Osteomyelitis

Management of osteomyelitis in dedicated units, with close multidisciplinary working using evidence-based guidelines, may be associated with more efficient diagnostic workup, a higher rate of identifying the causative organism, improved adherence to initial antibiotic recommendations with fewer antibiotic changes during treatment, and fewer relapses.[139]Copley LA, Kinsler MA, Gheen T, et al. The impact of evidence-based clinical practice guidelines applied by a multidisciplinary team for the care of children with osteomyelitis. J Bone Joint Surg Am. 2013 Apr 17;95(8):686-93. http://www.ncbi.nlm.nih.gov/pubmed/23595066?tool=bestpractice.com [140]Arias Arias C, Tamayo Betancur MC, Pinzón MA, et al. Differences in the clinical outcome of osteomyelitis by treating specialty: orthopedics or infectology. PLoS One. 2015;10(12):e0144736. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0144736 http://www.ncbi.nlm.nih.gov/pubmed/26678551?tool=bestpractice.com ​​ The prognosis from early intervention is usually better, particularly in the context of implant-related infection. Delay in treating these patients is likely to worsen long-term outcomes. The functional outcome for osteomyelitis of the lower extremity depends on the status of the foot and knee. 

Most patients with acute osteomyelitis recover with no long-term complications if osteomyelitis is diagnosed promptly and treated adequately.

Chronic osteomyelitis

The success of treatment of chronic osteomyelitis depends largely on the host type (type A, B, or C according to the Cierny-Mader classification).[2]Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res. 2003 Sep;(414):7-24. http://www.ncbi.nlm.nih.gov/pubmed/12966271?tool=bestpractice.com A study of 1966 patients showed that primary treatment was successful in 96% of type A hosts and 73% of type B hosts.[136]Cierny G 3rd, DiPasquale D. Treatment of chronic infection. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S105-10. http://www.ncbi.nlm.nih.gov/pubmed/17003180?tool=bestpractice.com  Retreatment of the patients in whom treatment had failed gave a 95% success rate at 2 years for both type A and type B patients.

Recurrence of infection may occur early or late. Early relapse is usually seen shortly after stopping antibiotics and can be treated by repeated surgery. Most patients who relapse have symptoms within the first 2 years after surgery, although a few can return many years later.

There are now numerous published case series reporting in excess of 90% infection-free limbs at 2 years or more after treatment.[125]Ferguson JY, Dudareva M, Riley ND, et al. The use of a biodegradable antibiotic-loaded calcium sulphate carrier containing tobramycin for the treatment of chronic osteomyelitis: a series of 195 cases. Bone Joint J. 2014 Jun;96-B(6):829-36. https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.96B6.32756 http://www.ncbi.nlm.nih.gov/pubmed/24891586?tool=bestpractice.com [127]McNally MA, Ferguson JY, Lau AC, et al. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J. 2016 Sep;98-B(9):1289-96. http://www.ncbi.nlm.nih.gov/pubmed/27587534?tool=bestpractice.com [133]McNally MA, Small JO, Tofighi HG, et al. Two-stage management of chronic osteomyelitis of the long bones: the Belfast technique. J Bone Joint Surg Br. 1993 May;75(3):375-80. http://www.ncbi.nlm.nih.gov/pubmed/8496203?tool=bestpractice.com [136]Cierny G 3rd, DiPasquale D. Treatment of chronic infection. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S105-10. http://www.ncbi.nlm.nih.gov/pubmed/17003180?tool=bestpractice.com  These series are from centers with established multidisciplinary teams that can deliver all aspects of treatment.

Although recurrence becomes less likely with the passage of time, it is never possible to be completely certain about infection clearance. There are reported cases of infection reactivation many years after surgery when dormant bacteria cause an infection flare. Many of these patients have prolonged disease-free intervals and some die of other causes before relapse.