In general, microorganisms may infect bone through one or more of three basic methods: via the bloodstream, contiguously from local areas of infection (as in cellulitis), or penetrating trauma, including iatrogenic causes such as joint replacements or internal fixation of fractures or root-filled teeth.^[1] Once the bone is infected, leukocytes enter the infected area, and, in their attempt to engulf the infectious organisms, releaseenzymes that lyse the bone. Pus spreads into the bone's blood vessels, impairing their flow, and areas of devitalized infected bone, known assequestra, form the basis of a chronic infection.^[1] Often, the body will try to create new bone around the area of necrosis. The resulting new bone is often called an involucrum.^[1] On histologic examination, these areas of necrotic bone are the basis for distinguishing between acuteosteomyelitis and chronic osteomyelitis. Osteomyelitis is an infective process that encompasses all of the bone (osseous) components, including the bone marrow. When it is chronic, it can lead to bone sclerosis and deformity.

Chronic osteomyelitis may be due to the presence of intracellular bacteria (inside bone cells).^[2] Also, once intracellular, the bacteria are able to escape and invade other bone cells.^[3] At this point, the bacteria may be resistant to some antibiotics.^[4] These combined facts may explain the chronicity and difficult eradication of this disease, resulting in significant costs and disability, potentially leading to amputation. Intracellular existence of bacteria in osteomyelitis is likely an unrecognized contributing factor to its chronic form.

In infants, the infection can spread to a joint and cause arthritis. In children, large subperiosteal abscesses can form because the periosteum is loosely attached to the surface of the bone.^[1]

Because of the particulars of their blood supply, the tibia, femur, humerus, vertebra, the maxilla, and the mandibular bodies are especially susceptible to osteomyelitis.^[5] Abscesses of any bone, however, may be precipitated by trauma to the affected area. Many infections are caused by Staphylococcus aureus, a member of the normal flora found on the skin and mucous membranes. In patients with sickle cell disease, the most common causative agent remains Salmonella, but Staphylococcus aureus becomes proportionally more common pathogens than in healthy hosts.^{[citation needed]}

Treatment

Osteomyelitis often requires prolonged antibiotic therapy, with a course lasting a matter of weeks or months. A PICC line or central venous catheteris 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. A treatment lasting 42 days is practiced in a number of facilities.^[12] Local and sustained availability of drugs have proven to be more effective in achieving prophylactic and therapeutic outcomes.^[13]

In 1875, American artist Thomas Eakins depicted a surgical procedure for osteomyelitis at Jefferson Medical College, in a famous oil painting titledThe Gross Clinic.

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 them clean.^[14][15]

Hyperbaric oxygen therapy has been shown to be a useful adjunct to the treatment of refractory osteomyelitis.^[16][17]

Open surgery is sometimes needed for chronic osteomyelitis, whereby the involucrum is opened and the sequestrum is removed or sometimes saucerization^[18] can be done.