Posttraumatic Osteomyelitis Research Articles

Can bone SPECT/CT determine optimal sites for microbiological identification in post-traumatic or chronic osteomyelitis of extremities?

IntroductionAccurate microbiological identification is crucial when managing chronic osteomyelitis (COM) and post-traumatic osteomyelitis (PTO). Although bone single photon emission computed tomography/computed tomography (SPECT/CT) has helped in localizing osteomyelitis lesions, its effectiveness in guiding microbiological sampling remains unclear. This study aimed to determine whether bone SPECT/CT can improve microbiological identification rates in COM or PTO of the extremities. Patients and methodsFrom February 2020 to August 2024, 53 patients with suspected COM or PTO in the extremities were retrospectively analyzed. All patients underwent bone SPECT/CT, followed by microbiological sampling during surgery. Tissue samples were taken from the areas of high SPECT/CT uptake or based on intraoperative findings where no uptake was observed. Microorganism identification rates were analyzed, including a sub-group analysis based on antibiotic discontinuation. ResultsOf the 53 patients, 42 had positive bone SPECT/CT scan findings, with pathogen identification in 30 patients (71.4 %). In contrast, pathogen identification occurred in one out of twelve patients (9.1 %) with negative findings (odds ratio 25, p< 0.001). Bone SPECT/CT demonstrated a sensitivity of 96.8 % and an overall accuracy of 75.5 %. When antibiotics had been discontinued for ≥2 weeks, the pathogen identification rate increased to 90 %, compared with 50 % for <2 weeks of discontinuation (odds ratio 10.0, p= 0.006). In a sub-group of 30 patients with adequate antibiotic discontinuation duration, a positive bone SPECT/CT scan yielded a pathogen identification rate of 90.1 % (odds ratio 60.0, p= 0.001). ConclusionBone SPECT/CT effectively identifies optimal sites for microbiological sampling in COM and PTO of the extremities, particularly when antibiotics have been discontinued for ≥2 weeks, enhancing pathogen detection rates.

Posttraumatic Pseudomonas aeruginosa Osteomyelitis in Mosul and Gaza: A Retrospective Cohort Study, 2018-2022.

The history of conflicts in the Middle East has resulted in a high burden of complications from conflict-related wounds like posttraumatic osteomyelitis (PTO). This is particularly challenging to manage in settings like Mosul, Iraq and Gaza, Palestine, where healthcare systems are weakened. In nonconflict settings, PTO caused by Pseudomonas aeruginosa (PAPTO) can lead to >20% of treatment failures. We aim to describe the clinical characteristics, outcomes, and management, in PAPTO patients admitted to Médecins Sans Frontières (MSF) facilities in Mosul and Gaza between 1 April 2018 and 31 January 2022. We conducted a retrospective cohort study on patients with PAPTO diagnosed with culture of intraoperative bone biopsy, using routinely collected data. Among 66 PAPTO episodes from 61 enrolled patients, 37.9% had a multidrug-resistant Pseudomonas aeruginosa, with higher antibiotic resistance in Gaza. Polymicrobial infections were prevalent (74.2%), mainly involving Staphylococcus aureus (74.1%), being predominantly methicillin-resistant (95.0%). Overall, 81.7% received appropriate antibiotic treatment, with monotherapy used in 60.6% of episodes and a median treatment duration of 45.5 days. Recurrence was observed in 24.6% of episodes within a median of 195 days (interquartile range, 64-440 days). No significant differences were found in recurrence rates based on the type of antibiotic treatment (mono- or dual therapy) or episode (mono- or polymicrobial). Management of PAPTO in the conflict-affected, low-resource settings of Mosul and Gaza achieved a recurrence rate aligned with global reports through appropriate and targeted antibiotic use, primarily in monotherapy, provided over a mean treatment duration of 45.5 days.

Management strategies for Docking Site refractures: a comparative analysis of 19 patient cases

AimsThis study aimed to compare the clinical effectiveness of intramedullary nailing (IMN), percutaneous external plate fixation (PEPF), and re-applied external fixation (REF) in the treatment of refracture at the consolidated docking site following the removal of external fixation in patients with tibial defects who had previously undergone the Ilizarov bone transport technique.MethodsA retrospective review was performed on patients who received IMN, PEPF, or REF for refracture at the consolidated docking site subsequent to the removal of external fixation. A collection of data was made regarding the following parameters: age, gender, defect size, treatment methods, external fixation time (EFT), external fixation index (EFI), time of refracture (TOR) subsequent to fixation removal, and docking reunion time (DRT). Bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system and the Lower Extremity Functional Scale (LEFS) questionnaire.ResultsThe study included 14 males and 5 females with an average age of 38.1 ± 8.9 years (range, 26 to 55 years). Etiologies included post-traumatic osteomyelitis in 11 cases and post-traumatic bone loss in 8 cases. The median bone defect was 5.11 ± 0.87 cm (range, 3.8 to 6.8 cm). Following docking site refracture, 6 cases were treated with IMN, 8 with PEPF, and 5 with REF. All patients achieved both satisfactory bone union and functional outcomes, and there was no significant difference in preoperative baseline data or postoperative outcomes among the three groups.ConclusionIMN, PEPF, and REF were all demonstrated favorable postoperative bone and functional outcomes, suggesting their reliability as treatment options for managing docking site refracture following external fixation removal.

Preliminary osteogenic and antibacterial investigations of wood derived antibiotic-loaded bone substitute for the treatment of infected bone defects.

Introduction: The development of reliable treatments for infected or potentially infected bone loss resulting from open fractures and non-unions is extremely urgent, especially to reduce the prolonged courses of antimicrobial therapy to which affected patients are subjected. Numerous bone graft substitutes have been used over the years, but there are currently no effective solutions to treat critical bone loss, especially in the presence of infection. The present study evaluated the use of the biomorphic calcium phosphate bone scaffold b. Bone™, based on a next-generation resorbable biomimetic biomaterial, in bone reconstruction surgery in cases of infection. Methods: Using an "in vitro 3D bone fracture model" to predict the behavior of this drug delivery system during critical bone loss at an infected (or potentially infected) site, the effects of scaffolds loaded with gentamicin or vancomycin on the viability and differentiation capacity of human mesenchymal stem cells (hMSCs) were evaluated. Results: This scaffold, when loaded with gentamicin or vancomycin, exhibits a typical drug release curve that determines the inhibitory effects on the growth of Staphylococcus aureus, Enterococcus faecalis, and Escherichia coli, as well as relative biofilm formation. Discussion: The study demonstrates that b.bone scaffolds can effectively address key challenges in orthopedic surgery and patient care by inhibiting bacterial growth and biofilm formation through rapid, potent antibiotic release, reducing the risk of treatment failure due to resistance, and providing a promising solution for bone infections and improved patient outcomes. Future studies could explore the combination of different antibiotics on these scaffolds for more tailored and effective treatments against post-traumatic osteomyelitis pathogens.

Prevention and treatment of osteomyelitis after open tibia fractures.

Infection and chronic post-traumatic osteomyelitis of the tibia after open fracture are complex problems that cause significant morbidity and threaten the viability of a limb. Therefore, it is of utmost importance for the orthopaedic surgeon to understand both patient and treatment factors that modify the risk of developing these disastrous complications. Infection risk is largely based on severity of open injury in addition to inherent patient factors. Orthopaedic surgeons can work to mitigate this risk with prompt antibiotic administration, thorough and complete debridement, expedient fracture stabilization, and early wound closure. In the case osteomyelitis does occur, the surgeon should use a systematic multidisciplinary approach for eradication.

Trifocal versus Pentafocal bone transport in segmental tibial defects: a matched comparative analysis for posttraumatic osteomyelitis treatment

PurposeThe objective of this study was to evaluate and compare the effectiveness and clinical results of trifocal bone transport (TBT) and pentafocal bone transport (PBT) in treating distal tibial defects > 6 cm resulting from posttraumatic osteomyelitis, highlighting the potential advantages and challenges of each method.MethodsA retrospective assessment was conducted on an overall population of 46 eligible patients with distal tibial defects > 6 cm who received treatment between January 2015 and January 2019. Propensity score analysis was used to pair 10 patients who received TBT with 10 patients who received PBT. The outcomes assessed included demographic information, external fixation time (EFT), external fixation index (EFI), bone and functional outcomes assessed using the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated using the Paley classification.ResultsThe demographic and baseline data of the two groups were comparable. Following radical debridement, the average tibial defect was 7.02 ± 0.68 cm. The mean EFT was significantly shorter in the PBT group (130.9 ± 16.0 days) compared to the TBT group (297.3 ± 14.3 days). Similarly, the EFI was lower in the PBT group (20.67 ± 2.75 days/cm) than in the TBT group (35.86 ± 3.69 days/cm). Both groups exhibited satisfactory postoperative bone and functional results. Pin site infection was the most common complication and the rates were significantly different between the groups, with the PBT group demonstrating a higher incidence.ConclusionBoth TBT and PBT effectively treat posttraumatic tibial defects greater than 6 cm, with PBT offering more efficient bone regeneration. However, PBT is associated with a higher rate of pin site infections, highlighting the importance of careful management in these complex procedures and emphasizing the need for expert surgical execution and tailored treatment approaches in orthopedic reconstructive surgery.

Non‑contact locking plate: A useful alternative to external fixation in second‑stage treatment of post‑traumatic tibial osteomyelitis.

The treatment of infected tibial bone defects can be challenging for the orthopedic surgeon. Therefore, the aim of the present study was to compare the fixation endurance, bone union time, lower limb joint function and complications associated with different fixation methods in the treatment of bone defects caused by debridement in the treatment of post-traumatic osteomyelitis. The clinical data of 55 patients with infected bone defects of the lower extremities following traumatic injury, who had undergone radical debridement between January 2017 and September 2020, were retrospectively analyzed. The patients were divided into three groups according to the type of fixation during reconstruction, namely the external fixation (EX), internal fixation (IX) and non-contact locking plate (LP) groups. The demographic data, time to bone union, bacterial culture results, complications and Self-Rating Anxiety Scale (SAS) scores of the patients were compared among the three groups. The results indicated that the differences in time to bone union and recurrence rates of osteomyelitis among the three groups were not statistically significant. By contrast, functional status after surgery was significantly higher in the LP group compared with the EX group. In total, 8/22 patients (36.4%) in the EX group, 4/13 patients (30.8%) in the IX group and 4/20 patients (20.0%) in the non-contact LP group had shortened limbs and deformed tibia. The SAS assessment results revealed that patients in the non-contact LP group had the lowest rates of moderate and severe anxiety. In conclusion, the results of the present study demonstrate that the non-contact locking plate technique provided stable fixation without any contact between the implant and bone tissues. Therefore, this technique may be viable for use during the reconstruction stage of post-traumatic tibial osteomyelitis.

Inflammatory Microenvironment-Responsive Hydrogels Enclosed with Quorum Sensing Inhibitor for Treating Post-Traumatic Osteomyelitis.

Non-antibiotic strategies are desperately needed to treat post-traumatic osteomyelitis (PTO) due to the emergence of superbugs, complex inflammatory microenvironments, and greatly enriched biofilms. Previously, growing evidence indicated that quorum sensing (QS), a chemical communication signal among bacterial cells, can accelerate resistance under evolutionary pressure. This study aims to develop a medical dressing to treat PTO by inhibiting QS and regulating the inflammatory microenvironment, which includes severe oxidative stress and acid abscesses, through a reactive oxygen species (ROS)-responsive bond between N1- (4-borobenzoyl)-N3-(4-borobenzoyl)-the N1, the N1, N3, N3-tetramethylpropane-1,3-diamine (TSPBA) and polyvinyl alcohol (PVA), and the amino side chain of hyperbranched polylysine (HBPL). Physically enclosed QS inhibitors subsequently exerted the antibacterial effects. This hydrogel can scavenge hydrogen peroxide (H2O2), superoxide anion free radical (·O2 -), hydroxyl radicals (·OH) and 2,2-di(4-tert-octylphenyl)-1-picryl-hydrazyl (DPPH) to reduce oxidative stress and inhibit "bacteria-to-bacteria communication", thus clearing planktonic bacteria and biofilms, accelerating bacterial plasmolysis, reducing bacterial virulence and interfering with membrane transport. After in vivo treatment with hydrogel, nearly all bacteria are eliminated, inflammation is effectively inhibited, and osteogenesis and bone repair are promoted to facilitate recovery from PTO. The work demonstrates the clinical translational potential of the hydrogel in the treatment of drug-resistant bacteria induced PTO.

Increased production of aureolysin and staphopain A is a primary determinant of the reduced virulence of Staphylococcus aureus sarA mutants in osteomyelitis.

We previously demonstrated that mutation of sarA in Staphylococcus aureus limits biofilm formation, cytotoxicity for osteoblasts and osteoclasts, and virulence in osteomyelitis, and that all of these phenotypes can be attributed to the increased production of extracellular proteases. Here we extend these studies to assess the individual importance of these proteases alone and in combination with each other using the methicillin-resistant USA300 strain LAC, the methicillin-susceptible USA200 strain UAMS-1, and isogenic sarA mutants that were also unable to produce aureolysin (Aur), staphopain A (ScpA), staphylococcal serine protease A (subsp.), staphopain B (SspB), and the staphylococcal serine protease-like proteins A-F (SplA-F). Biofilm formation was restored in LAC and UAMS-1 sarA mutants by subsequent mutation of aur and scpA, while mutation of aur had the greatest impact on cytotoxicity to mammalian cells, particularly with conditioned medium (CM) from the more cytotoxic strain LAC. However, SDS-PAGE and western blot analysis of CM confirmed that mutation of sspAB was also required to mimic the phenotype of sarA mutants unable to produce any extracellular proteases. Nevertheless, in a murine model of post-traumatic osteomyelitis, mutation of aur and scpA had the greatest impact on restoring the virulence of LAC and UAMS-1 sarA mutants, with concurrent mutation of sspAB and the spl operon having relatively little effect. These results demonstrate that the increased production of Aur and ScpA in combination with each other is a primary determinant of the reduced virulence of S. aureus sarA mutants in diverse clinical isolates including both methicillin-resistant and methicillin-susceptible strains.IMPORTANCEPrevious work established that SarA plays a primary role in limiting the production of extracellular proteases to prevent them from limiting the abundance of S. aureus virulence factors. Eliminating the production of all 10 extracellular proteases in the methicillin-resistant strain LAC has also been shown to enhance virulence in a murine sepsis model, and this has been attributed to the specific proteases Aur and ScpA. The importance of this work lies in our demonstration that the increased production of these same proteases largely accounts for the decreased virulence of sarA mutants in a murine model of post-traumatic osteomyelitis not only in LAC but also in the methicillin-susceptible human osteomyelitis isolate UAMS-1. This confirms that sarA-mediated repression of Aur and ScpA production plays a critical role in the posttranslational regulation of S. aureus virulence factors in diverse clinical isolates and diverse forms of S. aureus infection.

Role of bone single photon emission computed tomography/computed tomography in managing chronic fracture-related infections: Determining the depth of infection and avoiding unnecessary bone procedures.

Fracture-related infections (FRIs) encompass a broad range of infections associated with bone fractures; they remain a significant clinical challenge. Here, we aimed to investigate the viability of focusing on soft-tissue management in patients suspected of chronic FRI, who exhibit no significant bony uptake on bone single photon emission computed tomography (SPECT)/computed tomography (CT) scans. Between January 2016 and January 2022, we managed 25 patients with chronic FRI or post-traumatic osteomyelitis using technetium 99m-methyl diphosphonate bone SPECT/CT to assess infection depth. Among them, 13 patients showing negligible bony uptake were included and categorized into two groups based on wound discharge reaching the bone/implant (Criteria 1, n = 6) or not (Criteria 2, n = 7). Patients in the Criteria 1 group were treated with antibiotics and soft tissue debridement without bony procedure. The average duration of antibiotic therapy was 6.7 weeks. Treatments were individualized, including implant changes, local flaps, skin grafts, and negative pressure wound therapy. No recurrence was reported in the mean follow-up of 21.3 months. Patients in the Criteria 2 group were treated with oral antibiotics (mean duration: 5.9 weeks) and daily wound dressings. No recurrence was reported in the mean follow-up of 26.0 months, and no surgical interventions were required. This study demonstrates the feasibility of focusing on soft-tissue management in patients with chronic FRI showing minimal bony uptake on bone SPECT/CT. Our treatment protocol avoided unnecessary surgical bone procedures, resulting in successful clinical outcomes with no recurrences.

Craniological features of the American mink in south-eastern Belarus

A series of skulls (n = 27) of the American mink (Neogale vison) from the south-east of Belarus (Gomel region, floodplain of the Sozh River) was studied. The animals were caught by different hunters in 2000–2004. The sex of individuals was not determined. When examining the skull, only the most pronounced morpho-anatomical changes that can be diagnosed confidently as deviations from the norm were taken into account. In all cases, lamellar deposition of calcium salts in the area of tentorium cerebelli osseum inside the cranial vault was detected. The growing plate length reached half of the arch height in some individuals. These traits (considerable area of bone plates; presence of a sharp spine growing in different plains) allow suggesting that the analysed growths are of pathological origin. This pathology can considerably affect the viability and physiological status of individuals as it disrupts the functioning of the central nervous system. It is difficult to identify the cause of intracranial calcifications due to the possible effect of factors of various nature. Some degree of calcification of the opisthion region of foramen magnum was found. The changes occurred in the foramen shape cannot be considered phenetic variability. In most individuals, the thinning of maxillary bone in the teeth roots area is observed. However, we believe that the identified degree of bone tissue thinning is not critical and therefore does not affect the life expectancy of individuals. Two adult individuals have swelling of the maxillary bone. In one case, an extensive bone tissue excavation was identified on the left lower jaw, which led to the loss of the canine tooth. The analysed pathomorphological change is not of traumatic nature because in case of post-traumatic osteomyelitis sequesters (separating fragments) are formed. It is necessary to further analyse the American mink skulls available at scientific collections of Belarus and to identify the degree of calcium salt deposits and their impact on the foramen magnum phenotypes. We consider it necessary to create an annotated catalogue of pathologies and anomalies of the skull of the American mink in the south-east of Belarus and adjacent territories of Ukraine, since the morphological method is essential in the diagnosis of bone tissue diseases.

Successful outpatient parenteral antibiotic therapy with cefiderocol for osteomyelitis caused by multi-drug resistant Gram-negative bacteria: a case report.

Post-traumatic osteomyelitis attributed to metallo-β-lactamase (MBL)-producing Gram-negative bacteria presents a challenging clinical scenario. Cefiderocol emerges as a viable treatment option within the limited therapeutic options available. In this brief report, we present a case of a Ukrainian patient with osteomyelitis caused by multi-drug resistant Pseudomonas aeruginosa, which was successfully treated with cefiderocol, facilitated in part by outpatient parenteral antibiotic therapy (OPAT). Administration of Cefiderocol via OPAT can present a safe and effective option for treatment of post-traumatic osteomyelitis with multi-drug resistant Pseudomonas aeruginosa. A possible effect on iron homeostasis of extended treatment duration with cefiderocol may be taken into consideration.

A clinical case of posttraumatic osteomyelitis associated with &lt;i&gt;kytococcus schroeteri&lt;/i&gt; and &lt;i&gt;enterococcus faecalis&lt;/i&gt;

Introduction. In most cases, osteomyelitis is the monomicrobial disease caused by various Gram-positive bacteria. However, previous injury may contribute to formation of a microbial association. Presence of two or more pathogens in the infectious focus can markedly complicate the disease clinical picture.Kytococcus schroeteriis one of the rarest pathogens found in clinical samples. Slightly more than twenty described cases related to such infection have been recorded globally. The aim of the research was to analyse the first identified clinical case of post-traumatic osteomyelitis associated withKytococcus schroeteriandEnterococcus faecalis.Materials and methods.The bacterial cultures were obtained from the wound discharge of the patient’s shin by the cultural method. Identification of the bacterial cultures was performed using a VITEK MS mass spectrometer followed by 16S rRNA gene sequencing. The morphological, tinctorial and biochemical features of the cultures obtained were established, and their antibacterial resistance was also determined.Results. The clinical case was associated with the diagnosis “Chronic post-traumatic osteomyelitis of the left shin”. Two types of microorganisms were isolated from the wound discharge, and identified asKytococcus schroeteriandEnterococcus faecalisusing the MALDI-ToF mass spectrometry method. 16S rRNA gene sequencing from the isolated bacterial cultures confirmed the MALDI-ToF mass spectrometry data. Antimicrobial susceptibility for this microorganism was determined according to the criteria for the staphylococcal group according to the clinical guide “Determination of sensitivity to antimicrobial drugs (rev. 2021)”.Conclusion. For the first time, the mixed infection caused by two Gram-positive bacteriaK. schroeteriandE. faecalishas been described. Such associations can enhance the pathogenic effects of each other bacterium, which may contribute to transition of the infection to a chronic form with a low probability of positive cultural test.K. schroeteriis a representative of the normal skin microbiota, but this microorganism is able to cause various infections. TheK. schroeterispecies should be differentiated from other representatives of the orderMicrococcales. At cultural examination, resistance to oxacillin is a suspicious sign indicating that the bacterial culture might be potentially assigned toK. schroeterispecies. Due to the unavailability of current biochemical tests for differentiationK. schroeterifrom related taxa, reliable identification of this species is recommended using MALDI-ToF mass spectrometry or 16S rRNA gene sequencing.

Maintenance of a cement spacer as definitive treatment of post traumatic osteomyelitis, a case report.

Background Septic nonunion is a devastating outcome following a tibial plafond fracture, causing significantly increased morbidity and a lengthy recovery. Treatment options include antibiotics and irrigation and debridement procedures focused on preventing posttraumatic osteomyelitis. If these options fail, surgical intervention is necessary to clear infection and debride nonviable bone, often resulting in a substantial bony void. Masquelet technique and Cement augmentation are well studied, multi-stage procedures designed specifically for combatting these defects. These procedures are associated with significant patient burden, a long non-weight-bearing period, and a lengthy recovery. The case presented here today highlights a variation of these techniques that reduced the need for the standard second stage procedure and resulted in a quicker return to normal activity. Case A 51-year-old obese male presented with a septic nonunion with posttraumatic osteomyelitis following a tibial plafond fracture. The patient underwent implant removal with simultaneous irrigation and debridement of all nonviable bone resulting in a substantial bony void. The nonunion was then stabilized with an antibiotic tibial nail, and an antibiotic cement spacer to fill the bony void. The patient was allowed to partial weight bear post operatively and quickly progressed weight bearing status. By postoperative week eight, the patient’s activity level had returned to near his baseline, and the patient was not interested in another procedure to remove the spacer and bone graft. At this time, it was elected to permanently maintain the cement spacer, and only exchange it for bone graft as needed. By one-year, radiographic films demonstrating bony healing around the cement spacer, and the patient was back to full pain-free function. Conclusions Permanently maintaining the cement spacer in cement augmentation or the Masquelet technique allowed this patient to quickly progress weight-bearing status, regain function, and return to normal life without the need for the stage two procedure.

Infectious complications in pediatric traumatology and orthopedics (analysis of clinical series)

BACKGROUND: Infectious complications in pediatric traumatology and orthopedics are relatively rare. Publications on this issue are less common than in the adult population. However, the resulting complications often lead to a persistent anatomical and functional defect, bearing the economic burden and legal consequences.&#x0D; AIM: To analyze a clinical series of pediatric patients with infectious complications of injuries and surgical interventions in the skeletal system.&#x0D; MATERIALS AND METHODS: A retrospective analysis of the clinical series of patients over 5 years was conducted. The study involved children aged 18 years. A sample of 34 children was included. The average age was 13.5 (minmax, 417 years). Patients with infectious and inflammatory complications after mechanical and/or surgical trauma, availability of a complete data archive (anamnesis, radiation therapy, and medical documentation), traced relief of inflammatory phenomena, and achievement of remission of the chronic process for more than 6 months were included.&#x0D; RESULTS: Infectious complications of injuries were noted in 26 (76%) patients, complications of orthopedic interventions in 8 (24%), and open injuries in 9 (34%). The injuries were isolated in 11 (42%) children, multiple trauma in 5 (19%), and combined in 10 (39%) patients. Defects of large skeletal segments were common: the thigh in 8 (24%) patients, humerus in 5 (15%), shin in 5 (15%), and spine in 4 (12%). Five (15%) had infection of the pelvic bones, and one patient had infectious complications in the lower jaw, collarbone, elbow joint, knee joint arthritis, and foot bones. Superficial infection of the surgical intervention area was noted in 3 cases (9%), deep infection in 27 (79%), and posttraumatic osteomyelitis in 4 (12%). The average duration of the diagnostic pause was 33 days, and the therapeutic pause was 36 days. Antibacterial prophylaxis before surgery for closed injuries and orthopedic operations was carried out in only 17 patients. Bacteriological verification was not performed in 8 (23.5%) patients with complications. In 9 (26%) patients, it was not possible to identify a microbial agent in the presence of a clinical picture. The structure of pathogens correlates with the literature data on the problem in the adult population. In 10 out of 25 positive bacteriological studies, polyresistant strains were isolated. Thirty-three children underwent surgery, and the basic principle is radical surgical rehabilitation. The average number of interventions performed was 3 (minmax, 112). Stable relief of the infectious and inflammatory process has been achieved in all cases. The average period of inpatient treatment was 39 days, recovery was achieved in 24 (71%) children, and persistent anatomical and functional defect and disability were noted in 10 (29%) children.&#x0D; CONCLUSIONS: Infectious complications in pediatric traumatology should be considered a complex multidisciplinary problem, and part of the solutions largely lies in the field of healthcare organization, specifically with an adequate choice of indications, compliance with the osteosynthesis technique, compliance with the principles of antibiotic prophylaxis, patient routine, and training of pediatric surgeons and orthopedic traumatologists on surgical infections, using modern principles and technologies for the treatment of these complications.

Preliminary Results and a Treatment Algorithm for Osteomyelitis of the Distal Tibia and Talus

Category: Hindfoot; Ankle Introduction/Purpose: Management of hindfoot osteomyelitis involves eradication of infection, deformity correction, and bony stabilization in the setting of bone loss and poor bone quality. This case series of 20 patients presents a two-stage technique: debridement, deformity correction, joint surface preparation, intramedullary reaming with antibiotic-impregnated polymethyl methacrylate rod and ring external fixation, followed by a second stage of external fixator removal and exchange of antibiotic rod for definitive hindfoot fusion rod. The purpose of the study is to highlight techniques and preliminary results that can improve the success of obtaining stable fixation, remission of infection and ultimately fusion. Techniques highlighted are ring fixator placement, antibiotic rod formulation, intramedullary canal preparation, rod exchange and use of blocking screws to enhance compression and axial loading of the fusion. Methods: Twenty patients were treated with this two-stage protocol. The most common indication was post-traumatic osteomyelitis followed by neuropathic (Charcot) joint. All were treated with an initial debridement of nonviable tissue including osteomyelitic bone. The tibiotalar and talocalcaneal joint surfaces were prepared for fusion at the initial debridement. Provisional stabilization and compression were obtained using a ring external fixator for patients without rotational stability. The polymethyl methacrylate-antibiotic impregnated rod (PMMA with gentamycin and vancomycin) was introduced through the calcaneus, talus, and the intramedullary space of the tibia. The patients were kept in the fixator until the skin was healed and all incisions were dry. At this point, the fixator was removed, and the antibiotic rod was exchanged for the definitive hindfoot fusion rod. Results: Cultures were positive for Staphylococcal or Streptococcal species in 60% of cases, Fingeoldia magna 10%, Cutibacterium Acnes 2%, and Gram-negative organisms in 30%. On average patients spent 80 days in the fixator while wounds were healing, and were receiving systemic antibiotics. One patient died while in the frame. There have been no amputations in the series. Of the patients that have completed the protocol, all have gone on to either bony fusion or stable fibrous union. All are able to walk unaided and 25% used an AFO to control and protect the foot and equalize leg length. Secondary procedures are described. Conclusion: This technique of staged fusion for hindfoot osteomyelitis offers the following advantages. The first stage involves thorough debridement and deformity correction. Oftentimes, there is extensive scarring, and the soft tissue envelope is not conducive to internal fixation. This technique allows the soft tissues to heal before placing the definitive internal fixation. It also allows for graduated compression at the fusion site with the ring fixator. The antibiotic rod not only delivers high concentration of local antibiotics, but it prevents deformity recurrence during the compression phase. The definitive rod provides support of pathologic bone and maintains deformity correction.

X-ray features and diagnostics of purulent-necrotic lesions of the jaws

X-ray data of 750 patients with odontogenic and non-odontogenic osteomyelitis of the jaws aged 18 to 65 years were studied. The results of orthopantomography, panoramic zonography of facial bones, telerentgenography of the skull, intraoral radiography, computed tomography of the maxillofacial region are analyzed.&#x0D; The radiological characteristics of odontogenic acute, subacute, chronic and primary chronic osteomyelitis, hematogenic and posttraumatic osteomyelitis, radiation, bisphosphonate and phosphorus necrosis of the jaws are presented, taking into account differential diagnosis.&#x0D; The radiological semiotics of osteomyelitis of the jaws is diverse, since the features of the manifestation of osteomyelitis depend on the etiology, stage of the course and form of the bone inflammatory process.&#x0D; Orthopantomography is a method of primary diagnosis of osteomyelitis of the jaws. The use of computed tomography contributes to the accurate identification of the structure of the affected area, the magnitude of the destruction of anatomical details of the jaws and the boundaries of the spread of the purulent-necrotic process.

Pharmacological elevation of sphingosine-1-phosphate by S1P lyase inhibition accelerates bone regeneration after post-traumatic osteomyelitis.

Posttraumatic osteomyelitis and the ensuing bone defects are a debilitating complication after open fractures with little therapeutic options. We have recently identified potent osteoanabolic effects of sphingosine-1-phosphate (S1P) signalling and have now tested whether it may beneficially affect bone regeneration after infection. We employed pharmacological S1P lyase inhibition by 4-deoxypyrodoxin (DOP) to raise S1P levels in vivo in an unicortical long bone defect model of posttraumatic osteomyelitis in mice. In a translational approach, human bone specimens of clinical osteomyelitis patients were treated in organ culture in vitro with DOP. Bone regeneration was assessed by μCT, histomorphometry, immunohistology and gene expression analysis. The role of S1P receptors was addressed using S1PR3 deficient mice. Here, we present data that DOP treatment markedly enhanced osteogenesis in posttraumatic osteomyelitis. This was accompanied by greatly improved osteoblastogenesis and enhanced angiogenesis in the callus accompanied by osteoclast-mediated bone remodelling. We also identified the target of increased S1P to be the S1PR3 as S1PR3-/- mice showed no improvement of bone regeneration by DOP. In the human bone explants, bone mass significantly increased along with enhanced osteoblastogenesis and angiogenesis. Our data suggest that enhancement of S1P/S1PR3 signalling may be a promising therapeutic target for bone regeneration in posttraumatic osteomyelitis.

Risk Factors and Characteristics of Recalcitrant Osteomyelitis Following Initial Surgical and Antibiotic Treatment.

To evaluate the injury, patient, and microbiological characteristics that place patients at risk for recalcitrant fracture related infection and osteomyelitis despite appropriate initial treatment. Retrospective Chart Review. Three level I trauma centers. Two hundred and fifty-seven patients undergoing surgical debridement and antibiotic therapy for osteomyelitis from 2003 to 2019. Patients were categorized as having undergone serial bone debridement if they had two separate procedures a minimum of six weeks apart with a full course of appropriate antibiotics in between. Patient records were reviewed for age, injury location, body mass index (BMI), smoking status, comorbidities, and culture results including the presence of multidrug resistant organisms (MDRO) and culture-negative osteomyelitis. A total of 257 patients were identified; 49% (n=125) had a successful single course of treatment, and 51% (n=132) required repeat debridement for recalcitrant osteomyelitis. At the index treatment for osteomyelitis, the most common organisms in both groups were Methicillin-resistant (MRSA) and Methicillin-sensitive Staphylococcus aureus (MSSA). There was no significant difference in incidence of polymicrobial infection between the two groups (25% vs 20%, p=0.49). The most common organisms cultured at the time of repeat saucerization remained MRSA and MSSA, however, the same organism was cultured from both the index and repeat procedure in only 28% (n=37) of cases. Diabetic patients, IVDU, delay to diagnosis, and open fractures of the lower leg are independent risk factors for failure of initial treatment of post-traumatic osteomyelitis. Successful eradication of fracture related infection and post-traumatic osteomyelitis is difficult and fails 51% of the time despite standard surgical and antimicrobial therapy. While MRSA and MSSA remain the most common organisms cultured, patients who fail initial treatment for osteomyelitis often do not culture the same organisms as those obtained at the index procedure.

Extreme presentation of lower limb post-traumatic chronic osteomyelitis: a 56-year-long untreated and actively secreting fistula

Extreme presentation of lower limb post-traumatic chronic osteomyelitis: a 56-year-long untreated and actively secreting fistula