Unrecognized Osteomyelitis in Pressure Injuries: Missed Diagnoses, Missed HBOT Opportunities

When pressure injuries stop healing, the first instinct is to adjust local care — dressings, debridement, repositioning. But what if the real issue lies deeper? Literally.

In many cases, a chronic pressure injury that refuses to improve may be masking a more serious, underdiagnosed complication: osteomyelitis, or infection of the bone. Left unaddressed, this silent culprit can prolong hospital stays, limit reimbursement, and worsen patient outcomes — despite a wound that may not appear infected on the surface.

Below, we’ve summarized findings from a wide range of peer-reviewed studies that point to one consistent trend: osteomyelitis is more common than it seems — and often missed.

What the Research Shows

Advanced-Stage Pressure Injuries Often Harbor Osteomyelitis

• 81% of Stage IV pressure injuries had underlying osteomyelitis when formally assessed in acute care settings².

  
  

• Bone exposure is a clinical red flag. Chronic osteomyelitis is “almost always present” when bone is visible or can be probed¹.

  
  

• Autopsy studies confirm the trend. In one forensic review, 72% of deceased patients with grade IV ulcers had confirmed osteomyelitis¹². Another found 66% of bone samples taken beneath pressure ulcers were infected¹¹.

  
  

Imaging and Diagnostics Can Improve Detection

• MRI shows strong diagnostic performance. In spinal cord injury patients, MRI identified osteomyelitis with 98% sensitivity and 89% specificity compared to biopsy³.

  
  

• Standard tests can miss it. A blind trial found 23% of patients had underlying osteomyelitis, but stage and depth weren’t always predictive⁶.

  
  

Osteomyelitis Is Often Missed in “Low-Risk” Cases

• Even Stage II/III wounds may be infected. Of 36 pressure ulcer patients, only two were Stage III or IV — both had osteomyelitis; 17% of the overall group tested positive⁴.

  
  

• Non-healing wounds often have hidden infection. In a VA study, 82% of patients with deep wounds and drainage/inflammation had biopsy-confirmed osteomyelitis⁷.

  
  

• Spinal cord injury patients are especially vulnerable. One study found 58% had osteomyelitis; over half of those with any wound infection tested positive⁸.

  
  

Wounds That Appear Clean May Still Be Infected

• “Clean” wounds aren’t always clean. In a 267-patient study, 49 ulcers appeared uninfected — yet most had confirmed osteomyelitis on biopsy⁹.

  
  

• Delayed healing is a red flag. If a pressure injury doesn’t improve within several days to a week of offloading, osteomyelitis should be strongly considered¹⁰.

Why It Matters for Hospitals and Physician Practices

For healthcare leaders, delayed or missed diagnosis of osteomyelitis isn’t just a clinical oversight — it’s a strategic and financial risk.

• Chronic, unhealed wounds drive up care costs, prolong treatment timelines, and elevate the risk of serious complications like sepsis or amputation — whether managed in an inpatient setting or outpatient clinic.

  
  

• Coding and reimbursement may fall short when underlying conditions like osteomyelitis aren’t identified and documented. This can lead to revenue loss and poor performance in both hospital wound care service lines and physician practices.

  
  

• Quality-of-care concerns and liability increase when high-risk conditions go unrecognized — especially in populations like spinal cord injury, nursing home residents, or patients with limited mobility.

Where Hyperbaric Oxygen Therapy Fits

Once osteomyelitis is diagnosed, treatment options often extend beyond topical care. For chronic cases — especially with poor vascularity — Hyperbaric Oxygen Therapy (HBOT) offers a valuable adjunctive option.

Research has shown HBOT to be effective in improving oxygen delivery to ischemic tissues, supporting bone regeneration, and enhancing antibiotic efficacy in infected bone. But here’s the catch: the therapy only works when the underlying infection is recognized and treated.

How SHS Supports Your Team

At Shared Health Services, we partner with hospitals and physician practices to bridge the gap between clinical recognition and operational execution.

We support your wound care team with:

• Evidence-based protocols and case identification tools

• Workflow strategies to prompt imaging or biopsy when osteomyelitis is suspected

• Reimbursement guidance to support accurate documentation and maximize program value

• Clinical training on the use of HBOT in chronic osteomyelitis cases

  
  

Our role is to simplify the complex — giving your team the tools and peer-to-peer support needed to confidently manage high-risk wounds and deliver lasting impact.

References

1. Cunha BA. Osteomyelitis in elderly patients. Aging Infect Dis. 2002;35:287-293.

   
   

2. Deloach DE, Christy RS, Ruf LE, et al. Osteomyelitis underlying severe pressure sores. Contemp Surg. 1992;40:25-32.

   
   

3. Huang AB, Schweitzer ME, Hume E, Battle WG. Osteomyelitis of the pelvis/hips in paralyzed patients: accuracy and clinical utility of MRI. J Comput Assist Tomogr. 1998;22:437-443.

   
   

4. Darouiche RO, Landon GC, Klima M, Musher DM, Markowski J. Osteomyelitis associated with pressure sores. Arch Intern Med. 1994;154:753-758.

   
   

5. Heinemann A, Tsokos M, Püschel K. Medico-legal aspects of pressure sores. Leg Med (Tokyo). 2003;5 Suppl:S263-S266.

   
   

6. Lewis VL, Bailey M, Pulawski G, et al. Diagnosis of osteomyelitis in patients with pressure sores. Plast Reconstr Surg. 1987;81(2):229-232.

   
   

7. Sugarman B, Hawes S, Musher DM, et al. Osteomyelitis beneath pressure sores. Arch Intern Med. 1983;143:683-688.

   
   

8. Sugarman B, Brown D, Musher D. Fever and infection in spinal cord injury patients. JAMA. 1983;248(1):66-70.

   
   

9. Sugarman B. Infection and pressure sores. Arch Phys Med Rehabil. 1985;66(3):177-179.

   
   

10. Sugarman B. Pressure sores and underlying bone infection. Arch Intern Med. 1987;147:553-555.

    
    

11. Thornhill-Joynes M, Gonzales F, Stewart CA, et al. Osteomyelitis associated with pressure ulcers. Arch Phys Med Rehabil. 1986;67:314-318.

    
    

12. Turk E, Tsokos M, Delling G. Autopsy-based assessment of osteomyelitis in sacral pressure ulcers. Arch Pathol Lab Med. 2003;127:1599-1602.

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– Wound Care: Charcot Foot

– Ever Wonder Why Some Wounds Hurt and Others Don’t?