Hyperbaric oxygen for refractory osteomyelitis

Refractory osteomyelitis is defined as a chronic osteomyelitis that persists or recurs after appropriate interventions have been performed or where acute osteomyelitis has not responded to accepted management techniques [1]. To date, no randomized clinical trials examining the effects of hyperbaric oxygen (HBO2) therapy on refractory osteomyelitis exist, and the number of new osteomyelitis clinical trials conducted over the past decade has been limited. However, based on a comprehensive review of the scientific literature, the addition of HBO2 therapy to routine surgical and antibiotic treatment of previously refractory osteomyelitis appears to be both safe and ultimately improves infection resolution rates. In most cases, the best clinical results are obtained when HBO2 treatment is administered in conjunction with culture-directed antibiotics and initiated soon after clinically indicated surgical debridement. Where extensive surgical debridement or removal of fixation hardware is relatively contraindicated (e.g., cranial, spinal, sternal, or pediatric osteomyelitis), a trial of culture-directed antibiotics and HBO2 therapy prior to undertaking more than limited surgical interventions provides a reasonable prospect for osteomyelitis cure. HBO2 therapy is ordinarily delivered on a once daily basis, five-seven days per week, for 90-120 minutes using 2.0-3.0 atmospheres absolute (ATA) pressure. Where prompt clinical improvement is seen, the existing regimen of antibiotics and HBO2 therapy should be continued for approximately four to six weeks. Typically, 20-40 HBO2 sessions are required to achieve sustained therapeutic benefit. In contrast, if prompt clinical response is not noted or osteomyelitis recurs after this initial treatment period, then continuation of the current antibiotic and HBO2 treatment regimen is unlikely to be effective. Instead, clinical management strategies should be reassessed and additional surgical debridement and/or modification of antibiotic therapy considered. Subsequent reinstitution of HBO2 therapy will again help maximize the overall chances for treatment success in these persistently refractory patients.

Bioactive glass as dead space management following debridement of type 3 chronic osteomyelitis

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.

The Beit CURE Classification of Childhood Chronic Haematogenous Osteomyelitis--a guide to treatment

BACKGROUND

The Beit CURE (BC) classification is a radiographic classification used in childhood chronic haematogenous osteomyelitis. The aim of this study is to assess correlation between this classification and the type and extent of treatment required.

METHODS

We present a retrospective series of 145 cases of childhood chronic haematogenous osteomyelitis classified using the BC classification. Variables measured include age, sex, bone involved, number of admissions, length of stay, type/number of operations and microbiology.

RESULTS

The most commonly affected bone was the tibia (46%), followed by femur (26%) and humerus (10%). Bone defects were most common in the tibia. Staphylococcus aureus was the most commonly isolated organism. Type B, sequestrum type, was the most common (88%), followed by type C, sclerotic type, (7%) and type A, Brodie's abscess (5%). Types A and B1 had the shortest length of hospitalisation (11 days), type B4 had the longest (87 days). Types A and B1 had the fewest infection control operations. Type B4 had the greatest total number of operations.

CONCLUSIONS

This study shows that the BC classification can guide surgical strategy and help predict length of inpatient treatment and number and type of procedures required.

Primary subacute osteomyelitis of the talus in children: a case series and review

Subacute haematogenous osteomyelitis of the talus in children is a rare condition. All previously reported cases have been managed by hospital admission with surgical debridement and antibiotics or by intravenous antibiotic therapy followed by oral antibiotics. This case series documents the management of the condition at our institution and reviews the current published literature. We conclude that with appropriate patient selection, primary subacute haematogenous osteomyelitis of the paediatric talus can be managed on an out-patient basis with oral antibiotic therapy.

Diagnosis and treatment of pyogenic bone infections

BACKGROUND

Pyogenic osteomyelitis is still frequently seen in the developing world and the treatment of chronic osteomyelitis presents a considerable challenge despite advances in microbiological techniques, antibiotics and surgical techniques. Acute haematogenous osteomyelitis is commoner in children.

RESULTS

In the pre-antibiotic era, mortality rate was high and progression to chronic osteomyelitis was common. A near similar scenario still exists in many developing countries due to the combination of inappropriate and/or inadequate antibiotic therapy, delayed presentation and unorthodox interventions by traditional healers.

DISCUSSION

Chronic osteomyelitis may result from poorly treated or untreated acute osteomyelitis, open fractures, surgery for an array of orthopaedic conditions and from contiguous spread from infected soft tissue as may occur in diabetic foot infections. A large array of treatment techniques hinged on sequestrectomy/ debridement, management of dead space, improvement of oxygenation and perfusion to ischaemic tissue exist. Despite these, total eradication of disease is difficult.

CONCLUSION

This article summarizes the pathology and methods of management available for pyogenic osteomyelitis. In its acute and chronic forms, the disease is likely to remain prevalent in the developing world until issues of ignorance, poverty and prompt access to appropriate and efficacious medical care are addressed.

Adult osteomyelitis

Adult osteomyelitis remains difficult to treat, with considerable morbidity and costs to the health care system. Bacteria reach bone through the bloodstream, from a contiguous focus of infection, from penetrating trauma, or from operative intervention. Bone necrosis begins early, limiting the possibility of eradicating the pathogens, and leading to a chronic condition. Appropriate treatment includes culture-directed antibiotic therapy and operative debridement of all necrotic bone and soft tissue. Treatment often involves a combination of antibiotics. Operative treatment is often staged and includes debridement, dead space management, soft tissue coverage, restoration of blood supply, and stabilization. Clinicians and patients must share a clear understanding of the goals of treatment and the difficulties that may persist after the initial course of therapy or surgical intervention. Chronic pain and recurrence of infection still remain possible even when the acute symptoms of adult osteomyelitis have resolved.

Diagnosis and classification of mandibular osteomyelitis

To establish a unified classification system for mandibular osteomyelitis, various diagnostic terms were critically assessed and clinicopathologic findings of the lesions were carefully reviewed. We recommend classifying mandibular osteomyelitis into bacterial osteomyelitis and osteomyelitis associated with the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. Other diagnostic terms were excluded because they were not appropriate for classification. Diagnostic criteria for bacterial osteomyelitis are suppuration and osteolytic change. The lesions are easily cured by antibiotic treatments. Mandibular osteomyelitis in SAPHO syndrome is characterized by nonsuppuration and a mixed pattern on radiography, with solid type periosteal reaction, external bone resorption, and bone enlargement. The presence of osteomyelitis in other bones, arthritis, or skin diseases (palmoplantar pustulosis, pustular psoriasis, and acne) strongly suggests this syndrome. Antibiotic therapy is usually ineffective and the symptoms of SAPHO syndrome are often persistent.

Periostitis ossificans (Garrè's osteomyelitis) radiographic study of two cases

BACKGROUND

Periostitis Ossificans (PO) is a non-suppurative type of Osteomyelitis, commonly occurring in children and young adults, in mandible. The most common cause for PO is periapical infection of mandibular first molar. Radiographically PO is characterized by the presence of lamellae of newly formed periosteal bone outside the cortex, giving the characteristic appearance of "onion skin".

CASE REPORTS

Two male children 11 years of age reported to the Department of Oral Medicine with a painless and persistent bony hard swelling in the mandible, with a short duration (Figs 1, 5). Both the patients had grossly decayed mandibular permanent first molar tooth with periapical infection and buccal cortical plate expansion (Figs 2, 6). The radiographic study revealed different appearances, the Orthopantomograph of case I showed a single radiopaque lamella outside the lower cortical border, without altering original mandibular contour (Fig. 3) and in case II showed a newly formed bony enlargement on the outer aspect of the lower cortical border without altering the original mandibular contour (Fig. 7). Occlusal radiograph of both the patients showed two distinct radiopaque lamellae of periosteal bone outside the buccal cortex (Figs 4, 8). Kawai et al. classified PO of mandible into type I and type II, based on whether the original contour of mandible is preserved or not. Each type is further classified into two sub types (Table 1). In case I, the orthopantomographic appearance is characteristic of type I-1 (Fig. 3), but the appearance in occlusal radiograph is characteristic of type I-2 (Fig. 4). In case II, the appearances in both the radiographs are characteristic of type I-2 (Figs 7, 8).

CONCLUSIONS

Apart from the typical onion skin appearance, PO shows various other radiographic appearances. The radiographic appearance of Periostitis Ossificans may reflect the duration, progression and the mode of healing of the disease process. The radiographic classification of PO depends on the type of radiographs taken for evaluation.

A new classification of osteomyelitis for developing countries

BACKGROUND

The term osteomyelitis (OSM) was first coined by Nelaton in 1844. Waldvogel et al, Cierny-Mader, May et al classifications of OSM from developed countries and Meier et al's from Nigeria have been described.

OBJECTIVE

This new classification was developed to highlight significant pathology seen in developing countries not covered by existing classifications.

DESIGN

A prospective study.

SETTING

University of Ilorin Teaching Hospital, Ilorin, Nigeria.

SUBJECTS

All OSM patients treated from January 1998 to June 2000.

MAIN OUTCOME MEASURES

Age, sex, clinical features, radiographs and treatment offered were analysed. Five stages were recognised: stage 0 (potential OSM with bone contamination), stage I (early or acute OSM), stage II (intermediate OSM with subperiosteal abscess), stage III (lateorchronic OSM with sequestrum and subdivided into IIIa 'curable', IIIb 'controllable', IIIc 'complicated'). Stage IV (compound OSM) with joint involvement: IVa, if anatomical and IVb if physiological. Patients' haemoglobin (Hb) status is added to the staging, for example stage II (Hb SS).

RESULTS

All 271 patients comprising 198 males and 73 females (M: F = 2.7: 1) with age range 2-48 years (mean 29.4 +/- 12.2) were studied. Only 93 patients had Hb genotype done; only 42 had Hb S. The stage O had 184 patients (120 open fractures and 64 bone operations). Stage I had nine patients, stage II 19 patients, stage III 51 patients and stage IV eight.

CONCLUSIONS

This new staging incorporates pre-emptive OSM seen in developing countries where certain practices, if unchecked lead to OSM. The severity of OSM featuring florid disease not common in the developed world, and for which existing classifications did not accommodate, is included.

Surgical management of chronic osteomyelitis

Chronic osteomyelitis is a surgical disease that can require significant dedication from both patients and surgeons to eradicate. Osteomyelitis can result from a variety of etiologies but most often is a consequence of trauma to a long bone, frequently the tibia. It is important to understand the etiology of the infection, as well as the pathophysiology of its chronicity. Additionally, the surgeon must individualize treatment for each patient, because host morbidities often play an important role in propagation of infection. Treatment requires isolation of the pathogens, significant debridement for removal of all infective and necrotic material, and then bony and soft tissue reconstruction. We review the literature of surgical treatment of chronic osteomyelitis and discuss the numerous techniques available to the treatment team, including debridement, dead space management, Ilizarov techniques, and vascularized reconstruction. These patients often require a multimodality approach that incorporates a team approach involving orthopedic and plastic surgery, as well as infectious disease and general medicine.

Verlaufsformen und Mikrobiologie der bakteriellen Osteomyelitis

The clinical presentation of osteomyelitis is multifarious. Therefore, patients are diagnosed and treated by various specialists with many different concepts of optimal management. Originally, only the acute and the chronic presentations were differentiated. The classification of Waldvogel, which is based on pathogenetic mechanisms, is more sophisticated. Diabetic foot is classified according to Wagner, who takes into account the continuous progression from sore to ulcer to osteomyelitis to gangrene. The staging according to Cierny-Mader is the most useful for the therapeutic management by surgeons. The spectrum of microorganisms is variable according to the type of osteomyelitis, epidemiology, age of the patient, co-morbidity, microbiological technique (culture, PCR), and duration of the infection. S. aureus is the leading pathogen in each type of osteomyelitis. Over the past 20 years, antimicrobial resistance has become an increasing problem. In case of osteomyelitis, standard susceptibility testing can be inaccurate. In case of device-related infection or in any type of chronic osteomyelitis, antimicrobial agents must be efficacious on stationary-phase and adhering microorganisms. Microbiologic culture and susceptibility testing should always be performed, in order to optimize the antimicrobial therapy.

Long-Term Results of Multiple-Stage Treatment for Posttraumatic Osteomyelitis of the Tibia

BACKGROUND

The treatment of posttraumatic osteomyelitis of the tibia requires meticulous debridement and adequate soft tissue coverage. At our institution, we perform a staged procedure consisting of surgical debridement followed by muscle coverage. If necessary, implantation of a cancellous iliac bone graft was always performed as a three-stage treatment.

METHODS

We performed a retrospective analysis of 47 patients treated for posttraumatic osteomyelitis of the tibia between 1987 and 1998.

RESULTS

Twenty-two patients originally had a Gustilo grade III fracture, 21 patients had a Gustilo grade I or II or closed fracture, the Gustilo grade was not known for 2 patients, and 2 patients had no fracture. Using the Cierny-Mader classification, most patients had a localized osteomyelitis. To cover the debrided area, 20 pedicled muscle transfers and 28 microvascular free flaps were used; one patient had two localizations of osteomyelitis (both proximal and distal) and received two muscle flaps. Flap failure was 8% and was successfully treated by additional flap coverage in two cases; one was closed by a split skin graft and one was closed by secundum. Twenty-six patients received a cancellous bone graft. During an average follow-up of 94 months, 9% had a recurrence of osteomyelitis for which additional surgical interventions were necessary. Finally, all the infections were eventually cured.

CONCLUSION

Our staged surgery proved to be an excellent method of treating osteomyelitis after open or closed fractures of the tibia.

Is primary chronic osteomyelitis a uniform disease? Proposal of a classification based on a retrospective analysis of patients treated in the past 30 years

INTRODUCTION

Primary chronic osteomyelitis of the jaw is a rare, non-suppurative, chronic inflammatory disease of unknown aetiology. To date, classification is confusing due to a non-uniform terminology. The aim of this study was to establish a simple (clinical) classification based on patient data from our clinic.

METHODS

Retrospective analysis revealed 30 cases of which clinical course, radiology, pathology, therapy and outcome were analysed.

RESULTS

Both sexes were equally represented. The mean age at onset of disease was 35 years (range 5-76 years). Onset of disease revealed two peaks of incidence, one in adolescence and one after age 50 years. While clinical symptoms were similar in all cases, an increased intensity of these symptoms was noted in younger individuals as well as in the early stages of the disease. Five adults and one adolescent presented with additional non facial bone, joint and skin manifestations consistent with the diagnosis of SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, or chronic recurrent multifocal osteomyelitis. Radiology demonstrated sclerosis, osteolysis and periosteal reaction in variable stages in all cases. However, findings were more extensive in younger patients. Histology revealed different stages of chronic inflammation in all cases. Microabscess formation was noted in 11 cases, six of which were children/adolescents. Therapy consisted mainly of surgery, antibiotics and hyperbaric oxygen therapy. At the end of the follow up period, 11 patients demonstrated complete remission, while in 14 cases amelioration and in 5 no significant improvement was noted.

CONCLUSION

Based on differences in age at presentation, clinical appearance and course, radiology and histology, a subclassification into early and adult onset primary chronic osteomyelitis has been established. Cases with purely mandibular involvement should further be distinguished from cases associated with other syndromes.

Autopsy-Based Assessment of Extent and Type of Osteomyelitis in Advanced-Grade Sacral Decubitus Ulcers: A Histopathologic Study

Context.—Decubitus ulcers constitute a serious medical problem, often encountered in association with hospitalization or institutionalization in senior citizens' or nursing homes. Potentially life-threatening sepsis has been reported to originate not only from soft tissue infection, but also from osteomyelitis as a complication of involvement of bone tissue in decubitus ulcers.

Objective.—To assess the histopathology of osseous structures involved in grade IV decubitus ulcers.

Design.—Autopsy-based histopathologic assessment of the presence and extent of osteomyelitis on os sacrum specimens from 28 deceased individuals with grade IV sacral decubitus ulcers using an undecalcified preparation following plastic embedding (staining with Goldner, Kossa modification, toluidine blue, and Giemsa).

Results.—The histologic findings were classified in 4 types of pathomorphologic changes: type 1, decubitus ulcer confined to soft tissue, no inflammation (n = 7); type 2, decubitus ulcer involving bone, no inflammation (n = 7); type 3, decubitus ulcer involving bone, inflammation of soft tissue, no osteomyelitis (n = 1); and type 4, decubitus ulcer involving bone, presence of osteomyelitis (n = 13). Type 4 changes are further described as follows: type 4a, chronic osteomyelitis alone (n = 6); and type 4b, chronic and acute osteomyelitic changes (n = 7). More than half of the cases (n = 15) showed no inflammatory reaction within the medullary cavity (types 1–3). In all cases with osteomyelitis, inflammation was exclusively confined to the superficial parts of the os sacrum. Chronic osteomyelitis was seen in all cases in which osteomyelitis was present. In addition, mild acute osteomyelitic changes were observed in 7 cases. Severe liquefying osteomyelitis affecting deeper layers of the os sacrum was not found. Sepsis was present in 2 cases; in one of these cases, the decubitus ulcer was considered a possible source of infection.

Conclusions.—Our results provide evidence that in cases of grade IV decubitus ulcers, the macroscopic aspect and clinical imaging techniques may lead to an overestimation of the extent of osseous involvement. We suggest that the investigation of bone biopsies is not necessary in a considerable proportion of cases of grade IV decubitus ulcers in patients without sepsis, as the minor osseous alterations are of little consequence when establishing a therapeutic approach.

Juvenile mandibular chronic osteomyelitis: a distinct clinical entity

Sclerosing osteomyelitis of the mandible is an uncommon disease of unknown aetiology. A series of eight female children (6 to 12 years old) with a distinct mandibular inflammatory disease were studied. Each presented with pain and a recurrent soft tissue swelling overlying a predominantly unilateral mandibular enlargement. On imaging, this deformity demonstrated a mixture of patchy sclerosis and radiolucency. A raised erythrocyte sedimentation rate was the only consistent serological finding. Treatment varied from symptomatic control with non-steroidal anti-inflammatory medication, to surgical management that included decortication and contouring and, in one case, resection with reconstruction. A potential protocol for treatment of this disease is given. The early age of onset of the disease process and the uniformity of the features distinguish this condition from other groups of disorders that, previously, have been collectively designated as chronic diffuse sclerosing osteomyelitis. It is proposed that this inflammatory disease of mandibular bone, in the paediatric patient, should be regarded as a separate clinical entity: 'juvenile mandibular chronic osteomyelitis'.

A dedicated team approach enhances outcomes of osteomyelitis treatment

To assess the impact of a dedicated musculoskeletal infection team, 70 musculoskeletal infections (traumatic and non-traumatic chronic osteomyelitis, Cierny-Mader Type III or IV) in 58 patients with were treated in two groups. Group I (43 infections) was treated with the assistance of an on-call infectious disease specialist. Group II (27 infections) was treated with the assistance of a dedicated musculoskeletal infectious disease specialist. Overall, there was a 42% success in Group I compared with 78% success in Group II. When stratified by infection type, in patients with Type III infections, there was a 56% success in Group I and a 90% success rate in Group II. For patients with Type IV infections, there was a 25% success rate in Group I and a 71% success rate in Group II. The participation of the dedicated musculoskeletal infectious disease specialist significantly improved patient outcomes.

Treatment of post-traumatic tibial osteomyelitis using microsurgical flaps

Between 1994 and 1998, the authors treated 70 patients presenting with post-traumatic tibial osteomyelitis. Eighty-five percent were males, with a mean patient age of 32 years. The mean duration of the disease was 2 years. Fifty-one percent were of type IV in the Cierny-Mader classification. The mean follow-up period was 36 months. Case management was through thorough debridement, antibiotic therapy, and soft-tissue reconstruction using free flaps: latissimus dorsi (39.4 percent), scapular (28.2 percent), lateral arm (19.7 percent), and anterior serratus (12.7 percent). To evaluate the results, the control of infection and the quality of the soft tissue repaired were considered. The success rate was 90 percent. The authors conclude that their described method constitutes an effective treatment for post-traumatic tibial osteomyelitis.

Value of computed tomography findings in differentiating between intraosseous malignant tumors and osteomyelitis of the mandible affecting the masticator space

OBJECTIVES

We sought to evaluate the diagnostic efficacy of computed tomography (CT) images in the differentiation between intraosseous malignant tumors and osteomyelitis spreading into the masticator space.

STUDY DESIGN

A retrospective evaluation was carried out by using CT images from 12 patients with intraosseous malignant tumors and 9 patients with osteomyelitis involving the masticator space and accompanying mandibular bone destruction. The following CT observations are discussed: (1) bone destruction pattern subdivided into spotty, gross, or permeative; (2) cortical bone expansion; (3) diffuse osteosclerotic changes; (4) periosteal reaction; (5) masticator muscle involvement; (6) enlargement of the facial muscle; and (7) attenuation in the subcutaneous adipose tissue.

RESULTS

The pattern of permeative bone destruction, cortical bone expansion, and the enlargement of both the masseter and medial pterygoid muscles were all observed in patients with malignant tumors. In contrast, diffuse sclerotic change and a periosteal reaction were significant observations in patients with osteomyelitis.

CONCLUSION

The efficacy of CT in establishing a differential diagnosis of malignant tumors or osteomyelitis is supported by this study.

Osteomyelitis of the pelvis and proximal femur: diagnostic difficulties

Osteomyelitis of the pelvis or proximal femur may still be diagnosed late because the infection is deeply placed and investigations may concentrate solely upon the possibility of septic arthritis. Periacetabular infection was diagnosed in 16 children between 1994 and 1998. A high index of suspicion and the use of appropriate imaging will ensure that the condition is not allowed to progress, although in this series one child underwent an unnecessary appendectomy, and a subsequent sepsis of the hip joint was drained in another case. Radiographs of the pelvis were rarely abnormal within 7 days of the onset of symptoms and an ultrasound scan focused on the hip joint may miss the periarticular changes.

Subacute osteomyelitis in children

Subacute osteomyelitis has a very anodyne symptomatology and is, therefore, difficult to diagnose. We studied 21 cases treated between 1984 and 1998 with subacute osteomyelitis of variable location and a mean diagnostic delay of 158.5 days. Of these, 10 cases could not be placed in the current classification. Diagnosis was radiologic in all cases, although in a few patients confirmation by isotopic bone scan and magnetic resonance imaging was required. Treatment was surgical in the first 11 cases to become, currently, predominantly conservative. The causal microorganism was only isolated in nine cases. Complete healing without sequelae was achieved in all but one case, which was of very tardy diagnosis and developed coxarthrosis.

Diagnosis and treatment of osteomyelitis

The diagnosis and therapy of osteomyelitis remains difficult despite recent advances. Clinical decision making is also difficult because of considerable variations in the types of disease observed and the lack of large comparative trials studying the variety of approaches.

[SAPHO syndrome: clinico-rheumatologic and radiologic differentiation and classification of a patient sample of 86 cases]

Synovitis (inflammatory arthritis), acne (pustulosa), pustulosis (psoriasis, palmoplantar pustulosis), hyperostosis (acquired), and ostitis (bland osteomyelitis) are symptoms forming the acronym SAPHO, which is a syndrome of nosologic heterogeneity. All entities forming the SAPHO syndrome are connected by a non-obligate dermatoskeletal association with an aseptic pustulous character. 86 cases were analyzed clinically, radiologically and by histology/histopathology. 31 adult patients showed the typical triad of pustulosis palmo-plantaris (psoriatica, PPP), sterno-costo-clavicular hyperostosis (SCCH), and "productive" spondylopathy, which we define as entity I. spondarthritis hyperostotica pustulopsoriatica (Spond.hyp.pp). Twelve adolescent and 13 adult patients showed entity no. II: chronic recurrent multifocal osteomyelitis (CRMO), being characterized by non-purulent osteomyelitis of plasma-cell sclerotic type, potentially being a reactive inflammatory process. 50% of the adult patients with CRMO showed PPP. Differentiation between these two entities is possible by detection of ossifying enthesiopathy in cases of Spond. hyp.pp and primarily chronic osteomyelitis in cases of CRMO. Two more entities or abortive forms of group I and II are III: the inflammatory syndrome of the anterior chest-wall (ACW syndrome) and IV: the more productive form of isolated sterno-costoclavicular hyperostosis (SCCH). Both are connected quite frequently to HLA-B-27-independent forms of spondarthritis and to pustulous dermatosis. More rarely we find osteo-articular symptoms in cases of acne pustulosa, which form group V: acne-associated spondarthritis and CRMO in the case of acne. Adult forms of CRMO with different forms of appearance (lumosacro-iliac hyperostosis with retroperitobeal fibrosis, pelvic type with affection of the hip-joint) are described. The immunologic theory of a "reactive osteomyelitis" potentially triggered by saprophytes is described. The inverse acne triad is brought in a context of skin symptoms. A case of intercurrent postpartum symptoms together with ulcerative colitis is described. Three cases of patients with Crohn's disease are described. Clinical features, radiological findings, and histopathological elements are brought together to determine the connections between the different entities and the possibilities of differentiation. With these elements together with bone-scan, it is often not necessary to obtain a bone specimen. Therapeutical possibilities, especially concerning CRMO, are discussed. "SAPHO syndrome" is more a sign-post on the way to a more subtle diagnosis when it comes to hyperostotic, skin-associated diseases, and it needs interdisciplinary work to clear the situation.

Changing pattern of osteomyelitis in infants and children

A retrospective analysis of 332 children with osteomyelitis (OM), managed from 1966 to 1996, was undertaken to evaluate etiology, clinical course and treatment results. In 64% of all patients positive bacterial cultures were obtained, Staphylococcus aureus, streptococci, pneumococci, and Haemophilus influenzae were the most frequently cultured pathogens. In two-thirds of the cases long bones (femur, tibia, humerus) were affected. Osteoarthritis or suppurative arthritis was evident in 27%; 32 of 170 (19%) re-evaluated patients had moderate or severe sequelae. Risk factors for an unfavorable course were the onset of disease in early infancy, suppurative arthritis, and an affected epiphysis. Suppurative arthritis, in particular, needs early evacuation to prevent sequelae. In recent years we observed an increasing number of patients presenting with atypical forms of OM. Since 1989 10 patients were considered to have chronic recurrent multifocal OM (CRMO). In 6 of them the clavicle was involved; their ages ranged from 3 to 14 years. The erythrocyte sedimentation rate was elevated (median 48, range 9-110 mm), while other inflammatory parameters like C-reactive protein (median 9, range <5-85 mg/l) or leucocyte count were slightly elevated or normal. Histopathology was stage-dependent, with a predominance of lymphoplasmacellular infiltration. A nonbacterial origin of CRMO is probable but not proven. Histopathology is not suitable for differentiation between bacterial and nonbacterial forms of bone inflammation.

[The structure, severity and dynamics of disability as a consequence of chronic posttraumatic osteomyelitis]

Medical documentation was studied as were experts' reports in 256 patients and invalids. The specific weight of those patients with posttraumatic osteomyelitis assigned to expert medical evaluation was noted to be on the increase (4.5% in 1995 versus 2.7% in 1992), with posttraumatic osteomyelitis of the lower extremity being most prevalent (90.6%). The problem of invalidity secondary to chronic posttraumatic osteomyelitis is still urgent, which fact necessitates developing innovative treatment modalities for dealing with injuries and their complications.

Primary sternal osteomyelitis in infants: a report of two cases

Primary sternal osteomyelitis in infants, older children, and adults is rare. Secondary sternal osteomyelitis, however, is more common because of the increased frequency of cardiothoracic surgery and intravenous drug abuse. Primary sternal osteomyelitis is reviewed, two infants with further cases of primary sternal osteomyelitis are presented, and diagnosis and management are discussed.

Introduction to adult posttraumatic osteomyelitis of the tibia

The tibia is the most frequent site of an open fracture, and treatment of adult posttraumatic osteomyelitis of the tibia represents a significant clinical problem that has been recognized for centuries. Ancient modalities such as immobilization and debridement are still mainstays of therapy, and recent developments such as the use of antibiotics and muscle transfer have helped to improve outcome. Osteomyelitis is classified based on the Cierny-Mader system to provide prognostic and therapeutic information. Open fractures can be classified by the Gustilo system, again providing prognostic and therapeutic data. Gustilo Type III fractures have a high likelihood of having infection develop. Treatment principles include immobilization, thorough debridement, control of infection through antibiotic use, control of dead space, and soft tissue coverage.

The host and the skeletal infection: classification and pathogenesis of acute bacterial bone and joint sepsis

Bone and joints are normally sterile areas. Bacteria may reach these sites by either haematogenous spread or spread from an exogenous or endogenous contiguous focus of infection. Bone infection, or osteomyelitis, is characterized by a progressive infectious process resulting in inflammatory destruction of bone, bone necrosis and new bone formation. Joint infections, or infectious arthritis, arise either from the haematogenous spread of organisms through the highly vascularized synovial membrane or from direct extension of a contiguous bone or soft tissue infection. The most commonly involved joints are the knee and the hip, although any joint can become infected. Infectious arthritis is monoarticular in 90% of cases. Some of the questions to be answered in this chapter include: how bacteria reach and cause damage in the bones and joints; what the current classification systems of bone and joint infections are; what some risk factors and host factors associated with bone and joint infection are; what some current characteristics of musculoskeletal infections are and whether the damage to joints can be diminished by treatment.

Culture results in open wound treatment with muscle transfer for tibial osteomyelitis

Fifty-three patients who underwent a two-staged protocol of debridement and muscle flap coverage for chronic osteomyelitis of the tibia between 1991 and 1996 were evaluated. All patients underwent a thorough debridement of all nonviable tissue and bone at initial debridement. Multiple cultures were taken, including aerobic, anaerobic and fungal cultures from the pus, soft tissue, bone curettings and bone. All patients were treated with open wound management and dressing changes. Between 2 to 7 days, median 4 days, all patients underwent a second debridement with a complete set of identical cultures, and immediate soft tissue muscle transfer. There were 42 free vascularized and 11 local tissue transfers. The 53 patients were classified according to the Cierny-Mader classification for chronic osteomyelitis. Twenty-four patients had Stage IVA osteomyelitis, 10 patients had Stage IIIA osteomyelitis, nine patients had Stage IIIB osteomyelitis, eight patients had Stage IVB osteomyelitis, one patient had Stage IA osteomyelitis, and one patient had Stage IIB osteomyelitis. All 53 patients had positive cultures at the time of their initial debridement, and 14 of 53 (26%) had a positive culture at the time of the second debridement. Based on the results, it seems from a bacteriologic stand-point that the second debridement allows for the opportunity for redebridement and wound sterilization of organisms that still may be present.

[Osteomyelitis--imaging methods and their value]

Various imaging modalities are used in diagnosis of acute and chronic infectious endogenous osteomyelitis and exogenous ostitis. The pathophysiological changes of osteomyelitis/ostitis in the bone and surrounding soft tissue are known. Findings in plain film radiography show these changes only in relatively advanced stages of disease. Hence, plain film radiographs are useful as a basic imaging modality by excluding other differentials and as a follow-up modality under therapy. Ultrasound-using advanced technology--offers diagnostic help in acute osteomyelitis, especially in infants. The various techniques of nuclear medicine show much higher sensitivity for detecting osteomyelitis than plain film radiography, but do not permit good separation for bone involvement and infectious changes in the surrounding soft tissue. While computed tomography offers the ability to display bone and soft tissue separately, it has been widely replaced by magnetic resonance imaging using fat-suppressed sequences and paramagnetic contrast media which show the spread of the infectious changes with higher sensitivity and accuracy.

Sternocostoclavicular hyperostosis in children: a report of eight cases

OBJECTIVE

The aim of this paper is to clarify the clinical and radiologic features of sternocostoclavicular hyperostosis by reviewing eight previously unpublished cases in children, identifying its similarities to chronic recurrent multifocal osteomyelitis and the differences between the pediatric and adult population affected with sternocostoclavicular hyperostosis. Appropriate imaging workup will obviate unnecessary diagnostic and therapeutic procedures.

MATERIALS AND METHODS

We investigated the clinical and imaging features of sternocostoclavicular hyperostosis in eight children (seven girls and one boy) and compared those features with the characteristic features of chronic recurrent multifocal osteomyelitis and sclerosing Garré's osteomyelitis to determine if sternocostoclavicular hyperostosis can justifiably be classified as a separate entity. All patients underwent one or more bone biopsies to determine the cause of the bone lesion(s).

RESULTS

Seven of the eight patients had involvement of the clavicle. Five of the eight patients had associated distant involvement in the pelvis, femur, tibia, fibula, talus, or sacroiliac joints. Except for predominant localization in the anterior chest wall, the symptoms, the clinical and imaging features, and the results of biopsy and histopathologic examination resemble those of chronic recurrent nonspecific sclerosing osteomyelitis. No skin lesion and no causative organism was found in any of the cases.

CONCLUSION

Sternocostoclavicular hyperostosis is a descriptive term used to designate a form of chronic sclerosing osteomyelitis. Its only distinctive feature is localization on one or more sites of the anterior chest wall.

Osteomyelitis of the foot in diabetic patients

Osteomyelitis of the foot, a common and serious problem in diabetic patients, results from diabetes complications, especially peripheral neuropathy. Infection generally develops by spread of contiguous soft-tissue infection to underlying bone. The major diagnostic difficulty in diabetic patients is distinguishing bone infection from noninfectious neuropathic bony lesions. Certain clinical signs suggest osteomyelitis, but imaging tests are usually needed. The 111In-labeled leukocyte scan and magnetic resonance imaging are the most diagnostically useful. Staphylococcus aureus is the most common etiologic agent, followed by other aerobic gram-positive cocci. Aerobic gram-negative bacilli and anaerobes are occasionally isolated, often in mixed infections. Antimicrobial therapy is best directed by cultures of the infected bone, obtained percutaneously or at surgery. Antibiotic therapy should usually be given parenterally, at least initially, and continued for at least 6 weeks. Surgical debridement or resection of the infected bone, when feasible, improves the outcome. With appropriate therapy most cases of osteomyelitis can be successfully managed.

Staging and staging application in osteomyelitis

Osteomyelitis is traditionally staged by the Waldvogel classification system. The Waldvogel classification is an etiologic system and does not readily lend itself to guiding surgical or antibiotic therapy. Other classifications have been developed to emphasize different clinical aspects of osteomyelitis. These classifications include those of Ger, Kelly, Weiland, Gordon, May, and Cierny-Mader. The Cierny-Mader classification is based on the anatomy of bone infection and the physiology of the host. The Cierny-Mader classification permits the development of comprehensive treatment guidelines for each stage. The Cierny-Mader classification is used to demonstrate the application of staging for the diagnosis and treatment of osteomyelitis.

Experimental models of bone and prosthetic joint infections

Bone and joint infections are difficult to cure. The difficulty is related to the presence of bacteria adherent to foreign material in many cases and also to the limited activity of antibiotics in infected bones. Clinical trials are difficult to design because of the heterogeneity of the disease and the number of factors that could influence the therapeutic response. To control for these multiple variables, attempts have been made to develop reliable animal models of osteomyelitis and prosthetic joint infections that closely mimic the different infections seen in orthopedic surgery and that allow evaluation of the efficacy of surgical procedures as well as local or systemic antibiotic therapy. These models will continue to provide us information on the pathogenesis and management of such infections.

Diffuse sclerosing osteomyelitis of the mandible: its characteristics and possible relationship to synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome

PURPOSE

This article reports on the possible relationship of diffuse sclerosing osteomyelitis (DSO) of the mandible to synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome.

PATIENTS AND METHODS

The pathologic features in 12 new DSO patients and those in previously reported cases were reviewed and compared with those of SAPHO syndrome.

RESULTS

Many similarities were noted between the two entities in terms of the clinical, radiographic, and histologic features. Furthermore, multiple bone lesions and skin lesions (palmoplantar pustulosis and psoriasis) were observed not only in SAPHO syndrome but also in DSO patients.

CONCLUSION

DSO is concluded to be one manifestation of SAPHO syndrome.

[Differential diagnosis of childhood osteomyelitis--classification according to scintigraphic, radiologic and magnetic resonance tomographic characteristics]

We present a retrospective study on children with the final diagnosis osteomyelitis, who have been examined in Tübingen from 1985 to 1991. The different types of infantile osteomyelitis were classified due to the causative organism and findings in 3-phase scintigraphy and X-ray films. For the chronic type of osteomyelitis the study was extended to the years from 1979 to 1991 and the results of an earlier report were included. We worked up 17 cases of acute/peracute osteomyelitis, including 5 cases of early infancy, 2 cases of tuberculosis, 2 Brodie's abscesses, 5 plasmacellular types, 2 cases of primary chronic multifocal osteomyelitis (PCMO), and 5 cases of unspecific chronic osteomyelitis. All cases were examined with scintigraphy, X-ray films and in part with magnetic resonance tomographic imaging. In 23 cases scintigrams and X-ray films were performed in the follow-up. We show the importance of scintigraphy for the early detection and localisation of osteomyelitis, the importance of findings on X-ray films for the specific diagnosis of osteomyelitis, and the importance of magnetic resonance tomography for high-resolution detection of the expansion of osteomyelitis.

Possible identity of diffuse sclerosing osteomyelitis and chronic recurrent multifocal osteomyelitis. One entity or two

On the basis of the findings of nine of our patients and our review of previously reported cases of diffuse sclerosing osteomyelitis and chronic recurrent multifocal osteomyelitis, we discuss the similarity of these two entities. Our nine patients had initially been given diagnoses of diffuse sclerosing osteomyelitis on the basis of their clinicopathologic findings. However, technetium 99m-MDP bone scans performed on four of them revealed multiple bone lesions leading to the diagnosis of chronic recurrent multifocal osteomyelitis. Furthermore, no clear difference between clinical features in the patients with multiple bone lesions and those in the patients with diffuse sclerosing osteomyelitis was found. We conclude that diffuse sclerosing osteomyelitis is an expression of chronic recurrent multifocal osteomyelitis.

Multimodality imaging of osteomyelitis

Early diagnosis of osteomyelitis continues to be a clinical problem. Multiple imaging modalities are being used for the diagnosis of osteomyelitis, but none of them is ideal for all cases. The choice of modality depends on several factors based on an understanding of the pathophysiologic aspects of different forms of osteomyelitis. After a brief introduction outlining some basic principles regarding the diagnosis of osteomyelitis, pathophysiologic aspects are reviewed. Advantages and disadvantages of each imaging modality and their applications in different forms of osteomyelitis are discussed. The use of different imaging modalities in the diagnosis of special forms of osteomyelitis, including chronic, diabetic foot, and vertebral osteomyelitis, and osteomyelitis associated with orthopedic appliances and sickle cell disease is reviewed. Taking into account the site of suspected osteomyelitis and the presence or absence of underlying pathologic changes and their nature, an algorithm summarizing the use of various imaging modalities in the diagnosis of osteomyelitis is presented.

Osteomyelitis

The complexities of osteomyelitis make its diagnosis and treatment challenging. Current trends emphasize early diagnosis and aggressive treatment. Imaging has improved, with nuclear scans and magnetic resonance imaging, and technique modifications have enhanced the specificity of these tests. Treatment depends on thorough debridement of necrotic bone and tissue, accurate cultures and administration of culture, and sensitivity-specific antibiotics. Antibiotic delivery has expanded to include effective oral agents and local agents mixed with polymethylmethacrylate or a biodegradable substance. Success rates in treating this disease have improved with the use of a systematic approach, making outcome more predictable.

Osteomyelitis of the jaws

Osteomyelitis is described as an inflammation of bone and bone marrow that may develop in the jaws following a chronic odontogenic infection or for a variety of other reasons. This situation may be acute, sub-acute or chronic, resulting in a totally different clinical picture.

Long-bone osteomyelitis diagnosis and management

The pathogen may proliferate years after seemingly successful treatment. The authors describe a classification system to evaluate both the disease and the patient's capacity to undergo the rigors of therapy. Two cases illustrate the clinical issues.

Osteomyelitis

Osteomyelitis can be difficult to treat. Current trends emphasize early diagnosis and aggressive treatment. Imaging has improved with nuclear scans and magnetic resonance imaging, and recent modifications in technique have enhanced the specificity. Treatment depends on debridement of necrotic bone and tissue, obtaining accurate cultures, and administration of culture- and sensitivity-directed antibiotics. Antibiotic delivery has expanded to include effective oral agents and local agents mixed with polymethylmethacrylate or a biodegradable substance. Success rates in treating this disease have improved with a systematic approach, making outcome more predictable.

Hematogenous osteomyelitis in infants and children in the northwestern region of Namibia. Management and two-year results

We reviewed the records of fifty-five children, including eleven infants (three of whom were neonates), who had at least one skeletal manifestation of hematogenous osteomyelitis. Forty-two of the patients were boys and thirteen were girls. The patients were classified into three groups: those who had early acute, those who had late acute, and those who had chronic osteomyelitis. This classification system was based on clinical and radiographic criteria. Seven patients had early acute osteomyelitis; eighteen, late acute osteomyelitis; and thirty, chronic osteomyelitis. The bones most often affected were the tibia (twenty-two patients) and the femur (nineteen patients). Penicillin-resistant Staphylococcus aureus grew on culture of specimens of purulent material from twenty-nine (76 per cent) of thirty-eight patients. Escherichia coli, Proteus mirabilis, and Enterobacter grew on culture of specimens of purulent material from one patient each. Six cultures showed no growth. No purulent material was obtained from seventeen of the fifty-five patients. The seven patients who had early acute osteomyelitis, and four of the eighteen patients who had late acute osteomyelitis, responded well to antibiotic treatment only. A combination of antibiotic and operative treatment was needed in fourteen of the eighteen patients who had late acute osteomyelitis and in all thirty patients who had chronic osteomyelitis. Forty-nine of the fifty-five patients were followed for two years; the remaining six patients were lost to follow-up. The two-year results were good in nineteen of the twenty-three patients who had acute (early or late) osteomyelitis and in fifteen of the twenty-six patients who had chronic osteomyelitis.(ABSTRACT TRUNCATED AT 250 WORDS)