Synopsis
Understand persistent bone infection as a combined microbiological, dead-space, stability and soft-tissue problem, protect diagnostic yield, identify malignant change, and plan durable multidisciplinary eradication or suppression.
- Chronic osteomyelitis is an anatomical disease of sequestrum, biofilm, dead space, instability and inadequate soft-tissue cover; antibiotics alone rarely correct all five.
- A draining sinus communicating with bone strongly supports infection, but a superficial sinus swab usually reflects colonisers and should not select definitive therapy.
- If septic, take blood cultures and start parenteral treatment immediately. If stable, avoid empirical antibiotics and preserve deep-sample yield for a planned bone-infection pathway.
- Define previous injuries, implants, organisms, antibiotics, operations, union, perfusion, smoking, diabetes and every change in the sinus before choosing tests or surgery.
- Initial radiographs assess sequestrum, involucrum, cloaca, deformity, fracture, non-union and implants; MRI maps marrow and soft tissue, while CT better defines cortical sequestra for planning.
- Definitive sampling comes from multiple separately instrumented deep bone or interface specimens with histology, not a superficial swab; coordinate any tumour concern with biopsy planning.
- Curative surgery removes infected and non-viable tissue, restores stability, manages dead space and provides vascularised cover, followed by culture-directed antimicrobials and rehabilitation.
- Inspect a long-standing sinus for bleeding, everted edges, fungation or mass at every review because malignant transformation may present as a change in an otherwise familiar wound.
Key red flags
Fever, hypotension, spreading erythema, escalating deep pain or abrupt cessation of drainage with swelling suggests acute-on-chronic abscess or sepsis and needs urgent source-control assessment.
New deformity, mechanical pain, abnormal mobility or inability to load raises concern for infected non-union or pathological fracture and requires protection and urgent imaging.
A sinus that bleeds, enlarges, becomes everted or fungating, develops a mass or changes after years of drainage requires urgent biopsy planning for squamous carcinoma.
Coldness, pulse change, new motor or sensory deficit, or extensive soft-tissue loss demands immediate vascular, nerve and reconstructive assessment alongside infection care.
Investigation priorities
Assess chronic bone architecture, union and implant status.
Management branches
Sepsis, spreading infection, abscess, neurovascular compromise or threatened fracture complicates chronic disease.
- Stabilise physiology, obtain blood cultures and start immediate parenteral therapy when septic.
- Protect an unstable bone segment and obtain urgent radiographs and source-focused cross-sectional imaging.
- Drain pus and remove immediately life-threatening necrosis while preserving multiple deep cultures and histology where possible.
- Escalate new sinus mass or bleeding through sarcoma or skin-cancer pathways rather than routine wound excision.
Chronic pain, sinus or infected non-union is present without systemic instability.
- Withhold empirical antibiotics and discuss a safe minimum two-week antibiotic-free period in non-acute infection with microbiology.
- Define host, perfusion, union, implants, soft tissue and disease extent with radiographs and targeted MRI or CT.
- Plan orthopaedic, plastic, infection, radiology and rehabilitation input in the bone-infection multidisciplinary team.
- At surgery obtain five deep culture samples and two histology samples before antimicrobials and irrigation.