Chronic Osteomyelitis - Pathophysiology and Treatment

Chronic osteomyelitis remains a significant challenge in orthopaedic and trauma surgery, despite substantial advancements in surgical techniques, antimicrobial therapy, and microbiological diagnostics. The progression from acute to chronic infection is characterised by the formation of bacterial biofilms, which result in profoundly reduced antibiotic susceptibility and pathogen persistence. The Cierny-Mader classification provides a critical clinical framework, by integrating the anatomical extent of the infection with the host's physiological condition. This review summarises current understanding of the pathophysiology of osteomyelitis and delineates stage-appropriate surgical strategies, including radical debridement, dead-space management with local antibiotic carriers, soft-tissue reconstruction, and subsequent bone reconstruction. Furthermore, recent developments in single-stage surgical approaches, shortened systemic antibiotic therapy, and the necessity of interdisciplinary treatment concepts are discussed. A comprehensive understanding of the mechanisms underlying biofilm-associated infection and the implementation of evidence-based, classification-guided treatment protocols are essential for achieving definitive infection control and optimal functional outcomes.