From the Guidelines
Tibial osteomyelitis is characterized by signs such as localized pain, tenderness, swelling, warmth, and redness over the affected area, and may be accompanied by systemic symptoms like fever, malaise, and fatigue, as noted in the IWGDF/IDSA guidelines 1, 2.
Clinical Presentation
The diagnosis of tibial osteomyelitis can be challenging, but certain signs and symptoms can help in its identification. These include:
- Localized pain and tenderness over the affected area of the tibia
- Swelling and warmth of the overlying skin
- Redness and erythema, which may extend beyond the wound margin
- Limited mobility of the affected limb due to pain
- Systemic symptoms such as fever, malaise, fatigue, and night sweats
- Laboratory findings showing elevated inflammatory markers, including white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) ### Diagnostic Considerations According to the IWGDF/IDSA guidelines, the diagnosis of osteomyelitis can be suspected in patients with a deep ulcer that does not heal after at least 6 weeks of appropriate wound care and off-loading 2. The presence of exposed bone, ulcer area larger than 2 cm2, and previous history of a wound can increase the likelihood of osteomyelitis. The probe-to-bone (PTB) test can also be useful in predicting osteomyelitis, especially in the presence of a clinically infected wound 3.
Classification and Management
The IWGDF/IDSA classification system can be used to define the presence and severity of foot infection in persons with diabetes, including osteomyelitis 2. The classification system includes four categories: uninfected, mild, moderate, and severe, with osteomyelitis indicated by the presence of bone infection. Prompt recognition and treatment of tibial osteomyelitis are crucial to prevent complications like chronic infection or pathological fractures. Treatment may involve antibiotics, such as nafcillin or ceftriaxone, and possible surgical debridement 1, 2.
From the Research
Signs and Symptoms of Tibial Osteomyelitis
- Pain is a frequent clinical symptom of tibial osteomyelitis, as reported in a study of 282 patients with chronic tibial osteomyelitis 4
- Local swelling is another common symptom, often accompanied by pus discharge and skin ulceration 4
- Inflammatory markers such as white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) may be elevated, with positive results reported in 30.85%, 59.93%, and 53.90% of cases, respectively 4
- The most common site of infection is the middle tibia, according to a retrospective study of 282 cases 4
Clinical Features and Pathogen Distribution
- Staphylococcus aureus is the most commonly isolated organism in cases of tibial osteomyelitis, followed by Pseudomonas aeruginosa and Escherichia coli 4
- The Cierny-Mader classification is often used to categorize osteomyelitis, with type IIIA, IVA, and IIA being the most common types 4
- Risk factors for chronic tibial osteomyelitis include history of smoking and drinking, history of multiple repeated surgeries, and impaired immunity 4
Treatment and Management
- Removal of infected tissue, dead-space management, and antibiotic therapy are core principles in the treatment of chronic tibial osteomyelitis 5
- Ceftriaxone has been shown to be effective in the treatment of osteomyelitis, including cases caused by Staphylococcus aureus 6, 7
- Outpatient therapy with intravenous antibiotics is a viable option for some patients with osteomyelitis 8