Risk factors for osteomyelitis: a systematic review and meta-analysis

Background: Osteomyelitis (OM) is a serious infection of the bone, often resulting from diabetic foot ulcers, trauma, or surgical interventions. Given its complex pathophysiology and recurrent nature, identifying reliable risk factors is essential for early diagnosis and intervention. This study identifies independent OM risk factors through a systematic review and meta-analysis method. Methods: A search was conducted across several databases up to January 2025. Data were extracted independently, and study quality was assessed using the Newcastle-Ottawa Scale. Statistical analysis was performed with RevMan 5.3 and Stata 15.0 software, using univariate and multivariate analyses. Heterogeneity was assessed by methods of subgroup analysis and sensitive analysis, and publication bias was evaluated with Egger’s test and funnel plots. Results: A total of 4,019 potential articles were systematically reviewed, with 27 studies (n = 11,941 participants) were included. These studies were analyzed to identify risk factors across five categories: demographic features, medical history, clinical features, laboratory findings, and bacterial characteristics. Medical history factors, such as history of foot ulcers/foot disease (OR = 2.520), operation duration time (>3 hours, OR = 1.740), and incision length >10 cm (OR = 6.530), were significant. Clinical features including inflamed ulcer (OR = 6.200), fever (OR = 2.200), and ulcer size >4/5 cm 2 (OR = 2.740) also increased OM risk. Laboratory findings such as elevated HbA1c (OR = 1.140), hypoalbuminemia (OR = 1.740), anemia (OR = 1.540), and microbiological perspective such as polymicrobial infections (OR = 2.580) were also recognized as independent risk factors of OM. Subgroup analysis accounted for heterogeneity arising from the type of OM and different risk factor characteristics. Sensitivity analysis confirmed the reliability of the results. Additionally, both funnel plots and Egger tests showed no evidence of publication bias. Conclusions: This is the first meta-analysis to integrate univariate and multivariate evidence on OM risk factors. It establishes clinically preventable risk factors across OM subtypes, enabling early targeted interventions to reduce amputations and healthcare burdens.