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Crisci A, Raffaele D, Crisci M. Clinical Trial on Solid Second-Generation Platelet-Concentrates in the Management of the Chronic Osteomyelitis: Advanced Bioregenerative Surgeries. INT J LOW EXTR WOUND 2021; 22:259-269. [PMID: 33876978 DOI: 10.1177/15347346211003732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The supposition is that the usage of fibrin rich in leukocytes and platelets advanced (A-PRF) in ulcerative osteomyelitis of the diabetic foot allows rehabilitation from this critical illness. In this investigation, the focus was to normalize the use of platelet-rich fibrin (PRF) in patients with osteomyelitis not amputated, to use this second-generation platelet concentrate as a regeneration enabler. The researchers submitted and utilized A-PRF membranes (1300 g × 8 min) in 7 patients (all diabetics) with osteomyelitis and cutaneous injury for 6 months. The membranes, in combination with the supernatant fluid produced by stress, have been integrated into the skin lesion down to the bone after surgical debridement. The advancement of the lesions after some period of time has been analyzed. All 7 subjects had a probe-to-bone positive assay; magnetic resonance imaging indicated cortico-periosteal coagulation and/or foci of cortico-spongeous osteolysis contiguous to the lesion. Gram-positive bacteria were identified in our procedures in 52% of cases. Gram + Cocci, for example, Staphylococcus aureus (15.6%), β-hemolytic Streptococci (12.1%), Streptococcus viridans (7.1%), and Gram-negative bacteria, for example, Pseudomonas (10.6%), Proteus (7.8%), Enterobacter (5.7%) were present. Candida albicans was active in 2.8% of cases. The blood count showed no relevant differences. To date, cutaneous lesions have been cured in 6 of the 7 subjects treated (1 patient for more than 6 years) without any evidence of infection or recurrence. The results obtained on our subjects indicate that PRF membranes may be a therapeutic option in this problematic disease. In fact, this clinical approach may have the potential to promote the healing of diabetic skin lesions with osteomyelitis.
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Affiliation(s)
- Alessandro Crisci
- School of Medicine, University of Salerno Italy, Fisciano, SA, Italy.,Unit of Dermosurgery Cutaneous Transplantations and Hard-to-Heal Wound, "Villa Fiorita" Private Hospital, Aversa, CE, Italy.,Institute for the Studies and Care of Diabetics, Casagiove, CE, Italy
| | - D'Adamo Raffaele
- Unit of Dermosurgery Cutaneous Transplantations and Hard-to-Heal Wound, "Villa Fiorita" Private Hospital, Aversa, CE, Italy
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Veis DJ, Cassat JE. Infectious Osteomyelitis: Marrying Bone Biology and Microbiology to Shed New Light on a Persistent Clinical Challenge. J Bone Miner Res 2021; 36:636-643. [PMID: 33740314 DOI: 10.1002/jbmr.4279] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/01/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022]
Abstract
Infections of bone occur in a variety of clinical settings, ranging from spontaneous isolated infections arising from presumed hematogenous spread to those associated with skin and soft tissue wounds or medical implants. The majority are caused by the ubiquitous bacterium Staphyloccocus (S.) aureus, which can exist as a commensal organism on human skin as well as an invasive pathogen, but a multitude of other microbes are also capable of establishing bone infections. While studies of clinical isolates and small animal models have advanced our understanding of the role of various pathogen and host factors in infectious osteomyelitis (iOM), many questions remain unaddressed. Thus, there are many opportunities to elucidate host-pathogen interactions that may be leveraged toward treatment or prevention of this troublesome problem. Herein, we combine perspectives from bone biology and microbiology and suggest that interdisciplinary approaches will bring new insights to the field. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Deborah J Veis
- Division of Bone and Mineral Diseases, Departments of Medicine and Pathology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA.,Musculoskeletal Research Center, Washington University School of Medicine, St. Louis, MO, USA.,Shriners Hospitals for Children, St. Louis, MO, USA
| | - James E Cassat
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville,, TN, USA.,Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.,Vanderbilt Institute for Infection, Immunology and Inflammation (VI4), Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN, USA
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53
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Zhou AK, Girish M, Thahir A, Lim JA, Chen X, Krkovic M. Radiological evaluation of postoperative osteomyelitis in long bones: Which is the best tool? J Perioper Pract 2021; 32:15-21. [PMID: 33719739 PMCID: PMC8750142 DOI: 10.1177/1750458920961347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Currently, definitive diagnosis of osteomyelitis involves a combination of clinical signs, symptoms, laboratory tests, imaging modalities and cultures from blood, joint or body fluid. Imaging plays a critical role in the osteomyelitis diagnosis. Each of these tests incurs an additional cost to the patient or healthcare system and their use varies according to the preference of the healthcare professional and the healthcare setup. Imaging plays a critical role in the diagnosis and management of postoperative long bone osteomyelitis, with the aim of reducing long-term complications such as non-union, amputation and pathological fractures. In this review, we discuss the key findings on different radiological modalities and correlate them with disease pathophysiology. Currently, magnetic resonance imaging is the best available imaging modality due to its sensitivity in detecting early signs of long bone osteomyelitis and high soft tissue resolution. Other modalities such as radio-nuclear medicine, computed tomography and ultrasound have been proved to be useful in different clinical scenarios as described in this narrative review.
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Affiliation(s)
- Andrew Kailin Zhou
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Milind Girish
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Azeem Thahir
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
| | - Jiang An Lim
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Xiaoyu Chen
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Matija Krkovic
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
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54
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Gimza BD, Cassat JE. Mechanisms of Antibiotic Failure During Staphylococcus aureus Osteomyelitis. Front Immunol 2021; 12:638085. [PMID: 33643322 PMCID: PMC7907425 DOI: 10.3389/fimmu.2021.638085] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/25/2021] [Indexed: 12/13/2022] Open
Abstract
Staphylococcus aureus is a highly successful Gram-positive pathogen capable of causing both superficial and invasive, life-threatening diseases. Of the invasive disease manifestations, osteomyelitis or infection of bone, is one of the most prevalent, with S. aureus serving as the most common etiologic agent. Treatment of osteomyelitis is arduous, and is made more difficult by the widespread emergence of antimicrobial resistant strains, the capacity of staphylococci to exhibit tolerance to antibiotics despite originating from a genetically susceptible background, and the significant bone remodeling and destruction that accompanies infection. As a result, there is a need for a better understanding of the factors that lead to antibiotic failure in invasive staphylococcal infections such as osteomyelitis. In this review article, we discuss the different non-resistance mechanisms of antibiotic failure in S. aureus. We focus on how bacterial niche and destructive tissue remodeling impact antibiotic efficacy, the significance of biofilm formation in promoting antibiotic tolerance and persister cell formation, metabolically quiescent small colony variants (SCVs), and potential antibiotic-protected reservoirs within the substructure of bone.
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Affiliation(s)
- Brittney D Gimza
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - James E Cassat
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, United States.,Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States.,Vanderbilt Institute for Infection, Immunology, and Inflammation (VI4), Vanderbilt University Medical Center, Nashville, TN, United States
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55
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Daunaraite K, Uvarovas V, Ulevicius D, Sveikata T, Petryla G, Kurtinaitis J, Satkauskas I. Reciprocal hematogenous osteomyelitis of the femurs caused by Anaerococcus prevotii: A case report. World J Clin Cases 2021; 9:830-837. [PMID: 33585629 PMCID: PMC7852651 DOI: 10.12998/wjcc.v9.i4.830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 12/01/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Haematogenous osteomyelitis is an extremely rare disease occurring in adults, especially in developed countries. It is clearly a systemic infection, because bacteraemia spreads over proximal and distal long bones or paravertebral plexuses, resulting in acute or chronic bone infection and destruction.
CASE SUMMARY A 46-year-old Caucasian male was complaining of a left thigh pain. It is known from the anamnesis that the patient developed severe pneumonia three months ago before the onset of these symptoms. The patient was diagnosed with haematogenous osteomyelitis, which developed a turbulent course and required complex combination therapy. The primary pathogen is thought to be Anaerococcus prevotii, which caused pneumonia before the onset of signs of osteomyelitis. Unfortunately, due to the complexity of identifying anaerobes and contributing nosocomial infections, the primary pathogen was not extracted immediately. After the manifestation of this disease, pathological fractures occurred in both femurs, as well as purulent processes in the lungs and molars accompanied. The patient received broad-spectrum antibiotic therapy and countless amounts of orthopaedic and reconstructive surgeries, but no positive effect was observed. The patient underwent osteosynthesis using an Ilizarov’s external fixation apparatus, re-fixations, external AO, debridements, intrame-dullary osteosynthesis with a silver-coated intramedullary nail, abscessotomies. The right femur healed completely after the pathological fracture and osteomyelitis did not recur. Left femur could not be saved due to non-healing, knee contracture and bone destruction. After almost three years of struggle, it was decided to amputate the left limb, after which the signs of osteomyelitis no longer appeared.
CONCLUSION To sum it all up, complicated or chronic osteomyelitis requires surgery to remove the infected tissue and bone. Osteomyelitis surgery prevents the infection from spreading further or getting even worse up to such condition that amputation is the only option left.
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Affiliation(s)
- Karolina Daunaraite
- Vilnius University, Institute of Clinical Medicine, Faculty of Medicine, Vilnius LT-08661, Lithuania
| | - Valentinas Uvarovas
- Department of Orthopedics and Traumatology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius LT-08661, Lithuania
| | - Donatas Ulevicius
- Vilnius University, Institute of Clinical Medicine, Faculty of Medicine, Vilnius LT-08661, Lithuania
- Department of Orthopedics and Traumatology, Vilnius LT-04130, Lithuania
| | - Tomas Sveikata
- Department of Orthopedics and Traumatology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius LT-08661, Lithuania
| | - Giedrius Petryla
- Department of Orthopedics and Traumatology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius LT-08661, Lithuania
| | - Jaunius Kurtinaitis
- Department of Orthopedics and Traumatology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius LT-08661, Lithuania
| | - Igoris Satkauskas
- Department of Orthopedics and Traumatology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius LT-08661, Lithuania
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56
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Morgenstern M, Erichsen C, Militz M, Xie Z, Peng J, Stannard J, Metsemakers W, Schaefer D, Alt V, Søballe K, Nerlich M, Buckley RE, Blauth M, Suk M, Leung F, Barla JD, Yukata K, Qing B, Kates SL. The AO trauma CPP bone infection registry: Epidemiology and outcomes of Staphylococcus aureus bone infection. J Orthop Res 2021; 39:136-146. [PMID: 32720352 PMCID: PMC7749080 DOI: 10.1002/jor.24804] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 02/04/2023]
Abstract
Bone infection represents a serious complication of orthopedic surgery and Staphylococcus aureus is the most common pathogen. To improve the understanding of host-pathogen interaction, we developed a biospecimen registry (AO Trauma CPP Bone Infection Registry) to collect clinical data, bacterial isolates, and serum from patients with S. aureus bone infection. A prospective multinational registry with a 12-month follow-up was created to include adult patients (18 years or older) with culture-confirmed S. aureus infection in long bones after fracture fixation or arthroplasty. Baseline patient attributes and details on infections and treatments were recorded. Blood and serum samples were obtained at baseline, 6, and 12 months. Patient-reported outcomes were collected at 1, 6, and 12 months. Clinical outcomes were recorded. Two hundred and ninety-two patients with fracture-related infection (n = 157, 53.8%), prosthetic joint infection (n = 86, 29.5%), and osteomyelitis (n = 49, 16.8%) were enrolled. Methicillin-resistant S. aureus was detected in 82 patients (28.4%), with the highest proportion found among patients from North American sites (n = 39, 48.8%) and the lowest from Central European sites (n = 18, 12.2%). Patient outcomes improved at 6 and 12 months in comparison to baseline. The SF-36 physical component summary mean (95% confidence interval) score, however, did not reach 50 at 12 months. The cure rate at the end of the study period was 62.1%. Although patients improved with treatment, less than two-thirds were cured in 1 year. At 12-month follow-up, patient-reported outcome scores were worse for patients with methicillin-resistant S. aureus infections.
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Affiliation(s)
- Mario Morgenstern
- Department of Orthopaedic and Trauma SurgeryUniversity Hospital BaselBaselSwitzerland,Department of Trauma SurgeryBG Unfallklinik MurnauMurnauGermany
| | | | - Matthias Militz
- Department of Trauma SurgeryBG Unfallklinik MurnauMurnauGermany
| | - Zhao Xie
- Department of Orthopaedics, Southwest HospitalThird Military Medical UniversityChongqingChina
| | - Jiachen Peng
- Department of OrthopedicsAffiliated Hospital of Zunyi Medical University, Zunyi, China; Joint Orthopaedic Research Center of Zunyi Medical University & University of Rochester Medical CenterZunyiChina
| | - James Stannard
- Department of Orthopaedic SurgeryUniversity of Missouri, Missouri Orthopaedic InstituteColumbiaMissouri
| | | | - Dirk Schaefer
- Department of Plastic, Reconstructive, Aesthetic and Hand SurgeryUniversity Hospital BaselBaselSwitzerland
| | - Volker Alt
- Department of Trauma SurgeryUniversity Hospital Giessen, Justus‐Liebig University GiessenGiessenGermany,Department of Trauma Surgery, Orthopaedic Surgery, SportsmedicineUniversity Hospital RegensburgRegensburgGermany
| | - Kjeld Søballe
- Department of OrthopaedicsAarhus University HospitalAarhusDenmark
| | - Michael Nerlich
- Department of Trauma Surgery, Orthopaedic Surgery, SportsmedicineUniversity Hospital RegensburgRegensburgGermany
| | - Richard E. Buckley
- Department of Surgery, Foothills Medical CentreUniversity of CalgaryCalgaryAlbertaCanada
| | - Michael Blauth
- Department of Trauma SurgeryMedical University InnsbruckInnsbruckAustria
| | - Michael Suk
- Department of Orthopaedic SurgeryGeisinger Medical CenterDanvillePennsylvania
| | - Frankie Leung
- Department of Orthopaedics and Traumatology, Queen Mary HospitalThe University of Hong KongPokfulam RoadHong Kong
| | - Jorge D. Barla
- Department of Orthopedic TraumaHospital Italiano de Buenos AiresBuenos AiresArgentina
| | - Kiminori Yukata
- Department of OrthopaedicsHamawaki Orthopaedic HospitalNakakuHiroshimaJapan
| | - Bi Qing
- Department of Orthopaedic SurgeryZhejiang Provincial People's HospitalZhejiangHangzhouChina
| | - Stephen L. Kates
- Department of Orthopaedic SurgeryVirginia Commonwealth UniversityRichmondVirginia
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57
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Yu KE, Alder KD, Morris MT, Munger AM, Lee I, Cahill SV, Kwon HK, Back J, Lee FY. Re-appraising the potential of naringin for natural, novel orthopedic biotherapies. Ther Adv Musculoskelet Dis 2020; 12:1759720X20966135. [PMID: 33343723 PMCID: PMC7727086 DOI: 10.1177/1759720x20966135] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/22/2020] [Indexed: 01/03/2023] Open
Abstract
Naringin is a naturally occurring flavonoid found in plants of the Citrus genus that has historically been used in traditional Chinese medical regimens for the treatment of osteoporosis. Naringin modulates signaling through numerous molecular pathways critical to musculoskeletal development, cellular differentiation, and inflammation. Administration of naringin increases in vitro expression of bone morphogenetic proteins (BMPs) and activation of the Wnt/β-catenin and extracellular signal-related kinase (Erk) pathways, thereby promoting osteoblastic proliferation and differentiation from stem cell precursors for bone formation. Naringin also inhibits osteoclastogenesis by both modifying RANK/RANKL interactions and inducing apoptosis in osteoclasts in vitro. In addition, naringin acts on the estrogen receptor in bone to mimic the native bone-preserving effects of estrogen, with few systemic side effects on other estrogen-sensitive tissues. The efficacy of naringin therapy in reducing the osteolysis characteristic of common musculoskeletal pathologies such as osteoporosis, degenerative joint disease, and osteomyelitis, as well as inflammatory conditions affecting bone such as diabetes mellitus, has been extensively demonstrated in vitro and in animal models. Naringin thus represents a naturally abundant, cost-efficient agent whose potential for use in novel musculoskeletal biotherapies warrants re-visiting and further exploration through human studies. Here, we review the cellular mechanisms of action that have been elucidated regarding the action of naringin on bone resident cells and the bone microenvironment, in vivo evidence of naringin’s osteostimulative and chondroprotective properties in the setting of osteolytic bone disease, and current limitations in the development of naringin-containing translational therapies for common musculoskeletal conditions.
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Affiliation(s)
- Kristin E Yu
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 330 Cedar St, TMP 523 PO Box 208071, New Haven, CT 06520-8071, USA
| | - Kareme D Alder
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA
| | - Montana T Morris
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA
| | - Alana M Munger
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA
| | - Inkyu Lee
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Department of Life Science, Chung-Ang University, Seoul, Republic of Korea
| | - Sean V Cahill
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA
| | - Hyuk-Kwon Kwon
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA
| | - JungHo Back
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA
| | - Francis Y Lee
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA
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58
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Biphasic composite of calcium phosphate-based mesoporous silica as a novel bone drug delivery system. Drug Deliv Transl Res 2020; 10:455-470. [PMID: 31820299 PMCID: PMC7066108 DOI: 10.1007/s13346-019-00686-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We reported the new biphasic composites of calcium phosphate and mesoporous silica material (CaP@MSi) in the form of powders and pellets as a potential bone drug delivery system for doxycycline hydrochloride (DOX). The CaP@MSi powders were synthesized by cationic surfactant-templating method. The effects of 10, 20, and 30% CaP content in the CaP@MSi powders on the molecular surface structure, the cytotoxicity against osteoblast cells in vitro, and the mineralization potential in simulated body fluid were investigated. The CaP@MSi characterized by the highest mineralization potential (30% CaP content) were used for DOX adsorption and pelletization process. The CaP which precipitated in the CaP@MSi composites was characterized as calcium-deficient with the Ca:P molar ratio between 1.0 and 1.2. The cytotoxicity assays demonstrated that the CaP content in MSi increases osteoblasts viability indicating the CaP@MSi (30% CaP content) as the most biocompatible. The combination of CaP and MSi was an effective strategy to improve the mineralization potential of parent material. Upon immersion in simulated body fluid, the CaP of composite converted into the bone-like apatite. The obtained pellets preserved the mineralization potential of CaP@MSi and provided the prolonged 5-day DOX release. The obtained biphasic CaP@MSi composites seem to have an application potential as bone-specific drug delivery system.
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59
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Mais DD, Hackman S, Ross J. Histopathologic findings in culture-positive secondary osteomyelitis. Ann Diagn Pathol 2020; 50:151661. [PMID: 33197866 DOI: 10.1016/j.anndiagpath.2020.151661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/06/2020] [Accepted: 11/06/2020] [Indexed: 11/25/2022]
Abstract
As peripheral vascular disease and diabetes mellitus are increasingly common, chronic wounds are often seen. Bone biopsies, with imaging and microbial cultures, are often obtained to evaluate for osteomyelitis. Because much of the historical literature describing the histology of osteomyelitis pertains to primary osteomyelitis, this study characterizes the histologic findings and provides correlation with culture results in secondary osteomyelitis. The histologic features of bone biopsies were assessed over a 5 year period. Concurrent laboratory and radiographic data were obtained and these data were compared with culture results. This study included 163 cases, of which 104 were culture-positive osteomyelitis. All culture-positive cases had been present longer than 28 days and had at least one of the following histologic features: neutrophilic inflammation, plasmacytic inflammation, or eosinophilic fibrosis. However, none of these findings were restricted to culture-positive cases. Overall, plasmacytic and neutrophilic inflammation provided similar specificity, and positive predictive values for osteomyelitis. Medullary fibrosis gave a sensitivity of 95%, the highest for any single feature, and the combination of fibrosis and neutrophilic inflammation had the greatest specificity of 96%. Additionally, neutrophilic inflammation correlated often with isolation of Staphylococcus aureus, while plasma cell predominance was found more frequently with other infectious agents. This study describes histologic features in secondary osteomyelitis, which may challenge the widespread inclination to equate a neutrophilic inflammation with 'acute osteomyelitis' and 'chronic osteomyelitis' with one rich in plasma cells. We report an early correlation between common histopathologic findings and specific culture isolates, which can be further refined with additional research.
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Affiliation(s)
- Daniel D Mais
- UT-Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Sarah Hackman
- UT-Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - Jenny Ross
- UT-Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
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60
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Jacobs A, Renaudin G, Forestier C, Nedelec JM, Descamps S. Biological properties of copper-doped biomaterials for orthopedic applications: A review of antibacterial, angiogenic and osteogenic aspects. Acta Biomater 2020; 117:21-39. [PMID: 33007487 DOI: 10.1016/j.actbio.2020.09.044] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/17/2020] [Accepted: 09/21/2020] [Indexed: 12/13/2022]
Abstract
Copper is an essential trace element required for human life, and is involved in several physiological mechanisms. Today researchers have found and confirmed that Cu has biological properties which are particularly useful for orthopedic biomaterials applications such as implant coatings or biodegradable filler bone substitutes. Indeed, Cu exhibits antibacterial functions, provides angiogenic ability and favors osteogenesis; these represent major key points for ideal biomaterial integration and the healing process that follows. The antibacterial performances of copper-doped biomaterials present an interesting alternative to the massive use of prophylactic antibiotics and help to limit the development of antibiotic resistance. By stimulating blood vessel growth and new bone formation, copper contributes to the improved bio-integration of biomaterials. This review describes the bio-functional advantages offered by Cu and focuses on the antibacterial, angiogenic and osteogenic properties of Cu-doped biomaterials with potential for orthopedic applications.
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61
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Three-Dimensional In Vitro Staphylococcus aureus Abscess Communities Display Antibiotic Tolerance and Protection from Neutrophil Clearance. Infect Immun 2020; 88:IAI.00293-20. [PMID: 32817328 DOI: 10.1128/iai.00293-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/06/2020] [Indexed: 12/22/2022] Open
Abstract
Staphylococcus aureus is a prominent human pathogen in bone and soft-tissue infections. Pathophysiology involves abscess formation, which consists of central staphylococcal abscess communities (SACs), surrounded by a fibrin pseudocapsule and infiltrating immune cells. Protection against the ingress of immune cells such as neutrophils, or tolerance to antibiotics, remains largely unknown for SACs and is limited by the lack of availability of in vitro models. We describe a three-dimensional in vitro model of SACs grown in a human plasma-supplemented collagen gel. The in vitro SACs reached their maximum size by 24 h and elaborated a fibrin pseudocapsule, as confirmed by electron and immunofluorescence microscopy. The in vitro SACs tolerated 100× the MIC of gentamicin alone and in combination with rifampin, while planktonic controls and mechanically dispersed SACs were efficiently killed. To simulate a host response, SACs were exposed to differentiated PLB-985 neutrophil-like (dPLB) cells and to primary human neutrophils at an early stage of SAC formation or after maturation at 24 h. Both cell types were unable to clear mature in vitro SACs, but dPLB cells prevented SAC growth upon early exposure before pseudocapsule maturation. Neutrophil exposure after plasmin pretreatment of the SACs resulted in a significant decrease in the number of bacteria within the SACs. The in vitro SAC model mimics key in vivo features, offers a new tool to study host-pathogen interactions and drug efficacy assessment, and has revealed the functionality of the S. aureus pseudocapsule in protecting the bacteria from host phagocytic responses and antibiotics.
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62
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Gallarate M, Chirio D, Chindamo G, Peira E, Sapino S. Osteomyelitis: Focus on Conventional Treatments and Innovative Drug Delivery Systems. Curr Drug Deliv 2020; 18:532-545. [PMID: 32933461 DOI: 10.2174/1567201817666200915093224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/23/2020] [Accepted: 08/03/2020] [Indexed: 12/12/2022]
Abstract
Osteomyelitis is a bone marrow infection which generally involves cortical plates and which may occur after bone trauma, orthopedic/maxillofacial surgery or after vascular insufficiency episodes. It mostly affects people from the Third World Countries, the elderly and patients affected by systemic diseases e.g. autoimmune disorders, AIDS, osteoporosis and microvascular disease. The highest percentage of osteomyelitis cases (almost 75%) is caused by Staphylococcus spp., and in particular by Staphylococcus aureus (more than 50%). The ideal classification and the diagnosis of osteomyelitis are two important tools which help the physicians to choose the best therapeutic strategies. Currently, common therapies provide an extensive debridement in association with intravenous administration of antibiotics (penicillin or clindamycin, vancomycin and fluoroquinolones among all for resistant microorganisms), to avoid the formation of sequestra. However, conventional therapeutic approach involves several drawbacks like low concentration of antibiotics in the infected site, leading to resistance and adverse effects due to the intravenous administration. For these reasons, in the last years several studies have been focused on the development of drug delivery systems such as cements, beads, scaffolds and ceramics made of hydroxyapatite (HA), calcium phosphate (CaP) and β-tricalcium phosphate (β-TCP) which demonstrated to be biocompatible, poorly toxic and capable to allow osteointegration and a prolonged drug release. The aim of this review is to provide a focus on current therapies and latest developed drug delivery systems with particular attention on those based on CaP and its derivatives, hoping that this work could allow further direction in the field of osteomyelitis.
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Affiliation(s)
- Marina Gallarate
- Department of Drug Science and Technology, University of Turin, via P. Giuria 9, Turin, 10125, Italy
| | - Daniela Chirio
- Department of Drug Science and Technology, University of Turin, via P. Giuria 9, Turin, 10125, Italy
| | - Giulia Chindamo
- Department of Drug Science and Technology, University of Turin, via P. Giuria 9, Turin, 10125, Italy
| | - Elena Peira
- Department of Drug Science and Technology, University of Turin, via P. Giuria 9, Turin, 10125, Italy
| | - Simona Sapino
- Department of Drug Science and Technology, University of Turin, via P. Giuria 9, Turin, 10125, Italy
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Change in Bone CT Attenuation and C-reactive Protein Are Predictors of Bone Biopsy Culture Positivity in Patients With Vertebral Discitis/Osteomyelitis. Spine (Phila Pa 1976) 2020; 45:1208-1214. [PMID: 32205702 DOI: 10.1097/brs.0000000000003504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case-control study. OBJECTIVE The objective of this study was to identify the best laboratory and imaging factors to predict bone biopsy culture positivity in the setting of vertebral discitis/osteomyelitis (VDO). SUMMARY OF BACKGROUND DATA Good predictors of bone biopsy culture positivity in the setting of VDO are unknown. METHODS Retrospective review was performed for 46 patients who underwent CT-guided bone biopsy for the evaluation of clinically confirmed VDO. Erythrocyte sedimentation rate, C-reactive protein (CRP), mean CT attenuation of the biopsied bone, and the change in the CT attenuation of the bone compared to unaffected vertebral bone (delta CT attenuation) were measured. Receiver-operator characteristic curve analyses were performed to identify the optimal threshold value for each variable. A multivariable logistic regression model was used to predict the probability of a positive bone culture using delta CT attenuation and CRPx100% fold above normal. RESULTS For one of the 46 VDO patients, bone cultures were not obtained. Approximately 35.6% (16/45) of bone cultures were positive. The most significant predictors of bone culture positivity were CRP x100% fold above normal (P = 0.011) and delta CT attenuation (P = <0.001). Optimized predictive thresholds were calculated to be CRP 4-fold above normal reference value (90.9% sensitivity, 73.7% specificity), or if the CT attenuation of the affected vertebral body was >25.9 HU lower relative to unaffected bone (93.8% sensitivity, 75.0% specificity). CONCLUSION Delta CT attenuation, as well as CRP level over four times the upper limits of normal, were the strongest predictors for bone culture positivity in patients with VDO. LEVEL OF EVIDENCE 3.
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Cipollaro L, Trucillo P, Bragazzi NL, Della Porta G, Reverchon E, Maffulli N. Liposomes for Intra-Articular Analgesic Drug Delivery in Orthopedics: State-of-Art and Future Perspectives. Insights from a Systematic Mini-Review of the Literature. ACTA ACUST UNITED AC 2020; 56:medicina56090423. [PMID: 32825518 PMCID: PMC7557801 DOI: 10.3390/medicina56090423] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/06/2020] [Accepted: 08/17/2020] [Indexed: 12/24/2022]
Abstract
Background and objectives: Liposomal structures are artificial vesicles composed of one or several lamellae of phospholipids which surround an inner aqueous core. Given the amphoteric nature of phospholipids, liposomes are promising systems for drug delivery. The present review provides an updated synthesis of the main techniques for the production of liposomes for orthopedic applications, focusing on the drawbacks of the conventional methods and on the advantages of high pressure techniques. Materials and Methods: Articles published in any language were systematically retrieved from two major electronic scholarly databases (PubMed/MEDLINE and Scopus) up to March 2020. Nine articles were retained based on the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) guidelines. Results: Liposome vesicles decrease the rate of inflammatory reactions after local injections, and significantly enhance the clinical effectiveness of anti-inflammatory agents providing controlled drug release, reducing toxic side effects. Conclusions: This review presents an update on the improvement in musculoskeletal ailments using liposome treatment.
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Affiliation(s)
- Lucio Cipollaro
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Via San Leonardo 1, 84131 Salerno, Italy;
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi (SA), Italy;
| | - Paolo Trucillo
- Department of Industrial Engineering, University of Salerno, Via Giovanni Paolo II, 84084 Salerno, Italy; (P.T.); (E.R.)
- Department of Chemical, Material and Industrial Production Engineering, University of Naples Federico II, Piazzale V. Tecchio, 80-80125 Napoli, Italy
| | - Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON M3J 1P3, Canada;
- Postgraduate School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, 16132 Genoa, Italy
| | - Giovanna Della Porta
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi (SA), Italy;
- Department of Industrial Engineering, University of Salerno, Via Giovanni Paolo II, 84084 Salerno, Italy; (P.T.); (E.R.)
| | - Ernesto Reverchon
- Department of Industrial Engineering, University of Salerno, Via Giovanni Paolo II, 84084 Salerno, Italy; (P.T.); (E.R.)
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Via San Leonardo 1, 84131 Salerno, Italy;
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi (SA), Italy;
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London E1 4DG, UK
- School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent ST4 7QB, UK
- Correspondence:
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Szewczyk A, Skwira A, Konopacka A, Sądej R, Walker G, Prokopowicz M. Mesoporous silica pellets as bifunctional bone drug delivery system for cefazolin. Int J Pharm 2020; 588:119718. [PMID: 32750441 DOI: 10.1016/j.ijpharm.2020.119718] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/16/2022]
Abstract
For decades, bone drug delivery systems dedicated for osteomyelitis treatment have been investigated as bifunctional materials that exhibit prolonged drug release and mineralization potential. Herein, composite-type pellets based on cefazolin-loaded amino-modified mesoporous silica SBA-15 and microwave-assisted hydroxyapatite were investigated as potential bone drug delivery system in vitro. Pellets were obtained by granulation, extrusion and spheronization methods in laboratory scale and studied in terms of physical properties, drug release, mineralization potential, antimicrobial activity and cytotoxicity towards human osteoblasts. The obtained pellets were characterized for hardness and friability which indicated the pellets durability during further investigations. Prolonged (5-day) release of cefazolin from pellets was observed. The pellets exhibited mineralization potential in simulated body fluid, i.e., a continuous layer of bone-like apatite was formed on the surface of pellets after 28 days of incubation. An antimicrobial assay of pellets revealed an antibacterial effect against Staphylococcus aureus strain during 6 days. No cytotoxic effects of pellets towards human osteoblasts were observed. The obtained results proved that proposed pellets appear to have potential applications as bone drug delivery systems.
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Affiliation(s)
- Adrian Szewczyk
- Department of Physical Chemistry, Faculty of Pharmacy, Medical University of Gdańsk, Hallera 107, 80-416 Gdańsk, Poland
| | - Adrianna Skwira
- Department of Physical Chemistry, Faculty of Pharmacy, Medical University of Gdańsk, Hallera 107, 80-416 Gdańsk, Poland
| | - Agnieszka Konopacka
- Department of Pharmaceutical Microbiology, Faculty of Pharmacy, Medical University of Gdańsk, Hallera 107, 80-416 Gdańsk, Poland
| | - Rafał Sądej
- Department of Molecular Enzymology and Oncology, Intercollegiate Faculty of Biotechnology, University of Gdańsk and Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Gavin Walker
- Bernal Institute and Department of Chemical Science, University of Limerick, Limerick, Ireland
| | - Magdalena Prokopowicz
- Department of Physical Chemistry, Faculty of Pharmacy, Medical University of Gdańsk, Hallera 107, 80-416 Gdańsk, Poland.
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Steinmetz RG, Maupin JJ, Smith JN, White CB. Septic arthritis of the acromioclavicular joint: a case series and review of the literature. Shoulder Elbow 2020; 12:272-283. [PMID: 32788932 PMCID: PMC7400718 DOI: 10.1177/1758573218815289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/28/2018] [Accepted: 10/30/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report a case series of three patients with septic arthritis of the acromioclavicular joint and a review of the literature for this condition. Additionally, we developed an algorithm for diagnosing and treating septic arthritis of the acromioclavicular joint. METHODS A retrospective review of patients treated at our institution for septic arthritis of the acromioclavicular joint during the collection period was performed and three cases were identified. A review of the English literature on this rare condition was also performed with only 28 cases being identified. RESULTS A series of three consecutive patients were treated for septic acromioclavicular arthritis with resolution of the infection. Two patients underwent open surgical debridement and one underwent aspiration. All patients were treated with a minimum of six weeks of tailored intravenous antibiotic therapy. CONCLUSION Septic arthritis of the acromioclavicular joint can be difficult to diagnose and requires a high index of suspicion. Surgical debridement, open or arthroscopic, with tailored antibiotic therapy is an effective means for the management of septic arthritis of the acromioclavicular joint. In patients who are unable to have surgical debridement, aspiration and tailored antibiotics have been shown to be effective.
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Affiliation(s)
- Raymond G Steinmetz
- Garrett Steinmetz, 800 Stanton L Young Blvd, AAT-3400 Oklahoma City, OK 73104, USA.
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Thijssen EGJ, van Gestel NAP, Bevers R, Hofmann S, Geurts J, van Loo IHM, Arts JJ. Assessment of Growth Reduction of Five Clinical Pathogens by Injectable S53P4 Bioactive Glass Material Formulations. Front Bioeng Biotechnol 2020; 8:634. [PMID: 32676498 PMCID: PMC7333246 DOI: 10.3389/fbioe.2020.00634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/22/2020] [Indexed: 11/13/2022] Open
Abstract
The one-stage treatment of chronic osteomyelitis with S53P4 bioactive glass (BAG) granules has shown excellent results. However, these granules possess suboptimal handling properties. Therefore, new injectable S53P4 putty materials have been developed by the incorporation of a synthetic binder to contain glass granules. The goal of the current study was to assess their potential to eradicate five clinically relevant pathogens: methicillin sensitive Staphylococcus aureus (MSSA), methicillin resistant Staphylococcus aureus (MRSA), Enterococcus coli (E. coli), Enterococcus faecalis (E. faecalis), and Pseudomonas aeruginosa (P. aeruginosa). As a control, S53P4 granules (500–800 μm) and S66 glass (< 45 μm) were used. To evaluate the antimicrobial properties, the materials were cultured with the pathogens in a Müller-Hinton II broth for a week with daily colony forming unit (CFU) counting. One of the tested putty formulations was observed to reduce the number of CFU/mL compared to a negative control (no material, only pathogen in broth) for E. coli, E. faecalis and P. aeruginosa. However, none of the tested putty formulations was able to completely eradicate the pathogens in the broths, which would be needed for safe infection treatment. The results obtained for the control materials were unexpected. S66 glass showed full eradication of P. aeruginosa and reduced the number of CFUs of other pathogens, while the S53P4 granules did not show eradication. The observations on the loose S53P4 granules in this study contradict available literature, which needs further investigation. The results obtained in this study also stretch the importance for a better understanding of the underlying antimicrobial mechanism of S53P4 BAG and how this is related to the dosage. In addition, it should be elucidated how these antimicrobial properties are affected by changes in the material formulation, for example by addition of binders to improve the handling properties or by changing the surface area.
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Affiliation(s)
- Eline G J Thijssen
- Laboratory for Experimental Orthopedics, Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Nicole A P van Gestel
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Raymond Bevers
- Laboratory for Experimental Orthopedics, Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sandra Hofmann
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Jan Geurts
- Laboratory for Experimental Orthopedics, Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Inge H M van Loo
- Department of Medical Microbiology, Research School CAPHRI, Maastricht University Medical Centre, Maastricht, Netherlands
| | - J J Arts
- Laboratory for Experimental Orthopedics, Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Centre, Maastricht, Netherlands.,Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
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Abstract
Osteomyelitis, or inflammation of bone, is most commonly caused by invasion of bacterial pathogens into the skeleton. Bacterial osteomyelitis is notoriously difficult to treat, in part because of the widespread antimicrobial resistance in the preeminent etiologic agent, the Gram-positive bacterium Staphylococcus aureus Bacterial osteomyelitis triggers pathological bone remodeling, which in turn leads to sequestration of infectious foci from innate immune effectors and systemically delivered antimicrobials. Treatment of osteomyelitis therefore typically consists of long courses of antibiotics in conjunction with surgical debridement of necrotic infected tissues. Even with these extreme measures, many patients go on to develop chronic infection or sustain disease comorbidities. A better mechanistic understanding of how bacteria invade, survive within, and trigger pathological remodeling of bone could therefore lead to new therapies aimed at prevention or treatment of osteomyelitis as well as amelioration of disease morbidity. In this minireview, we highlight recent developments in our understanding of how pathogens invade and survive within bone, how bacterial infection or resulting innate immune responses trigger changes in bone remodeling, and how model systems can be leveraged to identify new therapeutic targets. We review the current state of osteomyelitis epidemiology, diagnostics, and therapeutic guidelines to help direct future research in bacterial pathogenesis.
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Oliveira RLMS, Barbosa L, Hurtado CR, Ramos LDP, Montanheiro TLA, Oliveira LD, Tada DB, Trichês EDS. Bioglass‐based scaffolds coated with silver nanoparticles: Synthesis, processing and antimicrobial activity. J Biomed Mater Res A 2020; 108:2447-2459. [DOI: 10.1002/jbm.a.36996] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/30/2020] [Accepted: 04/04/2020] [Indexed: 12/27/2022]
Affiliation(s)
| | - Lucas Barbosa
- Bioceramics Laboratory, Science and Technology Institute UNIFESP São José dos Campos SP Brazil
| | - Carolina R. Hurtado
- Nanomaterials and Nanotoxicology Laboratory, Science and Technology Institute UNIFESP São José dos Campos SP Brazil
- IFSP São José dos Campos SP Brazil
| | - Lucas de P. Ramos
- Science and Technology Institute UNESP São José dos Campos SP Brazil
| | | | | | - Dayane B. Tada
- Nanomaterials and Nanotoxicology Laboratory, Science and Technology Institute UNIFESP São José dos Campos SP Brazil
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Kates SL, Hurni S, Chen MS. Development and challenges in setting up an international bone infection registry. Arch Orthop Trauma Surg 2020; 140:741-749. [PMID: 31701213 PMCID: PMC7202964 DOI: 10.1007/s00402-019-03303-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Osteomyelitis is an increasing burden on the society especially due to the emergence of multiple drug-resistant organisms. The lack of a central registry that prospectively collects data on patient risk factors, laboratory test results, treatment modalities, serological analysis results, and outcomes has hampered the research effort that could have improved and provided guidelines for treatments of bone infections. The current manuscript describes the lessons learned in setting up a multi-continent registry. MATERIALS AND METHODS This multicenter, international registry was conducted to prospectively collect essential patient, clinical, and surgical data with a 1-year follow-up period. Patients 18 years or older with confirmed S. aureus long bone infection through fracture fixation or arthroplasty who consented to participate in the study were included. The outcomes using the Short Form 36 Health Survey Questionnaire (version 2), Parker Mobility Score, and Katz Index of Independence in Activities of Daily Living were assessed at baseline and at 1 month, 6 months, and 12 months. Serological samples were collected at follow-ups. RESULTS Contract negotiation with a large number of study sites was difficult; obtaining ethics approvals were time-consuming but straightforward. The initial patient recruitment was slow, leading to a reduction of target patient number from 400 to 300 and extension of enrollment period. Finally, 292 eligible patients were recruited by 18 study sites (in 10 countries of 4 continents, Asia, North and South America, and Central Europe). Logistical and language barriers were overcome by employing courier service and local monitoring personnel. CONCLUSIONS Multicenter registry is useful for collecting a large number of cases for analysis. A well-defined data collection practice is important for data quality but challenging to coordinate with the large number of study sites.
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Affiliation(s)
- Stephen L. Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1200 East Broad St, PO Box 980153, Richmond, VA 23298, USA
| | - Severine Hurni
- AO Clinical Investigation and Documentation, Davos, Switzerland
| | - Maio S. Chen
- AO Clinical Investigation and Documentation, Davos, Switzerland
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Drago L, Romanò CL, Cecchinato R, Villafañe JH, De Vecchi E, Lamartina C, Berjano P. Are Modic type 2 disc changes associated with low-grade infections? A pilot study. J Neurosurg Sci 2020; 64. [DOI: 10.23736/s0390-5616.17.03997-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Wagh Y, Reddy R, Gundavda M, Agarwal M, Agashe VM, Bajwa S. Tuberculosis (T.B.) masquerading as tumor. An 8-year study on 25 cases of long bone tuberculosis presenting as tumors. SICOT J 2020; 6:14. [PMID: 32463012 PMCID: PMC7254868 DOI: 10.1051/sicotj/2020011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 04/17/2020] [Indexed: 11/14/2022] Open
Abstract
Aim: To highlight radiological features and emphasize the need for tissue diagnoses to confirm bone pathology. Tuberculosis is known to present without constitutional symptoms and with unconventional imaging features mimicking sarcomas as shown in our series of 25 patients; where the imaging and biopsy protocols at our institute helped to solve these diagnostic dilemmas. Material and methods: We retrospectively analyzed clinical and radiological features and tissue diagnoses in 25 patients referred to the department of orthopedic oncology with radiological suspicion of tumor. Results: Only 7 patients had cultures positive for Mycobacterium Tuberculosis T.B. Radiological features suggestive of infection were Metaphyseal and joint involvement, permeative lesions, absence of Codman’s triangle, and soft tissue mass suggestive of a cold abscess. The predictive accuracy of the orthopedic oncologist was 60% and musculoskeletal radiologist was 72% (based on radiology). Final diagnosis is 100% confirmed on histopathology. Conclusion: Diagnosis based primarily upon imaging is a wrong approach. A multimodal approach to differentiating tuberculous bone infections from sarcomas is essential.
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Affiliation(s)
- Yash Wagh
- Department of Orthopedics, P D Hinduja Hospital and Medical Research Centre, Mahim, Mumbai 400016, India
| | - Rajeev Reddy
- Department of Orthopedics, P D Hinduja Hospital and Medical Research Centre, Mahim, Mumbai 400016, India
| | - Manit Gundavda
- Department of Orthopedics, P D Hinduja Hospital and Medical Research Centre, Mahim, Mumbai 400016, India
| | - Manish Agarwal
- Department of Orthopedics, P D Hinduja Hospital and Medical Research Centre, Mahim, Mumbai 400016, India
| | - Vikas M Agashe
- Department of Orthopedics, P D Hinduja Hospital and Medical Research Centre, Mahim, Mumbai 400016, India - Dr Agashe's Maternity and Surgical Nursing Home, Kurla, Mumbai 400070, India
| | - Supreet Bajwa
- Department of Orthopedics, P D Hinduja Hospital and Medical Research Centre, Mahim, Mumbai 400016, India
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Stupina TA, Sudnitsyn AS, Subramanyam KN, Migalkin NS, Kirsanova AY, Umerjikar S. Applicability of histopathological osteomyelitis evaluation score (HOES) in chronic osteomyelitis of the foot - A feasibility study. Foot Ankle Surg 2020; 26:273-279. [PMID: 31000385 DOI: 10.1016/j.fas.2019.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/10/2019] [Accepted: 03/23/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Diagnosis and classification of chronic osteomyelitis is not based on any objective criteria. None of the available methods for this is completely reliable. Tienmann et al. (2014) has described the so called histopathological osteomyelitis evaluation score (HOES) to overcome this limitation. But this has not been externally validated or tested in cases with foot osteomyelitis. METHODS We prospectively reviewed the histopathological samples of 30 consecutive patients (30 feet) with foot osteomyelitis managed operatively. There were 19 males and 11 females with an average age of 41.6 (range, 27-63) years. The underlying pathology was spina bifida in 12, Charcot's arthropathy in eleven and post-traumatic in seven patients. The bones involved were calcaneum, talus and fifth metatarsal. Pathological diagnosis was made based on HOES by a single pathologist blinded to the clinical diagnosis and both were compared. Intra- and inter-observer reliability of HOES was assessed by analysing the scores of each patient assigned independently by four different pathologists (blinded to the clinical diagnoses and to each other) at two different occasions one week apart. RESULTS All samples showed features of long-standing osteomyelitis. When attempting to classify to "acute on chronic", "chronic" and "quiescent" forms, the pathological diagnosis correlatead with the clinical diagnosis only in 16 cases (53.3 percent). Histological classification to Tienmann's types as per the scoring system yielded three distinct pathological entities that had common histological features with regard to bone, soft tissue and inflammatory infiltration. HOES exhibited excellent intra- and inter-observer reliability. CONCLUSIONS HOES is well applicable in foot osteomyelitis both for diagnosis and classification by unambiguous and precise scoring system. This makes diagnostic labelling more accurate and repeatable. The clinical relevance of these histopathological types in guiding management and determining prognosis needs to be investigated further.
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Affiliation(s)
- Tatiana Anatolievna Stupina
- Laboratory of Morphology, Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, 640014 Kurgan, Russian Federation.
| | - Anatoliy Sergeyevich Sudnitsyn
- Laboratory of Bone Infection Osteology and Limb Lengthening, Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, 640014 Kurgan, Russian Federation.
| | - Koushik Narayan Subramanyam
- Dept. of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134 India.
| | - Nikolai Sergeevich Migalkin
- Laboratory of Morphology, Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, 640014 Kurgan, Russian Federation.
| | - Anastasia Yrievna Kirsanova
- Laboratory of Morphology, Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics, 6, M. Ulianova Street, 640014 Kurgan, Russian Federation.
| | - Sagar Umerjikar
- Dept. of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134 India.
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Sreeja S, Muraleedharan C, Varma PH, Sailaja G. Surface-transformed osteoinductive polyethylene terephthalate scaffold as a dual system for bone tissue regeneration with localized antibiotic delivery. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 109:110491. [DOI: 10.1016/j.msec.2019.110491] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/23/2019] [Accepted: 11/24/2019] [Indexed: 02/07/2023]
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Madhuri V, Ramesh S, Varma H, Sivadasan SB, Sahoo B, John A, Fernandez F, Rajagopal K, Mathews V, Balakumar B, Dinesh VD, Chilbule SK, Gibikote S, Srivastava A. First Report of a Tissue-Engineered Graft for Proximal Humerus Gap Non-union After Chronic Pyogenic Osteomyelitis in a Child: A Case Report. JBJS Case Connect 2020; 10:e0031. [PMID: 32224678 DOI: 10.2106/jbjs.cc.19.00031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CASE An 11-year-old child who presented with a postseptic gap nonunion of 4 cm in the proximal humerus was treated with a customized hydroxyapatite-tricalcium phosphate-tricalcium silicate composite (HASi) scaffold loaded with culture-expanded autologous bone marrow-derived mesenchymal stem cells (MSCs) primed into osteogenic lineage. Union occurred at 3 months, and at 3 years, the child had improved joint mobility, with radiographic and computed tomographic imaging evidence of incorporation of the graft. CONCLUSIONS This case demonstrated the feasibility of MSC directed into osteogenic lineage on HASi to repair a long bone defect owing to postseptic osteomyelitis, a condition notorious for a high failure rate.
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Affiliation(s)
- Vrisha Madhuri
- Paediatric Orthopaedics unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India.,Centre for Stem Cell Research, a unit of inStem, Bengaluru, Christian Medical College, Bagayam, Tamil Nadu, India
| | - Sowmya Ramesh
- Paediatric Orthopaedics unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India.,Centre for Stem Cell Research, a unit of inStem, Bengaluru, Christian Medical College, Bagayam, Tamil Nadu, India
| | - Harikrishna Varma
- Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, Kerala
| | - Suresh Babu Sivadasan
- Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, Kerala
| | - Bibhudatta Sahoo
- Paediatric Orthopaedics unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Annie John
- Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, Kerala
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76
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Microbiological Evaluation of Osteomyelitis with A Special Reference to Antibiotic Sensitivity Pattern of Isolates from A Tertiary Care Hospital. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2020. [DOI: 10.22207/jpam.14.1.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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77
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Lee HT, Sebro R. Predictors of positive bone cultures from CT-guided bone biopsies performed for suspected osteomyelitis. J Med Imaging Radiat Oncol 2020; 64:313-318. [PMID: 32174011 DOI: 10.1111/1754-9485.13012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Bone biopsies are often used to direct antibiotic choice in patients with suspected osteomyelitis. The aim of this study was to identify the best predictors of positive bone biopsy cultures. METHODS A retrospective review of 845 patients who underwent computed tomography (CT)-guided non-spine bone biopsies at a tertiary academic healthcare institution. Thirty-seven patients (4.4%) had biopsies performed for suspected osteomyelitis. Laboratory markers, as well as imaging features, were measured. t-Tests and Fisher's exact tests were used to compare clinical and demographic variables between patients with positive bone cultures and patients with negative bone cultures. Multivariable logistic regression was used to identify the best predictors of bone culture positivity. RESULTS All patients had negative blood cultures; however, only eight patients (21.6%) had positive bone cultures, with Staphyloccocus the most common organism. Multivariable logistic regression analysis showed that an open wound (OR = 14.00, 95% CI (1.74, 112.4), p = 0.013) and any fluid aspirated at the time of biopsy (OR = 10.50, 95% CI (1.21, 91.01), p = 0.033) were the best predictors of bone culture positivity. The area under the curve (AUC) for this multivariable model was 0.784 with sensitivity and specificity of 0.778 and 0.778, respectively. Interestingly, and contrary to popular belief, open wounds with exposed bone did not always yield positive bone cultures, and when cultures were positive, were not polymicrobial. CONCLUSIONS Aspiration of fluid at the time of biopsy and the presence of an open wound are the best predictors of positive bone cultures.
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Affiliation(s)
- Harrison T Lee
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ronnie Sebro
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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78
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Hofstee MI, Muthukrishnan G, Atkins GJ, Riool M, Thompson K, Morgenstern M, Stoddart MJ, Richards RG, Zaat SAJ, Moriarty TF. Current Concepts of Osteomyelitis: From Pathologic Mechanisms to Advanced Research Methods. THE AMERICAN JOURNAL OF PATHOLOGY 2020; 190:1151-1163. [PMID: 32194053 DOI: 10.1016/j.ajpath.2020.02.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 01/18/2023]
Abstract
Osteomyelitis is an inflammation of the bone and bone marrow that is most commonly caused by a Staphylococcus aureus infection. Much of our understanding of the underlying pathophysiology of osteomyelitis, from the perspective of both host and pathogen, has been revised in recent years, with notable discoveries including the role played by osteocytes in the recruitment of immune cells, the invasion and persistence of S. aureus in submicron channels of cortical bone, and the diagnostic role of polymorphonuclear cells in implant-associated osteomyelitis. Advanced in vitro cell culture models, such as ex vivo culture models or organoids, have also been developed over the past decade, and have become widespread in many fields, including infectious diseases. These models better mimic the in vivo environment, allow the use of human cells, and can reduce our reliance on animals in osteomyelitis research. In this review, we provide an overview of the main pathologic concepts in osteomyelitis, with a focus on the new discoveries in recent years. Furthermore, we outline the value of modern in vitro cell culture techniques, with a focus on their current application to infectious diseases and osteomyelitis in particular.
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Affiliation(s)
- Marloes I Hofstee
- AO Research Institute Davos, Davos, Switzerland; Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | - Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research and Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| | - Gerald J Atkins
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
| | - Martijn Riool
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | | | - Mario Morgenstern
- Department of Orthopedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland
| | | | | | - Sebastian A J Zaat
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
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79
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Oosthuysen W, Venter R, Tanwar Y, Ferreira N. Bioactive glass as dead space management following debridement of type 3 chronic osteomyelitis. INTERNATIONAL ORTHOPAEDICS 2020; 44:421-428. [PMID: 31701158 DOI: 10.1007/s00264-019-04442-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/21/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Chronic osteomyelitis is a challenging condition to treat and although no exact treatment guidelines exist, the surgical management strategy includes wide resection of necrotic and infected bone followed by dead space management. This study evaluates the use of bioactive glass as a single-stage procedure for dead space management following surgical debridement. METHODS A consecutive series of 24 patients with Cierny-Mader type 3 osteomyelitis, treated between March 2016 and June 2018, were identified and evaluated retrospectively. Patients were managed with bioactive glass as dead space management following surgical debridement. RESULTS Of the patients who completed more than 12 months follow-up, all fourteen (100%) showed complete resolution of symptoms. Of the remaining ten patients with less than 12 months follow-up, eight had complete resolution of symptoms. Therefore, a preliminary result of 22 out of 24 patients (91.65%) had resolution of symptoms following debridement and dead space management with bioactive glass. One patient experienced a complication related to the use of bioactive glass. This manifested as prolonged serous wound drainage that resolved with local wound care. CONCLUSION The use of bioactive glass appears to be effective for dead space management following debridement of anatomical type 3 chronic osteomyelitis of the appendicular skeleton.
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Affiliation(s)
- Willem Oosthuysen
- Division of Orthopaedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, 7505, South Africa
| | - Rudolph Venter
- Division of Orthopaedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, 7505, South Africa
| | - Yashwant Tanwar
- Division of Orthopaedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, 7505, South Africa
| | - Nando Ferreira
- Division of Orthopaedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, 7505, South Africa.
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80
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Afzelius P, Heegaard PMH, Jensen SB, Alstrup AKO, Schønheyder HC, Eek A, Boerman O, Nielsen OL. [ 99mTc]-labelled interleukin-8 as a diagnostic tool compared to [ 18F]FDG and CT in an experimental porcine osteomyelitis model. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2020; 10:32-46. [PMID: 32211217 PMCID: PMC7076304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/07/2020] [Indexed: 06/10/2023]
Abstract
Osteomyelitis (OM) is an important cause of morbidity and sometimes mortality in children and adults. Long-term complications can be reduced when treatment is initiated in an early phase. The diagnostic gold standard is microbial examination of a biopsy and current non-invasive imaging methods are not always optimal. [111In]-leukocyte scintigraphy is recommended for peripheral OM, but is time-consuming and not recommended in children. [18F]FDG PET/CT is recommended for vertebral OM in adults, but has the disadvantage of false positive findings and a relatively high radiation exposure; the latter is a problem in children. [99mTc]-based tracers are consequently preferred in children. We, therefore, aimed to find a [99mTc]-marked tracer with high specificity and sensitivity for early detection of OM. Suppurating inflammatory lesions like OM caused by Staphylococcus aureus (S. aureus) will attract large numbers of neutrophils and macrophages. A preliminary study has shown that [99m Tc]-labelled IL8 may be a possible candidate for imaging of peripheral OM. We investigated [99mTc]IL8 scintigraphy in a juvenile pig model of peripheral OM and compared it with [18F]FDG PET/CT. The pigs were experimentally inoculated with S. aureus to induce OM and scanned one week later. We also examined leukocyte count, serum CRP and IL8, as well as performed histopathological and microbiological investigations. [ 99m Tc]IL8 was easily and relatively quickly prepared and was shown to be suitable for visualization of OM lesions in peripheral bones detecting 70% compared to a 100% sensitivity of [18F]FDG PET/CT. [ 99m Tc]IL8 is a promising candidate for detection of OM in peripheral bones in children.
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Affiliation(s)
- Pia Afzelius
- Department of Nuclear Medicine, Aalborg University HospitalAalborg, Denmark
- North Zealand Hospital, Hillerød, University Hospital of CopenhagenDenmark
| | | | - Svend Borup Jensen
- Department of Nuclear Medicine, Aalborg University HospitalAalborg, Denmark
- Department of Chemistry and Biochemistry, Aalborg UniversityAalborg, Denmark
| | | | - Henrik Carl Schønheyder
- Department of Clinical Microbiology, Aalborg University HospitalAalborg
- Department of Clinical Medicine, Aalborg UniversityAalborg
| | - Annemarie Eek
- Department of Radiology and Nuclear Medicine, Raboud UMCNijmegen, The Netherlands
| | - Otto Boerman
- Department of Radiology and Nuclear Medicine, Raboud UMCNijmegen, The Netherlands
| | - Ole Lerberg Nielsen
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of CopenhagenCopenhagen, Denmark
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81
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Bourgeois M, Loisel F, Bertrand D, Nallet J, Gindraux F, Adam A, Lepage D, Sergent P, Leclerc G, Rondot T, Garbuio P, Obert L, Pluvy I. Management of forearm bone loss with induced membrane technique. HAND SURGERY & REHABILITATION 2020; 39:171-177. [PMID: 32061857 DOI: 10.1016/j.hansur.2020.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/15/2022]
Abstract
There are very few published studies describing the treatment of segmental bone defects of the forearm using the induced membrane technique. The objectives of this study were to evaluate the time to bone union, the function of the joints above and below the treated bone segment and the patients' quality of life over the long-term. We performed a retrospective study in all patients treated by the induced membrane for a forearm bone defect over at 13-year period. Demographics, bone union, complications, functional outcomes and occupational status were collected. Six patients were included: 2 posttraumatic injuries, 1 osteomyelitis, 1 septic arthritis, 1 aseptic nonunion, 1 tumor. The average defect length was 64mm (48-110). All defects were treated with internal fixation. Bone graft was harvested from the iliac crest in two patients, the femur (using the Reamer Irrigator Aspirator technique) in three patients and the radius in one patient. Five patients achieved bone union after a mean of 4months (3-6). Three complications were observed: 1 radioulnar instability, 1 infection of the fixation device, 1 abscess. At an average 8½ years' follow-up, the pain level on the VAS was 0.6 (0-3), the Mayo Elbow Performance Score was 98 (90-100), the Herzberg score was 108 (85.6-140) and the QuickDASH was 14.9 (2.7-35). All patients returned to work. Using the induced membrane technique avoids the complications associated with vascularized autograft and yields good functional outcome and quality of life.
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Affiliation(s)
- M Bourgeois
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France.
| | - F Loisel
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France; EA 4662 nanomédecine, imagerie, thérapeutique, UFR sciences & techniques, université de Franche-Comté, 16, route de Gray, 25030 Besançon cedex, France
| | - D Bertrand
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France
| | - J Nallet
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France
| | - F Gindraux
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France; EA 4662 nanomédecine, imagerie, thérapeutique, UFR sciences & techniques, université de Franche-Comté, 16, route de Gray, 25030 Besançon cedex, France
| | - A Adam
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France
| | - D Lepage
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France; EA 4662 nanomédecine, imagerie, thérapeutique, UFR sciences & techniques, université de Franche-Comté, 16, route de Gray, 25030 Besançon cedex, France
| | - P Sergent
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France
| | - G Leclerc
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France
| | - T Rondot
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France
| | - P Garbuio
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France; EA 4662 nanomédecine, imagerie, thérapeutique, UFR sciences & techniques, université de Franche-Comté, 16, route de Gray, 25030 Besançon cedex, France
| | - L Obert
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France; EA 4662 nanomédecine, imagerie, thérapeutique, UFR sciences & techniques, université de Franche-Comté, 16, route de Gray, 25030 Besançon cedex, France
| | - I Pluvy
- Service de chirurgie orthopédique, traumatologique et plastique, CHRU de Besançon, boulevard Fleming, 25030 Besançon cedex, France; EA 4662 nanomédecine, imagerie, thérapeutique, UFR sciences & techniques, université de Franche-Comté, 16, route de Gray, 25030 Besançon cedex, France
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82
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Sendi P, Kaempfen A, Uçkay I, Meier R. Bone and joint infections of the hand. Clin Microbiol Infect 2020; 26:848-856. [PMID: 31917233 DOI: 10.1016/j.cmi.2019.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/10/2019] [Accepted: 12/14/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Little guidance is currently available for standardized diagnostic protocols and therapeutic recommendations for bone and joint infections (BJIs) of the hand. OBJECTIVES To summarize the available data in the scientific English-language literature on the diagnosis and treatment of native BJIs of the hand. To illustrate these concepts from a narrative point of view in areas where there is lack of evidence. SOURCES We performed a systematic PubMed and Internet search of studies that investigated hand BJIs in adult patients. CONTENT Few studies have systematically investigated and validated diagnostic concepts, classifications or surgical treatment protocols. Most concepts derive from traditional intra-institutional experience, expert opinions and extrapolations from infections in large joints and long bones. Similarly, there is no uniformly accepted infection definition of BJIs of the hand. The best-documented literature is available for microbiological findings and antibiotic treatment duration in uncomplicated native joint arthritis of the fingers. Retrospective studies and one prospective randomized trial suggest that post-surgical targeted antibiotic therapy of 2 weeks results in a microbiological cure rate of ≥88%. IMPLICATIONS Studies on diagnostic workup and infection definition and classification are urgently needed to compare inter-institutional outcome results and generate guidelines for the best patient care. For uncomplicated pyogenic arthritis of native joints, current evidence suggests that a 2-week course of antibiotic therapy following surgery cures the infection.
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Affiliation(s)
- P Sendi
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Switzerland; Department of Orthopaedics and Traumatology, University Hospital Basel, University of Basel, Switzerland; Institute of Infectious Diseases, University of Bern, Bern, Switzerland.
| | - A Kaempfen
- Clinic for Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - I Uçkay
- Infectiology, Balgrist University Hospital, Zürich, Switzerland
| | - R Meier
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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83
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Krishnan AG, Biswas R, Menon D, Nair MB. Biodegradable nanocomposite fibrous scaffold mediated local delivery of vancomycin for the treatment of MRSA infected experimental osteomyelitis. Biomater Sci 2020; 8:2653-2665. [DOI: 10.1039/d0bm00140f] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The study shows the development of a biodegradable bi-functional composite scaffold that can reduce bacterial infection, while promotes bone regeneration in osteomyelitis, without the need for revision surgery.
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Affiliation(s)
- Amit G. Krishnan
- Amrita Centre for Nanosciences and Molecular Medicine
- Amrita Institute of Medical Sciences and Research Centre
- Amrita Vishwa Vidyapeetham
- India
| | - Raja Biswas
- Amrita Centre for Nanosciences and Molecular Medicine
- Amrita Institute of Medical Sciences and Research Centre
- Amrita Vishwa Vidyapeetham
- India
| | - Deepthy Menon
- Amrita Centre for Nanosciences and Molecular Medicine
- Amrita Institute of Medical Sciences and Research Centre
- Amrita Vishwa Vidyapeetham
- India
| | - Manitha B. Nair
- Amrita Centre for Nanosciences and Molecular Medicine
- Amrita Institute of Medical Sciences and Research Centre
- Amrita Vishwa Vidyapeetham
- India
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84
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Bao M, Zhang K, Wei Y, Hua W, Gao Y, Li X, Ye L. Therapeutic potentials and modulatory mechanisms of fatty acids in bone. Cell Prolif 2019; 53:e12735. [PMID: 31797479 PMCID: PMC7046483 DOI: 10.1111/cpr.12735] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/02/2019] [Accepted: 11/05/2019] [Indexed: 02/05/2023] Open
Abstract
Bone metabolism is a lifelong process that includes bone formation and resorption. Osteoblasts and osteoclasts are the predominant cell types associated with bone metabolism, which is facilitated by other cells such as bone marrow mesenchymal stem cells (BMMSCs), osteocytes and chondrocytes. As an important component in our daily diet, fatty acids are mainly categorized as long‐chain fatty acids including polyunsaturated fatty acids (LCPUFAs), monounsaturated fatty acids (LCMUFAs), saturated fatty acids (LCSFAs), medium‐/short‐chain fatty acids (MCFAs/SCFAs) as well as their metabolites. Fatty acids are closely associated with bone metabolism and associated bone disorders. In this review, we summarized the important roles and potential therapeutic implications of fatty acids in multiple bone disorders, reviewed the diverse range of critical effects displayed by fatty acids on bone metabolism, and elucidated their modulatory roles and mechanisms on specific bone cell types. The evidence supporting close implications of fatty acids in bone metabolism and disorders suggests fatty acids as potential therapeutic and nutritional agents for the treatment and prevention of metabolic bone diseases.
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Affiliation(s)
- Minyue Bao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Kaiwen Zhang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yangyini Wei
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Weihan Hua
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yanzi Gao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xin Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Ling Ye
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China.,State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Cariology and Endodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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85
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Muthukrishnan G, Masters EA, Daiss JL, Schwarz EM. Mechanisms of Immune Evasion and Bone Tissue Colonization That Make Staphylococcus aureus the Primary Pathogen in Osteomyelitis. Curr Osteoporos Rep 2019; 17:395-404. [PMID: 31721069 PMCID: PMC7344867 DOI: 10.1007/s11914-019-00548-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Staphylococcus aureus is the primary pathogen responsible for osteomyelitis, which remains a major healthcare burden. To understand its dominance, here we review the unique pathogenic mechanisms utilized by S. aureus that enable it to cause incurable osteomyelitis. RECENT FINDINGS Using an arsenal of toxins and virulence proteins, S. aureus kills and usurps immune cells during infection, to produce non-neutralizing pathogenic antibodies that thwart adaptive immunity. S. aureus also has specific mechanisms for distinct biofilm formation on implants, necrotic bone tissue, bone marrow, and within the osteocyte lacuno-canicular networks (OLCN) of live bone. In vitro studies have also demonstrated potential for intracellular colonization of osteocytes, osteoblasts, and osteoclasts. S. aureus has evolved a multitude of virulence mechanisms to achieve life-long infection of the bone, most notably colonization of OLCN. Targeting S. aureus proteins involved in these pathways could provide new targets for antibiotics and immunotherapies.
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Affiliation(s)
- Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY, 14642, USA
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Elysia A Masters
- Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY, 14642, USA
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA
| | - John L Daiss
- Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY, 14642, USA
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA
| | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY, 14642, USA.
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA.
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86
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Cahill SV, Yu KE, Dussik CM, Lee FY. Rotational Tibio-Pelvic Constrained Hip Arthroplasty: A Surgical Technique: A Case Report. JBJS Case Connect 2019; 9:e0404. [PMID: 31703012 DOI: 10.2106/jbjs.cc.18.00404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 25-year-old man presented with chronic bone and soft tissue infection of the right thigh following resection and radiation of epithelioid sarcoma. Multiple revisions and debridement procedures had failed to control the infection and left him unable to ambulate. We describe a modified Van Nes rotationplasty using a constrained, prosthetic hip between the tibia and pelvis following femur resection. With 18 months of follow-up, the patient was able to walk with a prosthetic device without evidence of recurrent infection. CONCLUSIONS We report this rotationplasty as a potential approach to avoid hip disarticulation in cases requiring extensive debridement for incurable infection.
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Affiliation(s)
- Sean V Cahill
- Department of Orthpaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Kristin E Yu
- Department of Orthpaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher M Dussik
- Department of Orthpaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Francis Y Lee
- Department of Orthpaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
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87
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The Implantation of Bioactive Glass Granules Can Contribute the Load-Bearing Capacity of Bones Weakened by Large Cortical Defects. MATERIALS 2019; 12:ma12213481. [PMID: 31652996 PMCID: PMC6862453 DOI: 10.3390/ma12213481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/17/2019] [Accepted: 10/22/2019] [Indexed: 11/25/2022]
Abstract
Bioactive glass (BAG) granules (S53P4) have shown good clinical results in one-stage treatment of osteomyelitis. During this treatment, a cortical window is created, and infected bone is debrided, which results in large defects that affect the mechanical properties of the bone. This study aimed to evaluate the role of BAG granules in load-bearing bone defect grafting. First, the influence of the geometry of the cortical window on the bone bending stiffness and estimated failure moments was evaluated using micro finite element analysis (µFE). This resulted in significant differences between the variations in width and length. In addition, µFE analysis showed that BAG granules contribute to bearing loads in simulated compression of a tibia with a defect grafted with BAG and a BAG and bone morsel mixture. These mixtures potentially can unload the cortical bone that is weakened by a large defect directly after the operation by up to approximately 25%, but only in case of optimal load transfer through the mixture.
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88
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Abstract
The inflammation of bone tissue is called osteomyelitis, and most cases are caused by an infection with the bacterium Staphylococcus aureus. To date, the bone-building cells, osteoblasts, have been implicated in the progression of these infections, but not much is known about how the bone-resorbing cells, osteoclasts, participate. In this study, we show that S. aureus can infect osteoclasts and proliferate inside these cells, whereas bone-residing macrophages, immune cells related to osteoclasts, destroy the bacteria. These findings elucidate a unique role for osteoclasts to harbor bacteria during infection, providing a possible mechanism by which bacteria could evade destruction by the immune system. Osteomyelitis (OM), or inflammation of bone tissue, occurs most frequently as a result of bacterial infection and severely perturbs bone structure. OM is predominantly caused by Staphylococcus aureus, and even with proper treatment, OM has a high rate of recurrence and chronicity. While S. aureus has been shown to infect osteoblasts, it remains unclear whether osteoclasts (OCs) are also a target of intracellular infection. Here, we demonstrate the ability of S. aureus to intracellularly infect and divide within OCs. OCs were differentiated from bone marrow macrophages (BMMs) by exposure to receptor activator of nuclear factor kappa-B ligand (RANKL). By utilizing an intracellular survival assay and flow cytometry, we found that at 18 h postinfection the intracellular burden of S. aureus increased dramatically in cells with at least 2 days of RANKL exposure, while the bacterial burden decreased in BMMs. To further explore the signals downstream of RANKL, we manipulated factors controlling OC differentiation, NFATc1 and alternative NF-κB, and found that intracellular bacterial growth correlates with NFATc1 levels in RANKL-treated cells. Confocal and time-lapse microscopy in mature OCs showed a range of intracellular infection that correlated inversely with S. aureus-phagolysosome colocalization. The propensity of OCs to become infected, paired with their diminished bactericidal capacity compared to BMMs, could promote OM progression by allowing S. aureus to evade initial immune regulation and proliferate at the periphery of lesions where OCs are most abundant.
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89
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Raven TF, Moghaddam A, Ermisch C, Westhauser F, Heller R, Bruckner T, Schmidmaier G. Use of Masquelet technique in treatment of septic and atrophic fracture nonunion. Injury 2019; 50 Suppl 3:40-54. [PMID: 31378541 DOI: 10.1016/j.injury.2019.06.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of atrophic non-unions and large bone defects or infections remains a challenging task for the treating surgeon. In the herein study, we present our experience of the 'Masquelet technique' according to the 'diamond concept' for the treatment of complex long bone reconstruction procedures. METHODS Between February 2010 and March 2015, 150 patients (mean age 51.4) with atrophic and- /or infected non-unions were included in this prospective study. All patients received autologous bone graft, a graft expander (TCP (tricalcium phosphate)) and BMP (bone morphogenic protein). Clinical and radiological parameters were assessed at 6 weeks, and at 3, 6 and 12 months. The SF-12 questionnaire was used to evaluate the subjective health of patients. RESULTS A successful bony consolidation of the non-unions was observed in 120 (80%) cases with a median healing time of 12.1 months. The mean defect gap was 4.4cm. Initial infection was documented in 54 cases. The most frequently identified pathogen was staphylococcus epidermidis and staphylococcus aureus. A successful removal of microorganisms with subsequent healing was achieved in 39 cases (72%). The SF-12 scores of subjective physical and mental health increased from PCS 31.5 preoperatively to 36.7 one year postoperatively, while MCS increased from 45.5 to 48.7. CONCLUSIONS Our study showed that the Masquelet technique according to the 'diamond concept' is a valid method to treat complex atrophic non-unions with large bone defects and associated infection. Following the principles of the 'diamond concept' (targeted optimization of tissue engineering and bone regeneration) a high rate of success can be expected in these difficult reconstruction cases.
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Affiliation(s)
- T F Raven
- ATORG - Aschaffenburg Trauma and Orthopaedic Research Group, Center for Trauma Surgery, Orthopaedics and Sports Medicine, Hospital Aschaffenburg-Alzenau, Am Hasenkopf 1, D-63739, Aschaffenburg, Germany; HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany.
| | - A Moghaddam
- ATORG - Aschaffenburg Trauma and Orthopaedic Research Group, Center for Trauma Surgery, Orthopaedics and Sports Medicine, Hospital Aschaffenburg-Alzenau, Am Hasenkopf 1, D-63739, Aschaffenburg, Germany; HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - C Ermisch
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - F Westhauser
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - R Heller
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
| | - T Bruckner
- Institute for Medical Biometry and Informatics, Im Neuenheimer Feld 130.3, D- 69120, Heidelberg, Germany
| | - G Schmidmaier
- HTRG - Heidelberg Trauma Research Group, Division of Trauma and Reconstructive Surgery, Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, University Hospital Heidelberg, Schlierbacher Landstraße 200a, D-69118, Heidelberg, Germany
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Prabhoo R, Chaddha R, Iyer R, Mehra A, Ahdal J, Jain R. Overview of methicillin resistant Staphylococcus aureus mediated bone and joint infections in India. Orthop Rev (Pavia) 2019; 11:8070. [PMID: 31312419 PMCID: PMC6600845 DOI: 10.4081/or.2019.8070] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Indexed: 11/23/2022] Open
Abstract
Staphylococcus aureus is the most common pathogen causing bone and joint infections (BJI). In India, prevalence of Methicillin resistant Staphylococcus aureus (MRSA) is increasing at an alarming rate and emerged as an important contributor towards the difficult to treat BJI. Currently available anti-MRSA agents have their own limitations with regards to reduced susceptibility as well as safety and tolerability. Furthermore, biofilms over the prosthesis with invariably multi-drug resistant strains leads to complex treatment processes. This necessitates the need to develop and screen new antibiotics against MRSA that can easily penetrate the deep pockets of infection and take care of the challenges discussed. This review aims to discuss on MRSA infection in bone and joint infection, current antibiotic regimen, its associated limitations, and finally, the need to develop new antibiotic therapy for effective management of patients with BJI.
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Affiliation(s)
- Ram Prabhoo
- Department of Orthopedic Surgery, Mukund Hospital Mumbai, Maharashtra
| | - Ram Chaddha
- Department of Orthopedic and Spine Surgery, Apollo Hospitals, Navi Mumbai, Maharashtra
| | - Rajagopalan Iyer
- Department of Orthopedics; Pondicherry Institute of Medical Sciences, Puducherry
| | - Apurv Mehra
- Department of Orthopedic Surgery, Vidya Jeevan Orthopedics Super Specialty Centre, New Delhi
| | - Jaishid Ahdal
- Department of Medical Affairs, Wockhardt Ltd, Wockhardt Towers, Bandra Kuerla Complex, G Block BKC, Bandra Kurla Complex, Bandra East, Mumbai, India
| | - Rishi Jain
- Department of Medical Affairs, Wockhardt Ltd, Wockhardt Towers, Bandra Kuerla Complex, G Block BKC, Bandra Kurla Complex, Bandra East, Mumbai, India
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91
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Giuliano C, Patel CR, Kale-Pradhan PB. A Guide to Bacterial Culture Identification And Results Interpretation. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2019; 44:192-200. [PMID: 30930604 PMCID: PMC6428495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE To provide a guide to interpreting bacterial culture results. METHODS Studies were identified via a PubMed literature search (from 1966 to January 2018). Search terms included microbial sensitivity tests, microbial drug resistance, and anti-infective agents/pharmacology. Articles were included if they were published in English. References within identified articles were also reviewed. RESULTS This paper reviewed core concepts of interpreting bacterial culture results, including timing of cultures, common culture sites, potential for contamination, interpreting the Gram stain, role of rapid diagnostic tests, conventional antibiotic susceptibility testing, and automated testing. CONCLUSION This guide can assist pharmacists in their role as integral members of the antimicrobial stewardship team in an effort to improve patient care.
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92
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Afzelius P, Nielsen OL, Schønheyder HC, Alstrup A, Hansen SB. An untapped potential for imaging of peripheral osteomyelitis in paediatrics using [ 18F]FDG PET/CT -the inference from a juvenile porcine model. EJNMMI Res 2019; 9:29. [PMID: 30903403 PMCID: PMC6430261 DOI: 10.1186/s13550-019-0498-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/11/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To examine parameters affecting the detection of osteomyelitis (OM) by [18F]FDG PET/CT and to reduce tracer activity in a pig model. BACKGROUND [18F]FDG PET/CT is recommended for the diagnosis of OM in the axial skeleton of adults. In children, OM has a tendency to become chronic or recurrent, especially in low-income countries. Early diagnosis and initiation of therapy are therefore essential. We have previously demonstrated that [18F]FDG PET/CT is promising in juvenile Staphylococcus aureus (S. aureus) OM of peripheral bones in a pig model, not failing even small lesions. When using imaging in children, radiation exposure should be balanced against fast diagnostics in the individual case. METHODS Twenty juvenile pigs were inoculated with S. aureus. One week after inoculation, the pigs were [18F]FDG PET/CT scanned. PET list-mode acquired data of a subgroup were retrospectively processed in order to simulate and examine the image quality obtainable with an injected activity of 132 MBq, 44 MBq, 13.2 MBq, and 4.4 MBq, respectively. RESULTS All lesions were detected by [18F]FDG PET and CT. Some lesions were very small (0.01 cm3), and others were larger (4.18 cm3). SUVmax was higher when sequesters (p = 0.023) and fistulas were formed (p < 0.0001). The simulated data demonstrated that it was possible to reduce the activity to 4.4 MBq without compromising image quality in pigs. CONCLUSIONS [18F]FDG PET/CT localized even small OM lesions in peripheral bones. It was possible to reduce the injected activity considerably without compromising image quality, impacting the applicability of PET/CT in peripheral OM in children.
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Affiliation(s)
- P. Afzelius
- Department of Diagnostic Imaging, Section of Clinical Physiology and Nuclear Medicine, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerod, Denmark
- Department of Nuclear Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - O. L. Nielsen
- Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
| | - H. C. Schønheyder
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A.K.O. Alstrup
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark
| | - S. B. Hansen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark
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93
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Handayani, Yaputra F, Hia B, Telaumbanua V, Widyadharma IPE. Chronic Osteomyelitis after Seven Years Neglected Bone Exposed in 12-Year-Old Boy: A Case Report. Open Access Maced J Med Sci 2019; 7:610-613. [PMID: 30894922 PMCID: PMC6420954 DOI: 10.3889/oamjms.2019.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/08/2019] [Accepted: 01/09/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND: Access to modern medicine is still limited in some rural areas in Indonesia. This is mostly due to lack of people’s knowledge and concern for their health, especially in orthopaedic cases. Osteomyelitis is generally described as infection and inflammation of the bone, which results in local bone destruction, necrosis, and apposition of new bone. Chronic post-traumatic osteomyelitis (CPTO) is a complex condition and one of the most challenging problems in orthopaedic surgery that cause considerable morbidity. CASE PRESENTATION: We present a case of chronic post-traumatic osteomyelitis with radial nerve injury, in which radical surgical debridement and broad-spectrum antibiotic administration were done. A 12-year-old boy with a history of falling from the three-meter-high tree had swollen, deformed, and neglected humerus bone exposed. After stabilisation in the emergency room, surgical limb amputation was scheduled, yet the family refused this medical care and chose debridement instead. CONCLUSION: This case is an important addition to the literature about chronic post-traumatic osteomyelitis with neglected bone exposed and the lacking of society’s concern in regards to orthopaedic cases.
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Affiliation(s)
- Handayani
- Department of Pediatrics, Gunungsitoli General Hospital, Nias, North Sumatera, Indonesia
| | - Faldi Yaputra
- Department of Neurology, Faculty of Medicine, Udayana University, Sanglah General Hospital, Bali, Indonesia
| | - Berkat Hia
- Department of Neurology, Gunungsitoli General Hospital, Nias, North Sumatera, Indonesia
| | - Victor Telaumbanua
- Department of Surgery, Gunungsitoli General Hospital, Nias, North Sumatera, Indonesia
| | - I Putu Eka Widyadharma
- Department of Neurology, Faculty of Medicine, Udayana University, Sanglah General Hospital, Bali, Indonesia
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94
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Zaid M, Chavez MR, Carrasco AE, Zimel MN, Zhang AL, Horvai AE, Link TM, O'Donnell RJ. Cutibacterium (formerly Propionibacterium) acnes clavicular infection. J Bone Jt Infect 2019; 4:40-49. [PMID: 30755847 PMCID: PMC6367193 DOI: 10.7150/jbji.29153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 10/03/2018] [Indexed: 12/02/2022] Open
Abstract
Cutibacterium (formerly Propionibacterium) acnes13, 16 is a slow growing, gram-positive bacteria that is naturally found in higher concentrations as skin flora on the chest and back, as well as in other areas with greater numbers of hair follicles.25, 37 Most of the reported cases of C. acnes shoulder girdle infection follow arthroplasty surgery,18, 20, 26, 27, 32, 35 which then often requires debridement, administration of intravenous antibiotics, and surgical revision of the implanted device.12, 15, 21, 28-30 In a recent study, 56% of 193 shoulder revisions had a positive culture, 70% of which grew C. acnes.30 Despite the relatively common presumed association of C. acnes humeral osteomyelitis with prosthetic infection, infection of the scapula or clavicle secondary to C. acnes is rare.4, 23, 36 Osteomyelitis of the clavicle involving any organism is also an uncommon event that can arise spontaneously via presumed hematogenous spread, or secondary to open fractures or internal fixation.6, 33 The most commonly found organism in clavicular osteomyelitis is Staphylococcus aureus.9 We here report two cases of clavicular infection secondary to C. acnes that were not associated with implants.
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Affiliation(s)
- Musa Zaid
- University of California San Francisco, Department of Orthopaedic Surgery
| | - Madisyn R Chavez
- University of California San Francisco, Department of Orthopaedic Surgery
| | | | - Melissa N Zimel
- University of California San Francisco, Department of Orthopaedic Surgery
| | - Alan L Zhang
- University of California San Francisco, Department of Orthopaedic Surgery
| | - Andrew E Horvai
- University of California San Francisco, Department of Orthopaedic Surgery
| | - Thomas M Link
- University of California San Francisco, Department of Orthopaedic Surgery
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Collagen scaffolds functionalised with copper-eluting bioactive glass reduce infection and enhance osteogenesis and angiogenesis both in vitro and in vivo. Biomaterials 2019; 197:405-416. [PMID: 30708184 DOI: 10.1016/j.biomaterials.2019.01.031] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 01/18/2019] [Accepted: 01/20/2019] [Indexed: 12/13/2022]
Abstract
The bone infection osteomyelitis (typically by Staphylococcus aureus) usually requires a multistep procedure of surgical debridement, long-term systemic high-dose antibiotics, and - for larger defects - bone grafting. This, combined with the alarming rise in antibiotic resistance, necessitates development of alternative approaches. Herein, we describe a one-step treatment for osteomyelitis that combines local, controlled release of non-antibiotic antibacterials with a regenerative collagen-based scaffold. To maximise efficacy, we utilised bioactive glass, an established osteoconductive material with immense capacity for bone repair, as a delivery platform for copper ions (proven antibacterial, angiogenic, and osteogenic properties). Multifunctional collagen-copper-doped bioactive glass scaffolds (CuBG-CS) were fabricated with favourable microarchitectural and mechanical properties (up to 1.9-fold increase in compressive modulus over CS) within the ideal range for bone tissue engineering. Scaffolds demonstrated antibacterial activity against Staphylococcus aureus (up to 66% inhibition) whilst also enhancing osteogenesis (up to 3.6-fold increase in calcium deposition) and angiogenesis in vitro. Most significantly, when assessed in a chick embryo in vivo model, CuBG-CS not only demonstrated biocompatibility, but also a significant angiogenic and osteogenic response, consistent with in vitro studies. Collectively, these results indicate that the CuBG-CS developed here show potential as a one-step osteomyelitis treatment: reducing infection, whilst enhancing bone healing.
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96
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Benedini L, Placente D, Ruso J, Messina P. Adsorption/desorption study of antibiotic and anti-inflammatory drugs onto bioactive hydroxyapatite nano-rods. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 99:180-190. [PMID: 30889690 DOI: 10.1016/j.msec.2019.01.098] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/05/2019] [Accepted: 01/22/2019] [Indexed: 01/19/2023]
Abstract
The use of high doses of antibacterial and anti-inflammatory drugs for patients with bone diseases, associated to implants or bone filling, can develop adverse effects; and consequently, it promotes to think new strategies to avoid this problem. In this work, it has been described the adsorption/release (or desorption) behavior of two drugs, ciprofloxacin (CIP) and ibuprofen (IBU), onto hydroxyapatite (nano-HA) at 37 °C. Through Ultraviolet-Visible (UV-Vis) spectroscopy, the concentrations of both drugs in adsorption, kinetic and desorption processes were obtained. The Fourier Transformed-Infrared (FT-IR) spectroscopy, Zeta-potential (ζ-potential), High-Resolution Transmission Electron Microscopy (H-TEM) and x-Ray Diffraction (xRD) were also used to characterize bared nanoparticles and those with adsorbed drugs. Five adsorption models (Langmuir, Freundlich, Sips, Temkin and Dubinin-Radushkevich) were used for describing the behavior of both active compounds. The adsorption processes (CIP/nano-HA and IBU/nano-HA) were better predicted by the Sips model than by the others. The kinetic adsorption data were processed, for both active agents, by application of Avrami's model. Desorption/release process (of both drugs) was evaluated though Korsmeyer-Peppas (K-P) model. Owing to the predictability of these systems, we propose the use of these active ceramics as potential bone filler for improving the treatment against bacterial bone infections and to avoid its associated inflammatory process.
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Affiliation(s)
- Luciano Benedini
- Department of Chemistry, Universidad Nacional del Sur, B8000CPB Bahía Blanca, INQUISUR-CONICET, Argentina.
| | - Damián Placente
- Department of Chemistry, Universidad Nacional del Sur, B8000CPB Bahía Blanca, INQUISUR-CONICET, Argentina
| | - Juan Ruso
- Soft Matter and Molecular Biophysics Group, Department of Applied Physics, University of Santiago de Compostela, 15782, Spain
| | - Paula Messina
- Department of Chemistry, Universidad Nacional del Sur, B8000CPB Bahía Blanca, INQUISUR-CONICET, Argentina
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97
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Zhou P, Wu J, Wang Y, Zhang H, Xia Y, Zhang Y, Xu S. The synergistic therapeutic efficacy of vancomycin and omega-3 fatty acids alleviates Staphylococcus aureus-induced osteomyelitis in rats. Biomed Pharmacother 2019; 111:1228-1233. [PMID: 30841436 DOI: 10.1016/j.biopha.2018.12.125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/27/2018] [Accepted: 12/30/2018] [Indexed: 11/18/2022] Open
Abstract
Our study evaluated the synergistic impact of vancomycin and omega-3 fatty acids against osteomyelitis in a Staphylococcus aureus-induced rat model of osteomyelitis. The animals were grouped as follows: sham (group I), osteomyelitis (group II, control), vancomycin (20 mg/kg body weight, group III), omega-3 fatty acids (20 mg/kg body weight, group IV) and vancomycin (20 mg/kg body weight) + omega-3 fatty acids (20 mg/kg body weight) (group V). Lipid peroxidation, superoxide dismutase (SOD), glutathione peroxidase (Gpx), catalase, reduced glutathione (GSH), tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) were measured. The determination of bacterial growth and histopathological analyses were carried out. The lipid peroxidation, GSH, SOD, catalase and Gpx levels recovered to near-normal levels following combined treatment with vancomycin and omega-3 fatty acids. The TNF-α and IL-6 levels were reduced to near-normal levels. Combined supplementation with vancomycin and omega-3 fatty acids significantly reduced bacterial growth in bone and the implanted wire. Furthermore, the bone infection levels and histopathological score were reduced. In summary, combined treatment with vancomycin and omega-3 fatty acids was effective against bacterial growth and bone infection compared to monotherapy with vancomycin or omega-3 fatty acids.
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Affiliation(s)
- Panyu Zhou
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Jianghong Wu
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Yang Wang
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Hongyue Zhang
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Yan Xia
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Yuntong Zhang
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Shuogui Xu
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China.
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Mishra V, Ajmera A, Solanki M, Lohokare R. Role of quantitative c-reactive protein and erythrocyte sedimentation rate for evaluation and management of acute osteoarticular infections in pediatric patients. JOURNAL OF ORTHOPEDICS, TRAUMATOLOGY AND REHABILITATION 2019. [DOI: 10.4103/jotr.jotr_25_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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99
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Zhou P, Xia D, Xia Y, Zhang H, Wang Y, Tang T, Xu S. Synergistic effect of vancomycin and l-homocarnosine alleviates Staphylococcus aureus-induced osteomyelitis in rats. Biomed Pharmacother 2018; 111:31-35. [PMID: 30572244 DOI: 10.1016/j.biopha.2018.11.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/19/2018] [Accepted: 11/25/2018] [Indexed: 10/27/2022] Open
Abstract
Osteomyelitis is a well-known bone infection in humans. The primary symptoms are fever, pain, weakness, and redness of the bone. l-Homocarnosine is a bioactive peptide abundant in brain and skeletal muscles. The present study evaluated the synergistic effect of vancomycin and l-homocarnosine against osteomyelitis in the Staphylococcus aureus-induced rat model of osteomyelitis. Animals were classified into the following groups: sham (group I), osteomyelitis (group II, control), vancomycin (25 mg/kg body weight, group III), l-homobrassinolide (25 mg/kg body weight, group IV), and vancomycin (25 mg/kg body weight) + l-homobrassinolide (25 mg/kg body weight) (group V). Lipid peroxidation, superoxide dismutase (SOD), glutathione peroxidase (Gpx), catalase, reduced glutathione (GSH), tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) were determined. Assessments of bacterial growth and histopathological analyses were carried out. Lipid peroxidation, GSH, SOD, catalase, and Gpx levels recovered to near normal levels with the combined treatment of vancomycin and l-homocarnosine. TNF-α and IL-6 levels were reduced to near normal levels. Combined supplementation of vancomycin and l-homocarnosine reduced bacterial growth in bone and wire. Furthermore, bone infections and histopathological scores were also reduced. In summary, we showed that combined treatment of vancomycin and l-homocarnosine was more effective against bacterial growth and bone infection compared to monotherapy with vancomycin or l-homocarnosine.
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Affiliation(s)
- Panyu Zhou
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Demeng Xia
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Yan Xia
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Hongyue Zhang
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Yang Wang
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Tao Tang
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Shuogui Xu
- Department of Emergency, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China.
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Garcia Del Pozo E, Collazos J, Carton JA, Camporro D, Asensi V. Factors predictive of relapse in adult bacterial osteomyelitis of long bones. BMC Infect Dis 2018; 18:635. [PMID: 30526540 PMCID: PMC6286499 DOI: 10.1186/s12879-018-3550-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 11/23/2018] [Indexed: 11/17/2022] Open
Abstract
Background Osteomyelitis is a difficult-to-cure infection with a high relapse rate despite combined medical and surgical therapies. Some severity factors, duration of antimicrobial therapy and type of surgical procedure might influence osteomyelitis relapse. Methods 116 patients with osteomyelitis were followed for ≥1 year after hospital discharge. Demographic, microbiological and clinical data, eight severity factors and treatment (surgical and antibiotic) were analyzed. Results Mean age was 53 years and 74.1% were men. Tibia (62.1%) and S. aureus (58.5%) were the most commonly involved bone and bacteria, respectively. Mean follow-up was 67.1 months. Forty-six patients underwent bone debridement, 61 debridement plus flap coverage and 9 antimicrobial therapy only. Twenty-six patients (22.4%) relapsed, at a mean of 11.2 months since hospital discharge. Duration > 3 months (p = 0.025), number of severity factors (P = 0.02) and absence of surgery (P = 0.004) were associated with osteomyelitis relapse in the univariate analysis. In the Cox regression analysis, osteomyelitis duration > 3 months (P = 0.012), bone exposure (P = 0.0003) and type of surgery (P < 0.0001) were associated with relapse. Regarding the surgical modalities, bone debridement with muscle flap was associated with better osteomyelitis outcomes, as compared with no surgery (P < 0.0001) and debridement only (P = 0.004). Conclusions Osteomyelitis extending for > 3 months, bone exposure and treatment other than surgical debridement with muscular flap are risk factors for osteomyelitis relapse.
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Affiliation(s)
- E Garcia Del Pozo
- Plastic Surgery Service, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, Spain
| | - J Collazos
- Infectious Diseases Unit, Hospital de Galdácano, Galdacano, Vizcaya, Spain
| | - J A Carton
- Infectious Diseases Unit, Hospital Universitario Central de Asturias (HUCA), Oviedo University School of Medicine, Oviedo, Spain.,Group of Translational Research in Infectious Diseases, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Asturias, Spain
| | - D Camporro
- Plastic Surgery Service, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, Spain
| | - V Asensi
- Infectious Diseases Unit, Hospital Universitario Central de Asturias (HUCA), Oviedo University School of Medicine, Oviedo, Spain. .,Group of Translational Research in Infectious Diseases, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Asturias, Spain.
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