Sequestrum Formation Research Articles

The role of osteitis of the lamina papyracea in the formation of subperiosteal orbital abscess in young children

BackgroundSub-periosteal orbital abscess (SPOA) typically presents as a collection of pus in the space between the periorbita and the lamina papyracea, adjacent to acute suppurative ethmoiditis. Osteitis of the lamina papyracea may lead to sequestrum formation, with progression of the infectious process to cause suppuration beneath the orbital periosteum. Materials and methodsA case series of children with rhinosinusitis and SPOA admitted to our institute, from January 2005 to December 2011, was carried out. Included were children operated upon, in whom the lamina papyracea was submitted for histological examination, and in which bacteriologic studies were obtained. ResultsNine children with SPOA with a mean age of 5.03 years (range 1–12 years) were included in the present study. In five of them (55.5%), features of osteitis were noted histologically. No pathogens were observed histologically in the sections. Bacteriologic studies revealed Streptococcus viridans in four patients, and coagulase negative Staphylococcus in one. ConclusionSPOA in rhinosinusitis children was associated in our small cohort with high rate of lamina papyracea osteitis. The direct spread through the involved bone was raised as a possible pathophysiology of SPOA formation.

Surgical treatment of jaw osteonecrosis in “Krokodil” drug addicted patients

Retrospective study of jaw osteonecrosis treatment in patients using the “Krokodil” drug from 2009 to 2013.On the territory of the former USSR countries there is widespread use of a self-produced drug called “Krokodil”. Codeine containing analgesics (“Sedalgin”, “Pentalgin” etc), red phosphorus (from match boxes) and other easily acquired chemical components are used for synthesis of this drug, which used intravenously. Jaw osteonecrosis develops as a complication in patients who use “Krokodil”. The main feature of this disease is jawbone exposure in the oral cavity. Surgery is the main method for the treatment of jaw osteonecrosis in patients using “Krokodil”.40 “Krokodil” drug addict patients with jaw osteonecrosis were treated. Involvement of maxilla was found in 11 patients (27.5%), mandible in 21 (52.5%), both jaws in 8 (20%) patients. 35 Lesions were found in 29 mandibles and 21 lesions in 19 maxillas. Main factors of treatment success are: cessation of “Krokodil” use in the pre- (minimum 1 month) and postoperative period and osteonecrosis area resection of a minimum of 0.5 cm beyond the visible borders of osteonecrosis towards the healthy tissues. Surgery was not delayed until sequestrum formation. In the mandible marginal or segmental resection (with or without TMJ exarticulation) was performed. After surgery recurrence of disease was seen in 8 (23%) cases in the mandible, with no cases of recurrence in the maxilla.According to our experience in this case series, surgery is the main method for the treatment of jaw osteonecrosis in patients using “Krokodil”. Cessation of drug use and jaw resection minimize the rate of recurrences in such patients.

Platelet-Rich Plasma in Treatment of Zoledronic Acid-Induced Bisphosphonate-related Osteonecrosis of the Jaws.

Background:Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a well-known challenging entity warranting management. Platelet-Rich Plasma (PRP) plays an important role in bone biology by enhancing bone repair and regeneration.Objectives:The aim of this animal study was to evaluate the effects of PRP on zoledronic acid-induced BRONJ.Materials and Methods:Seven rats were given 0.04 mg Zoledronic acid intravenously once a week for five weeks. Two weeks later, the animals underwent extraction of their first lower molars, bilaterally. After clinical confirmation of the osteonecrosis, PRP was injected randomly into one of the extraction sockets of each rat. Three weeks later, all rats were sacrificed in order to obtain histological sections. The analysis of epithelialization was performed by McNamar’s test, and the analysis of osteogenesis and angiogenesis was performed by the Wilcoxon Sign Rank test. P value was set at 0.05.Results:We found no significant differences between the two groups regarding the amount of epithelialization, angiogenesis or sequestrum formation (P > 0.05), but a significant difference was seen between the two groups regarding the amount of existing vital bone (P < 0.05).Conclusions:Our study demonstrates positive results (preservation or regeneration of bone) using PRP in treatment of BRONJ. Although PRP may enhance osseous regeneration, long-term follow-ups are required to confirm its benefits.

Bisphosphonates inhibit bone remodeling in the jaw bones of rats and delay healing following tooth extractions

This study aimed to evaluate the impact of concurrent administration of clinically relevant doses of zoledronic acid (ZA) and dexamethasone (DX) on bone healing after tooth extraction (EXO). Forty-four Sprague-Dawley rats (6-8 month old) were randomized into five groups: ZA + DX = weekly injection of ZA with DX for 7 weeks; WD = ZA with DX for 3 weeks then DX alone for 4 weeks; C = control saline for 7 weeks; ZA = ZA alone for 7 weeks and DX = DX alone for 7 weeks. ZA was administered at 0.13 mg/kg/week and DX at 3.8 mg/kg/week and body weights recorded at the time of injection. All rats underwent extraction (EXO) of the mandibular and maxillary first molars at 3 weeks and were euthanized at 7 weeks. The extracted and non-extracted sides of both jaws were harvested for micro-CT analyses. All rats, particularly those injected with ZA, exhibited weight gain till EXO followed by decline then recovery. ZA + DX group demonstrated highest fractional bone to tissue volume (BV/TV) in the non-extracted side. ZA + DX rats exhibited also highest volume and surface of sequestra. Only sequestra volume was statistically higher in the WD group compared to C group. Combined treatment with ZA and DX over a prolonged period inhibits bone remodeling and increased sequestra formation to a greater extent than either drug alone. Trauma caused by these sequestra cutting through the mucosa could play a key role in the development of BRONJ by potentially facilitating infection. ZA withdrawal may promote bone-remodeling reactivation following EXO.

Long term outcome after surgical correction of mandibular brachygnathia with unilateral type 1 external skeletal fixation

To describe complications and long-term outcome after surgical correction of severe overbite in 7 horses using corrective osteotomy and a Type I external fixator. Case series. Horses (n = 7). Seven horses with severe mandibular brachygnathia were treated by corrective osteotomy and a Type I external fixator. Data on surgical technique, complications, long-term outcome and owner satisfaction were recorded. Severe mandibular brachygnathia was corrected successfully in all horses. Short term follow-up revealed a relatively high morbidity due to several complications such as surgical site infection, sequestrum formation and instability due to early pin loosening. Long-term over all owner satisfaction was very high. Corrective osteotomy and fixation with an external fixator is an effective surgical technique for correction of severe mandibular brachygnathia and offers good results in a long-term perspective.

Radiographic findings of bisphosphonate-related osteomyelitis of the jaw: investigation of the diagnostic points by comparison with radiation osteomyelitis, suppurative osteomyelitis, and diffuse sclerosing osteomyelitis

To investigate the possibility of radiographic examination as a tool for differential diagnosis of bisphosphonate-related osteomyelitis of the jaw (BROMJ). The radiographic findings of the mandibular lesions in 25 BROMJ patients were compared with those in 36 radiation osteomyelitis, 92 suppurative osteomyelitis, and 34 diffuse sclerosing osteomyelitis patients. The diagnostic criterion for BROMJ was osteomyelitis in patients with experience of bisphosphonate therapy. The amount and duration of bisphosphonate administration and presence and term of bone exposure were not considered for diagnosis. BROMJ revealed characteristic radiographic findings. Osteolytic change that started at the superficial layer of bone (cortical bone), followed by extension between the cortical and cancellous bone, large cancellous bone sequestrum formation often accompanied by extensive osteolytic change of the cortical bone or fairly large cortical bone sequestrum formation, and solid-type periosteal reaction formed at a site related to the margin of the remaining cortical bone were found to be pathognomonic, and were observed not only in cases with bone exposure but also in cases without bone exposure. A relationship between lamina dura thickening and the lesion was doubtful. Osteosclerotic change was frequent and remarkable, but not specific. Radiographic examination was considered to be useful for differential diagnosis of BROMJ. Inclusion of the pathognomonic radiographic findings into the definition of BROMJ will make it possible to achieve earlier and more accurate diagnoses. In addition, the active bone remodeling in the lesions confirmed by radiography suggested that osteonecrosis was not the cause, but the result of infection.

The phosphorous necrosis of the jaws and what can we learn from the past: a comparison of “phossy” and “bisphossy” jaw

The osteopathology of the jaws associated with bone resorption inhibitors is a current topic that engages a variety of clinical specialists. This has increased after the approval of denosumab for treatment of osteoporosis and skeletal-related events in patients with solid malignancy. Early after the first publications, there is a possible connection between phosphorous necrosis of the jaws, a dreadful industrial disease mentioned, and bisphosphonate-induced pathology. The nineteenth century was the prime time for phosphorus necrosis of match factory workers. This occurrence provides an interesting insight into the medical and surgical profession in the nineteenth century. There are striking parallels and repetition of current and old ideas in the approach to this "new disease." There are similar examples in case descriptions when compared with today's patients of bisphosphonate-related osteonecrosis of the jaws (BRONJ). Phosphorus necrosis was first described in Austria. Soon after this, surgeons in German-speaking countries including well-known clinicians Wegner (1872) and von Schulthess-Rechberg (1879) pioneered the analysis, preventative measures, and treatment of this disease. The tendency at this time was to approach BRONJ as a "special kind of osteomyelitis" in pretreated and metabolically different bone. Not only the treatment strategy to wait until sequestrum formation with subsequent removal and preventative measures but also the idea of focusing on the periosteum as the triggering anatomical structure may have been adopted from specialists in the nineteenth century. Therefore, phosphorous necrosis of the jaw is an excellent example of "learning from the past."

Chronic osteomyelitis of ilium presenting as an expansile mutiloculated lytic lesion - A case report.

Chronic iliac osteomyelitis classically presents radiologically as an ill defined radiolucent lesion with moth eaten appearance along with periosteal reaction and sequestrum formation. Our case report presents a rare radiological picture of iliac bone osteomyelitis in the form of an expansile mutiloculated lytic lesion.

PDGF-Simvastatin Delivery Stimulates Osteogenesis in Heat-induced Osteonecrosis

Heat generated during implant osteotomy might lead to osteonecrosis and delayed bone repair, thus resulting in impaired early osseointegration and fixation of bone-anchoring devices. In this study, we proposed to overcome heat-induced injury to bone by fabricating core-shell polymeric biodegradable microspheres encapsulating a mitogenic factor, platelet-derived growth factor (PDGF), and a differentiation factor, simvastatin, in a simultaneous or sequential release profile. Microspheres encapsulating bovine serum albumin (BSA), PDGF, simvastatin, PDGF-in-core with simvastatin-in-shell, and simvastatin-in-core with PDGF-in-shell were delivered to fill standardized osteotomy sites on edentulous ridges of rat maxillae under irrigated or non-irrigated conditions. In the absence of irrigation, significant reduction of cell viability and increase in inflammation and sequestrum formation without evidence of osteogenesis were observed. Both PDGF and simvastatin deliveries facilitated cell viability and reduced osteonecrosis. Localized osteogenesis was seen under simvastatin treatment, while generalized but primitive osteogenesis was noted in PDGF-treated osteotomy sites. In addition, sequential PDGF-simvastatin delivery further augmented osteogenesis and promoted bone maturation. The results suggested that sequential PDGF-simvastatin delivery was an effective modality to prevent heat-induced complications and facilitate bone apposition after implant osteotomy, potentially favoring the early fixation of bone-anchoring devices and oral implant osseointegration.

Keratocystic odontogenic tumors and Carnoy’s solution: results and complications assessment

Keratocystic odontogenic tumors (KOTs) can be treated with Carnoy's solution, although this treatment modality is not free from complications. It is important to verify the incidence of complications after the use of Carnoy's solution and compare these with the literature. This study verified the effects of a complementary treatment for KOTs and assessed the incidence of such complications as recurrence, infection, sequestrum formation, mandibular fracture, dehiscence, and neuropathy. Twenty-two KOTs treated with Carnoy's solution combined with peripheral ostectomy were included, and the follow-up period varied from 12 to 78months with a mean of 42.9months. Complications included recurrence (4.5%), dehiscence (22.7%), infection (4.5%), and paresthesia (18.2%). No difference was found among lesions associated (9.1%) or not (0%) with nevoid basal cell carcinoma syndrome (P>0.05). Dehiscence was influenced by marsupialization (P<0.05), and paresthesia was observed exclusively in cases of mandibular canal fenestration (P<0.01). Complementary treatment with Carnoy's solution and peripheral ostectomy appear to provide efficient treatment for KOTs. Complications originating from the use of the solution are less frequent and less serious than complications associated with cryotherapy. Neuropathy seems to be related to direct contact between the solution and the epineurium.

Craniofacial fibrous dysplasia

Fibrous dysplasia can present clinically in varied forms which may appear as collision of different pathologic processes. We report a rare case of craniofacial fibrous dysplasia with coexisting epithelial lined cyst and superimposed osteomyelitis with sequestrum formation. Its clinical features and management with possible hypotheses are described along with the post operative course. Pertinent literature has been reviewed with emphasis on pathogenesis of this unique occurrence.

Treatment of bisphosphonate-related osteonecrosis of the jaws: presentation of a protocol and an observational longitudinal study of an Italian series of cases

The aim of this study was to evaluate the efficacy of a treatment protocol for bisphosphonate-related osteonecrosis of the jaws (BRONJs). We conducted a longitudinal observational non-controlled study in 94 patients with confirmed BRONJ. Treatment was in two phases: supportive (antimicrobial mouth rinses, antibiotics, and anti-inflammatory steroids) to minimise infection and pain before the formation of a bony sequestrum; and surgical plus pharmacological treatment (sequestrectomy with antibiotic prophylaxis) after the sequestrum had developed. We did a Kaplan–Meier analysis (survival curve) to evaluate the time from the initial assessment until the formation of the bony sequestrum (endpoint), and a log-rank (Mantel–Haenszel) test to compare the formation times of the sequestra in men and women. Ninety-one of the 94 patients developed sequestra and were operated on. Three patients were withdrawn from the study because of severe pain and were treated by debridement before the sequestra developed. The results showed that sequestra developed within 15 months in all 91 patients. The Kaplan–Meier analysis showed that the mean time to formation of a sequestrum was 8 months (range 5–11). The difference between the mean time for men (5 months, range 2–8) and women (9 months, range 6–12) was highly significant (p<0.0001). Within the limits of this study, we conclude that by waiting for the formation of bony sequestra while controlling infection and pain, it is possible to do a conservative resection, unless pain is severe or there is a risk of fracture. This non-aggressive approach permits the removal of all necrotic bone, avoids damage to adjacent healthy bone, and does not result in recurrences.

Association of Enterococcus cecorum with vertebral osteomyelitis and spondylolisthesis in broiler parent chicks

Enterococcus cecorum is the most frequently occurring enterococcal species in the intestine of chickens of over 12 weeks of age, and there are few reports on its isolation from the skeleton of broiler parent chicks. In the present study, observations on vertebral osteomyelitis and spondylolisthesis ('kinky back syndrome') showing high incidence in 8 broiler parent flocks in different parts of Hungary are summarised. Clinical signs were seen only in roosters between 5 and 13 weeks of age. Diseased birds were alert and remained sitting on their hocks with their feet slightly raised off the ground. Incidence of the disease among male birds ranged from 8% to 30% depending on flocks. Enlargement and distortion of the body of the 6th vertebra were seen as the main pathological lesions. The cavity of the spinal canal was constricted by the distorted vertebral bodies. Resorption of bone tissue and sequestrum formation, signs of increased osteoclast activity, proliferation of fibrotic tissues, infiltration with heterophils and formation of sclerotic layers were detected in the vertebral bodies. From all 24 samples collected from the vertebral lesions, Enterococcus cecorum was isolated and identified using metabolic fingerprinting as well as 16S rRNA gene sequencing. Demonstration of E. cecorum from the vertebral lesions in all examined broiler breeder roosters showing the same clinical and pathological findings in different flocks suggested the pathogenic role of this microorganism for the first time in Hungary.

Participatory rural appraisal of livestock diseases among the Fulani community of the Barkin Ladi Local Government Area, Plateau State, Nigeria.

The effect of long-acting oxytetracycline treatment in the development of sequestra in contagious bovine pleuropneumonia (CBPP)-infected animals was determined. Thirty five clinically healthy zebu cattle, negative for CBPP antibodies (as tested by a competitive ELISA), were infected with Mycoplasma mycoides subsp. mycoidessmall colony variant - field isolate. All the animals were monitored for clinical signs of illness and regularly sampled for serological and bacteriological analysis. Nine animals were treated with long-acting tetracycline upon the first evidence of clinical signs of illness. The 26 remaining animals were left untreated and served as control animals. Post-mortem examinations were performed to assess the presence or absence of CBPP gross lesions. The experimentation lasted for 10 months during which, 13 animals (all untreated) died with acute lung lesions. When the 22 surviving animals (13 untreated and 9 treated) were slaughtered at the end of experimentation, chronic lesions were observed in all of them. Among the 13 untreated animals, 10 had visible lung sequestra and 3 had cicatrical lesions indicative of resolved lung lesions. Conversely, among the 9 treated animals, only 1 had a small lung sequestrum and the remaining 8 had pulmonary adhesions. The results presented demonstrate that, under the experimental conditions used, treatment with oxytetracycline did not result in significant sequestra formation in CBPP-infected animals. Full field validation is required in order to confirm these findings. Key words: Participatory rural appraisal, open-ended interview, proportional piling, key informants, animal disease control.

Surgical treatment of osteomyelitis and formation of a sequestrum in the distal metaphysis of the humerus in an alpaca cria

CASE HISTORY: An 8-week-old, 16-kg alpaca cria was presented with a 2-week history of acute onset of left forelimb lameness. CLINICAL FINDINGS: The cria was weight-bearing but lame at the walk in the left forelimb. There was swelling, heat and pain on palpation of the soft tissues, extending from the mid-shaft of the humerus to the elbow. There was no evidence of a traumatic injury. Radiologically, there was evidence of osteomyelitis and a sequestrum involving the distal metaphysis of the humerus. The sequestrum was removed surgically. No bacteria were cultured from samples taken during surgery. After an initial improvement, the cria became acutely lame, and developed an abscess at the surgical site, which was drained. A pure growth of a strictly anaerobic, Gram-negative, non-spore-forming, pleomorphic, filamentous rod was cultured from fluid from the abscess. Further radiographs suggested a second sequestrum was present, and this was removed surgically. Apart from partial dehiscence of the wound, the cria recovered well, and was sound and without complications 18 months after surgery. DIAGNOSIS: Osteomyelitis and formation of sequestra in the distal metaphysic of the left humerus. CLINICAL RELEVANCE: There has only been one case of osteomyelitis and bone sequestration without evidence of trauma in alpaca crias reported in the literature. However, anecdotal reports by veterinary practitioners described similar cases of osteomyelitis and bone sequestration, usually affecting the long bones. Further investigation of osteomyelitis and bone sequestration in crias is needed, to define the incidence, determine the pathogenesis, and develop specific recommendations for prevention and treatment.

Experimental studies on the effect of long-acting oxytetracycline treatment in the development of sequestra in contagious bovine pleuropneumonia- infected cattle

The effect of long-acting oxytetracycline treatment in the development of sequestra in contagious bovine pleuropneumonia (CBPP)-infected animals was determined. Thirty five clinically healthy zebu cattle, negative for CBPP antibodies (as tested by a competitive ELISA), were infected with Mycoplasma mycoides subsp. mycoidessmall colony variant - field isolate. All the animals were monitored for clinical signs of illness and regularly sampled for serological and bacteriological analysis. Nine animals were treated with long-acting tetracycline upon the first evidence of clinical signs of illness. The 26 remaining animals were left untreated and served as control animals. Post-mortem examinations were performed to assess the presence or absence of CBPP gross lesions. The experimentation lasted for 10 months during which, 13 animals (all untreated) died with acute lung lesions. When the 22 surviving animals (13 untreated and 9 treated) were slaughtered at the end of experimentation, chronic lesions were observed in all of them. Among the 13 untreated animals, 10 had visible lung sequestra and 3 had cicatrical lesions indicative of resolved lung lesions. Conversely, among the 9 treated animals, only 1 had a small lung sequestrum and the remaining 8 had pulmonary adhesions. The results presented demonstrate that, under the experimental conditions used, treatment with oxytetracycline did not result in significant sequestra formation in CBPP-infected animals. Full field validation is required in order to confirm these findings. Key words: Contagious bovine pleuropneumonia, antibiotherapy, oxytetracycline, lung sequestra, experimental transmission, Mali.

Chronic suppurative osteomyelitis of maxilla mimicking actinimycotic osteomyelitis: A rare case report

Osteomyelitis is a disease which is heterogeneous in its pathophysiology, clinical presentation and management. It is considered to be one of the most difficult-to-treat infectious diseases. Progressive bony destruction and the formation of sequestra are hallmarks of osteomyelitis. We hereby report a rare case of maxillary osteomyelitis, which had actinomycotic osteomyelitis like presentation but was histopathologically diagnosed as a severe form of chronic suppurative osteomyelitis.

Benign Osteonecrosis of the Temporal Bone: A Rare Etiology

A retrospective review of 6 patients treated at our institution was conducted following submission to the institutional review board, which determined that the investigation qualified for exemption These patients were treated between 2006 and 2009. Hospital and office charts were reviewed for ascertainment of relevant information. Of the 6 patients, 5 patients had undergone biopsy and subsequent reconstruction of the surgical defect. Of the 5 patients whom underwent surgery, mean follow-up time was 9 months postoperatively. One patient who declined surgical intervention has been followed for 29 months. Benign Osteonecrosis of the temporal bone (BONTB) is a rare condition with an obscure etiology. The suggested pathophysiologic process involves compromise of the blood supply to the tympanic plate, leading to the formation of an avascular bony sequestrum. The literature available on BONTB is sparse, and are usually case series. Details of the management-both surgical and medical-of patients with BONTB are also sparse. In this study, we wish to present our experience with six patients with BONTB, including a review of the literature regarding BONTB.

Osteomyelitis-related sequestrum formation in association with the combination tibial plateau levelling osteotomy and cranial closing wedge osteotomy procedure

A twenty-eight-month old female spayed American Bulldog was presented for evaluation of a chronic draining tract and intermittent left hindlimb lameness twenty-eight weeks after a combination tibial plateau levelling osteotomy and cranial closing wedge osteotomy (TLPO/CCWO) had been performed. The patient had developed an infection of the surgical site three weeks postoperatively. Drainage persisted despite implant removal 10 weeks postoperatively and several weeks of culture and sensitivity-directed antibiotic therapy. Twenty-eight weeks postoperatively, a sequestrum was identified on radiographs. Surgical removal of the sequestrum resulted in resolution of the drainage. While osteomyelitis is a known complication of TPLO surgery, this case represents the first described case of osteomyelitis-related sequestrum formation in association with the combined TPLO/CCWO procedure.

Occult metastatic intestinal adenocarcinoma resulting in pathological fracture of the proximal humerus

Intestinal adenocarcinomas are rare but have been described in the literature. The present case is unusual in both its clinical presentation and in the distribution of metastatic lesions. The sequestrum formation and pathological fracture present are most commonly associated with osteomyelitis in horses and the details of the case highlight the need for differential diagnosis in these particular circumstances and of which clinicians should be aware.