The following case was submitted via the “Quick Contact – Osteomyelitis.com” form:http://www.osteomyelitis.com/html/osteomyelitis.html – 9/01/09: I am a 53 year male with intra-meddulary osteomyelitis (I had acute osteomyelitis when I was a child). Now I may have heavy pain in the area for a couple of days per year (worst in night). The rest of the time, the pain is low but always there. I am fully mobile, cycle, jog and ski. QUESTIONS: Q1: will the infection gradually spread to the rest of the bone and destroy it? Q2: Should I treat the osteomyelitis now, or wait until the pain gets worse or more continuous?  Q3: will the intra-medullary osteomyelitis gradually develop into another type of osteomyelitis?

Dr. Cierny’s Response:  Chronic, type I osteomyelitis (with a remote, hematogenous source) is unpredictable in two ways: 1) when it becomes symptomatic; 2)when and if it re-activates to acutely require treatment(fever, illness, pain, drainage).  In either situation, the cause will be due to the release of a few ‘active’ bacteria (planktonic organisms) from a majorly dormant colony(sessile organisms).  Chronic bone infections do not usually spread throughout the bone, or to other bones, particularly when dormant.  The infection will, however, never spontaneously go away.

This is a biofilm disease where the bacteria are permanently attached to surfaces inside the bone where the old ‘scars’ have remained all these years. As a result, the infection will always be due to the very same bacteria that caused the original episode back in your youth.  The reason for this is that the bacteria, while within their biofilm cocoon (called a slime), are immune to both antibiotics and host defenses (your immune system).  They are vulnerable only when ‘active’ and free-floating, outside the slime.  Over 90% of the bacterial colony is, at any one time, dormant (sessile).  So, antibiotic treatment, alone, is rarely(if ever) curative. Today, there is no cure other than with surgical excision of the entire biofilm burden.  This is, essentially, a physical removal of the non-viable core of bone and dead marrow housing the attached colony. 

Parallel visual:  The visual is likened to a rock geode that has been broken open to reveal the inside: the outside of the geode looks like a regular rock (the bone looks on the outside);  But, when the geode is broken open, it is hollow and there is an inside layer of crystals (likened to a biofilm colony inside the bone) that is intimately attached throughout the inner cavity of the rock (making it a geode). It is very difficult to remove the crystal lining from the rock, itself.

Fortunately, the surgical removal of the attached, biofilm colony can usually be accomplished without injuring the residual bone or disabling the patient. Within the last year, we have treated two such cases (right femurs); both men remained full-weight-bearing and active throughout treatment.  The treatment protocol requires at least two surgical interventions: one to remove the biofilm and its surface attachments; one to reconstruct the window we make in the bone to visualize and remove the disease. We recommend crutches for about two weeks post-op.  The success rate after one treatment attempt is 98% for healthy patients and 90% in patients with health problems.  If re-treatment is necessary, the overall success rates are 99% and 94%, respectively ( treatment outcomes ).

I cannot tell you when to have the surgery.  Nor can I tell you if you will ever require surgical treatment.  I can, however, tell you that most reconstruction surgeons will not operate you for an elective surgery (rotator cuff repair, artificial joint replacement, ACL repair, cosmetic surgery) when there is an on-going site of infection somewhere else in your body (ie; your osteomyelitis).   This is because such remote sites of infection have, histori-cally been proven to increase the risk of elective, clean, surgical procedures.  However,  the most impelling reason to pursue ealy  surgical treatment of your osteomyelitis is to avoid every having a fracture through that femur.    If this happens, the fracture will get infected (100%) and treatment will be very (VERY) difficult, indeed.     GC / 9/02/09