Chronic Osteomyelitis In Children Research Articles

Surgical Debridement for Acute and Chronic Osteomyelitis in Children.

Osteomyelitis is an infection of the bone that commonly occurs in pediatric populations. First-line treatment most often involves a course of antibiotics. In recent studies, surgical debridement, in addition to antibiotics, has been shown to provide positive clinical and functional outcomes in children. Debridement is most often indicated in patients with an abscess or in those who do not respond to empiric antibiotic therapy; however, there are limited video resources describing this technique in pediatric patients. The key steps of the procedure, which are demonstrated in the present video article, are (1) preoperative planning, (2) positioning, (3) subperiosteal exposure and debridement, (4) cortical window creation, (5) irrigation, (6) adjunctive treatment, (7) drain placement, (8) wound closure, (9) dressing and immobilization, and (10) wound check and drain removal. Nonoperative treatment is usually indicated for acute osteomyelitis in which patients present with little to no necrotic tissue or abscess formation. In these cases, a course of broad-spectrum antibiotics may be sufficient for a cure. This procedure allows for the removal of necrotic bone and soft tissue, thus facilitating the recovery process. It also allows for the retrieval of tissue samples that may be used to guide selection of the appropriate antibiotic therapy. Surgical debridement is a safe and reliable technique that has been associated with positive long-term outcomes. We expect that some patients will require repeat surgical debridement procedures to decrease pathogen burden and prevent future complications. However, we expect that the majority of patients who undergo surgical debridement for uncomplicated osteomyelitis will recover full functionality of the affected limb with no associated long-term sequelae10. Understand preoperative imaging to identify areas of infection, localize critical structures and the physis, and plan surgical approaches.Use extensile approaches and preserve vascularity during the approach.Perform subperiosteal dissection and create a cortical window to debride areas of infection, but avoid excessive periosteal stripping.Close the dead space and wound in a layered manner. MRI = magnetic resonance imagingK-wire = Kirschner wireMRSA = methicillin-resistant Staphylococcus aureusPDS = polydiaxonone.

Bioactive glass in the treatment of chronic osteomyelitis in children: Description of four consecutive cases and literature review

IntroductionChronic osteomyelitis in children is a rare condition. Debridement surgery, along with appropriate antibiotic therapy, is widely agreed to represent the best procedure in the treatment of chronic osteomyelitis but can result in an extensive dead space formation. In this study, we evaluated the use of bioactive glass to address dead space management. MethodsFour consecutive cases of chronic osteomyelitis treated with antibiotic therapy, one stage- surgical debridement and bioglass implantation between September 2016 and February 2017 were prospectively followed for a minimum of three years. Two cases followed acute hematogenous osteomyelitis, two cases followed fracture fixation. Clinical, histology, laboratory and radiographic findings were recorded. Primary endpoint was eradication of infection. Possible complication related to bioglass application were investigated. ResultsAll patients achieved healing at the latest follow-up of minimum three years. No successive surgical treatments were required at any time. No complications related to the bioglass were detected. Radiographic reconstruction of normal anatomy progressed through the years. ConclusionsBioglass for the treatment of dead space after surgical debridement appears a viable option in the treatment of chronic osteomyelitis in children.

1369. The Spectrum of Chronic Osteomyelitis in Children

BackgroundWhile the majority of pediatric osteomyelitis cases are acute in nature, a significant subset present with prolonged symptoms often associated with substantial morbidity. Little data exist to guide clinicians in the management of these infections. We sought to describe the epidemiology, clinical features and management of chronic osteomyelitis in children.MethodsWe reviewed hospital admissions with an ICD10 code for chronic osteomyelitis from 2011-2018 at Texas Children’s Hospital. Cases were included if symptoms lasted >28 days on presentation. Patients diagnosed with chronic recurrent multifocal osteomyelitis were excluded. Cases were classified as those 1) associated with a contiguous focus (CoF), 2) penetrating or open trauma, 3) orthopedic hardware (OH), 4) post-acute chronic osteomyelitis (PACO, those occurring after >28 days of therapy for acute osteomyelitis) and 5) primary hematogenous chronic osteomyelitis (PHCO, those with 28 days of symptoms without other clear risk factors).Results114 cases met inclusion criteria. The median patient age is 11.8 years and 35.9% patients had underlying comorbidities. 83% of patients underwent a surgical procedure. Cases were diverse in terms of pathogenesis (Figure 1). A microbiologic etiology was identified in 72.8% of cases and was polymicrobial in 20.2% of cases; Staphylococcus aureus was the single most common etiology (Figure 2). CoF infection was more often associated with polymicrobial etiology with or without Pseudomonas (P< 0.001) and disease of the foot. PACO was caused by S. aureus in 95% of cases (p< 0.001, Figure 3). The overall median duration of total therapy was 210 days. 41% were discharged from hospital on OPAT with or without later transition to oral antibiotics. 26.3% of patients had persistent functional limitations at time of last follow-up of which 46% experienced repeat hospital admission/surgery. There was no association between duration of intravenous therapy and persistent functional limitations.Figure 1. Categories of Chronic Osteomyelitis Figure 2. Microbiology of Pediatric Chronic Osteomyelitis Figure 3. Clinical Features of Pediatric Chronic Osteomyelitis ConclusionChildren with chronic osteomyelitis are diverse both in terms of pathogenesis and microbiology. Pathogenesis and clinical presentation can provide clues to microbiologic etiology. Prolonged intravenous therapy does not appear to improve functional outcomes in chronic osteomyelitisDisclosures Jonathon C. McNeil, MD, Allergan (Research Grant or Support, Allergan provided ceftaroline powder for use in studies described in this abstract)

Radiological and clinical outcomes using induced membrane technique combined with bone marrow concentrate in the treatment of chronic osteomyelitis of immature patients.

AimsTreatment of chronic osteomyelitis (COM) for young patients remains a challenge. Large bone deficiencies secondary to COM can be treated using induced membrane technique (IMT). However, it is unclear which type of bone graft is optimal. The goal of the study was to determine the clinical effectiveness of bone marrow concentrator modified allograft (BMCA) versus bone marrow aspirate mixed allograft (BMAA) for children with COM of long bones.MethodsBetween January 2013 and December 2017, 26 young patients with COM were enrolled. Different bone grafts were applied to repair bone defects secondary to IMT procedure for infection eradication. Group BMCA was administered BMCA while Group BMAA was given BMAA. The results of this case-control study were retrospectively analyzed.ResultsPatient infection in both groups was eradicated after IMT surgery. As for reconstruction surgery, no substantial changes in the operative period (p = 0.852), intraoperative blood loss (p = 0.573), or length of hospital stay (p = 0.362) were found between the two groups. All patients were monitored for 12 to 60 months. The median time to bone healing was 4.0 months (interquartile range (IQR) 3.0 to 5.0; range 3 to 7) and 5.0 months (IQR 4.0 to 7.0; range 3 to 10) in Groups BMCA and BMAA, respectively. The time to heal in Group BMCA versus Group BMAA was substantially lower (p = 0.024).ConclusionIMT with BMCA or BMAA may attain healing in large bone defects secondary to COM in children. The bone healing time was significantly shorter for BMCA, indicating that this could be considered as a new strategy for bone defect after COM treatment.Cite this article: Bone Joint Res 2021;10(1):31–40.

Tobramycin-impregnated calcium sulfate pellets for the treatment of chronic osteomyelitis in children and adolescents.

The aim of this work was to evaluate the outcome and efficacy of treatment in a homogeneous group of skeletally immature patients with chronic osteomyelitis of the long bones managed by a combination of radical debridement and insertion of tobramycin-impregnated calcium sulfate pellets to fill the bone defect in a single-stage procedure. Between 2011 and 2016, 12 skeletally immature patients were treated surgically by the reported technique. Single-stage surgery using tobramycin-impregnated calcium sulfate pellets in association with systemic antibiotic therapy yields satisfactory outcomes in skeletally immature children presenting chronic osteomyelitis by reducing the risk of occurrence of comorbidities, hospital stays, and healthcare costs.

Bone Defect Reconstruction in a 2 Years Old Boy with Non-Vascularized Fibular Graft Using the Induced Membrane Technique in Country with Low-Income: A Case Report

Chronic osteomyelitis in children is frequent in the developing countries. Their complications and morbidity burden the functional prognosis. The reconstruction of diaphyseal bone loss after sequestrectomy in young children remains a difficult and expensive challenge in our context. The delay in care and the lack of social security for all, are risk factors for morbidity. The induced membrane technique described by Masquelet starts to be applied and showed satisfactory results. We report the results of a case of reconstruction of the proximal humerus by using a non-vascularized fibula and supplemental bone substitute in a boy of 2 years with sickle cell. No scarring occurred at the sampling site. The process of bone consolidation is underway.

RESULTS CHILD ORTHODONTIC REHABILITATION WITH CHRONIC OSTEOMYELITIS MAXILLA HISTORY OF

Chronic osteomyelitis in children poorly understood disease. Moreover, insufficient data on patients’ rehabilitation, it underwent. Chronic osteomyelitis is more common in the age of 8-10 years, the more interesting the clinical case of rehabilitation of the child who has had chronic osteomyelitis of the upper jaw to the right at the age of 4 years. In most cases chronic form of osteomyelitis in children occur соmplex dentoalveolar deformations, facial aesthetics violation. To eliminate the disease apply complex orthodontic and surgical interventions, dentures. We explored the possibility of forming a physiological ratio dentoalveolar arches using orthodontic rehabilitation of a child who has had chronic osteomyelitis at an early age. Monitoring and treatment of the patient was carried out at the age of 4-15 years. In the treatment of used removable orthodontic appliances replacement dentition defect, non-removable orthodontic appliances, orthopedic extraoral traction. For the control treatment and the results of the analysis were used different types of X-ray examination: a panoramic picture, computed tomography, as well as calculations of models of the jaws and face and smile detection photometry. During treatment persists infantile type was eliminated, to form a neutral type of jaw relations, create conditions for the eruption of permanent teeth on the modified disease right half of the upper jaw. A detailed analysis of the results showed that the effectiveness of orthodontic treatment depend on its early start, the sequence and scope of the orthodontic treatment, care, timeliness, as well as the activity of a doctor and patient cooperation.

Immediate bone transport: a novel technique for the management of bone defects after chronic osteomyelitis in children.

Immediate bone transport: a novel technique for the management of bone defects after chronic osteomyelitis in children.

Successful treatment of chronic osteomyelitis in children with debridement, antibiotic-laden cement spacer and bone graft substitute.

Chronic osteomyelitis and infected nonunion are relatively rare conditions in pediatric patients and are more frequently seen in developing countries. Although relatively rare, they are medically and surgically challenging. Here we report a novel surgical technique used to manage five patients with chronic osteomyelitis of long bones. Five skeletally immature patients with chronic osteomyelitis and infected nonunion of the long bones were treated surgically between 2010 and 2014 by a combination of resection of necrotic infected bone, debridement of surrounding soft tissue, and application of antibiotic-laden cement spacer inducing periosteal membrane before final bone reconstruction. Once inflammatory markers normalized, all the patients were re-operated for cement removal, bone graft substitution, and concomitant osteosynthesis of the affected bone, if needed. All patients underwent MRI, CT scan, and laboratory evaluation prior to surgery. The antibiotic regimen was started empirically and then adjusted according to culture and sensitivity results. Mean patient age at the time of diagnosis was 11years (range 4-14), and all patients had at least 2-year follow-up (range 2-5). At last follow-up, clinical and laboratory evaluation had normalized, the bone had healed, and all patients had resumed daily living and sports activities. Surgical debridement is the standard approach to chronic osteomyelitis. Use of antibiotic-laden cement is recommended to penetrate local infection, with antibiotic therapy playing an adjunctive role. The cement also induces membrane formation that aids bone reconstruction. IV.

The Induced Membrane Technique for Bone Defects of Critical Size After Infection in Children

We report 3 consecutive cases of bone defects of critical size after chronic osteomyelitis in children that were treated with the induced membrane technique, in 2 girls and a boy 7 months to 7 years old. All defects were diaphyseal. The length of resection was from 4 to 12 cm (35% to 55% of the total bone length). Resection of the infected bone, filling of the defect with a cement spacer, and intramedullary fixation were followed by autologous bone-grafting 60 to 90 days later. All defects healed. At the latest follow-up, which ranged from 21 months to 6 years, no recurrence or complication had occurred. The induced membrane technique is an attractive option for bone defects of critical size after chronic osteomyelitis in children.

Treatment of Chronic Osteomyelitis in Children by Ilizarov Technique

Chronic osteomyelitis in children is very difficult to eradicate completely. The patient with chronic osteomyelitis has a new hope of cure by recent advances in the management of chronic osteomyelitis. Systemic manifestations may subside, but one or more foci in the bone may contain purulent material, infected granulation tissue or a sequestrum. Treatment of this condition is to irradiate the infection and to restore the functional activity of the patient. Our objective is to highlight the various causes of recurrence, relevant classification, pathophysiology and modern treatment of chronic osteomyelitis with Ilizarov technique [1-3].

Surgical treatment of chronic osteomyelitis in children admitted from developing countries

The surgical management of chronic osteomyelitis in children is still challenging in developing countries. This study analysed the extent of the disease and the therapeutic regime. This was a retrospective study in two primary health care hospitals from January 2009 to December 2013, 27 children (20 males and 7 females, mean age 7 years) admitted from developing countries who were treated for chronic osteomyelitis. Localization, duration of the disease, extent of the osseous involvement, spectrum of germs, number of previous and required surgical procedures and duration of hospital stay are reported. A total of 16 cases had haematogenous and 11 cases post-traumatic aetiology. The mean duration of the disease was 18 months. On average, three (range, 1-12) previous surgical procedures were performed. The affected bones were: Tibia in 11, femur in 8, forearm in 6 cases, spine and humerus each in 1 case. Staphylococcus aureus was the responsible germ in 75%. On average, four (range, 2-8) surgical procedures were required. Osseous stabilizations were necessary in 17, plastic soft tissue reconstructions in 8 cases. In three cases with metaphyseal/diaphyseal defect, bone transfers had to be performed (2 × fibula-pro-tibia, 1 × rib for radius). The mean hospital stay took 8 (range, 4-20) weeks. Three local recurrences occurred within 3 months, all could be cured surgically. The surgical treatment of chronic osteomyelitis in children requires a radical osseous debridement. The knowledge of different plastic-surgical procedures is necessary to reconstruct osseous and/or soft tissue defects.

Chronic osteomyelitis in children: prognosis of the current and ways of patients’ rehabilitation

For improvement results of the treatment of children with chronic osteomyelitis author offers to put into practice more frequent control examinations of patients and definition direction of the current of local pathological process with help elaborated the prognostic table. At the same time are recommended different variants of treatment and rehabilitation until the patient be under observation.

Chronic Osteomyelitis in Children: Treatment by Intramedullary Reaming and Antibiotic-impregnated Cement Rods

Chronic osteomyelitis (CO) is rarely encountered in developed countries and is especially rare in children and adolescents. However, on occurrence, it can pose a difficult therapeutic challenge necessitating a combination of aggressive surgical treatment and prolonged antibiotic administration. Four patients were treated for CO in the Pediatric Orthopaedic Unit at Schneider Children's Medical Center between June 2005 and December 2006 and were reviewed retrospectively. Surgical treatment consisted of debridement and lavage, reaming of the intramedullary canal and insertion of gentamycin-impregnated polymetamethacrylate rods into the canal and beads around the infection site. At rod removal reaming and lavage were repeated. Antibiotic treatment was initiated with intravenous cephalothin, followed by prolonged oral treatment according to bacterial sensitivity. Cement rods and beads were removed 16 to 62 days after insertion. Intravenous antibiotics were continued for 6 weeks (3-13) and total antibiotic treatment length was 16 weeks (10-37). Total treatment time from presentation to full resolution averaged 8 months (2-18). One patient sustained a fracture requiring osteotomy and correction. At mean follow-up of 41 months from rod removal (36-46), all patients are asymptomatic and fully functional with no clinical signs of infection. C-reactive protein is within normal limits in all 4 patients. The method presented combining reaming, lavage and local and systemic antibiotic treatment was found to be safe and effective in the treatment of CO, eradicating the infection and preventing further tissue loss. Therapeutic study, clinical case series: level IV.

The Use of Over-Penetrated Radiographs for Assessment of Chronic Osteomyelitis in Children

The Use of Over-Penetrated Radiographs for Assessment of Chronic Osteomyelitis in Children

Technical Notes and Tips: The Use of Over-Penetrated Radiographs for Assessment of Chronic Osteomyelitis in Children

Technical Notes and Tips: The Use of Over-Penetrated Radiographs for Assessment of Chronic Osteomyelitis in Children

Chronic osteomyelitis in children: Shriners Hospital Honolulu experience

Chronic osteomyelitis incidence and severity in 55 hospitalized Pacific Island children between 1990 and 2002 were compared with the expected incidence and reports in the literature. Of these 55 cases, 87% were from Polynesia/Micronesia. The average length of hospital stay was 104 days. Staphylococcus aureus was cultured in 64% of the cases with 43% of those being methicillin resistant S. aureus. A total of 111 bones were involved. Average antibiotic treatment was 135 days. Each case required an average of 1.3 irrigations/debridements and 45% required a sequestrectomy. Ninety-two percent had elevated erythrocyte sedimentation rate on admission. Sixty-nine percent of the cases involved metaphyseal, diaphyseal and epiphyseal segments of the bone and 29% were multifocal. Results indicate that Pacific Island children have a higher incidence and increased severity of osteomyelitis when compared with non-Pacific Island children in the literature, requiring a high suspicion for multifocal osteomyelitis, extensive bone involvement, S. aureus positive cultures and a longer period of antibiotic treatment.

Chronic Osteomyelitis in Children

Summary: In developing countries, chronic osteomyelitis often results from untreated acute hematogenous osteomyelitis but may also be seen as sequelae of trauma (war injuries). This condition is characterized by areas of devitalized bone/soft tissue (sequestra), which serve as a nidus for recurrent episodes of infection. The periosteal response (involucrum) serves to restore structural integrity, and partial or complete reabsorption of sequestra usually accompany this host response. In addition to providing adequate nutritional support, and treating any coexisting medical or infectious diseases, the treatment of chronic osteomyelitis involves surgical removal of all infected/devitalized tissue with or without antibiotic therapy. Sequestrectomy is usually delayed until a suitable involucrum has formed to preserve stability and minimize the chances of fracture and/or segmental bone loss. The disease and/or its treatment may result in focal or segmental loss of bone, requiring further intervention to restore osseous continuity, alignment, and length. Treatment options for focal bone loss include conventional bone grafting and open cancellous bone grafting (subcutaneous bones), and the limb should be protected (cast or external fixator) until healing is complete. For segmental loss of bone, options include conventional bone grafting (external fixator to maintain length and stability) or bone transport. The latter technique, if technically feasible, allows the simultaneous management of limb malalignment and limb length discrepancy. The choice depends on the local resources, and either technique may result in a suitable outcome for the majority of patients. For segmental defects in the tibia, the ipsilateral fibula may be used as a bypass graft. Creation of a single-bone forearm may represent the best option in cases with significant loss of the radius or ulna, provided that the wrist and elbow are normal.

Retrospective assessment of subacute or chronic osteomyelitis in children and young adults.

To identify factors associated with and to describe treatment outcomes of pediatric subacute or chronic osteomyelitis (S/CO), we retrospectively identified 52 patients with S/CO from January 1994 to November 1999 seen at a large pediatric hospital infectious disease clinic. S/CO was defined by the following: >10 days of clinical symptoms; radiographic, surgical, or pathologic changes consistent with S/CO; or relapse of prior osteomyelitis. Of these patients 63% were male, median age 9 years. Bones involved included vertebra (19% of subjects), femur (17%), finger (12%), humerus (10%), and tibia (8%). Sixty-five percent had at least 1 risk factor (most commonly hardware, neurologic disease or preceding trauma, sepsis, or surgery). Blood, bone, or wound aspirate cultures were positive in 67%, most commonly for Staphylococcus aureus. Erythrocyte sedimentation rate (ESR) was elevated in 88% of 41 patients at the time of diagnosis. Intravenous antibiotics were given for a median of 6 weeks and oral antibiotics for a median of 4.5 months. One child had a complication. In conclusion, consideration of S/CO should be high when predisposing factors are present. ESR may be useful for determining effectiveness and duration of therapy. With prolonged antibiotic therapy nearly all patients demonstrated resolution of disease.

Chronic osteomyelitis in children.

Chronic osteomyelitis in children.