Sternal Osteomyelitis Research Articles

Musculoskeletal infections associated with Nocardia species: a case series.

Background: Nocardia is an uncommon pathogen that has been reported to infect musculoskeletal structures. However, studies are largely limited to case reports, and little is known regarding management and outcomes of these infections. Methods: We performed a multicenter retrospective cohort study of adults with culture-confirmed musculoskeletal Nocardia infections at three Mayo Clinic centers in Arizona, Florida, and Minnesota from November 2011 through April2022. Results: Nine cases of Nocardia musculoskeletal infection were identified. Seven (78 %) occurred in men, and the median age was 57.3 years (range 32.6-79.0). Specific infections included native joint septic arthritis with or without associated osteomyelitis ( ), hardware-associated infection ( ), sternal osteomyelitis ( ), pyomyositis ( ), bursitis ( ), and tenosynovitis ( ). Three cases (33 %) were associated with disseminated disease, all three occurring in solid organ transplant recipients. Surgical intervention was performed in all but the bursitis case. Length of treatment varied from 21 d for tenosynovitis to 467 d for osteomyelitis. The 1-year mortality was 22 %, and all fatal cases involved disseminated disease. Conclusion: Patients with localized nocardiosis affecting musculoskeletal structures generally have good outcomes, as opposed to those with disseminated infection. Management often required operative intervention, with one patient experiencing recurrence within 1year.

Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification.

Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken. This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF). Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA). Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm). By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.

Sonographic features of sternal pseudotumour in children

AbstractIntroductionSternal pseudotumour is an important but rare entity thought to be an inflammatory, non‐neoplastic lesion that can mimic tumours. The purpose of this paper was to illustrate the imaging features of this lesion to avoid unnecessary investigations.MethodsThe clinical notes and imaging features of four patients with a diagnosis of sternal pseudotumour were reviewed over a period from February 2016 to July 2019.ResultsAll patients were afebrile with no history of trauma. The median age at presentation was 12.5 months. The median length of symptoms prior to presentation was 3.5 days. One patient had a mildly elevated C‐reactive protein. Chest radiographs showed a pre‐sternal soft‐tissue mass, with or without osseous destruction of the subjacent sternum. Ultrasound showed a heterogeneous, hypoechoic pre‐sternal soft‐tissue mass with variable internal vascularity with extension between sternal ossification centres. CT and MRI showed an enhancing dumbbell‐shaped lesion with a pre‐sternal and retro‐sternal soft‐tissue component. The median time to complete resolution was 3 months. One patient had a biopsy that showed chronic inflammation and fibrosis.DiscussionThese lesions present in young children typically with a 1‐ to 2‐week history of a focal 2‐ to 4‐cm swelling over the sternum. The aetiology is unknown but may be on the basis of a yet‐to‐be identified pathogen. Inflammatory markers and cultures are normal or mildly elevated. Important differential considerations include sternal osteomyelitis or neoplastic causes such as Ewing sarcoma, rhabdomyosarcoma, Langerhans cell histiocytosis and infantile fibrosarcoma.ConclusionSternal pseudotumor is a rare but important entity to be aware of to avoid unnecessary invasive biopsy or further investigations. Our suggestion is that this is a ‘Don't touch’ lesion that requires close short‐interval follow‐up at a surgical outpatient clinic and with ultrasound until resolution.

A case of chest wall reconstruction with pedicled rib-latissimus dorsi osteo-muscle flap for sternal osteomyelitis and mediastinitis

A case of chest wall reconstruction with pedicled rib-latissimus dorsi osteo-muscle flap for sternal osteomyelitis and mediastinitis

DIFFICULTY OF DIAGNOSING METASTATIC BREAST CANCER IN A PATIENT AFTER MINIMALLY INVASIVE AORTIC VALVE REPLACEMENT: A CLINICAL CASE

HighlightsThe article describes a clinical case of a patient with metastatic breast cancer detected after aortic valve replacement. The case was initially treated as sternal osteomyelitis due to ministernotomy performed during aortic valve surgery. However, the diagnosis of metastatic breast cancer with sternal and spinal (third thoracic vertebra) metastatses, and ribs lesion was established upon further study. Adjuvant endocrine therapy was prescribed to the patient due to her age and previous surgery. AbstractBreast cancer is an urgent problem in oncology as it remains the most frequent type of cancer in the Russian Federation and world wide. Long-term treatment success and survival of patients depend on selected treatment modality, and long-term postopertive monitoring of patients as the means of the early detection of metastatic recurrence. Furthermore, concominant somatic ilness could change or mask the symptoms of local recurrence or metastasis, resulting in difficulties with establishing the proper diagnosis. We report a clinical case of metastatic breast cancer in a patient with severe aortic stenosis who underwent aortic valve replacement. We have not found analogious cases in domestic and foreign literature.

A Case Report of a LVAD Driveline Infection Diagnosed by Point-of-care Ultrasound.

As the prevalence of patients with left ventricular assist devices (LVAD) presenting to the emergency department (ED) increases, clinicians must be aware of LVAD-associated infections. A well-appearing, 41-year-old male with history of heart failure status post prior-LVAD placement presented to the ED for swelling of his chest. What appeared initially as a superficial infection was further assessed with point-of-care ultrasound and found to represent a chest wall abscess involving the driveline, ultimately resulting in sternal osteomyelitis and bacteremia. Point-of-care ultrasound should be considered an important tool in the initial assessment of potential LVAD-associated infection.

Microbiological study of sternal osteomyelitis after median thoracotomy – a retrospective cohort study

IntroductionDeep sternal wound infection is a rare but feared complication of median thoracotomies and is usually caused by microorganisms from the patient’s skin or mucous membranes, the external environment, or iatrogenic procedures. The most common involved pathogens are Staphylococcus aureus, Staphylococcus epidermidis and gram-negative bacteria. We aimed to evaluate the microbiological spectrum of deep sternal wound infections in our institution and to establish diagnostic and treatment algorithms.MethodsWe retrospectively evaluated the patients with deep sternal wound infections at our institution between March 2018 and December 2021. The inclusion criteria were the presence of deep sternal wound infection and complete sternal osteomyelitis. Eighty-seven patients could be included in the study. All patients received a radical sternectomy, with complete microbiological and histopathological analysis.ResultsIn 20 patients (23%) the infection was caused by S. epidermidis, in 17 patients (19.54%) by S. aureus, in 3 patients (3.45%) by Enterococcus spp., in 14 patients (16.09%) by gram-negative bacteria, while in 14 patients (16.09%) no pathogen could be identified. In 19 patients (21,84%) the infection was polymicrobial. Two patients had a superimposed Candida spp. infection. Methicillin-resistant S. epidermidis was found in 25 cases (28,74%), while methicillin-resistant S. aureus was isolated in only three cases (3,45%). The average hospital stay for monomicrobial infections was 29.93 ± 13.69 days and for polymicrobial infections was 37.47 ± 19.18 (p = 0.03). Wound swabs and tissue biopsies were routinely harvested for microbiological examination. The increasing number of biopsies was associated with the isolation of a pathogen (4.24 ± 2.22 vs. 2.18 ± 1.6, p < 0,001). Likewise, the increasing number of wound swabs was also associated with the isolation of a pathogen (4.22 ± 3.34 vs. 2.40 ± 1.45, p = 0.011). The median duration of antibiotic treatment was 24.62 (4–90) days intravenous and 23.54 (4–70) days orally. The length of antibiotic treatment for monomicrobial infections was 22.68 ± 14.27 days intravenous and 44.75 ± 25.87 days in total and for polymicrobial infections was 31.65 ± 22.29 days intravenous (p = 0.05) and 61.29 ± 41.45 in total (p = 0.07). The antibiotic treatment duration in patients with methicillin-resistant Staphylococci as well as in patients who developed an infection relapse was not significantly longer.ConclusionS. epidermidis and S. aureus remain the main pathogen in deep sternal wound infections. The number of wound swabs and tissue biopsies correlates with accurate pathogen isolation. With radical surgical treatment, the role of prolonged antibiotic treatment remains unclear and should be evaluated in future prospective randomized studies.

Pathological study of sternal osteomyelitis after median thoracotomy—a prospective cohort study

PurposeOsteomyelitis of the sternum may arise either as a primary condition or secondary to median thoracotomy after cardiac surgery, with the latter being decidedly more frequent. Deep sternal wound infections appear as a complication of median thoracotomy in 0.2 to 4.4% of cases and may encompass the infection of the sternal bone. To date, there are no exhaustive histopathological studies of the sternal osteomyelitis.MethodsOur work group developed a surgical technique to remove the complete infected sternal bone in deep sternal wound infections. We therefore prospectively examined the en bloc resected sternal specimens. Seven standard histological sections were made from the two hemisternums.ResultsForty-seven sternums could be investigated. The median age of the patients in the cohort was 66 (45–81) years and there were 10 females and 37 males. Two methods were developed to examine the histological findings, with one model dividing the results in inflammatory and non-inflammatory, while the second method using a score from 0 to 5 to describe more precisely the intensity of the bone inflammation. The results showed the presence of inflammation in 76.6 to 93.6% of the specimens, depending on the section. The left manubrial sections were more prone to inflammation, especially when the left mammary artery was harvested. No further risk factors proved to have a statistical significance.ConclusionOur study proved that the deep sternal wound infection may cause a ubiquitous inflammation of the sternal bone. The harvest of the left mammary artery may worsen the extent and intensity of infection.

Experience of successful treatment of a patient with chronic non-bacterial osteomyelitis (clinical case)

BACKGROUND: Chronic nonbacterial osteomyelitis is a rare autoinflammatory bone disease with periods of relapses and remissions. No etiotropic therapy, diagnostic and treatment standards exist, patients are observed by rheumatologists, immunologists, and orthopedist. They receive symptomatic, anti-inflammatory treatment, broad-spectrum antibiotics, immunosuppressants to control inflammation, which helps to prevent new or to reduce existing pathological foci.&#x0D; CLINICAL CASE DESCRIPTION: This article describes the effect of immune therapy and osteotropic treatment with zoledronic acid combination in a patient with chronic non-bacterial osteomyelitis. In a clinical observation involving comprehensive examination, including radiological (radiography, computed tomography and magnetic resonance imaging) and laboratory methods, a positive outcome was achieved using conservative methods of treatment in a patient with chronic non-bacterial sternum osteomyelitis.&#x0D; CONCLUSION: Thus, a combination of bisphosphonates and immunotherapy may be promising in the treatment of chronic non-bacterial osteomyelitis. However, it is unknown as to how long the remission will last and what treatment program is necessary for the final disease resolution.

Free Flaps in Sternal Osteomyelitis After Median Sternotomy: A Center's 12-Year Experience.

Adequate treatment of deep sternal wound infections (DSWIs) after open thoracic surgery still presents a major challenge. This study retrospectively analyzes the results of a single center's 12-year experience in treating DSWI, with special emphasis on free flap reconstruction. In this single-center, retrospective study, all patients admitted with the diagnosis of DSWI after open thoracic surgery between 2009 and 2020 were included. A comparative analysis was performed between: (1) pedicled versus free flaps, (2) the center's two workhorse flaps-the pedicled latissimus dorsi (pLD) versus free anterolateral thigh (fALT) flaps, as well as (3) myocutaneous (MC) versus fasciocutaneous (FC) flaps. Primary endpoints were length of hospital stay (LOS) after reconstruction and in-hospital mortality. Of a total of 165 patients included, 152 underwent DSWI defect reconstruction with a total of 12 different reconstruction methods. Although the defect size was larger in patients who underwent free flap coverage, and the risk profile in the fALT and FC flap groups was higher, the LOS after reconstruction (in days) did not differ significantly between the groups (pedicled vs. free flaps: 23 vs. 28, p > 0.05; pLD vs. fALT: 24.5 vs. 26, p > 0.05; MC vs. FC flaps: 23 vs. 26, p > 0.05). Also, no significant differences were found in terms of in-hospital mortality when comparing the groups (pedicled vs. free flaps: 11.2 vs. 17.4%, p > 0.05; pLD vs. fALT: 11.5 vs. 12.5%, p > 0.05; MC vs. FC flaps: 12.9 vs. 12.5%, p > 0.05). With proper patient selection, free tissue transfer is a valuable alternative in the treatment of sternal dehiscence after a DSWI. Furthermore, our data demonstrate that MC flaps are not necessarily superior to FC flaps in the reconstruction of sternal osteomyelitis defects.

A case of sternal osteomyelitis caused by defective wound healing after surgery of gingival cancer.

A case of sternal osteomyelitis caused by defective wound healing after surgery of gingival cancer.

Rare case of primary sternal osteomyelitis in immunocompetent patient caused by Candida albicans

Sternal Osteomyelitis is common in post CABG patients/with chest injury. Causative organisms in immunocompetent, non-surgical patients are Streptococcus, Pseudomonas & Candida. Candida albicans is extremely rare with limited number of cases reported. Materials and Methods: Observational type of case study using Contrast enhanced MDCT in a 68-year male with continuous pain of insidious onset over anterior chest wall for 6 days with history of Diabetes mellitus of 20 years. Results: MDCT helped in diagnosing & intervention in sternal osteomyelitis & it’s extension. Early surgical intervention, culture & appropriate treatment prevents high morbidity & mortality.Conclusion: Based on the patient's clinical, culture, & radiological characteristics,

972. Bone and Joint Infections : Looking Beyond Gram Positive Bugs, A Case Series from Mumbai, India

Abstract Background Bone and joint infection (BJI) is a dreadful complication of arthroplasties and orthopaedic trauma. Infection with non traditional organisms is a trade off for medical advances such as newer immunosuppressants and implants. Complex BJIs, may be complicated by longer hospitalizations and higher costs due to the virulence of organisms, growing resistance to antibiotics and patient comorbidities, especially immunocompromised status. The purpose of this study was to analyse the various characteristics of BJIs with emphasis on the organisms cultured. Methods 21 consecutive patients of BJIs were prospectively included from June 2021 to March 2022. Demographic features, comorbidities, anatomic site involved, previous surgical intervention, presence of implant, infecting organism, their susceptibility patterns, inflammatory markers, surgical procedure performed, antibiotics given , their route, duration and the outcome were noted. Results 12/21 (57.14 %) had spondylodiscitis ; 4/21 (19.04 %) knee joint involvement ; 3/21 (14.29 %) orthopaedic trauma ; 3/21 (14.29 %) hip involvement ; 1 ankle joint involvement (diabetic foot) and 1 sternal osteomyelitis. 17/21 (80.95 %) had comorbidities. 7/21 (33.33 %) were immunosuppressed . 14/21 (66.67 %) had undergone recent surgery. 11 gram positive, 8 gram negative organisms and 3 fungi were isolated . 2 were culture negative and 4 had mycobacterial infection. Histopathology revealed pyogenic inflammation in bacterial and granulomatous inflammation in fungal and mycobacterial infections. CRP and ESR were elevated in all bacterial infections and were used to guide antibiotic route switchover. All bacterial infections were treated with 6 weeks of antibiotics .14/21 (66.67 %) underwent surgery, whereas the rest underwent diagnostic aspiration and biopsy only. 3/21 (14.29 %) had relapse on stopping antibiotics and responded after restarting. Conclusion Though staphylococcus is thought to be the culprit in most cases of BJIs, gram negative organisms, mycobacteria and fungi are gaining centrestage. Histopathology can give important clues in the absence of positive cultures. Surgical interventions, implant presence and immunosuppressed states are implicated in a majority of the infections. CRP guided therapy is a valuable strategy. Disclosures All Authors: No reported disclosures.

A new clinical classification and reconstructive strategy for post-sternotomy surgical site infection.

Post-sternotomy surgical site infection (SSI) is a serious complication of cardiovascular surgery. Here, we proposed a new clinical classification and reconstructive strategy for this condition. A retrospective study based on medical records was performed on 100 consecutive cases requiring wound management by plastic surgeons for post-sternotomy SSI at Kobe University Hospital between January 2009 and December 2021. We classified 100 cases into four categories according to the anatomical invasiveness of the infection (type 1, superficial SSI; type 2, sternal osteomyelitis; type 3, mediastinitis; and type 4, aortic graft infection). The standard treatment plan comprised initial debridement, negative pressure wound therapy with continuous irrigation, and reconstructive surgery. Reconstructive methods and their outcomes (in-hospital mortality rate, follow-up period, and infection recurrence rate) were investigated for each SSI category. There were nine SSI cases in type 1, 28 in type 2, 25 in type 3, and 38 in type 4. The pectoralis major (PM) muscle advancement flap was mainly selected in types 1 and 2 (100 and 70.4%, respectively), while the omental flap or latissimus dorsi (LD) myocutaneous flaps were mainly selected in types 3 and 4 (77.3 and 81.8%, respectively) for reconstructive surgery. The in-hospital mortality rates for types 1, 2, 3, 4 were 44.4, 3.6, 12.0, and 15.8%, respectively. The mean follow-up periods for types 1, 2, 3, 4 were 542.8, 1514.5, 1154.5, and 831.1 days, respectively. Infection recurrence rates for types 1, 2, 3, 4 were 0, 11.5, 13.3, and 19.2%, respectively. All of these recurrent cases, except for 4 cases of type 4 that required surgical intervention, were treated with conservative wound management. A volume-rich flap (omental or LD flap) was required to fill the dead space after debridement in mediastinitis (type 3) or aortic graft infection (type 4), whereas superficial SSI (type 1) or sternal osteomyelitis (type 2) received a less-invasive flap (PM muscle advancement flap). Our new classification method was based on the anatomical invasiveness of the infection, providing both a simple and easy diagnosis and definitive treatment strategy.

Fungal sternal osteomyelitis in a diabetic patient on hemodialysis.

Fungal sternal osteomyelitis in a diabetic patient on hemodialysis.

Una tumefazione sternale: un semplice ematoma, o c’è dell’altro?

The case of a 6-year-old boy with sternal swelling finally diagnosed as sternal osteomyelitis is described.

Chest wall reconstruction with MatrixRIB after resection of primary chest wall abscess and sternal osteomyelitis

Chest wall reconstruction with MatrixRIB after resection of primary chest wall abscess and sternal osteomyelitis

Sternal Osteomylitis due to Arrow-head Injury: A Rare Case Report

Sternal osteomyelitis secondary to penetrating trauma is an uncommon entity and only few cases have been reported. We report a case of sternal osteomyelitis in a patient with sickle-cell anaemia with a unique past history of arrow-head injury who presented with signs and symptoms of sternal infection. Imaging studies suggested osteomyelitis and the patient underwent sternal debridement, with a successful outcome. [Indian J Chest Dis Allied Sci 2012;54:255-257]

PRIMARY STERNAL OSTEOMYELITIS IN A CHILD: A CASE REPORT

TYPE: Case Report TOPIC: Pediatrics INTRODUCTION: Primary sternal osteomyelitis which develop without any contiguous focus of infection is a rare condition, that too in children. MRI and biopsy are required for diagnosis. Rarity of the condition often results in delayed diagnosis and treatment. CASE PRESENTATION: A 9 year old boy , who was otherwise normal, presented with high fever - 9 days, followed by painful limitation of movement of right upper limb.O/E- Sick and toxic child..Tender, firm swelling, 2 x 2cm ,over the sterno-chondral junction of 2nd and 3rd rib with signs of inflammation.Rest of physical examination WNL. Investigation revealed anemia, polymorphonuclear leucocytosis with elevated ESR and CRP. Cultures were sterile. USG revealed collection below Rt sternoclavicular joint which yielded a dry tap . CECT showed non enhancing collection with no cortical defect in sternum. MRI revealed T2 hyperintensity and T1 hypointensity showing diffusion restriction of sternum suggestive of bone marrow edema.CT-guided sternal biopsy confirmed sternal osteomyelitis. Patient responded to Meropenem and Vancomycin after nonresponse to Cloxacillin and cefotaxime.Treatment continued for 4 weeks and patient recovered completely. DISCUSSION: Primary sternal osteomyelitis is diagnosed after exclusion of other sources of infection. Close proximity to vital organs can complicate the condition. Early recognition, identification of the causal organism, and early initiation of culture-driven intravenous antibiotic therapy is crucial in determining outcome. Staphylococcus aureus,coagulase negative staphylococcus, group B streptococcus, and other streptococcus species are most commonly implicated organisms.Nearly half requires surgical debridement and resection. CONCLUSIONS: Early diagnosis and appropriate treatment results in complete recovery of sternal osteomyelitis DISCLOSURE: Nothing to declare. KEYWORD: sternal osteomyelitis

COMBINATION OF LICAP AND IMAP FLAP FOR TREATMENT OF LONG-LASTING CUTANEOUS FISTULAS OF THE CHEST WALL WITH OSTEOMYELITIS

Patients presenting large chest wall defects often represent a challenge, the more when other conditions, like osteomyelitis, may complicate the wound healing process. We present a case of long-lasting cutaneous fistulas of the chest wall caused by ribs and sternum osteomyelitis, refractory to both conservative and surgical treatment. Both lateral intercostal perforator flap and internal mammary perforator flap were performed in the same surgery for chest wall coverage after accurate debridement. The procedure allowed for resolution of osteomyelitis and wound healing with no recurrence. The purpose of this report is to highlight how, in apparently untreatable cutaneous fistulas caused by ribs and sternum osteomyelitis, an accurate debridement and coverage with perforators propeller flaps may be successful.