Chronic Pyogenic Osteomyelitis Research Articles

Outcome of intramedullary nail coated with antibiotic-impregnated cement in chronic osteomyelitis.

Chronic osteomyelitis (Chr OM) may result as a sequel of acute hematogenous infection or following open fractures or orthopedic surgeries. Among various osteoarticular infections, Chr OM is one of the most challenging in terms of treatment. In the present study, we evaluate the outcome of antibiotic cement-coated nails in the treatment of chronic pyogenic osteomyelitis and also discuss the future innovations in field of antibiotic-compatible biomaterials for coating the implants. Twelve cases of Chr OM (5 hematogenous and 7 exogenous following trauma or surgery) were operated by intramedullary nail coated with antibiotic-impregnated bone cement from September 2018 to January 2021. All the cases had bacteriological confirmation of infection by deep curettage and its subsequent culture sensitivity. K nail was used in 10 cases and elastic stable intramedullary nails were used in 2 cases. Out of 12 cases, 8 were male and 4 were female. The average duration of follow-up was 13 months. Infection was controlled in all the cases (two cases required repeat antibiotic-coated nailing), and there was no incidence of relapse in any case. The control of infection was assessed by clinical assessment and laboratory parameters. Antibiotic cement-coated nails are an effective method in local control of infection in Chr OM without any systemic side effect.

Chronic pyogenic osteomyelitis of the Rib: A case report in a sickle cell disease patient

Chronic pyogenic osteomyelitis of the Rib: A case report in a sickle cell disease patient

Bilateral tibial Brodie\u2019s abscess in a young patient treated with BAG-S53P4: case report

BackgroundBrodie’s abscess is a form of chronic pyogenic osteomyelitis that usually affects the cancellous part of the long bones in children. Its treatment is represented by antibiotic therapy alone or in association with surgical procedures.Case presentationA 12-years-old male affected by a Brodie’s abscess of the tibia involving the distal growth plate was admitted to the Pediatric Department for a conservative treatment. After several attempts of antibiotic therapy interrupted for intolerance manifestations he was surgically treated with bioactive glass BAG-S53P4 (BonAlive, BonAlive Biomaterials Ltd., Biolinja, Finland), with excellent results.ConclusionsIn our experience BAG-S53P4 has proven to be an effective bone substitute without side effects even in the pediatric population. In our case it eradicated the infection without interfere with the growth; neither epiphysiodesis nor other disorders were found during the follow-up.For the publication of this case report we followed the CARE guidelines for good clinical case reports; the parents gave consent for publication.

Pathology in the appendicular bones of southern tamandua, Tamandua tetradactyla (Xenarthra, Pilosa): injuries to the locomotor system and first case report of osteomyelitis in anteaters

BackgroundThe southern tamandua, Tamandua tetradactyla (Linnaeus, 1758), is the most common species of anteater. Even though much is known about its ecology, behavior, and parasites, there is very limited information about bone diseases in Tamandua and other anteaters. Here, we examined postcranial skeletons of 64 T. tetradactyla museum specimens covering most of the material available in Brazilian collections.ResultsThe following bone diseases were identified for the first time in Tamandua and other extant and fossil vermilinguans: osteophytes, osteitis, osteoarthritis, periostitis, exostoses, enthesopathies, and a severe chronic pyogenic osteomyelitis associated with fistulae, cloacae (pus), bone loss, and neoformation processes. Musculoskeletal reconstruction revealed that an old specimen was restricted to terrestrial locomotion due to osteopathological processes that impaired its climbing.ConclusionsNew osteopathological informations are presented for T. tetradactyla, favoring a better understanding of the expression of some bone diseases in wild animals. In addition, the diagnosis of these bone diseases in living anteaters provides useful information for studies on animal health and welfare, as well as contributing to the more effective recognition of paleodiseases in fossil xenarthrans.

Evaluation of the Operative Treatment in Chronic Haematogenous Pyogenic Osteomyelitis by Sequestrectomy and Saucerisation in Children

Background: Complete resolution occurs in many other types of infections with the use of antibiotics but not always with chronic pyogenic osteomyelitis.Objective: The aim of the present study was to evaluate the effectiveness of most conventional method of surgical treatment of chronic pyogenic osteomyelitis by sequestrectomy and saucerisation in Children.Methodology: This present study was a prospective study conducted at Bangabandhu Shekh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2015 to December 2016 for a period of two (2) years. Patients aged up to 16 years were included in the study. Purposive sampling was done. Only chronic osteomyelitis of haematogenous origin were included after proper selection of the patients. Sequestrectomy and saucerisation was done. Wound was kept open and allowed to heal from bottom and sides of the wound.Result: A total 36 patients aged up to 16 years were included in the study. Among the cases two third were male 26(72.23%) and rest were female 10(27.77%). The male female ratio was 2.6:1.Therefore the incident was significantly high in males (p<0.01). Most of the patients 28(77.77%) were in 6 to 16 age group, which was significantly high (p<0.01) and mean age was 9.83years. Average time taken for wound healing was 3.75 weeks. Regarding antibiotics, Cap Flucloxacillin was the maximum choice. Patients were followed up to maximum 2 years and evaluated clinically and radiologically. Maximum patients 31(86.10%) had satisfactory (good and fair) outcome, but only 5(13.88%) patients had poor outcome. There was a significant association among sequestrectomy and saucerisation with final outcome (p<0.001).Conclusion: It was concluded that describing operative technique is still method of choice for surgical treatment of chronic haematogenous pyogenic osteomyelitis.Bangladesh Journal of Infectious Diseases 2018;5(1):15-20

Childhood Pyogenic Osteomyelitis in Abakaliki, South East Nigeria.

Background:Pyogenic osteomyelitis is an important child health problem in developing countries. It is a one-disease state with a spectrum of pathological features and clinical forms ranging from acute to chronic presentation. Its pattern of presentation varies from and within subregions. The aim of this study was to determine the pattern and outcome of childhood pyogenic osteomyelitis in a low-resource environment.Materials and Methods:This was a retrospective study of all the children aged 18 years and under seen with pyogenic osteomyelitis in Federal Teaching Hospital Abakaliki between January 2005 and December 2015.Results:In 76 patients, there was pyogenic osteomyelitis involving 85 bones. Female-to-male ratio was 1:1.7, and the mean age was 9.9 ± 5.1 years. The clinical forms of presentation were acute in 16 (21.1%), subacute in 10 (13.2%), and chronic in 50 (65.8%) patients. Acute osteomyelitis was the more likely form of presentation among infants (P < 0.001) and urban children (P < 0.011) whereas subacute and chronic osteomyelitis were more likely among the older children (P < 0.001) and rural residents (P < 0.011). Staphylococcus aureus was the most common isolated pathogen. Anemia, septic arthritis, and pathological fractures were the three top complications observed. Fifty patients (65.8%) recovered and adjudged cured, 9 (11.8%) were lost to follow-up, and 17 (22.4%) were unable to afford the financial cost of the treatment.Conclusion:In our environment, chronic pyogenic osteomyelitis sequel to acute hematogenous bone infection in childhood is common. Poverty is also a limiting factor in its definitive treatment. These calls for a policy response aimed at improved care and preventive strategies based on the observed pattern.

Decalcified allograft in repair of lytic lesions of bone: A study to evolve bone bank in developing countries.

Background:The quest for ideal bone graft substitutes still haunts orthopedic researchers. The impetus for this search of newer bone substitutes is provided by mismatch between the demand and supply of autogenous bone grafts. Bone banking facilities such as deep frozen and freeze-dried allografts are not so widely available in most of the developing countries. To overcome the problem, we have used partially decalcified, ethanol preserved, and domestic refrigerator stored allografts which are economical and needs simple technology for procurement, preparation, and preservation. The aim of the study was to assess the radiological and functional outcome of the partially decalcified allograft (by weak hydrochloric acid) in patients of benign lytic lesions of bone. Through this study, we have also tried to evolve, establish, and disseminate the concept of the bone bank.Materials and Methods:42 cases of lytic lesions of bone who were treated by decalcified (by weak hydrochloric acid), ethanol preserved, allografts were included in this prospective study. The allograft was obtained from freshly amputated limbs or excised femoral heads during hip arthroplasties under strict aseptic conditions. The causes of lytic lesions were unicameral bone cyst (n = 3), aneurysmal bone cyst (n = 3), giant cell tumor (n = 9), fibrous dysplasia (n = 12), chondromyxoid fibroma, chondroma, nonossifying fibroma (n = 1 each), tubercular osteomyelitis (n = 7), and chronic pyogenic osteomyelitis (n = 5). The cavity of the lesion was thoroughly curetted and compactly filled with matchstick sized allografts.Results:Quantitative assessment based on the criteria of Sethi et al. (1993) was done. There was complete assimilation in 27 cases, partial healing in 12 cases, and failure in 3 cases. Functional assessment was also done according to which there were 29 excellent results, 6 good, and 7 cases of failure (infection, recurrence, and nonunion of pathological fracture). We observed that after biological incorporation, the graft participates in bone physiology and morphology. We did not observe any adverse host graft antigenic reaction.Conclusions:We conclude that decalcified allograft is suitable alloimplant for use in benign lesions of bone, is easy to prepare and store, and is thus well suited for use in developing countries.

Diaphyseal Tuberculosis of Tibia- Rare Occurrence: Case Report and Review of Literature

Skeletal tuberculosis is less common as compared to pulmonary tuberculosis. The incidence of Osteo articular tuberculosis is 1-3%. Of these, spine and hips involvement is more frequent. Long bones Diaphyseal tuberculosis incidence is extremely low even in endemic regions, but particularly in the Western countries. The paucity of specific nature of the symptoms usually results in a late diagnosis. The indolent nature of disease puts a great challenge to clinicians in diagnosing Diaphyseal tuberculosis of long bones accurately. Differential diagnosis of a solitary lesion in the diaphysis of the long tubular bone includes Brodie’s abscess, cystic bone lesions, bone tumors, chronic pyogenic osteomyelitis or fungal/bacterial granulomatous lesions. Because of such varied clinical and radiological presentations, the diagnosis requires a high index of suspicion and usually establishes through biopsy and culture. We reported this case to emphasize the unusual occurrence of long bones tubercles among immigrants to Western Countries as in our patient. A 25-year-old Man immigrant from Asia presented with chronic leg pain and swelling. He responded poorly to anti tuberculosis medical treatment due to noncompliance. His X-ray, CTscan and MRI Scans revealed a lytic lesion in lower shaft of tibia. Percutaneous CTguided biopsy of the lesion was done. Following curettage, tubercles osteomyelitis was diagnosed from obtained sample. Cementing of curettage cavity was done with newer version of antibiotic impregnated biodegradable cement. On Anti TB medical treatment, symptoms alleviated rapidly.

Cystic Transphyseal Tubercular Osteomyelitis

Tubercular osteomyelitis of shaft without the joint involvement is very rare. The most commonly associated symptoms are pain and swelling in the affected bone. Diagnosis is often delayed as radiologically it mimics Brodie's abscess, chronic pyogenic osteomyelitis, cystic lesions, tumours and other granulomatous conditions, either fungal or bacterial. Tuberculosis of all the bones has been reported. Most common site of extra pulmonary tuberculosis is the spine constituting about 50% of all the patients. Isolated tuberculosis of tubular bones consist of only 1% of all the skeletal tuberculosis. The mode of spread of the tubercular infection is due to the lodging of the tubercular emboli in the hair pin bends of the metaphysis. The final diagnosis is made by histopathological examination. Here, we present a case of isolated tubercular osteomyelitis of tibia without any articular involvement. A 12 year old male patient came to OPDwith complaint of pain just below the left knee since the past 3 months. On radiological evaluation, a well circumscribed lytic lesion involving the proximal transphyseal region of left tibia was seen (Fig. 1). On biopsy, the section showed granulation tissue with caseous necrosis and Langerhans giant cells (Fig. 2). This microscopic picture was highly suggestive of tuberculosis. The patient was started on anti-tubercular treatment using the first line anti tubercular a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 1 5 8 – 1 5 9

Osseous manifestations of non-Hodgkin's lymphoma in Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS)

BACKGROUND: Lymphoma is the second most common Acquired Human Immunodeficiency Syndrome (AIDS)-associated neoplasm, the commonest being Kaposi sarcoma. The diagnosis and treatment of bone lymphoma still remains a challenge in our environment. MATERIALS AND METHODS: This is a retrospective chart review of 105 patients who were diagnosed histopathologi-cally with lymphoma involving the bone over a period of 11 years in six local hospitals. RESULTS: Forty-five (42.9%) patients with bone lesions and who were positive for Human Immunodeficiency Virus (HIV) formed the cohort. Clinical manifestations varied from swelling and pain in all patients to pathological fractures (n = 5, 11.1%) and paraplegia (n = 11, 24.4%) due to cord compression. Common sites included the spine, pelvis, femur, humerus, ribs, tibia and mandible. Treatment included chemotherapy and radiation, splinting or surgical fixation of pathological fractures and decompression of the spine with or without fusion. CONCLUSION: Bone lymphoma should be considered in any HIV-positive patient presenting with unexplained swelling and pain. The radiological picture may mimic bone infections like chronic pyogenic osteomyelitis, tuberculosis and fungal infections, other systemic disorders like Paget's disease, blood-related tumours such as leukaemia and other primary and metastatic bone neoplasms.

Disseminated osteomyelitis or bone metastases of breast cancer: 18F-FDG-PET/CT helps unravel an unusual presentation

We present a case wherein striking (18)F-FDG-PET/CT findings initially considered consistent with recurrent disseminated skeletal metastases of breast cancer were later identified as an unusual presentation of disseminated chronic pyogenic osteomyelitis with Staphylococcus aureus and warneri identified on microbiological culture. A 76-year-old female with previous history of breast cancer presented with a 6-month history of pyrexia, myalgia and weight loss. Besides neutrophilia and elevated C-reactive protein, other blood indices, cultures and conventional imaging failed to identify the cause of pyrexia of unknown origin (PUO). (18)F-FDG-PET/CT demonstrated multiple widespread foci of intense FDG uptake in lytic lesions throughout the skeleton. Coupled with previous history of malignancy, findings were strongly suggestive of disseminated metastases of breast cancer. Through targeting an FDG avid lesion, (18)F-FDG-PET/CT aided CT-guided biopsy, which instead identified the lesions as chronic pyogenic osteomyelitis. Following prolonged antibiotic therapy, repeat (18)F-FDG-PET/CT demonstrated significant resolution of lesions. This case demonstrated an unusual presentation of disseminated osteomyelitis on (18)F-FDG-PET/CT and highlighted the use of (18)F-FDG-PET/CT as a trouble shooter in PUO but demonstrated that unusual presentations of benign or malignant pathologies cannot always reliably be differentiated on imaging alone without aid of tissue sampling. Furthermore, this case highlights the potential role (18)F-FDG-PET/CT could provide in assessing response to antibiotic therapy.

English

Background: Cases of osteomyelitis of maxilla were reported as a rare presentation. But osteomyelitis involving multiple cranial bones is a rarest of rare case. Here we present a case of 65 year old male, who presented with features of multiple discharging sinuses intraorally, externally over left cheek and left post-auricular region. On evaluation, the condition was found to be chronic pyogenic osteomyelitis involving maxilla, zygoma and temporal bones and odontogenic in origin. AIM: We have decided to report this interesting case because of its extensive involvement of multiple cranial bones in this antibiotic era and complete resolution of infection was gained with antibiotic therapy and surgical treatment.

Femoral Chronic Pyogenic Osteomyelitis With Three Coexisting Cancers

It is uncommon but possible for positron emission tomography or computed tomography to demonstrate multiple concomitant malignant tumors in one setting. In this clinical setting of synchronous malignancies, it is difficult to distinguish an unexpected benign hypermetabolic osseous process from bone metastasis. The authors present a patient with thyroid, gastroesophageal, and renal neoplasms with distal femoral bone chronic pyogenic osteomyelitis.

Tubercular and chronic pyogenic osteomyelitis of cranio-facial bones: a retrospective analysis

To analyse current trends in our population with respect to the presentation, diagnosis and management of tubercular and chronic pyogenic osteomyelitis of the cranio-facial bones. Retrospective study. Tertiary healthcare centre. The study population comprised 14 patients with tubercular and chronic pyogenic osteomyelitis who were managed in the otorhinolaryngology department between May 2002 and December 2005. Odontogenic infections, sinus infections and aural infections were the most commonly identified aetiological factors. Most of the patients presented with swelling, pain and discharging sinus. The diagnosis was established on the basis of clinical evaluation, radiological investigations and histopathological analysis, with six cases diagnosed with tubercular osteomyelitis and eight cases with chronic pyogenic osteomyelitis. All the patients were initially commenced on oral antibiotics, which were continued for two weeks in all cases with chronic pyogenic osteomyelitis. All the patients with pyogenic osteomyelitis underwent surgical management, with one patient requiring repeated surgical interventions. All the patients with tubercular osteomyelitis received anti-tubercular chemotherapy, with complete cure. Osteomyelitis of the cranio-facial bones is an uncommon entity which requires a high index of clinical suspicion along with radiological and histopathological investigations in order to establish the diagnosis. Tubercular osteomyelitis is clinically and radiologically indistinguishable from pyogenic osteomyelitis, and the two conditions can be differentiated only on the basis of histopathological evaluation of involved tissue.

PET/CT of a Brodie Abscess

Brodie abscess is a rare, localized type of subacute or chronic pyogenic osteomyelitis, usually of staphylococcal origin. Imaging with standard radiographs, bone scintigraphy, and MRI has been described in the literature. We present the case of a 28-year-old patient with pain in the right knee. Whole-body FDG-PET/CT scan showed a solitary FDG-active (SUV max 5.2) intracortical lesion in the meta-/epiphysis of the proximal tibia. CT demonstrated a sclerotic rim around the lesion. A Brodie abscess was considered a possible diagnosis. Multifocality could be excluded. CT-guided transosseous biopsy and curettage was performed and the diagnosis of a Brodie abscess was confirmed.

THE CLASSIC: Penicillin: Its Practical Application in Orthopaedic Surgery and Fractures

THE CLASSIC: Penicillin: Its Practical Application in Orthopaedic Surgery and Fractures

Tuberculosis of the Metacarpals and Phalanges of the Hand

Skeletal tuberculosis (TB) is less common than the pulmonary form. Involvements of the metacarpals and phalanges of the hand are infrequent. The authors report their experience with treatment and outcome of TB of the metacarpals and phalanges of the hand in 7 patients. There were 4 women and 3 men in the study who ranged in age from 3 to 60 years (average age, 22.7 years). The duration of complaints at presentation ranged from 4 to 17 months (average, 9 months). The most common presentation was pain and swelling. The presumptive preoperative diagnoses were bone tumor in 4 patients, spina ventosa in 2, and chronic pyogenic osteomyelitis in 1 patients. The results of the laboratory examination showed a mild increase in the erythrocyte sedimentation rate. No patient had an active tubercular lesion or history of pulmonary disease. The diagnosis was based on the clinical picture and radiographic features, and was confirmed by open biopsy. No patient had bony debridement or arthrodesis to control the infection. The treatment of all patients began with a 4-drug regimen for 2 months, followed by a 2-drug regimen for 10 months. The mean follow-up was 30.28 months (range, 16-52 months). At the time of the last follow-up, all lesions had healed with no recurrence. The functional results were satisfactory in all patients. One patient with thumb metacarpophalangeal TB had joint irregularity and thumb metacarpal shortening. Arthrodesis was not needed in any patient. TB of the metacarpals and phalanges of the hand can be difficult to diagnose during the early stages. TB should be suspected in cases of long-standing pain and swelling in the metacarpals and phalanges. It is necessary to keep TB in mind when making the differential diagnosis of several osseous pathologies.

Acute and chronic pyogenic vertebral osteomyelitis: Is there a role for adjunctive internal fixation during surgical management?

Pyogenic osteomyelitis is a serious illness and up to 7% of all osteomyelitis cases involve vertebral structures. Major risk factors for pyogenic vertebral osteomyelitis (PVO) include infections at distant sites, which can seed the spine through hematogenous spread, and medically compromised status. The most commonly reported complications associated with PVO include pain, kyphotic deformity and neurological sequelae. While PVO remains rare, the epidemiology is changing with an evolving population risk profile. The most frequently isolated microbe associated with PVO in the general population is S. aureus and post-spinal surgery osteomyelitis is frequently polymicrobial, however the ability to obtain definitive blood cultures is highly variable. Diagnosis of PVO includes laboratory findings consistent with escalating markers for inflammatory response. While MRI remains the imaging method of choice for PVO, plain radiographic changes associated with vertebral body or disk space infection are usually apparent 2–4 weeks following clinical symptoms. Initial medical management for uncomplicated PVO includes antibiotic therapy and immobilization. Approximately 25% of cases fail conservative therapies. Among the most consistently cited factors impacting surgical results regardless of approach are the number of significant co-morbidity factors and the impact of effective medical management. An analysis of the literature suggests that decompression and anterior grafting alone in patients who can tolerate prolonged immobilization is adequate. The use of instrumentation is more strongly indicated in circumferential decompression for anterior/posterior abscess, gross instability after debridement, medical compromise precluding prolonged bed rest or bracing, and in those patients with progressive spinal deformity.

Psychological and functional profiles in select subjects with low back pain

Background context: Some researchers have found a correlation of poor treatment outcomes in patients with low back pain and abnormal psychological profiles, whereas others have failed to confirm this correlation. A critical feature of this debate has been whether abnormal psychological profiles seen in patients with back pain are the result of the ongoing back pain or whether pre-existing psychological features predispose to a poor clinical outcome. Purpose: To determine the relationship of psychometric testing scores to the presence and duration of back pain of differing causes. Study design/setting: This was a prospective observational study of the psychological profiles of groups of patients with low back pain and controls. Patient sample: Subjects having a variety of painful back conditions (n=310) were compared with a control group of subjects without low back complaints who had undergone cervical spine surgery (n=73). Outcomes measures: Psychometric testing (Modified Zung and Modified Somatic Pain Questionnaire) was performed along with pain scores (visual analog scale [VAS]), a standardized Low Back Pain Questionnaire, and the Oswestry Low Back Pain Disability Questionnaire in the evaluation of back pain and control subjects. Methods: The subjects with painful back conditions included patients with presumed discogenic pain undergoing discography (n=95); patients with symptomatic isthmic spondylolisthesis coming to fusion (n=61); patients with chronic vertebral osteomyelitis before diagnosis and treatment (n=39). There was also a nonpatient group of soldiers with chronic low back pain not seeking medical care (n=115). The control subjects without low back pain consisted of a group who had undergone cervical spine surgery (n=73). Psychometric testing was performed and compared in the evaluation of subjects having these different painful back conditions. Analysis was done comparing pain scores, function scores, and psychological testing scores between the symptomatic and asymptomatic groups. Results: The VAS maximum in last week score for the entire group was 7.1, and scores were not significantly different in all low back pain groups. The Oswestry scores were poorest in the discography group compared to spondylolisthesis and osteomyelitis. Functional scores were similar in the soldiers with low back pain and controls without low back pain. Both Depression and Somatic Pain scores were most abnormal in the discogenic low back pain group. Only 21% of this group had normal scores, compared with 71% of the spondylolisthesis group, 79% of osteomyelitis group, and 88% of the group with chronic low back pain not seeking treatment ( p<.001 in all groups). The asymptomatic control group had 85% normal scores. Conclusions: Despite similar pain levels and pain duration, patients with the discographic diagnosis of discogenic back pain have poorer functional scores and very abnormal psychological scores compared with other subjects with chronic low back pain resulting from spondylolisthesis requiring surgery or chronic pyogenic osteomyelitis. Chronic moderately severe mechanical low back pain in healthy subjects was not associated with abnormal psychological scores or functional disability.

Tuberculous osteomyelitis.

Tuberculous osteomyelitis which does not involve a joint is uncommon and may fail to be diagnosed by an orthopaedic surgeon. We treated 28 lesions of tuberculous osteomyelitis in 25 patients between 1988 and 1995. The duration of symptoms was from two to 39 months, and most of our patients had been treated initially with non-steroidal anti-inflammatory drugs which failed to provide relief. Bone pain which does not promptly respond to analgesic medication is often due to infection or neoplasia. In the early stages, when plain radiographs are normal, MRI or CT may help to localise lesions. On plain radiographs, more advanced lesions may mimic chronic pyogenic osteomyelitis, Brodie's abscess, tumours or granulomatous lesions. Biopsy is mandatory to confirm the diagnosis, and antituberculous drugs are the mainstay of treatment. When operative findings at biopsy have the features of skeletal tuberculosis curettage of the affected bone may promote earlier healing.