Treatment Of Chronic Osteomyelitis Research Articles

Antibiotic-Loaded Collagen Sponges in Clinical Treatment of Chronic Osteomyelitis: A Systematic Review.

Chronic osteomyelitis is caused by bacterial infection of the bone and is a major problem in orthopaedic surgery. Treatment of chronic osteomyelitis requires surgical debridement accompanied by local and systemic administration of antibiotics. A widely established biodegradable local antibiotic carrier is antibiotic-loaded collagen sponges (fleeces). These sponges are commonly used in the treatment of chronic osteomyelitis, but a systematic review of their clinical efficacy and assessment of the quality of evidence have not been conducted, to our knowledge. This systematic review, performed according to the PRISMA statement, examined the clinical efficacy of and quality of evidence regarding different antibiotic-loaded collagen sponges in the clinical treatment of chronic osteomyelitis. Clinical efficacy was defined as eradication of infection with bone and wound-healing. In addition, the in vivo pharmacokinetics of the various collagen sponges were evaluated. Quality was based on the Level of Evidence, methodological quality, and risks of bias. A total of 813 articles were screened, and 10 were included. Gentamicin-sulfate sponges and gentamicin-sulfate/gentamicin-crobefate sponges were studied. A total of 413 patients were treated, with a success rate of 91%. Reported complications were fistulas, prolonged wound drainage, and wound-healing problems. In vivo pharmacokinetic profiles showed an average local antibiotic concentration that was above the minimum inhibitory concentration for only 5 days. The general quality of the included studies was low to moderate, and there was a moderate to high risk of bias. The evidence quality and Level of Evidence of the included studies were low, and the risk of bias in these studies was high. This makes the evidence regarding these sponges inconclusive, and no clinical decision-making can be based on these studies. Utilization of antibiotic-loaded collagen sponges in the treatment of chronic osteomyelitis should only be carried out with caution; studies with high-level evidence are needed. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of chronic osteomyelitis with multidose oritavancin: A case series and literature review

Osteomyelitis remains difficult to treat, typically requiring a prolonged course of intravenous (i.v.) antibiotics. The optimal route and duration of antibiotics remains ill-defined due to limited prospective clinical trials. Oritavancin is a long-acting, semisynthetic lipoglycopeptide antibiotic with rapid concentration-dependent bactericidal activity against many Gram-positive organisms. Favourable pharmacokinetics makes oritavancin an appealing alternative to currently available antibiotics requiring daily infusion to decrease the risk of vascular access complications associated with outpatient antimicrobial therapy. The purpose of this study was to report the outcomes of nine patients with chronic osteomyelitis receiving multidose oritavancin. Using electronic medical records, patients aged ≥18 years treated with i.v. oritavancin between September 2015 and April 2018 at Downtown Dublin Wound Center, a hospital-owned outpatient wound care clinic and infusion centre affiliated with Meadows Regional Health System in Dublin, GA, were identified. Of 12 cases reviewed, 9 patients received at least two doses of i.v. oritavancin for the treatment of chronic osteomyelitis. All nine patients experienced clinical cure at 6-month follow-up after the last dose of oritavancin. Multidose oritavancin was found to be a safe and efficacious option for chronic osteomyelitis when treatment options are limited by patient complexities or barriers in their ability to access healthcare services.

Comments of Clinical and Microbiological Experience with Daptomycin in Chronic Osteomyelitis Treatment

Comments of Clinical and Microbiological Experience with Daptomycin in Chronic Osteomyelitis Treatment

Epidemiology, microbiology and therapeutic consequences of chronic osteomyelitis in northern China: A retrospective analysis of 255 Patients

The study aimed to explore the epidemiology and clinical characteristics of chronic osteomyelitis observed in a northern China hospital. Clinical data of 255 patients with chronic osteomyelitis from January 2007 to January 2014 were collected and analyzed, including general information, disease data, treatment and follow-up data. Chronic osteomyelitis is more common in males and in the age group from 41–50 years of age. Common infection sites are the femur, tibiofibular, and hip joint. More g+ than g- bacterial infections were observed, with S. aureus the most commonly observed pathogenic organism. The positive detection rate from debridement bacterial culture is 75.6%. The detection rate when five samples are sent for bacterial culture is 90.6%, with pathogenic bacteria identified in 82.8% of cases. The two-stage debridement method (87.0%) has higher first curative rate than the one-stage debridement method (71.2%). To improve detection rate using bacterial culture, at least five samples are recommended. Treatment of chronic osteomyelitis with two-stage debridement, plus antibiotic-loaded polymethylmethacrylate (PMMA) beads provided good clinical results in this study and is therefore recommended.

Selective resection of the bone with preservation of soft tissues (“empty toe technique”) combined with negative pressure wound therapy for treatment of osteomyelitis of the great toe - a case report

Diabetic foot ulceration (DFU) is a serious complication of diabetes mellitus, and one that is difficult to treat. In many cases of DFU, chronic osteomyelitis occurs in the foot. The present paper describes the course of treatment for chronic osteomyelitis of the great toe with metatarsophalangeal arthritis using selective resection of the bone preserving the soft tissues (the “empty toe technique”). Following the procedure, to promote surgical wound healing, negative pressure wound therapy was administered for 7 days, with a constant pressure of –120 mmHg. The presented method was found to be effective in treating osteomyelitis in a patient with DFU, partially preserving the function and completely preserving the shape of the treated toe.

One-stage surgery for adult chronic osteomyelitis: concomitant use of antibiotic-loaded calcium sulphate and bone marrow aspirate.

To report our experience with one-stage treatment of chronic osteomyelitis using a prospective protocol involving the concomitant use of the antibiotic-loaded calcium sulphate pellets with addition of bone marrow aspirate after bony debridement. A total of 30 patients with the mean age of 26.2years were treated according to a protocol that included (1) surgical debridement of bone and infected tissues, (2) local antibiotic therapy including vancomycin and garamycin loaded on calcium sulphate space filling biodegradable pellets, (3) bone marrow aspirate added to the biocomposite, (4) primary closure with external fixation (when needed) and (5) intravenous antibiotics according to culture and sensitivity results. After a minimum of oneyear follow-up, infection was eradicated in 23 (76.7%) patients, the average rate of filling of the bony defect was 70.47%, complete filling of defect in 15 patients (50%) and pathological fracture in one patient. The technique proved safety and efficacy in eradicating the infection and bony healing of the defects after debridement. Simple bone marrow aspiration is cheap, reproducible, safe and not exhausting the scanty autograft resources.

Treatment of chronic osteomyelitis with locally made calcium sulfate bone cement pellets impregnated with antibiotics at University Teaching Hospital of Butare (CHUB), Rwanda

Background: Chronic osteomyelitis remains a challenging and potentially lifelong disease. Its treatment includes surgery, which is essential and consists of the removal of all dead bone and necrotic soft tissues, and systemic antibiotic administration. One excellent modality for antibiotic delivery is the use of antibiotic-impregnated bone cement. In this paper, we report our experience of operating-room-made antibiotic-impregnated bone cement at University Teaching Hospital of Butare (CHUB), Rwanda. Methods: Fifty-five patients with haematogenously spread chronic osteomyelitis were operated upon and benefited from our protocol between January 2015 and December 2016. Excluded from this study were cases in which we estimated that soft tissue bone coverage might have been a challenge. We mixed 300 g of calcium sulfate powder with 2 g of ceftriaxone and 480 mg of gentamicin to form pellets. To allow for drying, we prepared the mixture 2 hours before implantation into operated bone. Results: Thirty-one patients (56%) were children under 15 years of age, and 44 (80%) of the cases involved the tibia or the femur. After 12 months of follow-up, only 3 cases (5%) presented with complications that needed additional surgeries. All complications were related to the biodegradation of the calcium sulfate pallets. The rest of the patients in this study improved without complications. Conclusions: The locally made (within in the operating room) antibiotic-impregnated bone cement at CHUB was safe, effective, and of low cost. Keywords: chronic osteomyelitis; bone cement; calcium sulfate; antibiotics; locally available materials; Rwanda

Novel nano-hydroxyapatite/polyurethane composite scaffold in the treatment of chronic osteomyelitis

To evaluate the bone repair efficacy of the new nano-hydroxyapatite (n-HA)/polyurethane (PU) composite scaffold in the treatment of chronic osteomyelitis in tibia. A novel levofloxacin@mesoporous silica microspheres (Lev@MSNs)/n-HA/PU was successfully synthesized. Its surface structure was observed by scanning electron microscopy (SEM). Fifty adult female New Zealand rabbits were randomly selected, and osteomyelitis was induced in the right tibia of the rabbit by injecting bacterial suspension ( Staphylococcus aureus; 3×10 7 CFU/mL), which of the method was described by Norden. A total of 45 animals with the evidence of osteomyelitis were randomly divided into 4 groups, and the right medullary cavity of each animal was exposed. Animals in the blank control group (group A, n=9) were treated with exhaustive debridement only. The remaining animals were first treated by exhaustive debridement, and received implantations of 5 mg Lev@PMMA (group B, n=12), 1 mg Lev@MSNs/n-HA/PU (group C, n=12), and 5 mg Lev@MSNs/n-HA/PU (group D, n=12), respectively. At 12 weeks postoperatively, the right tibia of rabbits were observed by X-ray film, and then gross observation, methylene blue/acid fuchsin staining, and SEM observation of implant-bone interface, as well as biomechanical test (measuring the maximal compression force) were performed. X-ray films showed that the infection were severer than those of preoperation in group A, while the control of inflammation and bone healing of rabbits in group D were obviously better than those at preoperation. The gross observation showed extensive bone destruction in group A, a significant gap between bone tissue and the material in groups B and C, and close combination between bone tissue and the material in group D. The histology of the resected specimens showed that there was no obvious new bone formation around the materials in groups B and C, and there was abundant new bone formation around the periphery and along the voids of the materials and active bone remodeling in group D. The SEM observation of the bone-implant interface demonstrated that no new bone formation was observed at the bone-implant interface in groups B and C. However, bony connections and blurred boundaries were observed between the material and host bone tissue in group D. The biomechanical test showed the maximal compression force of groups B and D were significantly higher than that of groups A and C ( P<0.05), but there was no significant difference between groups B and D ( P>0.05). The novel synthetic composite Lev@MSNs/n-HA/PU exhibit good antibacterial activities, osteoconductivity, and biomechanical properties, and show great potential in the treatment of chronic osteomyelitis of rabbits.

Effectiveness of Hyperbaric Oxygen Therapy for the Management of Chronic Osteomyelitis: A Systematic Review of the Literature.

Hyperbaric oxygen has been used as an adjunctive measure in the treatment of chronic osteomyelitis. The aim of this systematic literature review was to analyze the outcome and the complications of hyperbaric oxygen for chronic osteomyelitis. Forty-five of 96 studies reporting the use of hyper-baric oxygen for 460 patients with chronic osteomyelitis met the inclusion criteria and were analyzed qualitatively. All patients previously received antibiotics and surgical debridement. Mixed bacterial flora was detected in most of the studies. Staphylococcus aureus was the isolated pathogen in 12 (60%) of the 20 cohort and in 4 (20%) of the 20 case studies. Adjuvant hyperbaric oxygen was effective in 16 (80%) of the 20 cohort and 19 (95%) of the 20 case studies. Overall, 308 (73.5%) of 419 patients with complete data had a successful outcome and no reported relapse. Available evidence supports a potentially beneficial role of adjunctive hyperbaric oxygen, especially in refractory cases of chronic osteomyelitis. [Orthopedics. 2018; 41(4):193-199.].

Activity of isolated specific bacteriophage in treatment of chronic osteomyelitis induced by multiple drug resistance Pseudomonas aeruginosa in Rabbits

This study was conducted to find out the possibility of using the Pseudomonas aeruginosa specific-bacteriophage as an alternative to antibiotics in treatment of chronic osteomyelitis in rabbits by injection of Pseudomonas aeruginosa suspension in tibia. The current study included an isolation of bacteriophage from sewage water by using agar overlay method and also an isolation of the bacteria from patients suffering from post-traumatic bone infection. The second experiment was in-vivo evaluation of phage activity in treatment of chronic osteomyelitis in rabbits. All animals of infected groups with Pseudomonas aeruginosa before treatment exhibited histopathological changes after 35 days of infection, the infected groups showed chronic osteomyelitis represented by sever chronic inflammatory cells infiltrates mainly lymphocytes, and macrophages and hemorrhage between bone trabeculae, also some sections showed extensive fibrosis in the marrow spaces. The treated group with P. aeruginosa specific – bacteriophage (1.5 ×107) PFU/ml for 10 days showed early repair elucidated by presence whorls of chondrocytes, and also the presence of multiple osteoblasts indicated bone formations. Also the presence of extensive fibrosis in the marrow space with present of osteoblasts indicated bone formations and repair.

Combined application of latissimus dorsi myocutaneous flap and iliac bone flap in the treatment of chronic osteomyelitis of the lower extremity

BackgroundTo evaluate the clinical efficacy and safety of latissimus dorsi myocutaneous flap (stage I) combined with iliac bone flap (stage II) in the treatment of chronic osteomyelitis of the lower extremity.MethodsClinical data of 18 patients undergoing latissimus dorsi myocutaneous flap in combination with iliac bone flap grafting were retrospectively analyzed. Among them, 2 patients developed chronic osteomyelitis of the lower segment of the femur, 4 were diagnosed with chronic osteomyelitis of the tibial plateau, and 12 with chronic osteomyelitis of the lower segment of the tibia.ResultsAll the latissimus dorsi myocutaneous flaps survived in 18 patients. After the corresponding surgery, primary wound healing was achieved in 11 patients, and delayed wound healing was obtained in 7 cases. All wounds were completely healed with postoperative 2 months. Following the iliac bone flap grafting, primary would healing was accomplished in all cases. All dorsal window chambers survived. The bone defects were properly restored within 4–12 postoperative months. Functional training was performed after removal of the internal and external fixators. Postoperative follow-up was endured from 6 months to 10 years. All patients were satisfied with the bone healing and flap texture without the incidence of osteomyelitis and sinus tract. No contraction was observed in the grafting area of 2 patients receiving latissimus dorsi myocutaneous flap grafting. Residual linear scars were noted in the dorsal and iliac donor sites.ConclusionCombined usage of stage I latissimus dorsi myocutaneous flap and stage II iliac bone flap grafting is an efficacious and safe surgical technique in clinical practice.

The Effectiveness of Ozone Therapy in Chronic Osteomyelitis: A Randomized Controlled Clinical Trial

Background: Treatment of chronic osteomyelitis is complex and includes long-term management with antibiotics and debridement. Inadequate blood supply, underlying diseases, and deep involvement of the infected area can cause classic treatments to fail and lead to serious complications, such as limb amputation. Recently, there has been increasing interest in the use of ozone therapy for infectious diseases. Objectives: This study was designed to investigate the beneficial effects of ozone therapy on chronic osteomyelitis. Methods: Sixty patients with chronic osteomyelitis were divided into two homogenized groups: ozone therapy and control. Ozone therapy at a concentration of 30 mg/mL was performed daily by ozone bagging, minor autohemotherapy, and ozone saline injection into the bone. Data were analyzed to determine recovery and erythrocyte sedimentation rates. Results: The recovery rate was 73.33% in the control group versus 86.66% in the ozone group (P = 0.31). No significant difference was found between the groups regarding the recovery rate (P = 0.86). However, considering the erythrocyte sedimentation rate, the results were significantly superior in the ozone group (P = 0.0001). Conclusions: These findings indicate that ozone therapy, as a promising complementary treatment, can be applied in chronic osteomyelitis management.

The Use of Bioactive Glass S53P4 as Bone Graft Substitute in the Treatment of Chronic Osteomyelitis and Infected Non-Unions – a Retrospective Study of 50 Patients

Treatment of chronic osteomyelitis (COM) remains challenging and often results in large bone defects. Dead space management and proper defect filling are essential for successful treatment. Bioactive glass S53P4 (BAG-S53P4) is an anorganic bone graft substitute with antibacterial, osteoconductive, osteostimulative and angiogenic properties. The aim of our study was to analyse the outcome of patients with COM and infected non-unions, whose bone defects were filled with BAG-S53P4. In this retrospective study (07/13 - 02/16), we analysed all patients with COM and infected non-unions, who obtained BAG-S53P4 after surgical debridement to fill their bone defects. Epidemiological data, pre-, peri- and postoperative characteristics were evaluated. The primary endpoint was the successful control of infection during the follow-up period. Secondary endpoints were the absence of BAG-S53P4-related complications, the time period to full weight bearing as well as to radiologically detectable incorporation of BAG. X-ray examinations were routinely performed 1 month, 3 - 4 months, 6 months and 12 months postoperatively. 50 patients were analysed. Staphylococcus aureus was the most common pathogen involved. On average, 11.1 ± 6.7 cm3 BAG-S53P4 were implanted. Mean follow-up was at 12.3 months. After 6 months, 26/37 (70.3%) and after 12 months, 35/42 (83.3%) of the filled bone defects were healed. X-ray examinations showed a thickened neo-cortex. 40 patients (80%) have achieved full weight bearing after a mean of 4 months. There were no complications at all in 76% of patients. Seven patients suffered reinfection. BAG-associated complications were not seen. The use of BAG-S53P4 in patients with COM and infected non-unions is promising. Adequate debridement and proper defect filling are necessary. BAG is well tolerated. X-ray examinations showed a thickened neo-cortex. The antibacterial effect is not mediated by antibiotics and is advantageous in times of evolving antibiotic resistance. High quality studies with a longer follow-up are required. TRN DRKS00011679.

Effects of alkaloids from Sophora flavescens on osteoblasts infected with Staphylococcus aureus and osteoclasts.

Chronic osteomyelitis is primarily caused by infection with Staphylococcus aureus (S.aureus). Antibiotics are commonly administered; however, it is a challenge to promote bone healing. The aim of this study was to investigate the in vitro effects of alkaloids from the herbal remedy Sophora flavescens (ASF) on rat calvarial osteoblasts (ROBs) infected with S.aureus and healthy osteoclasts. Cell proliferation and alkaline phosphatase, interleukin-6, and tumour necrosis factor-α activity was measured in infected ROBs; tartrate-resistant acid phosphatase was evaluated in osteoclasts via enzyme-linked immunosorbent assay. The mRNA and protein expression levels of bone morphogenetic protein 2, runt-related transcription factor 2, osteoprotegerin, and receptor activator of nuclear factor kappa-B ligand were assessed in infected ROBs through reverse transcription-polymerase chain reaction and western blotting analysis, respectively. Results indicated that ASF increased the viability of uninfected ROBs and infected ROBs treated with vancomycin via regulation of bone morphogenetic protein 2, runt-related transcription factor, osteoprotegerin, and receptor activator of nuclear factor kappa-B ligand mRNA and protein expression levels. In addition, the secretion of the inflammatory factor tumour necrosis factor-α was decreased and alkaline phosphatase activity was increased, inhibiting the viability of osteoclasts and tartrate-resistant acid phosphatase activity. Therefore, the herbal remedy ASF has potential as a new treatment for chronic osteomyelitis.

Osteomielite crônica pós‐operatória nos ossos longos – O que sabemos e como conduzir esse problema?

Chronic postoperative osteomyelitis represents an important health problem due to its significant morbidity and low mortality rate. This pathology is challenging because of difficulties in understanding the pathogenesis and treatment decision‐making. The objective of this article was to review the theme regarding its definition, pathogenesis, clinical aspects, diagnosis, and treatment, gathering all this information in a single Brazilian update publication.PubMed, LILACS, and the Cochrane Library medical databases were analyzed, using related keywords. Current and relevant articles were selected.This paper gathered established information, as well as innovations related to chronic osteomyelitis disease and its treatment, offering updated data to assist professionals involved in the treatment of chronic osteomyelitis.

Evaluation immunomodulatory therapy effect in the treatment of chronic osteomyelitis of long tubular bones

Evaluation immunomodulatory therapy effect in the treatment of chronic osteomyelitis of long tubular bones

Contemporary treatment of chronic osteomyelitis: implementation in low- and middle-income countries

Aim: Chronic osteomyelitis is still a difficult problem to treat in the developed world, but even more so in low- and middle-income countries. Contemporary treatment options result in satisfying outcomes in a setting with abundant resources, but the question is whether these treatment options can be translated to other, less supported health care systems and if they obtain the same results. Methods: Eighteen patients with established chronic osteomyelitis (eight type III, ten type IV) were prospectively enrolled and treated in a one-stage procedure with radical debridement and dead space management using bioactive glass S53P4 granules, together with adjuvant antibiotic therapy. Results: Thirteen patients were assessed at 24 months. Infection control was achieved in five patients (38%). Eight patients (61.5%) had persistence or recurrence of infection. Loss to follow-up was substantial (five patients, 28%). Conclusion: Due to specific challenges treating chronic osteomyelitis in low- and middle-income countries, contemporary treatment options cannot be ‘copy-pasted’ with the same results in these settings. Level of evidence: Level 4

Therapy for Chronic Recurrent Osteomyelitis with Multi-Resistant Pseudomonas aeruginosa Using Local Antibiotic Release by a Polymethylmethacrylate Custom-Made Tibia Nail

Background: The treatment of chronic osteomyelitis by antibiotics administered intravenously is limited by the blood supply that is not present in bone sequestra. Local delivery of antibiotics using acrylic bone cement has been reported with favorable results for treatment of chronic osteomyelitis. Case Presentation: Treatment of a patient with recurrent osteomyelitis after a third- degree open tibia fracture at our hospital failed several times because of recurrent infection with Pseudomonas aeruginosa that later became multi-resistant. Suitable antibiotic treatment was limited to colistin that was mixed with polymethylmethacrylate (PMMA) matrix (Copal® G+C Plus, Heraeus, Hanau, Germany) and used to cover an Ender nail. The PMMA–tibia nail construct was placed intra-medullary for two weeks under appropriate antibiotics applied intravenously. The patient has been pain free for 18 months without any signs of infection and with normal blood tests. Conclusion: We provide evidence that colistin can be applied locally with Copal G+C providing appropriate concentration because of elution over a period of at least two weeks. This technique demonstrates a custom-made solution for patients with multi-resistant osteomyelitis for P. aeruginosa when conventional treatment fails.

Magnetic hyperthermia enhance the treatment efficacy of peri-implant osteomyelitis

BackgroundWhen bacteria colony persist within a biofilm, suitable drugs are not yet available for the eradication of biofilm-producing bacteria. The aim of this study is to study the effect of magnetic nano-particles-induced hyperthermia on destroying biofilm and promoting bactericidal effects of antibiotics in the treatment of osteomyelitis.MethodsSixty 12-weeks-old male Wistar rats were used. A metallic 18G needle was implanted into the bone marrow cavity of distal femur after the injection of Methicillin-sensitive Staphylococcus aureus (MSSA). All animals were divided into 5 different treatment modalities. The microbiological evaluation, scanning electron microscope examination, radiographic examination and then micro-CT evaluation of peri-implant bone resorption were analyzed.ResultsThe pathomorphological characteristics of biofilm formation were completed after 40-days induction of osteomyelitis. The inserted implants can be heated upto 75 °C by magnetic heating without any significant thermal damage on the surrounding tissue. We also demonstrated that systemic administration of vancomycin [VC (i.m.)] could not eradicate the bacteria; but, local administration of vancomycin into the femoral canal and the presence of magnetic nanoparticles hyperthermia did enhance the eradication of bacteria in a biofilm-based colony. In these two groups, the percent bone volume (BV/TV: %) was significantly higher than that of the positive control.ConclusionsFor the treatment of chronic osteomyelitis, we developed a new modality to improve antibiotic efficacy; the protection effect of biofilms on bacteria could be destroyed by magnetic nanoparticles-induced hyperthermia and therapeutic effect of systemic antibiotics could be enhanced.

Treatment strategies for chronic osteomyelitis in low- and middle-income countries: systematic review.

To identify a standard treatment regime or highly successful procedure for chronic osteomyelitis in low- and middle-income countries. Systematic review following PRISMA guidelines. The initial search resulted in 102 studies of which nine met the inclusion criteria and were analysed qualitatively. The included studies involved 1173 patients from Africa and Asia. All patients were diagnosed with chronic osteomyelitis. Surgical and antibiotic treatment regimens differed substantially. No better judgement than moderate risk of selection bias could be made due to the study designs. The evidence is not sufficiently robust to identify the most effective treatment, or to even allow a recommendation of the best suitable treatment of chronic osteomyelitis in low-income countries.