IF YOU HAVE DIABETES, A JOINT REPLACEMENT OR ARTHRITIS…. YOU’RE AT INCREASED  RISK FOR A BONE INFECTION?  George Cierny, MD, and Doreen DiPasquale, MD; *BottomLine Health, 2010; Vol 24(3), pp9-11

* Bottom Line/Health interviewed George Cierny, MD, and Doreen DiPasquale, MD, physician-partners at REOrthopaedics in San Diego.  Dr. Cierny is an international lecturer in orthopedic surgery who has published more than 100 scien­tific papers and/or book chapters in the field of musculoskeletal pathology and infection. Dr.Di­Pasquale, an orthopedic-trauma surgeon, is former resi­dency program director at George Washington University in Washington, DC, and National Na­val Medical Center in Bethesda, Maryland.

—————- When most people think of bone problems, broken bones and osteoporosis (re­duced bone density and strength) come to mind. But our bones also can be the site of infections that can sometimes go unrecognized for months or even years. This is especially the case if the only symptoms of bone infection (a condition known as osteo­myelitis) are ones that are commonly mis­taken for common health problems, such as ordinary back pain or fa­tigue. What you need to know…

ARE YOU AT RISK? Older adults (age 70 and older), people with diabetes or arthritis and anyone with a weakened immune sys­tem (due to chronic disease, such as cancer, for example) are among those at greatest risk for osteo­myelitis.   Anyone who has an artificial joint (such as a total hip replacement or total knee replacement) or metal implants attached to a bone also is at increased risk for osteomyelitis and should discuss the use of anti­biotics before any type of surgery, including routine dental and oral surgery. Bacteria in the mouth can enter the bloodstream and cause a bone infection.

TYPES OF BONE INFECTIONS: Before the advent of joint-­replacement surgery, most bone in­fections were caused by injuries that expose the bone to bacteria in the en­vironment (such as those caused by a car accident) or a broken bone…or an infection elsewhere in the body, such as pneumonia or a urinary tract infection, that spreads to the bone through the bloodstream. Now: About half the cases of osteo­myelitis are complications of surgery in which large metal implants are used to stabilize or replace bones and joints (such as in the hip or knee).   

Osteomyelitis is divided into three main categories, depending on the origin of the infection… Blood-born osteomyelitis occurs when bacteria that originate else­where in the body migrate to and in­fect bone. People with osteoarthritis or rheumatoid arthritis are prone to blood-borne infections in their af­fected joints due to injury to cells in the lining of the joints that normally prevent bacteria from entering the bloodstream. Contiguous-focus osteomyelitis oc­curs when organisms— usually bacte­ria, but at times fungal species —infect bone tissue. These cases usually occur in people with diabetes, who will often de­velop pressure sores on the soles of their feet or ­buttocks due to poor cir­culation and impaired immunity.   Post-traumatic osteomyelitis: Trau­ma or surgery to a bone and/or sur­rounding tissue can open the area to bacteria and other microbes. The use of prosthetic joints, surgical screws, pins or plates also makes it easier for bacteria to enter and in­fect the bone.  Important: any of the three types of bone infections described above can lead to chronic osteomyelitis, an initially low-grade infection that can persist for months or even years with few or no symptoms. Eventu­ally it gets severe enough to liter­ally destroy bone. Left untreated, the affected bone may have to be amputated.

DIFFICULT TO DIAGNOSE – When osteomyelitis first develops (acute osteomyelitis), the symptoms —such as pain, swelling and tender­ness—are usually the same as those caused by other infections. If the initial infection is subtle (low-grade) or doesn’t resolve completely with treatment, it can result in chronic osteomyelitis. In this case, you may have no symptoms or symp-toms that are not specific.  For example, some one who has had surgery might blame discomfort on delayed recovery, not realizing what they have a bone infection.  A surprising finding: When we stud­ied the histories of more than 2,000 osteomyelitis patients, we found that most of those with chronic infections had relatively little pain from the in­fection itself. About 28% of those who required surgery for infection had normal white blood cell counts—suggesting that, over time, the body adjusts to lingering infections.  If a doctor suspects that you may have osteomyelitis because of chron­ic pain…swelling…possibly fever…fatigue…or other symptoms, he/she will usually order special laboratory tests that detect the formation of an­tibodies and/or cellular signaling compounds. If the results indicate the presence of infection, he/she may then order an X-ray, a magnetic reso­nance imaging (MRI) scan or a nuclear scan(bone scan). These and other imaging tests can readily detect damaged­ bone tissue and re­veal the presence of infection.

BEST TREATMENT OPTIONS   About 60% to 70% of people with acute osteomyelitis can be cured with antibiotics (or anti­fungal agents, if a fungal infection is present) if treat­ment begins early enough to prevent the infection from becoming chronic. In these cases, patients exhibit symp­toms…test positive for infection…and readily respond to drug treatments. Most patients can be cured with a four- to six-week course of antibiotics. Fungal infections are more resistant to treatment—antifungal drugs may be needed for several months.

For chronic osteomyelitis, surgical debridement (the removal of dam­aged tissue and bone using such in­struments as a scalpel, dental burrs and/or chisels) usually is necessary. Reasons: dam­aged bone can lose its blood supply, die and remain in the body without living cells or circu­lation. Such “dead bone” is invulnerable to the effects of antibiotics and provides safe haven to organisms attached to its surface.  To address this, the surgeon, after debridement, may insert a slow-release antibiotic depot (antibiotic beads) that release antibiotic for up to a month. This approach can increase drug concentrations up to 100 times more than oral antibiotic therapy and help to eliminate the sequestered microorganisms.   Using these and other innovations, the REOrthopaedics  center in Southern California now posts an overall success rate of 95%.    Nevertheless,  up to 6% of patients who are otherwise healthy may require a second or even a third operation to completely cure the infec­tion;  and, iIn patients suffering from diabetes or oth­er disorders affecting wound healing (compromised hosts) , the percentage may be as high as 25%.    To improve your chances of a full recovery from chronic osteomyeli­tis following treatment: eat well, maintain healthy blood sugar levels, stay active after treat­ment (to promote blood circulation, prevent blood clots and help main­tain an appetite) and don’t use to­bacco products.

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