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Unrecognized osteomyelitis in pressure injury patients; a missed HBO opportunity?

Below is a list of references with a synopsis of each paper. As you will see osteomyelitis is often overlooked. I hope that you and your team find this information compelling and interesting.


Cunha, Burke A. (2002). Osteomyelitis in elderly patients. Aging and Infectious Diseases, 35: 287-293. Dr. Cunha states that stage 3 or 4 pressure ulcers are often complicated by osteomyelitis. He also states that chronic osteomyelitis is almost always present when bone is visible or when one can probe to bone.

Darouiche, R., O., Landon, G., C., Klima, M., Musher, D., M., & Markowski, J. (1994). Osteomyelitis associated with pressure sores. Archives of Internal Medicine, 154: 753-758.

36 patients with pressure ulcers were evaluated for the presence of osteomyelitis. Only two were graded as stage III or IV, both of which were positive for osteomyelitis. A total of six patients were diagnosis with osteomyelitis, (17%).

Deloach, D. E., Christy, R. S., Ruf, L. E., Vann, S.W., Check, W. E., Cooper, J., & Long, R. (1992). Osteomyelitis underlying severe pressure sores. Contemporary Surgery, 40: 25-32.

This three year study of Stage IV pressure ulcers at a major metropolitan hospital found that (81%) had an underlying bone infection.

Heinemann, A., Tsokos, M., & Puschel, K. (2003). Medico-legal aspects of pressure sores. Legal Medicine. 5: S263-S266.

Forensic pathologists examined 20 post mortem cases with stage IV pressure ulcers and found osteomyelitis in 9, (45%).

Huang A., B., Schweitzer, M. E., Hume, E., & Battle, W. G. (1998). Osteomyelitis of the pelvis/hips in paralyzed patients: accuracy and clinical utility of MRI. Journal of Computer Assisted Tomography. 22: 437-443.

In a study of 41 patients with pressure ulcers associated with spinal cord injuries, MRI demonstrated a presence of osteomyelitis with a sensitivity of 98% and a specificity of 89%, compared with the reference standard of a bone biopsy. (79%) were positive for osteomyelitis.

Lewis, V. L., Bailey, M., Pulawaski, G., Kind, G., Bashioum, R. W., & Hendrix, R. W. (1987). The diagnosis of osteomyelitis in patients with pressure sores. Plastic and Reconstructive Surgery. 81 (2): 229-232.

This prospective blind trial was undertaken to assess the usefulness of commonly used test to diagnosis osteomyelitis underlying pressure ulcers. 52 patients were tested, (23%) were positive for osteomyelitis. No pressure ulcer staging or depth reported.

Sugarman, B., Hawes, S., Musher, D. M., Klima, M., Young, E. J., & Pircher, F. (1983). Osteomyelitis beneath pressure sores. Archives of Internal Medicine, 143: 683-688.

Sugarman states that osteomyelitis is a frequent complication of pressure ulcers. In this report 22 patients hospitalized at a large VA hospital during an 18 month period were studied. These patents had pressure ulcers that had not healed after at least two weeks of local care and the pressure ulcers were either (1) extended beneath subcutaneous tissue or (2) extended to subcutaneous tissue and had surrounding inflammation, purulent drainage, or both. (82%) tested positive for osteomyelitis.

Sugarman, B., Brown, D., Musher, D. (1983). Fever and infection in spinal cord injury patients. Journal of the American Medical Association, 248 (1): 66-70.

A retrospective study of 31 patients with pressure ulcers of which 18 (58%) were positive for osteomyelitis. Sugarman reports that over half of all pressure ulcers that had an infection at any time tested positive for osteomyelitis.

Sugarman, B. (1985). Infection and pressure sores. Archives of Physical Medicine and Rehabilitation, 66 (3): 177-179.

This report looked at 267 patients with pressure ulcers at a large VA hospital, over a 40 month period. Included in this group were 49 patients with pressure ulcers that did not appear to be infected. Of the 267 patients, 177 had pressure ulcers that extended beneath the epidermis including the group of 49 patients. Sugarman reported that a majority of these 49 patients has osteomyelitis that was confirmed by bone biopsy.

Sugarman, B. (1987). Pressure sores and underlying bone infection. Archives of Internal Medicine, 147: 553-555.

This study looked at 153 patients with pressure ulcers that did not heal or significantly improve (over several days to one week after initial evaluation) with removal of pressure, over a 4.5 year period. Patients were placed in one of three groups based on the depth of their pressure ulcers; Superficial (n=42), Deep tissue exposed (n=79), Bone exposed (n=32). 77% tested positive for osteomyelitis with a Tc99m bone scan and (62%) has positive bone cultures.

Thornhill-Joynes, M., Gonzales, F., Stewart, C. A., Kanel, G. C., Lee, G. C., Capen, D. A., Sapico, F. L., Canawati, H. N., & Montgomerie, J. Z. (1986). Osteomyelitis associated with pressure ulcers. Archives of Physical Medicine and Rehabilitation. 67: 314-318.

Studied 40 patients with 102 pressure ulcers, and bone was obtained from beneath 38 pressure ulcers. 25 tested positive for osteomyelitis, (66%).

Turk, E., Tsokos, M., Delling, G. (2003). Autopsy-based assessment of extent and type of osteomyelitis in advanced-grade sacral decubitus ulcers. Archives of Pathology and Laboratory Medicine. 127: 1599-1602.

28 deceased individuals with grade IV sacral pressure ulcers were examined, 20 were positive for osteomyelitis (72%).


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