Chronic Osteomyelitis Of Long Bones Research Articles

Antibiotic Impregnated Cement Coated Intramedullary Nailing in the Management of Infected Fractures and Chronic Osteomyelitis of Long Bones

Background: In the era of modern transportation there is an increased incidence of compound fractures especially of long bones. As the skin barrier is broken, the bacteria from dirt, other contaminants can colonize at the wound site and thus can cause infection. Healing at the fracture site and that of soft tissues can be severely compromised by infection. So, treating the infection first followed by definitive fixation of fracture will nearly take 4-6 weeks. The antibiotic nailing technique can thus achieve both the targets in a short time. Local delivery of drug controls the infection and the fixation achieves stability. This even reduces the side effects due to over use of systemic and oral antibiotics. Osteomyelitis is also very common which can be hematogenous or post traumatic. This can weaken the bone and can cause fractures with trivial trauma. Discharging sinuses may also be accompanying. So even in this scenario long term use of antibiotics systemically may be required causing side effects. Antibiotic nailing can be very useful in this scenario. Methods: This is a prospective observational study. 20 patients above age of 20 years who were admitted or on follow up during the period of 2 years were considered for study. The patients with infected fractures with or without implant in situ and patients with chronic osteomyelitis with discharging sinuses were included. ASAMI Criteria: The final outcome is graded based on ASAMI criteria proposed by Paley et al. This was usually developed for determining the outcome after treatment of nonunion with Ilizarov ring fixator. It was applied in our study with some modification. Results: The average duration for achieving bony union was around 5 months (20 weeks). Minimum duration for bony union was around 4 months (16 weeks). Maximum duration for bony union was around 7 months (28 weeks) Average duration for control of infection in case of chronic osteomyelitis was around 4 months. Minimum duration for control of symptoms was 5 months. Maximum duration for control of symptoms was 7 months. Conclusion: Antibiotic impregnated cement coated intramedullary nailing is a very good and effective treatment for infected nonunion and chronic osteomyelitis long bones with bone defect less than 2 cm. In case of infected nonunion, as the bone ends will be sclerosed, freshening of ends and bone grafting is needed.

Cost-effectiveness of a bone substitute delivering gentamicin in the treatment of chronic osteomyelitis of long bones: Protocol for the CONVICTION randomized multicenter study.

Chronic 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. The 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). The 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. If 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. This 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.

Микроабсцессы как возможная причина рецидива хронического остеомиелита

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.

МСКТ-семиотика мышц при хроническом остеомиелите бедра и голени

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.

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

BackgroundChronic osteomyelitis remains a major challenge for orthopedic surgeons due to its high recurrence rate. Surgeons currently have few tools to estimate the likelihood of individual recurrence. We here aimed to develop a nomogram to better estimate individual recurrence rate after surgical treatment of chronic osteomyelitis in long bones. MethodsWe first retrospectively identified patients as training cohort who had received surgical treatment of chronic osteomyelitis in long bones between January 2010 and January 2016 from four hospitals. Patient demographic, microbiological, clinical, and therapeutic variables were collected and analyzed. Univariate and multivariate analyses were performed successively to identify independently predictive factors for recurrence. To reduce overfitting, the Bayesian information criterion was used to reduce variables in the original model. Nomograms were created with the reduced model after model selection. The nomogram was then internally validated with bootstrap resampling. We then further validated the performance of the established nomogram in validation cohort (data from two distinct institutions). ResultsRecurrence was found in 136 of 655 (20.8%) and 52 of 201 patients (25.9%) in training and validation cohorts respectively. We included six independent prognostic factors for recurrence in our prediction model: number of previous recurrences, epiphysial involvement, preoperative serum albumin level, axial length of the infectious lesion, lesion-removal method, and application of a muscular flap. After incorporating these six factors, the nomogram achieved good discrimination, with concordance indexes of 0.82 (95% CI, 0.79–0.85) and 0.80 (95% CI, 0.78–0.83) in predicting recurrence in the training and validation cohorts, respectively. Calibration curves were well fitted for both training and validation cohorts. ConclusionsOur nomogram achieved good preoperative prediction of recurrence in chronic osteomyelitis of long bones. Using this nomogram, the recurrence risk can be confidently predicted for each patient and treatment plan. After considering and discussing the functional prognosis with patients, physicians can establish a rational therapeutic plan. Level of evidencePrognostic, Level III.

Chronic Osteomyelitis of Long Bones: Imaging Pearls and Pitfalls in Pediatrics

Chronic bacterial osteomyelitis is characterized by progressive inflammatory bone destruction and apposition of new bone most often caused by pyogenic bacteria. Clinical findings are nonspecific, and serum inflammatory markers can be normal. Prompt diagnosis and treatment are essential. Left untreated, chronic infection can lead to high morbidity and mortality. Imaging's major role is to suggest the correct diagnosis, exclude other diagnoses that can mimic osteomyelitis, document extent of disease, and guide interventions such as image-guided biopsy or surgical debridement. Several conditions can mimic chronic osteomyelitis clinically and radiographically. The main differential diagnoses include an oncologic process, chronic nonbacterial or chronic recurrent multifocal osteomyelitis, bone infarct in sickle cell disease, osteoid osteoma, and stress reaction/fracture. The oncologic process to consider includes metastatic neuroblastoma and Langerhans cell histiocytosis in a child younger than five years or leukemia, Ewing sarcoma, and osteosarcoma in the older age group. However, these lesions can typically be excluded based on radiographs and magnetic resonance imaging findings. Therefore, radiologist familiarity with imaging findings and mimickers is essential. In this article, we briefly review the epidemiologic, clinical, and histopathologic features of chronic bacterial osteomyelitis and emphasize imaging pearls and pitfalls, with discussion of the most common differential diagnoses.

Dynamics of bone tissue metabolism in the complex treatment of chronic posttraumatic osteomyelitis of long bones

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.

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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.

Different management modalities in chronic osteomyelitis of long bones following open fractures: A case series

Chronic osteomyletis is one of the most dreaded complication of 0pen fractures and a surgeons nightmare. Eradication of COM requires aggressive surgical excision combined with effective antibiotic treatment and reconstructive procedures. The goal of therapy in such patients is to restore the functional anatomy of the limb. Depending on our experience and the type of infected nonunion we individualize a modality of management for the patient and the type of nonunion. The various modalities used were Corticotomy and lengthening using Ilizarov or LRS, Customized antibiotic rod implantation, Membrane osteosynthesis, Resection and endoprosthesis and Papineau technique. We followed up these patients till the radiological and clinical union occured and eradication of infection. The outcomes were based on bony union, functional outcome based on range of motion and occupational rehabilitation with eradication of infection at the last follow up. We publish our series of such cases and review of literature with representative cases.

Management of Chronic Osteomyelitis Following Gunshot Injuries : A Systematic Review of Literature

Background: Chronic osteomyelitis of long bones are common in daily clinical practice, however, the treatment of these diseases has still been a challenge and difficult for orthopedic surgeons. Gunshot injuries lead to damage to bone and soft tissues that can complicate with bacterial invasion and cause bone infection. Many ways can overcome of bone infection, surgical debridement, bone fixation and antibiotic are used in management of chronic osteomyelitis. The objective of this systematic review was to review available studies reporting in management of chronic osteomyelitis following gunshot injuries and compare the methods used into the treatment. Methods: A comprehensive literature search was performed from the electronic databases Medline, PubMed, Google scholar, and Cochrane collaboration between 1995 and 2016. References were analyzed from included studies, inclusion criteria included (1) English literatures, (2) Humans clinical trials, (3) Orthopedic Journals only, (3) Definitive treatment strategy for management chronic osteomyelitis. In total, 5 articles were included in the systematic review. Results: A total of 278 patients from 5 studies were included in this systematic review. The mean age of the patients is all studies were 33.84 year, the ratio male to female is 6:1. The most of patients were classified as Gaustilio type lllB and CiernyMader type lllB. The result of all different studies shows a good outcome in 260 patients but 7 patients had poor outcome who were still had bone infection and one patient end by amputation. Radiographic X-ray did postoperative follow up every two weeks. The mean follow up duration was 40 months and all patients responsible for keep the fixator clean. Conclusion: Our systematic review showed that the patients with chronic osteomyelitis were treated by surgical debridement and bone fixation had a good result. But, this research lost the randomized trials methods, risk factors of patients, compare control groups and good statistical analysis. Without any direct comparison of treatment modalities, it is difficult to determine which individual treatment option is the most efficacious.

The microbiology of chronic osteomyelitis in a developing world setting

OBJECTIVES: The primary aim of this study was to identify the microorganisms that cause chronic osteomyelitis in a developing world clinical setting and to characterise the antibiotic sensitivity profile of these pathogens. Furthermore, we aimed to determine whether the causative organisms vary in relation to physiological status of the host, the HIV status of the patient or the cause of the infection (post-traumatic, post-operative and haematogenous. METHODS: We performed a retrospective review of consecutive adult patients treated curatively for chronic osteomyelitis of long bones, over a two-year period. Patient charts were reviewed and data extracted in respect of patient demographics, the cause of infection, physiological status of the host in accordance with the Cierny and Mader classification, HIV status, surgical treatment strategy and causative organism. RESULTS: A total of 108 organisms were identified in the 60 patients included in the study. Multiple organism were cultures in 45% of patients, a single Gram-positive organism in 22% and a single Gram-negative organism in 26% of patients. In four cases (7%) no causative organism was cultured. The most prevalent organisms were Enterobacteriaceae (34%), Staphylococcus spp. (29%), Pseudomonas aeruginosa (11%), and Enterococcus spp. (9%). Many isolates were found to be resistant to commonly used empirical anti-microbial agents. Seventy per cent of Enterobacteriaceae spp. were resistant to either cefuroxime and/or ampicillin-clavulanic acid. Seventy-seven per cent of Staphylococcus aureus isolates were susceptible to cloxacillin. More than 50% of Pseudomonas aeruginosa strains were resistant to meropenem, imipenem, piperacillin-tazobactam or cefepime. There was a significant association between the aetiology of the infection and the microorganisms involved (p-value < 0.01). The bacterial pathogen profile was, however, not associated with the physiological status of the host (p=0.22) or the HIV status of the patient. CONCLUSION: While the majority of haematogenous chronic osteomyelitis still involved a solitary Gram-positive organism, the incidence of Gram-negative infections was found to be higher than previously reported. Contiguous chronic osteomyelitis was mostly polymicrobial in nature and solitary infections involving a Gram-negative organism was most common in the post-traumatic group. The bacterial pathogen did not vary in relation to the HIV status of the patient or the physiological status of the host.

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.

A simple method for fashioning an antibiotic impregnated cemented rod for intramedullary placement in infected non-union of long bones.

The intramedullary insertion of antibiotic impregnated PMMA rods, beads or nails are widely used and accepted modality of treatment for chronic osteomyelitis of long bones. But at times it becomes difficult to insert and remove these antibiotic delivery systems owing to narrowed medullary canals. Here we present a technique for preparing PMMA rods with diameter ranging from 6mm to 3mm. These rods could easily be placed in narrow intramedullary canal of long bones with chronic osteomyelitis or infected non-union. We have used high viscosity bone cement (Simplex P) along with two antibiotics (cefuroxime and vancomycin) for preparing cement rods. Food grade straw and low profile teflon tube guide wire exchanger used in IM nailing were used as mold. Ilizarov wire, 1mmK wire and 24 gauge stainless steel wire were used as internal support core material for imparting strength. We used this technique in seven cases and were successful in treating infection of long bones of upper and lower limbs (femur). With average follow up of 7.28 months rate of union in our series was 71% (five cases). Four cases (57%) had no evidence of infection and two cases (29%) had control of infection and in one case (14%) infection was still there but union was achieved.

The outcome of treatment of chronic osteomyelitis according to an integrated approach.

Previous classification systems of chronic osteomyelitis have failed to provide objective and pragmatic guidelines for selection of the appropriate treatment strategy. In this study, we assessed the short-term treatment outcome in adult patients with long-bone chronic osteomyelitis prospectively where a modified host classification system was integrated with treatment strategy selection through a novel management algorithm. Twenty-six of the 28 enrolled patients were available for follow-up at a minimum of 12 months. The median patient age of was 36.5 years (range 18–72 years). Fourteen patients (54 %) were managed palliatively, and 11 patients (42 %) were managed through the implementation of a curative treatment strategy. One patient required alternative treatment in the form of an amputation. The overall success rate was 96.2 % (95 % CI 80.4–99.9 %) at a minimum of 12-months follow-up. Remission was achieved in all [11/11] patients treated curatively (one-sided 95 % CI 73.5–100.0 %). Palliative treatment was successful in 92.9 % [13/14] of cases (95 % CI 66.1–99.9 %). In patients with lower limb involvement, there was a statistically significant improvement of 28.3 (95 % CI 21.0–35.7; SD 17.0) in the AAOS Lower Limb Outcomes Instrument score (p value < 0.001). The integrated approach proposed in this study appears a useful guideline to the management of chronic osteomyelitis of long bones in adult patients in the developing world. Further investigation is required to validate the approach, and additional development of the algorithm may be required in order to render it useful in other clinical environments.

The clinical significance of bacteria Acinetobacter spp., separated from patients with chronic osteomyelitis.

The article deals with the results of analysis of 17 clinical strains of Acinetobacter spp., isolated from wounds of patients with chronic osteomyelitis of long bones. In 8 patients strains of Acinetobacter spp. were isolated in mono-culture, in 8 - in composition of association with staphylococci (Staphylococcus aureus - 4, S.epidermidis - 2, S.hatmolyticus - 1, S.capitis -1) and in one patient - with strains of Enteroccocus faecalis. highly adhesive characteristics were established in 29% of isolates of Acinetobacter spp, average adhesive - in 43% and low adhesive - in 28%. The average index of adhesiveness of analyzed strains made up to 2.86±0.02 units. The strains with high adhesive potential were isolated from associations with Staphylococcus spp. The strains of Acinebacter spp. are characterized as far as of incubating by increasing activity of formation of biofilm on the surface of 96 alveolar tray. The calculated integral coefficient (K>0.5 units) testifies high percentage of strains resistant to selected antibiotics. It is established that the most effective in relation to Acinebacter spp. were aminoglycosides (gentamycin and tobramycin) and carbapenems (meropenem, imipenem).The percentage of resistant strains did not exceed 38%. The implemented study demonstrated that inter-microbial relationships ameliorate capacity of association-forming strains Acinebacter spp. to form bio-films. The derived values of bio-film-forming capacity and coefficient of resistance of clinical isolates Acinebacter spp.isolated from patients with chronic osteomyelitis testify their high pathogenicity. The treatment of infection associated with Acinebacter spp. is to consider both results of antibioticgram and data concerning virulent characteristics of isolated agent.

A Novel Technique for the Surgical Treatment of Chronic Osteomyelitis of Long Bones: A Case Report.

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.

Optimal management of chronic osteomyelitis: current perspectives

Chronic osteomyelitis is a challenging condition to treat. It is seen mostly after open fractures or in implant-related infections following treatment of fractures and prosthetic joint replacements. Recurrence of infection is well known, and successful treatment requires a multidisciplinary team approach with surgical debridement and appropriate antimicrobial therapy as the cornerstone of treatment. Staging of the disease and identification of the causative microorganism is essential before initiation of treatment. Important surgical steps include radical debridement of necrotic and devitalized tissue, removal of implants, management of resultant dead space, soft-tissue coverage, and skeletal stabilization or management of skeletal defects. The route of administration and duration of antimicrobial therapy continues to be debated. The role of biofilm is now clearly established in the chronicity of bone infection, and newer modalities are being developed to address various issues related to biofilm formation. The present review addresses various aspects of chronic osteomyelitis of long bones seen in adults, with a review of recent developments.

Assessment of bone quality by the technique of multispiral computer tomography in patients with chronic osteomyelitis

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.

Dispensary observation and results of treatment of patients with chronic osteomyelitis

The article analyses results of a retrospective study of 224 patients with chronic osteomyelitis of long bones. The dispensary observation was carried out according to the authors’ system from 2005 to 2010. The influence of such factors as duration the disease, the patients’ age and etiology of osteomyelitis was studied. No statistically reliable difference in the development of the disease relapses depending upon the etiology of the examined pathology was revealed. As a result of the dispensary observation of patients with chronic osteomyelitis it became possible to succeed with reduction in the number of the disease relapses on average by a factor of 37. In patients with relapses of the disease the process was controlled with help of conservative methods of treatment in 81.5 % of cases.

Chronic Multifocal Osteomyelitis Due to Clostridium difficile in an Adolescent With Sickle Cell Anemia

To The Editors: Patients with sickle cell anemia (SCA) are at risk for osteomyelitis and septic arthritis, mainly involving long bones, caused by Salmonella species, Staphylococcus aureus, and other Gram-negative enteric bacilli.1 We report a case of multifocal chronic osteomyelitis of long bones caused by Clostridium difficile in a patient with SCA. A 13-year-old boy from Cameroon with homozygous SS SCA was hospitalized in France in July 2000 for evaluation of osteomyelitis of both femora, right tibia and fibula, and left radius present since January 2000. At admission he appeared healthy and afebrile. Radiographs and CT scans demonstrated widespread and heterogeneous metaphysodiaphyseal centromedullary cavities surrounded by osteosclerotic margins and cortical destruction of the involved bones. Magnetic resonance imaging (MRI) showed signal abnormalities of medullary cavities, suggesting multifocal chronic osteomyelitis. Fine needle aspirations of metaphyses in both femora, right tibia and fibula, and left radius, resulted in growth of C. difficile. Histopathology was consistent with chronic and subacute osteomyelitis. Stool and blood cultures were negative for the bacterium. Treatment with amoxicillin/clavulanic acid and metronidazole, to which the bacterium was susceptible, was given. Multiple relapses occurred, treated with penicillins, metronidazole, and vancomycin. Numerous soft tissue and bone debridements, excision of both condyles and trochlea, curettage of tibial plateaus with the use of external fixators in the Ilizarov technique of skeletal reconstruction,2 and bone graft or cement were performed during the following years. Most intraoperative specimens taken from different sites identified C. difficile, but in 2002 and 2004 superinfection of tibial fistulae with Staphylococcus aureus occurred. The last debridement was done in December 2007 for persistent fistulae in the scars of both legs with C. difficile on bacteriologic analysis. The patient never complained of symptoms related to the gastrointestinal tract and search for C. difficile in stools was always negative. Rare extracolonic manifestations of C. difficile infections are bacteremia, cellulitis and soft tissue involvement, intra-abdominal abscesses, infection of implanted prosthetic devices, and rheumatologic manifestations such as reactive arthritis and osteomyelitis.3 The presence of C. difficile from isolates may be difficult to interpret, and may represent contamination of extraintestinal organs with fecal flora. The presence of the bacteria in pure growth on several occasions and at different sites is strong evidence for its responsibility in the infectious process.3 Two patients with SCA have been previously described with osteomyelitis caused by this pathogen. One patient was a 30-year-old woman who presented with 2 areas of frontal bone osteomyelitis suspected to be hematogenous and recovering with bifrontal craniectomy and chloramphenicol.4 The other was a 15-year-old girl who had tibial osteomyelitis associated with mild colitis suggesting an invasion from the intestinal flora, treated successfully with surgical irrigation and debridement, and vancomycin and metronidazole.5 Our patient had multifocal chronic osteomyelitis suggesting a hematogenous spread. The infection was probably associated with intestinal breaches secondary to ischemic mucosae. Diagnosis of chronic osteomyelitis caused by C. difficile may be difficult to establish requiring the identification of the bacterium and study of the strain since resistance to antibiotics has been reported.5 Its treatment relies on a multidisciplinary approach combining antibiotics and surgery.2 Unfortunately, successful eradication of infection was not achieved in our patient despite an aggressive approach. Claude Bachmeyer, MD François Lionnet, MD Service de Médecine Interne CHU Tenon Paris, France Mathieu Gibeault, MD Service de Radiologie CHU Tenon Paris, France Jean-Pierre Damsin, MD Service d’Orthopédie CHU Armand Trousseau Paris, France