Case Study of Emphysematous Osteomyelitis of Both Femoral Heads

Early references of emphysematous osteomyelitis (EO) in the literature trace back to 1981, when the presence of intraosseous gas was mentioned in a paper of Ram et al.. Subsequently, 48 cases of EO were described. A significant underlying comorbidity was reported in most EO cases, especially diabetes and malignancy. This report presents a 37-year-old male with undiagnosed diabetes mellitus which was accompanied by emphysematous osteomyelitis of both femoral heads.

Mycobacterium avium Complex Septic Arthritis Presenting as Osteonecrosis of the Femoral Head in a Patient With Systemic Lupus Erythematosus

Mycobacterium avium complex is a rare cause of musculoskeletal infection, usually occurring in patients with compromised immune systems. Obtaining the diagnosis requires a high index of suspicion, and treatment can be delayed because of difficulty with isolating the organism. Treatment involves prolonged, targeted combination antibiotic therapy, and it is unclear whether eradication of the infection can occur in the presence of a foreign body, such as antibiotic spacers. The authors report a case of M avium infection presenting as presumed osteonecrosis of the femoral head in a young woman with systemic lupus erythematosus. She presented with collapse of her femoral head coinciding with several months of progressive, debilitating hip pain. She had mild fevers during that time, but results from multiple infectious workups, including hip aspiration, were negative. Purulent fluid was found in the operating room, but diagnosis was delayed for 5 weeks while waiting for cultures. The patient required 3 subsequent operations, eventually being left with a resection arthroplasty. Pertinent issues concerning diagnosis, therapy, and treatment challenges in M avium infections of the musculoskeletal system are discussed in this case report. [Orthopedics. 2017; 40(3):e549-e552.].

Bacteremia with an iliopsoas abscess and osteomyelitis of the femoral head caused by Enterococcus avium in a patient with end-stage kidney disease

A 70-year-old man on hemodialysis for end-stage kidney disease due to polycystic kidney disease presented with hip pain on extension and a high C-reactive protein level. Further examinations revealed an iliopsoas abscess and femoral head osteomyelitis caused by Enterococcus avium (E. avium) detected in blood and pus cultures. Complete resolution of the infection with ampicillin-resistant E. avium required six months of vancomycin therapy and two surgical drainage procedures. There have been no previous case reports in which both blood and abscess cultures confirmed E. avium infection. Careful attention should be paid to the detection of non-specific symptoms in patients on hemodialysis, with blood cultures being essential in such cases.

Chlamydia pneumoniae and osteoporosis-associated bone loss: a new risk factor?

We found an association between the presence of Chlamydia pneumoniae DNA both in osteoporotic bone tissue and peripheral blood mononuclear cells (PBMCs) and the increase in circulating resorptive cytokines.

INTRODUCTION

Our study was designed to determine whether C. pneumoniae infection may be involved in osteoporosis-associated bone loss.

METHODS

The study included 59 women undergoing hip joint replacement surgery for femoral neck fracture: 32 with osteoporosis and 27 with osteoarthritis. A total of 118 tissue specimens (59 bone tissues, 59 PBMCs) were examined for C. pneumoniae DNA by real-time polymerase chain reaction (PCR). Serum levels of soluble receptor activator of nuclear factor kappa B ligand (sRANKL), osteoprotegerin (OPG), interleukin (IL)-1β, tumor necrosis factor-α, and IL-6 were also measured.

RESULTS

C. pneumoniae DNA was detected in osteoporotic bone tissue whereas it was not found in non-osteoporotic bone tissue (p < 0.05). A significantly higher rate of C. pneumoniae DNA (p < 0.05) was found in PBMCs of osteoporotic patients than in those of osteoarthritis patients. Among osteoporotic patients, serum sRANKL, IL-1, and IL-6 concentrations as well as sRANKL/OPG ratio significantly differ between patients with bone tissue and PBMCs positive to C. pneumoniae and C. pneumoniae-negative patients.

CONCLUSION

The association between the presence of C. pneumoniae DNA, both in bone tissue and PBMCs, and the increase in sRANKL/OPG ratio as well as in IL-1β and IL-6 levels observed in osteoporotic patients suggests C. pneumoniae infection as a new risk factor for osteoporosis.

Screening femoral heads from living donors: a prospective study comparing swab-agar versus bone fragment-broth culture

Femoral heads are an important source of allograft bone used in reconstructive orthopaedic surgery. The sterility of donor material is of major importance for the recipient. Femoral heads intraoperatively retrieved during hip arthroplasty from medically screened living donors are routinely checked with a surface swab to exclude microbiological contamination. There is, however, evidence that swab cultures have limited sensitivity. We therefore prospectively compared two ways of screening femoral heads. Bacterial recovery from swabs in Amies transport medium taken intraoperatively, subsequently transported to the microbiology laboratory and inoculated on agar and in broth was compared with the recovery from a bone fragment also taken intraoperatively but immediately inoculated into Wilkins Chalgren broth. Forty femoral heads were tested with both methods. Bacteria were cultured neither from the femoral surface swabs nor from the femoral fragments. Consequently no distinct conclusions regarding the sensitivity of both techniques could be drawn. In addition the bacterial yield of two swabs in Amies transport medium streaked on a variety of culture media other than the conventional agar plates was also studied. Culturing of these swabs resulted in the detection of bacteria that are predominantly considered contaminants.

Salmonella enteritidis infection of the musculoskeletal system - case report

This article presents diagnostic and therapeutic problems in 2 patients with blood-borne infection of the coxofemoral joint and the humeral diaphysis caused by Salmonella enteritidis (S. enteritidis). These patients accounted for 4.6% of cases of blood-borne infections treated between 2002 and 2009 and 1.1% of all musculoskeletal infections treated at the Department of Orthopaedics and Traumatology of N. Copernicus Regional Specialized Hospital in Łódź. The inflammations developed nearly a year after an episode of Salmonella gastroenteritis. The aetiology and time of onset of manifestations raised some doubts as to the accuracy of diagnosis and required not only conventional microbiological methods but also serological tests to confirm the presence of specific antibodies to S. enteritidis antigens. The finding of osteolytic foci in imaging studies of bones necessitates extensive work-up that should also account for atypical causes of musculoskeletal inflammation.

Microbiological cultures of allografts of the femoral head just before transplantation

Allografts of bone from the femoral head are often used in orthopaedic procedures. Although the donated heads are thoroughly tested microscopically before release by the bone bank, some surgeons take additional cultures in the operating theatre before implantation. There is no consensus about the need to take these cultures. We retrospectively assessed the clinical significance of the implantation of positive-cultured bone allografts. The contamination rate at retrieval of the allografts was 6.4% in our bone bank. Intra-operative cultures were taken from 426 femoral head allografts before implantation; 48 (11.3%) had a positive culture. The most frequently encountered micro-organism was coagulase-negative staphylococcus. Deep infection occurred in two of the 48 patients (4.2%). In only one was it likely that the same micro-organism caused the contamination and the subsequent infection. In our study, the rate of infection in patients receiving positive-cultured allografts at implantation was not higher than the overall rate of infection in allograft surgery suggesting that the positive cultures at implantation probably represent contamination and that the taking of additional cultures is not useful.

Acute sepsis complicating degenerative arthritis of the hip joint: a report of three cases

This case report involves three patients in whom hip sepsis occurred in association with degenerative joint disease, in the absence of any risk factors for infection. The diagnosis had been missed on initial evaluation, and each patient had been referred to the authors' adult reconstructive service to have the arthritic hip replaced. In each instance, existing hip pain had worsened acutely. Further workup led to the correct diagnosis and appropriate treatment of the septic joint. These cases illustrate the value of differential diagnosis when treating patients with degenerative hip disease.

Microbial contamination of femoral head allografts

OBJECTIVE

To study the incidence of microbial contamination at the bone bank of the United Christian Hospital. DESIGN. Retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

A total of 151 patients (33 men and 118 women) who underwent hip arthroplasty surgery and from whom femoral head allografts were retrieved between January 1994 and March 2000; and 81 patients in whom allografts were implanted.

MAIN OUTCOME MEASURES

Bone biopsies were taken from the femoral head and used to detect any microbial contamination that might have occurred during removal and after storage. The rates of infection among recipients and donors were also assessed.

RESULTS

Of the 151 allografts, 94 non-contaminated allografts were implanted by the end of the study. Fourteen (9.3%) heads showed positive culture results after retrieval and were discarded. Four (4.3%) of the 94 stored allografts that were implanted tested positive for microbial growth, but the recipients of these allografts did not develop any clinical infection. Three (3.2%) had wound infections after implantation of the stored allografts although the grafts had previously been tested negative for any microbial contamination.

CONCLUSION

Our centre has a low allograft contamination rate. The wound infection rate among recipients was also low. The culture of a bone biopsy sample is a reliable method to detect contamination of bone grafts. However, the contamination rate among stored allografts should prompt orthopaedics departments to review allograft handling procedures, so as to minimise the chance of contamination.

Microbiological culture results for the femoral head

We determined the rate of contamination of donated femoral heads at primary hip arthroplasty within a single region between July 1992 and July 2001. We established the null hypothesis that culture results played no role in predicting early failure of the joint because of infection.

The rate of contamination was 9%. A positive culture, at the time of retrieval, was found in 367 of 4045 femoral heads. Coagulase-negative staphylococcus was isolated in 77% of the positive cases. At a minimum follow-up of one year, there was no statistically significant difference in the rate of complications or of revision of age-matched patients whose femoral heads had a positive culture compared with those whose femoral heads were sterile.

Our findings confirm that culture of the femoral head plays no part in determining future failure of joint replacement in the donor.

Cefuroxime, rifampicin and pulse lavage in decontamination of allograft bone

The risk of bacterial infection through allogenic bone transplantation is one of the major problems facing tissue banks. Different screening methods and decontamination procedures are being used to achieve a safe surgical result. The purpose of this study was to investigate the contamination rate in fresh frozen bone allografts after treating them with different decontamination methods. The allografts were contaminated by rubbing on the operating theatre floor for 60 min, after which they were rinsed either with sterile physiological saline, cefuroxime or rifampicin solution or they were washed with low-pressure pulse lavage of sterile physiological saline. Our findings show that low-pressure pulse lavage with sterile saline solution is very effective in removing bacteria from bone allograft, when compared with the antibiotic solutions tested.

Validation of the ‘Marburg bone bank system’ for thermodisinfection of allogenic femoral head transplants using selected bacteria, fungi, and spores

The Marburg Bone Bank System 'Lobator sd-2' is widely used to process human femoral heads removed during aseptic surgery by thermal disinfection. The inactivating capacity of the thermodisinfection system was validated in compliance with current standards using a newly developed femoral head model. The following micro-organisms, bacteria and fungi, taken from the American Type Culture Collection were investigated: Staphylococcus aureus, Staphyloccus epidermidis, Enterococcus faecium, Pseudomonas aeruginosa, Bacillus subtilis including spores, Clostridium sporogenes, Mycobacterium terrae, Candida albicans and Aspergillus niger spores. Highly enriched suspensions of these micro-organisms were applied to the centre of the femoral heads. The reduction in the number of micro-organisms was determined by counting the colony-forming units (cfu) before and after processing the spiked test device in the 'Lobator sd-2' system. Vegetative bacteria, fungi and fungal spores were completely inactivated (reduction factor >/=6 log(10)). The numbers of B. subtilis and C. sporogenes spores, both known to be heat-resistant, were reduced by one to two orders of magnitude. These bacteria serve as a model for spore forming pathogens which are not relevant in femoral heads from living donors. By processing human femoral heads from living donors by thermal disinfection using the Marburg Bone Banking system, a high level of safety is achieved regarding clinically relevant pathogens. To further increase the safety of the thermally treated femoral heads, we recommend that the medical history and present state of the donor, as well as the necessary serological tests should be taken into account.

Microwave sterilization of femoral head allograft

The potential shortage of allograft bone has led to the need to investigate other sources of bone for allografts. Some allograft bone donated from primary total hip arthroplasty recipients must be discarded or treated to become usable as a result of bacterial contamination. Femoral head allografts were contaminated with Staphylococcus aureus and Bacillus subtilis. A domestic microwave oven was used. The contaminated bone was exposed to microwave irradiation for different time periods. The samples were then cultured to attempt to grow the two bacterial species. The contaminated bone samples failed to grow any organisms after 2 min of exposure to microwave irradiation. This study shows that sterilization of femoral head allografts contaminated with S. aureus and B. subtilis can be achieved with microwave irradiation in a domestic microwave oven. This method of sterilization of bone allografts is cheap, easily used, and an effective way to process contaminated bone.

[Meningitis and osteitis caused by Pasteurella multocida in a three-month-old infant]

Pasteurella multocida is usually responsible for local infections occurring after animal bites. It can also be responsible for meningitis in infants. A three-month old infant was admitted to hospital with a diagnosis of bacterial meningitis and hip osteitis. Cultures of cerebrospinal fluid, blood and joint liquid were positive to Pasteurella multocida. Licking from the family dog was the transmission mode in this case. Despite initial neurological complications, clinical evolution was favourable after three weeks of intravenous antibiotic therapy followed by an oral administration for three months. Pasteurella multocida meningitis is rare in infants. It can be associated with arthritis, osteitis and septicaemia. Besides animal bites, licking is also a mode of contamination.

Anaerobic osteomyelitis of femoral head with intraosseous, intra-articular, bursal and muscle pneumatosis

A case is presented of anaerobic osteomyelitis with intraosseous pneumatosis resulting in extension of gas in soft tissue structures and femur in a patient with mitral valve vegetation and bacteremia. The finding of intraosseous pneumatosis and its extension into the hip joint, iliopsoas bursa and subgluteus medius bursa is depicted. Intraosseous pneumatosis is a rare but concerning finding for osteomyelitis in the absence of a penetrating wound, recent surgery, biopsy or fracture.

The real contamination of femoral head allografts washed with pulse lavage

At the Tampere Bone Bank, all the discarded femoral heads from September 1997 to May 2000 were recultured. The grafts had been washed with pulse lavage at harvesting. 48 grafts had been discarded because of a positive culture and 85 with negative cultures because of positive or insufficient serological information. The femoral heads were split into halves, which were recultured as a whole in thioglycolate broth for 14 days. The contamination of previously culture positive and negative femoral heads did not differ. In only 2 cases did we find the same type of bacteria in the primary as in the new culture. Most of the primary contamination proved to be false positive. The real contamination seems to be very low, at least after pulse lavage washing of the femoral head.

Bacterial contamination of femoral head allografts from living donors

We analyzed the bacterial contamination rate of femoral head allografts from living donors and determined the true bacterial load with cultures from the grafts in their entirety in a specially prepared medium. During 4 years we took swab cultures from 2,679 grafts of which 2,414 (90%) were negative. In a period of 12 months, grafts rejected for reasons other than infectious disease were cultured in their entirety to determine the true bacterial load. Of the 106 grafts included, 15 were contaminated. Microorganisms were isolated from 10 of the 91 initially swab culture-negative grafts (9%) and from only 5 of the 15 swab culture-positive grafts, most of which were normal skin contaminants. Swab culture negative grafts apparently may still be contaminated. It seems wise to subject all femoral head allografts from living donors to antibacterial processing.

The clinical significance of femoral head culture results in donors after hip arthroplasty: a preliminary report

The aim of this study is to determine whether a link exists between clinical wound problems and positive bacterial culture of the femoral head after primary hip arthroplasty. Clinical data were retrieved for 24 culture-positive and 26 culture-negative patients. Coagulase-negative Staphylococcus was the commonest pathogen, cultured in 19 of the 24 culture-positive femoral heads donated to a regional bone bank. Wound problems occurred in 2 of the patients from the culture-positive group and 4 of the patients from the culture-negative group. The relative risk of wound problems was 0.54 in the culture-positive group. Based on the available evidence in this preliminary short-term retrospective review, positive microbiology from donated femoral heads has no clinical implication in the donors. The practice of reporting culture-positive femoral heads should be continued.

The effect of 10% povidone--iodine solution on contaminated bone allografts

The aim of this study was to determine the efficacy of 10% povidone--iodine solution for the decontamination of bone allografts. Bone samples were prepared and tested for sterility using a femoral head removed at the time of primary hip replacement. They were contaminated by a suspension of Staphylococcus epidermidis and ground to measure the quantity of micro-organism attached to the bone. Two levels of contamination were used (1 x 10(3) vs. 1 x 10(4)CFU/mL) to check the efficiency of our method of measurement. Samples of the two groups were decontaminated with 10% povidone--iodine solution using different exposure times. Before decontamination, the count of bacteria attached to the bone was proportional to the bacterial concentration of the contaminating solution. The microbiocidal activity of 10% povidone--iodine solution was the same in both groups. The decontamination time was proportional to the bacterial concentration of the contaminating solution. The results of this preliminary study suggest that a 10% povidone--iodine solution can decontaminate inoculated bone grafts, but a sufficient time of exposure according to the level of contamination must be allowed.

High-pressure saline washing of allografts reduces bacterial contamination

60 fresh-frozen bone allografts were contaminated on the operating room floor. No bacterial growth was detected in 5 of them after contamination. The remaining 55 grafts had positive bacterial cultures and were processed with three methods: soaking in saline, soaking in antibiotic solution or washing by high-pressure saline. After high-pressure lavage, the cultures were negative in three fourths of the contaminated allografts. The corresponding figures after soaking grafts in saline and antibiotic solution were one tenth and two tenths, respectively. High-pressure saline cleansing of allografts can be recommended because it improves safety by reducing the superficial bacterial bioburden.

Contamination of banked femoral head allograft: incidence, bacteriology and donor follow up

BACKGROUND

Allograft donations are not uncommonly found to be contaminated. The issue of contaminated donations from live donors at the time of surgery, and the significance of this to the patient in terms of subsequent sepsis of the arthroplasty, were examined.

METHODS

The donations of femoral heads to the Queensland Bone Bank over a 9-year period were reviewed, and the incidence and bacteriology of contamination were detailed. Clinical outcomes were determined for donors who had positive cultures at the time of retrieval and they were compared with those of culture-negative donors.

RESULTS

Between March 1987 and February 1996, 232 femoral heads were donated to the Queensland Bone Bank. Four specimens were sent for culture with each femoral head (surface swab of femoral head, acetabular swab, bone biopsy and capsule). In 51 cases, one or more positive cultures were obtained (22% contamination rate). The majority of organisms cultured were Staphylococcus epidermidis. One hundred and seventy donations came from surgery performed at the Princess Alexandra Hospital, and 40 femoral heads were considered contaminated. Deep infection was recorded in one of the 40 cases with contaminated donations and three out of 130 non-contaminated donations had subsequent septic episodes.

CONCLUSION

The contamination rate detailed in the present report is higher than in most series. This may be due to the fact that four bacteriological specimens are taken to assess contamination. Two of these specimens are tissue samples which yielded more positive results than did the two swabs. All other series take no more than two bacteriological specimens, which are usually bone swabs. These are shown to have a poor yield of positive cultures. Therefore there is a significant underestimation of contamination rates by other bone banks. This has implications for the recipients of bone from those banks, particularly when the allograft material is not secondarily sterilized. This is important given increasing allograft usage, and the increasing numbers of revision joint arthroplasty and impaction grafting procedures being performed. Sterilization of all bone by irradiation to 25 kGy is recommended.

Insidious destruction of the hip by Mycobacterium tuberculosis and why early diagnosis is critical

Tuberculosis has re-emerged as an important problem in the United States. More than 10 million people presently are infected with Mycobacterium tuberculosis in the United States alone. The symptoms at first presentation of the disease have become more diverse. With extrapulmonary manifestations, such as musculoskeletal infections, as the sole presenting sign, it often can be difficult to determine the correct diagnosis early in the course of the disease. The presenting symptoms, physical signs, and radiographic findings of intra-articular tuberculosis can mimic those of other intra-articular diseases, such as rheumatoid arthritis, osteoarthritis, and avascular necrosis. In view of the nonspecific findings early in course of the disease, tubercular infection should be considered in the differential diagnosis when there is insidious articular destruction. Failure to consider tuberculosis can lead to devastating outcomes otherwise preventable with today's chemotherapies.

[Microbiology of femoral head grafts in bone banks]

The aim of the study was to describe the bacteriology of bone allografts, which were harvested for the bone bank at Hvidovr Hospital, and to evaluate any infections in the recipients, which may have been caused by microbiological contamination of the transplanted bone allografts. It was carried out as a retrospective examination of bone bank records and patient records allowing at least 12 months for possible manifestation of bacterial infection by the bone allograft. During donation of bone, both the capita femora and the acetabulum were cultured with swabs both an- and aerobically along with the already sterilized glass specimen jar used for storage. Of the 110 donated bone allografts, 10 were not used for transplantation, but only one allograft was discarded because of the development of a positive culture (Staphylococcus epidermidis). All cultures from the sterilized glass specimen jars were without microbiological growth. Three incidences of deep infection (one Acinetobacter calcoaceticus and two Staphylococcus aureus) followed the transplantation of 100 bone allografts in 58 patients at 62 operations. We conclude that the precautions (i.e. careful selection and screening of donor) and strict aseptic technique (including the use of perioperative administration of antibiotics) used, when bone allografts are harvested, ensure the procurement of non-contaminated bone in more than 99% of the donations. Culturing the already sterilized glass specimen jars seems unnecessary. The bone allograft per se was not contaminated and probably did not cause any infections. The rate of infection after transplantation of bone allograft is not higher than in other complicated surgery.

The bacteriology of bone allografts

We report the contamination rate in the Cambridge bone bank of 35 consecutive allograft specimens, all harvested in a clean-air environment, using a strict aseptic technique and antibiotic cover. Five of 27 femoral heads taken from living donors and three of eight massive allografts taken from cadavers were found to be contaminated. The contaminated femoral heads were discarded. All massive allografts were rendered sterile by gamma-irradiation. It is important to exclude bacteriological contamination of harvested and banked bone.

Fusobacterium osteomyelitis associated with intraosseous gas

The diagnosis of acute anaerobic osteomyelitis was made in a 57-year-old hypertensive diabetic woman complaining of groin pain and fever. Roentgenograms and computed tomography demonstrated intraosseous gas in the right femoral head and surrounding soft tissue. Cultures obtained from open biopsy were positive for the anaerobic gram-negative bacillus Fusobacterium necrophorum, a normal inhabitant of the mouth, bowel, and urogenital tract. The patient responded to an antibiotic regimen of metronidazole combined with initial debridement and drainage, followed by resection of the femoral head (Girdle-stone arthroplasty). The hospital course was complicated by fungal and pseudomonal superinfection. The patient was afebrile and ambulatory at discharge two months after admission. A case of Fusobacterium necrophorum osteomyelitis causing intraosseous gas seems not to have been previously reported in the literature.

Antibacterial activity of cefuroxime in human bone

Bone samples were taken at orthopaedic surgery from 12 patients, who had been treated with 2 doses of 750 mg cefuroxime by intravenous infusion. After grinding, extraction and assay by the agar diffusion method the levels of cefuroxime ranged between 0.4--1.9 micrograms/g bone. Using an electrophoretic method followed by microbiological assay, higher levels of cefuroxime were measured, possibly because of a diminution in the binding capacity of the bone.