Efficacy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography-assisted navigation system in the debridement of chronic osteomyelitis of the extremities

Between 1985 and 1990 25 patients with chronic osteomyelitis (osteitis) of long bones were treated by intramedullary reaming. In most cases the aetiology of the osteomyelitis was posttraumatic. 22 of these patients who had undergone intramedullary reaming at least 6 months ago were evaluated. The average postoperative observation period was 26 months, range (7-60 months). During this time, 21 patients showed no signs of recurrence. One patient produced a little extraosseous sequestrum 3 months after the operation but since then has had no recurrence. The purpose of this study is to propose intramedullary reaming as an excellent treatment for chronic osteomyelitis of long bones and show the pathophysiological background that led to this modality.

Treatment of patients with total chronic hematogenous osteomyelitis still remains one of the important and difficult problems of purulentsurgery. Objective: To increase the effectiveness of surgical treatment of patients with chronic total osteomyelitis of long bones. Materials and methods of research. A retrospective analysis of outcomes after managing 38 patients with chronic total hematogenous osteomyelitis of long bones has been made. Patients were treated with original techniques of defect plastic surgery and physical antiseptic methods, such as CO2-laser and low-frequency ultrasound. Research results. Of these, 24 patients with total osteodestructive changes underwent resection of the tibia and humerus, followed by their replacement with the fibula. In 14 patients with process location in the lower third of the tibia, grooved osteotomy was performed, followed by microsurgical plastic surgery of the defect with a fasciocutaneous flap on a vascular pedicle. Conclusion. The described surgical treatment of chronic osteomyelitis of long bones has high efficiency and minimal number of relapses at the early and late postoperative periods.

Introduction: Chronic post-traumatic osteomyelitis is a complex problem of modern traumatology and orthopedics, affecting, in addition to medical, social and economic aspects of healthcare. When planning treatment, it is necessary to take into account the metabolic state of the bone tissue, since the effect of an infectious pathogen goes far beyond the classical lytic process, disrupting the balance of bone formation and bone resorption in various ways. The study is devoted to the study of the dynamics of parameters reflecting the metabolism of bone tissue in patients receiving complex therapy for chronic post-traumatic osteomyelitis of long bones. Aim: To study the dynamics of metabolic disorders of bone tissue in patients with orthopedic infection of long bones and large joints under conditions of ongoing complex etiotropic and compensatory therapy for 6 months, the timing of bone tissue consolidation within 2 years from the moment of surgery. Materials and methods: The study was prospective, observational, comparative, exploratory, involving 138 patients with post-traumatic chronic osteomyelitis of the long bones. Complex therapy included a combination of surgical treatment with antibacterial, anti-inflammatory therapy and drug correction of the revealed disorders of bone metabolism. The timing of the consolidation of bone defects after treatment and the dynamics of indicators of bone metabolism were studied. Results: The similarity of the periods of consolidation of different segments in the conditions of the described therapy was shown; the time period corresponding to the most pronounced dynamics of changes (correction) of violations was determined (3 months from the beginning of treatment); shows the effectiveness of metabolic therapy for the treatment of osteoarticular infections in various anatomical segments of the extremities. The results corresponds both to the results of the previous study and to the pathophysiological aspects of bone metabolism described in the literature. Conclusion: the timing of consolidation in the treatment of metabolic disorders is generally similar; the greatest changes in the parameters of bone metabolism are recorded within 3 months after the start of therapy. Also, the metabolic therapy regimen can be considered as universal for all segments.

BackgroundChronic osteomyelitis of long bone is a difficult condition to treat. Local delivery of antibiotics via custom-made antibiotic cemented nail(ACN) enables delivery of antibiotics at high concentration, which helps in eradication of infection and provides mechanical stability in infected nonunion. The study aims to find out the role of ACN in the control of infection and union of long bones. Method30 patients presenting with the feature of chronic osteomyelitis of long bones & infected non union between 2014 and 2017 at Manipal Teaching Hospital were included. Cases were treated with debridement, sequestrectomy, and the use of ACN. Follow-up of patients was done till control of infection and union. Patients were assessed clinically and on laboratory parameters for control of infection & union. ResultAmong 30 patients, 13 (43%) were infected nonunion, 6 (20%) were of osteomyelitis following open fracture, 5 (17%) were of osteomyelitis following soft tissue procedure and 6 (20%) were of open fracture where ACN was used prophylactically. Infection control was achieved in 28 (93%) cases. The average time of radiological union was 12 months. The average duration of removal of ACN was 7.4 weeks. Complications included the failure of removal of antibiotic cement in one (3%) case & failure of union in one (3%) case. ConclusionACN is an economical method that can be used safely in the management of chronic osteomyelitis of long bones. The technique is simple, cost-effective with excellent results, minimal complications, and can be used in a minimal resources setting.

Background Staphylococcus hyicus is a zoonotic pathogen primarily associated with animal infections. Human infections are exceedingly rare, with only six cases documented in the literature. The pathogen’s role in chronic osteomyelitis of long bones has not been previously reported, presenting unique diagnostic and therapeutic challenges. Case Report We report the first case of chronic osteomyelitis of long bones caused by methicillin-resistant S. hyicus in a 34-year-old male farmer with a history of recurrent osteomyelitis following trauma and livestock exposure. The patient presented with purulent discharge from two fistulae on the medial aspect of the right thigh. Imaging studies revealed bony sequestration, periosteal reaction, and multiple fistulous tracts consistent with Cierny-Mader stage III chronic osteomyelitis. Microbiological identification of coagulase-negative methicillin-resistant S. hyicus was achieved via culture and phenotypic analysis of aspirates from the fistulae and intraoperative samples, with confirmation via matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS). A multidisciplinary treatment strategy was implemented, combining extensive surgical debridement and dead space management with a 24-week tailored antibiotic regimen. The regimen included intravenous teicoplanin and ciprofloxacin for 14 days, followed by oral ciprofloxacin and cotrimoxazole. The patient achieved sustained remission with no recurrence at 2.5 years of follow-up. Conclusion This case underscores the zoonotic potential of S. hyicus and highlights its capacity to cause severe, persistent infections in humans, particularly in individuals with occupational or environmental exposure to livestock. Advanced diagnostic techniques such as MALDI-TOF MS are essential for accurate identification, mitigating the risk of misdiagnosis due to phenotypic similarities with other staphylococcal species. Clinicians should consider S. hyicus in the differential diagnosis of chronic osteomyelitis in patients with relevant exposure histories to enable timely and targeted therapeutic interventions.

A twenty-eight-year-old man sustained an open, comminuted tibial plateau fracture from a gunshot wound. Treatment included external fixation, serial debridements, and subsequent open reduction and internal fixation. Five months later, he developed chronic osteomyelitis of the proximal part of the tibia. Intraosseous debridement and irrigation with an arthroscope and arthroscopic tools was performed through existing bone screw holes. At the time of the final follow-up, he had resolution of pain and no recurrent infection. This minimally invasive technique may be considered for the treatment of chronic osteomyelitis of long bones to prevent structural destabilization and minimize disability.

A nomogram for decision-making assistance on surgical treatment of chronic osteomyelitis in long bones: Establishment and validation based on a retrospective multicenter cohort

Purpose - to study the roentgenomorphological features of the lower limb long bones in patients with chronic osteomyelitis using the technique of multi-spiral computer tomography (MSCT), and to propose the complex of parameters to assess bone quality. Material and methods. Roentgenography and computer tomography of the hips were performed in 49 patients with chronic osteomyelitis of long bones of lower extremities. The studies made using computer tomographs GE Light Speed VCT, Toshiba Aquilion-64, Somatom Smile. Results. The changes in bone structure of proximal femur were characterized by extremely marked polymorphism, and they almost didn’t repeat in the anatomical component. The cortical plate had heterogenous structure with resorption zones in the area of its transfer to the shaft. The character of roentgenomorphological changes in the shaft was individual in all the patients, but there were common manifestations as well which consisted in thickening of the cortical plate, different intensity of periosteal and endosteal layers. The cortical plate was significantly different in density, which exceeded 1700 HU in some places. When osteomyelitic process localized in the knee marked changes affected its all components, they manifested themselves in extended osteoporosis and local osteosclerosis. When osteomyelitic process localized in proximal tibia extensive resorption zones observed, the cortical plate thinned in proximal parts, its density was not more than 350 HU. Conclusion. The data demonstrated that bone quality in patients with chronic osteomyelitis had significant deviations from normal values in terms of changing both its density and architectonics. The deviations consisted in bone density decrease in the meta-epiphyseal part regardless of the process localization, in highly variable density values of the cortical plate as a result of its thickening or thinning, presence of resorption or sclerosis areas.

Introduction It is known that the density of the cortical plate of long bones in patients with chronic osteomyelitis changes throughout its extension. However, the nature of structural disorders in the cortical layer outside the inflammation zone has not been studied well. Purpose To study the structural features of the cortical plate of the femur and tibia outside the focus of inflammation to identify microcavities and microabscesses. Material and methods The study is retrospective conducted at one center. Evidence level IV. In 92 patients with chronic osteomyelitis of long bones of the lower extremities, using polypositional radiography and multislice computed tomography (MSCT), the features of radiological morphology of the femur and tibia were studied in order to reveal structural features of the cortical plate and identify microcavities. Results The cause of osteomyelitis in 5 cases was a consequence of hematogenous osteomyelitis, and in 87 cases it developed due to trauma or surgery. The most common location of chronic osteomyelitis was the distal femur and tibia. Anatomical changes in the femur and tibia in all patients had individual differences. Radiological morphological manifestations such as local and general osteoporosis, foci of osteosclerosis, architectonic disorders occurred in all patients. However, the severity of changes in the bone structure was extremely diverse, including the changes in bone density. Conclusion The data obtained indicate that radiological morphological changes in the cortical plate outside the zone of destruction are manifested by formation of microcavities and microabscesses in 15.6 % of patients, what plays an important role in possible recurrence of osteomyelitis.

Introduction It is known that the function and structure of the muscles of the thigh and lower leg are closely related to the function of the lower limb, which is impaired to one degree or another in all patients with chronic osteomyelitis. However, the nature of structural changes in the muscles, which, in turn, affect the condition of the bones, has not been well studied. Purpose of the work To study the features of changes in the muscles of the thigh and lower leg in patients with chronic osteomyelitis according to MSCT data. Material and methods The study is retrospective conducted at a single centre of Evidence level IV. Multislice computed tomography (MSCT) was used in 112 patients with chronic osteomyelitis of long bones of the lower extremities to study the radiological morphology of the muscles of the thigh and lower leg, including density, muscle belly area, and anatomical features. Twenty patients had chronic osteomyelitis in the area of transosseous elements (pins). The mean age of the patients was 48.5 ± 9.8 years. Males prevailed among the patients (87.5 %). The cause of osteomyelitis in 107 cases was trauma or surgery, five patients had consequences of hematogenous osteomyelitis. Results The results of the study showed that the muscles of the thigh and lower leg in patients with chronic osteomyelitis have pronounced dystrophic changes. In 89.4 % of patients, they were manifested by an increase in the density of the anterior tibial muscle, long extensor of the toes (84.7 %), peroneal muscles (78.5 %) and a decrease in the density of the head of the gastrocnemius muscle (91.3 %). In 10.6 % of the patients, there was a decrease in the density of the anterior tibial muscle, the long extensor of the fingers. In all patients with chronic osteomyelitis of the femur, the density of the muscles of the anterior and posterior groups was reduced, except for the musculus vastus intermedius of the thigh that was characterized by fibrotic changes with an increase in density. Conclusion The data obtained indicate that radiological morphological changes in muscles occur in all patients with chronic osteomyelitis of the femur and lower leg. The most pronounced alterations in the architectonics were in the anterior tibial and gastrocnemius muscles, and the intermediate broad muscle of the thigh.

Due to low absolute morbidity rates a reliable descriptive epidemiology of the Ewing family of tumors (EFT) has been mainly provided by large population-based cancer registry reports. To date, only few reports on this topic have been published. The present report is based on data of 945 German patients who were enrolled into the (EI)CESS therapy studies between 1980 and 1997. It is assumed that under the age of 15 years an almost complete registration of all German patients with Ewing's sarcoma has been achieved. Diagnoses in all patients were ascertained by biopsies. In this analysis we looked at the associations between year of first diagnosis, age at first diagnosis, gender, the histological subtypes and the primary skeletal localisation of the tumours. The majority of patients with EFT was male (60%). More than half of the patients developed the disease between age 10 and 19 (57%) while about 20% were younger and almost a quarter was diagnosed after age 20 years. The percentage of patients older than 15 years was higher in men (55%) than in women (45%). The age-standardized annual incidence before age 15 years was estimated as 3 per million, and the cumulative incidence up to that age as about 46 per million. Long bones of the lower extremities (32%, femur alone 16%) and the pelvis were the most common sites of primary localisation. While 70 to 80% of all tumours in the long bones of the extremities were composed of Ewing's sarcomas, about one third in the central skeleton and over 20% in the pelvic bones were Primitive neuroectodermal tumours (PNET). Atypical Ewing's sarcoma accounted for about 10% of tumours in all sites. The large (EI)CESS database enables the meaningful and reliable description of epidemiological characteristics of the rare occurrence of the Ewing family of tumours. Further analyses of this database seem to hold great promise.

From September 1995 to August 2001, we treated 25 patients with chronic osteomyelitis of long bones by a two-stage technique. This consisted of the radical removal of all infected bone and soft tissue and immediate provision of soft-tissue cover. This was supplemented when necessary with delayed autogenous bone grafting. The average follow-up was 46 months (range: 19-80 months). One patient with haemoglobin sickle cell disease (HbSS) died after the second stage of surgery. There were four recurrences, one of which followed a myocutaneous flap that became necrotic. Ankylosis occurred in five patients.

Infection of the spine after surgical procedures is one of the most dreaded complications of spinal fusion surgery. Treatment goals are to eradicate the necrotic and infected tissue and to obtain a correct spinal profile. Traditionally many authors have recommended the posterolateral or double approach, anterior and posterior. Total en bloc spondylectomy is a surgical procedure traditionally used to treat primary and metastatic tumors. The use of this surgical procedure in treatment of chronic vertebral osteomyelitis is not clearly defined in literature. This case involved a 66-year-old female patient with a history of T9-S1 instrumentation after several surgeries, who developed chronic osteomyelitis of T8-T9 with extensive destruction of the vertebral body and severe thoracic kyphosis. After targeted antibiotic therapy, total en bloc spondylectomy of T8-T9 was performed according to the Tomita technique. Necrotic and infected tissues were removed proceeding as if it were chronic osteomyelitis of long bones and performing en bloc resection with clear margins, that is, applying the criteria of oncological surgery to this chronic infection. After resection, the sagittal plane is reconstructed in the affected segment, restoring the normal distance between the two healthy vertebrae and the mechanical stability of the spine. Total en bloc spondylectomy in the treatment of extensive infectious lesions with a mechanical component allows performing en bloc resection of infected and necrotic tissue along with biological and mechanical reconstruction. In our case, the complete resection of the infected bone and soft tissues achieved good outcome without complications. We propose total en bloc spondylectomy as a reasonable treatment option in complicated spondylodiscitis progressing to extensive chronic osteomyelitis and compromising spinal stability due to a significant loss of bone material.

IntroductionChronic osteomyelitis is a serious osteoarticular infection that most often occurs in the long bones, responsible for significant morbidity with the risk of fracture and amputation. Despite advances in both antibiotics and surgical treatment, the probability of recurrence of infection remains at around 20%. Cerament-G (BONESUPPORT AB, Sweden) is a synthetic bone substitute that fills the bone void left by surgery, prevents infection and promotes bone regeneration within this space. Cerament-G also provides the local delivery of high doses of gentamicin over several weeks. Two prospective observational studies described a number of infectious recurrences of 4 and 5% after the use of Cerament-G. Although available in France, Cerament-G is currently not reimbursed and its high cost constitutes a barrier to its use. We hypothesize that the use of Cerament-G will lead to fewer costs to the collectivity while improving patient utility and, as an innovative strategy, will be superior to standard of care on recurrence of infection.Methods and analysisThe Conviction Study is a prospective, multicenter, randomized, single blind study conducted in 14 French Reference Centers for Complex Osteoarticular infections. The main objective is to evaluate the cost-effectiveness of using Cerament-G in the treatment of chronic long bone osteomyelitis by comparing this innovative strategy to standard of care. A cost-utility analysis from the collective perspective will be conducted over a 24-month time horizon after the initial surgery. The outcome for the main medico-economic evaluation will be Quality Adjusted Life Years (QALYs).DiscussionThe study is being conducted throughout the CRIOAc network in France, in referral centers for the management of complex infections which will facilitate patient recruitment. This study has several limitations: the investigators have to be trained to handle the device, and it was impossible to blind the surgeon.ConclusionIf the use of Cerament-G is demonstrated to be superior to leaving the dead space empty during surgery for patients with stage III chronic long bone osteomyelitis, its use will be recommended to improve the prognosis of such patients, and this device may eventually qualify for reimbursement through the French Health Insurance scheme.Ethics and disseminationThis protocol received authorization from the Ethics Committee CPP Sud Méditerranée V on April 27, 2021 (21.03.10.77652) and the French National Agency for Medicines and Health Products on May 6, 2021 (2020-A02299-30). Results will be disseminated to the scientific community through congresses and publication in peer-reviewed journals.

Purpose Obtaining quantitative and informational characteristics of biofilms formed by clinical strains of Klebsiella pneumoniae in vitro on the surface of a cover glass. Materials and methods In vitro biofilm formation on the surface of the cover glass was studied for clinical Klebsiella pneumoniae strains, isolated in a monoculture (ESBL +) (n = 3) and in associations with Staphylococcus aureus (n = 6) in 9 patients with chronic osteomyelitis of long bones harvrested from fistulae in the preoperative period or from the infection focus during surgery. Results Monocultures of K. pneumoniae (BLRS +) differed by their lower adhesive ability when compared to strains of K. pneumoniae isolated from associations with S. aureus. The highest adhesive activity on the surface of the cover glass was observed in a mixed culture of K. pneumoniae + S. aureus. Informational characteristics depended on the type of biofilms formed. Common to biofilms was the absence of changes in the maximum possible structural diversity. Significant differences between the existing structural diversity of biofilms formed by monocultures of K. pneumonia, K. pneumonia isolated from associations and a mixed culture of K. pneumoniae + S. aureus were noted. Conclusion The absence of pronounced variability of information indicators during the experiment within each microbial community indicates the tendecy of all systems of emerging biofilms to preserve stability.