("below cartilage") sclerosis, subchondral cysts,
narrowing of the joint space between the articulating bones, and bone
spur formation (osteophytes) show up clearly on x-rays. Plain films,
however, often do not correlate well with the findings of physical
examination of the affected joints.

Treatment
Generally speaking, the process of clinically detectable osteoarthritis is
irreversible, and typical treatment consists of medication or other
interventions that can reduce the pain of OA and thereby improve the
function of the joint.

Gout
(also called metabolic arthritis) is a disease created by a buildup of uric
acid. In this condition, monosodium urate or uric acid crystals are
deposited on the articular cartilage of joints, tendons and surrounding
tissues due to elevated concentrations of uric acid in the bloodstream.
This provokes an inflammatory reaction of these tissues.

Signs and symptoms

Gout is characterized by excruciating, sudden, unexpected, burning pain,
as well as swelling, redness, warmth, and stiffness in the affected joint.
This occurs commonly in men in their toes but can appear in other parts
of the body and affects women as well. Low-grade fever may also be
present. The patient usually suffers from two sources of pain. The
crystals inside the joint cause intense pain whenever the affected area is
moved. The inflammation of the tissues around the joint also causes the
skin to be swollen, tender and sore if it is even slightly touched. For
example, a blanket or even the lightest sheet draping over the affected
area could cause extreme pain.

Diagnosis
Clinically, gout can be hard to distinguish from several other conditions,
including chondrocalcinosis. Chondrocalcinosis is a very similar disease,
caused by deposition of calcium pyrophosphate rather than uric acid.

Treatment
Acute attacks
The first line of treatment should be pain relief. Once the diagnosis has
been confirmed, the drugs of choice are indomethacin, other nonsteroidal
anti-inflammatory drugs (NSAIDs), oral glucocorticoids,[15] or intra-
articular glucocorticoids administered via a joint injection.

Colchicine was previously the drug of choice in acute attacks of gout, as it

impairs the motility of granulocytes and can prevent the inflammatory
phenomena that initiate an attack. Colchicine should be taken within the
first 12 hours of the attack and usually relieves the pain within 48 hours,
although side effects (gastrointestinal upset such as diarrhea and
nausea) can complicate its use. NSAIDs are the preferred form of
analgesia for patients with gout.

Infectious arthritis is a form of joint inflammation caused by a germ.

The germ can be a bacterium, a virus or a fungus. Infection of the joints
usually occurs after a previous infection elsewhere in the body.

There is usually only one joint involved, though sometimes two or three
joints can become infected. Mostly, infectious arthritis affects the large
joints (shoulders, hips, knees), but smaller joints (fingers, ankles) can also
be involved.

The symptoms
infectious arthritis vary according to the type of germ causing it. If the
arthritis is caused by a bacterium, inflammation is generally located in
only one place or area. The infection is often accompanied by fever and
chills and its onset is quite sudden. With infectious arthritis caused by a
virus, there is usually no fever, but there is an aching feeling all over the
body. Inflammation caused by a fungal infection can be in one area or
throughout the body, and it usually occurs very slowly, over weeks or
months. You may have a mild fever or no fever at all.

Medication
Anti-inflammatory medication is often given to treat the pain and swelling
of infectious arthritis. Nonsteroidal anti-inflammatory drugs (NSAIDs)
are a type of medication that helps reduce the pain and swelling of the
joints and decrease stiffness. However, they do not prevent further joint
damage.

Surgery
If your infectious arthritis is caused by a fungus, you and your doctor
may consider surgery to remove the infection from the joint.

Osteoporosis is a disease of bone that leads to an increased risk of

fracture. In osteoporosis the bone mineral density (BMD) is reduced,
bone microarchitecture is disrupted, and the amount and variety of non-
collagenous proteins in bone is altered. Osteoporosis is defined by the
World Health Organization (WHO) in women as a bone mineral density 2.5
standard deviations below peak bone mass (20-year-old healthy female
average) as measured by DXA; the term "established osteoporosis"
includes the presence of a fragility fracture.[1] Osteoporosis is most
common in women after menopause, when it is called postmenopausal
osteoporosis, but may also develop in men, and may occur in anyone in the
presence of particular hormonal disorders and other chronic diseases or
as a result of medications, specifically glucocorticoids, when the disease
is called steroid- or glucocorticoid-induced osteoporosis (SIOP or GIOP).
Given its influence on the risk of fragility fracture, osteoporosis may
significantly affect life expectancy and quality of life.

Signs and symptoms

Osteoporosis itself has no specific symptoms; its main consequence is the
increased risk of bone fractures. Osteoporotic fractures are those that
occur in situations where healthy people would not normally break a bone;
they are therefore regarded as fragility fractures. Typical fragility
fractures occur in the vertebral column, rib, hip and wrist.

Diseases and disorders

Many diseases and disorders have been associated with osteoporosis. For
some, the underlying mechanism influencing the bone metabolism is
straight-forward, whereas for others the causes are multiple or unknown.
 - In general, immobilization causes bone loss (following the 'use it or
lose it' rule). For example, localized osteoporosis can occur after
prolonged immobilization of a fractured limb in a cast. This is also more
common in active patients with a high bone turn-over (for example,
athletes). Other examples include bone loss during space flight or in
people who are bedridden or wheelchair-bound for various reasons.
- Hypogonadal states can cause secondary osteoporosis. These include
Turner syndrome, Klinefelter syndrome, Kallmann syndrome, anorexia
nervosa, andropause, hypothalamic amenorrhea or hyperprolactinemia. In
females, the effect of hypogonadism is mediated by estrogen deficiency.
It can appear as early menopause (<45 years) or from prolonged
premenopausal amenorrhea (>1 year). A bilateral oophorectomy (surgical
removal of the ovaries) or a premature ovarian failure cause deficient
estrogen production. In males, testosterone deficiency is the cause (for
example, andropause or after surgical removal of the testes).
- Endocrine disorders that can induce bone loss include Cushing's
syndrome, hyperparathyroidism, thyrotoxicosis, hypothyroidism, diabetes
mellitus type 1 and 2, acromegaly and adrenal insufficiency. In pregnancy
and lactation, there can be a reversible bone loss.
- Malnutrition, parenteral nutrition and malabsorption can lead to
osteoporosis. Nutritional and gastrointestinal disorders that can
predispose to osteoporosis include coeliac disease, Crohn's disease,
lactose intolerance, surgery (after gastrectomy, intestinal bypass surgery
or bowel resection) and severe liver disease (especially primary biliary
cirrhosis). Patients with bulemia can also develop osteoporosis. Those with
an otherwise adequate calcium intake can develop osteoporosis due to the
inability to absorb calcium and/or vitamin D. Other micro-nutrients such
as vitamin K or vitamin B12 deficiency may also contribute.
- Patients with rheumatologic disorders like rheumatoid arthritis,
ankylosing spondylitis, systemic lupus erythematosus and polyarticular
juvenile idiopathic arthritis are at increased risk of osteoporosis, either
as part of their disease or because of other risk factors (notably
corticosteroid therapy). Systemic diseases such as amyloidosis and
sarcoidosis can also lead to osteoporosis.
- Renal insufficiency can lead to osteodystrophy.
- Hematologic disorders linked to osteoporosis are multiple myeloma
and other monoclonal gammopathies, lymphoma and leukemia,
mastocytosis, hemophilia, sickle-cell disease and thalassemia.
- Several inherited disorders have been linked to osteoporosis. These
include osteogenesis imperfecta, Marfan syndrome, hemochromatosis,
hypophosphatasia, glycogen storage diseases, homocystinuria, Ehlers-
Danlos syndrome, porphyria, Menkes' syndrome, epidermolysis bullosa and
Gaucher's disease.
- People with scoliosis of unknown cause also have a higher risk of
osteoporosis. Bone loss can be a feature of complex regional pain
syndrome. It is also more frequent in people with Parkinson's disease and
chronic obstructive pulmonary disease.

Medication
Bisphosphonates are the main pharmacological measures for treatment.
However, newer drugs have appeared in the 1990s, such as teriparatide
and strontium ranelate.

Bisphosphonates
In confirmed osteoporosis, bisphosphonate drugs are the first-line
treatment in women. The most often prescribed bisphosphonates are
presently sodium alendronate (Fosamax) 10 mg a day or 70 mg once a
week, risedronate (Actonel) 5 mg a day or 35 mg once a week and or
ibandronate (Boniva) once a month.

Oral bisphosphonates are relatively poorly absorbed, and must therefore

be taken on an empty stomach, with no food or drink to follow for the
next 30 minutes. They are associated with esophagitis and are therefore
sometimes poorly tolerated; weekly or monthly administration (depending
on the preparation) decreases likelihood of esophagitis, and is now
standard. Although intermittent dosing with the intravenous formulations
such as zolendronate avoids oral tolerance problems, these agents are
implicated at higher rates in a rare but unpleasant mouth disease called
osteonecrosis of the jaw. For this reason, oral bisphosphonate therapy is
probably to be preferred, and prescribing advice now recommends any
remedial dental work to be carried out prior to commencing treatment.

Teriparatide
Recently, teriparatide (Forteo, recombinant parathyroid hormone
residues 1–34) has been shown to be effective in osteoporosis. It acts
like parathyroid hormone and stimulates osteoblasts, thus increasing
their activity. It is used mostly for patients with established
osteoporosis (who have already fractured), have particularly low BMD or
several risk factors for fracture or cannot tolerate the oral
bisphosphonates. It is given as a daily injection with the use of a pen-type
injection device. Teriparatide is only licensed for treatment if
bisphosphonates have failed or are contraindicated (however, this differs
by country and is not required by the FDA in the USA. However, patients
with previous radiation therapy, or Paget's disease, or young patients
should avoid this medication).

Strontium ranelate
Oral strontium ranelate is an alternative oral treatment, belonging to a
class of drugs called "dual action bone agents" (DABAs) by its
manufacturer. It has proven efficacy, especially in the prevention of
vertebral fracture. In laboratory experiments, strontium ranelate was
noted to stimulate the proliferation of osteoblasts, as well as inhibiting
the proliferation of osteoclasts.

Strontium, no matter what the form, must be water-soluble and ionized in

the stomach acid. Stontium is then protein-bound for transport from the
intestinal tract into the blood stream. Unlike drugs like sodium
alendronate (Fosamax), strontium doesn't inhibit bone recycling and, in
fact, may produce stronger bones. Studies have shown that after five
years alendronate may even cause bone loss, while strontium continues to
build bone during lifetime use.[citation needed]

Strontium must not be taken with food or calcium-containing preparations

as calcium competes with strontium during uptake. However, it's essential
that calcium, magnesium, and vitamin D in theraputic amounts must be
taken daily, but not at the same time as strontium. Strontium should be
taken on an empty stomach at night
Pathophysiology of skeletal System
Anatomy & Physiology

Osteoporosis
Osteomyelitis
Osteoarthitis
Infectious Arthritis
Gout