Both microbial and host factors are important determinants in the development of osteomyelitis.1'3'4 Healthy bone tissue is normally resistant to infection but may become

susceptible under certain conditions. ' Bone can become infected: (a) via the presence of bacteria in the bloodstream, (b) by direct inoculation from trauma or surgery, and

(c) by spread from an adjacent site (e.g., soft-tissue infection). ' The latter is particularly problematic in patients with foreign body implants (e.g., hip replacement) and chronic skin ulcers.2, Staphylococcus species possess bacterial adhesins, which promote their attachment to tissues and foreign devices.3 Microbial adherence to bone elicits an inflammatory response.4 The subsequent release of leukocytes and cytokines leads to edema and ischemia. In some cases, these processes can lead to bone nec-

rosis. Pieces of dead bone may become separated forming sequestra. ' These areas typically cannot be penetrated by antimicrobials and phagocytic cells and thus require surgical intervention to eradicate the bacterial nidus (Fig. 81-3)4

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