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Zamarud A, Kesten J, Park DJ, Pulli B, Telischak NA, Dodd RL, Do HM, Marks MP, Heit JJ. Percutaneous Disc Biopsy versus Bone Biopsy for the Identification of Infectious Agents in Osteomyelitis/Discitis. J Vasc Interv Radiol 2024; 35:852-857.e1. [PMID: 38613536 DOI: 10.1016/j.jvir.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 04/15/2024] Open
Abstract
PURPOSE To determine whether sampling of the disc or bone is more likely to yield positive tissue culture results in patients with vertebral discitis and osteomyelitis (VDO). MATERIALS AND METHODS Retrospective review was performed of consecutive patients who underwent vertebral disc or vertebral body biopsy at a single institution between February 2019 and May 2023. Inclusion criteria were age ≥18 years, presumed VDO on spinal magnetic resonance (MR) imaging, absence of paraspinal abscess, and technically successful percutaneous biopsy with fluoroscopic guidance. The primary outcome was a positive biopsy culture result, and secondary outcomes included complications such as nerve injury and segmental artery injury. RESULTS Sixty-six patients met the inclusion criteria; 36 patients (55%) underwent disc biopsy, and 30 patients (45%) underwent bone biopsy. Six patients required a repeat biopsy for an initially negative culture result. No significant demographic, laboratory, antibiotic administration, or pain medication use differences were observed between the 2 groups. Patients who underwent bone biopsy were more likely to have a history of intravenous drug use (26.7%) compared with patients who underwent disc biopsy (5.5%; P = .017). Positive tissue culture results were observed in 41% of patients who underwent disc biopsy and 15% of patients who underwent bone biopsy (P = .016). No vessel or nerve injuries were detected after procedure in either group. CONCLUSIONS Percutaneous disc biopsy is more likely to yield a positive tissue culture result than vertebral body biopsy in patients with VDO.
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Affiliation(s)
- Aroosa Zamarud
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Jamie Kesten
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - David J Park
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Benjamin Pulli
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Nicholas A Telischak
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Robert L Dodd
- Department of Radiology, Stanford University School of Medicine, Stanford, California; Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Huy M Do
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Michael P Marks
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California.
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Debs P, Boutin RD, Smith SE, Babic M, Blankenbaker D, Chandra V, Murphey M, Thottacherry E, Kreulen C, Fayad LM. Chronic Nonspinal Osteomyelitis in Adults: Consensus Recommendations on Percutaneous Bone Biopsies from the Society of Academic Bone Radiologists. Radiology 2024; 311:e231348. [PMID: 38625010 PMCID: PMC11070610 DOI: 10.1148/radiol.231348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
The diagnosis and management of chronic nonspinal osteomyelitis can be challenging, and guidelines regarding the appropriateness of performing percutaneous image-guided biopsies to acquire bone samples for microbiological analysis remain limited. An expert panel convened by the Society of Academic Bone Radiologists developed and endorsed consensus statements on the various indications for percutaneous image-guided biopsies to standardize care and eliminate inconsistencies across institutions. The issued statements pertain to several commonly encountered clinical presentations of chronic osteomyelitis and were supported by a literature review. For most patients, MRI can help guide management and effectively rule out osteomyelitis when performed soon after presentation. Additionally, in the appropriate clinical setting, open wounds such as sinus tracts and ulcers, as well as joint fluid aspirates, can be used for microbiological culture to determine the causative microorganism. If MRI findings are positive, surgery is not needed, and alternative sites for microbiological culture are not available, then percutaneous image-guided biopsies can be performed. The expert panel recommends that antibiotics be avoided or discontinued for an optimal period of 2 weeks prior to a biopsy whenever possible. Patients with extensive necrotic decubitus ulcers or other surgical emergencies should not undergo percutaneous image-guided biopsies but rather should be admitted for surgical debridement and intraoperative cultures. Multidisciplinary discussion and approach are crucial to ensure optimal diagnosis and care of patients diagnosed with chronic osteomyelitis.
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Affiliation(s)
- Patrick Debs
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Robert D Boutin
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Stacy E Smith
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Maja Babic
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Donna Blankenbaker
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Venita Chandra
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Mark Murphey
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Elizabeth Thottacherry
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Christopher Kreulen
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
| | - Laura M Fayad
- From The Russell H. Morgan Department of Radiology and Radiological Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.); Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department of Orthopaedic Surgery, University of California-Davis, Sacramento, Calif (C.K.)
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Sabir N, Akkaya Z. Musculoskeletal infections through direct inoculation. Skeletal Radiol 2024:10.1007/s00256-024-04591-w. [PMID: 38291151 DOI: 10.1007/s00256-024-04591-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
Musculoskeletal infections consist of different clinical conditions that are commonly encountered in daily clinical settings. As clinical findings and even laboratory tests cannot always be specific, imaging plays a crucial role in the diagnosis and treatment of these cases. Musculoskeletal infections most commonly occur secondary to direct inoculation into the skin involuntarily affected by trauma, microorganism, foreign bodies, or in diabetic ulcers; direct infections can also occur from voluntary causes due to surgery, vaccinations, or other iatrogenic procedures. Hematogenous spread of infection from a remote focus can also be a cause for musculoskeletal infections. Risk factors for soft tissue and bone infections include immunosuppression, old age, corticosteroid use, systemic illnesses, malnutrition, obesity, and burns. Most literature discusses musculoskeletal infections according to the diagnostic tools or forms of infection seen in different soft tissue anatomical planes or bones. This review article aims to evaluate musculoskeletal infections that occur due to direct inoculation to the musculoskeletal tissues, by focusing on the traumatic mechanism with emphasis on the radiological findings.
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Affiliation(s)
- Nuran Sabir
- Department of Radiology, Faculty of Medicine, Pamukkale University, Kinikli Kampusu, 20100, Denizli, Turkey.
| | - Zehra Akkaya
- Department of Radiology, Faculty of Medicine, İbni Sina Hospital, Ankara University, Ankara, Turkey
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Husseini JS, Huang AJ. Discitis-osteomyelitis: optimizing results of percutaneous sampling. Skeletal Radiol 2023; 52:1815-1823. [PMID: 35976405 DOI: 10.1007/s00256-022-04151-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 02/02/2023]
Abstract
Vertebral discitis-osteomyelitis is an infection of the spine that involves the intervertebral disc and the adjacent vertebral body but may also extend into the paraspinal and epidural soft tissues. If blood cultures and other culture data fail to identify a causative microorganism, percutaneous sampling is indicated to help guide targeted antimicrobial therapy. Despite limited supporting evidence, withholding antimicrobial therapy for up to 2 weeks is recommended to maximize microbiological yield, although literature supporting this recommendation is limited. During the procedure, technical factors that may improve yield include targeting of paraspinal fluid collections or soft tissue abnormalities for sampling, acquiring multiple core samples if possible, and use of larger gauge needles when available. Repeat sampling may be indicated if initial percutaneous biopsy is negative but should be performed no sooner than 72 h after the initial percutaneous biopsy to ensure adequate time for culture results to return.
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Affiliation(s)
- Jad S Husseini
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street Yawkey 6E, Boston, MA, 02114, USA.
| | - Ambrose J Huang
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street Yawkey 6E, Boston, MA, 02114, USA
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Marruzzo D, Mancini F, Ricciuti V, Barbieri FR, Preziosi R, Pagano S, Ricciuti RA. Modified percutaneous biopsy of the spine: improvement of the technique. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:221-227. [PMID: 36477894 DOI: 10.1007/s00586-022-07384-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 09/04/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Biopsy of the spine can be performed by open surgery or percutaneous needle sampling. The first has the highest diagnostic yield while the second is a less invasive procedure with lower rate of complications and shorter hospitalization time. We described a modified technique of percutaneous biopsy using semi-rigid grasping forceps that may offer the advantages of both, open and minimally invasive surgery. METHODS Thirty consecutive patients with spinal lesions requiring biopsy were admitted to Neurosurgical Unit of Belcolle Hospital (Viterbo, Italy) from January 2017 to September 2021. There was a suspicion of spondylodiscitis in 25 cases and of tumor in 5 cases. Percutanous trans-pedicular spine biopsy has been performed using this new semi-rigid grasping forceps. Combining the opening width, jaw length and full 360° rotation, the device allows a wide and precise sampling. RESULTS Sampling was sufficient in all cases (100%); tumors was observed in 5 cases (16.7%%) with a percentage of definitive histopathologic diagnosis of 100% (n = 5); among the remaining patients histological examination yielded a diagnosis of spinal infection in 25 cases (100%), and microbiologic culture provided an aetiologic diagnosis in 23 cases (92%). All procedures were well tolerated, and no postoperative complications were observed. Levels involved included: thoracic (T5-T9) in 8 cases, thoracolumbar junction (T10-L2) in 12 cases and lumbar (L3-L5) in 10 cases. CONCLUSIONS Percutaneous biopsy with the semi-rigid grasping forceps is a safe and effective procedure that can be used for diagnosis of both infectious and tumor lesions of the spine. It allows to obtain a larger specimen volume and to use a multidirectional trajectory for sampling, resulting in a minimally invasive technique with strong ability to yield etiologic diagnosis.
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Yen C, Kaushik S, Desai SB. Image-guided percutaneous bone biopsy for pediatric osteomyelitis: correlating MRI findings, tissue pathology and culture, and effect on clinical management. Skeletal Radiol 2023; 52:39-46. [PMID: 35882659 DOI: 10.1007/s00256-022-04131-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 02/02/2023]
Abstract
Bone biopsy remains the gold standard for diagnosis of osteomyelitis while MRI results in a radiologic diagnosis that generally precedes biopsy. This study's purpose is to examine the diagnostic yield and effect of biopsy results on clinical management in children with suspected osteomyelitis and positive MRI findings. A retrospective review was performed at a tertiary care children's hospital. Search of the EMR and radiology PACS identified patients below 18 years who underwent bone biopsy with interventional radiology for osteomyelitis and had positive MRI findings for osteomyelitis prior to biopsy. Data was collected on patient demographics, MRI findings, biopsy procedural details, tissue culture, histopathology results, and clinical management before and after biopsy. Changes in management were categorized as antibiotic type/quantity, duration, or diagnosis. A total of 82 biopsies in 79 patients with suspicion for osteomyelitis and positive MRIs prior to biopsy were performed over 5 years from 2014 to 2019. All biopsies were successful and sent for tissue culture. 22/82 biopsies (27%) yielded positive cultures. Of those with tissue cultures, 16/22 (72%) resulted in change in clinical management. Of all biopsies, 18/82 (22%) resulted in a change in management (15 antibiotic, 1 duration, 2 diagnosis). The 2 changes in diagnosis included one biopsy done which was positive for cancer and a second which was found to not demonstrate osteomyelitis on histology. In the pediatric population, bone biopsy is a reasonably low morbidity procedure. However, there is a relatively low rate of positive tissue cultures even with MRI findings suspicious for osteomyelitis. Approximately 1 in 5 biopsies resulted in a change in clinical management, mostly in antibiotic selection. Bone biopsy may have a higher clinical impact in pre-specified circumstances.
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Affiliation(s)
- Christopher Yen
- Department of Radiology, Section of Interventional Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Shivam Kaushik
- Rowan School of Osteopathic Medicine, 42 E Laurel Rd, Stratford, NJ, USA
| | - Sudhen B Desai
- Interventional Radiology, Division of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA.
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Hockney SM, Steker D, Bhasin A, Krueger KM, Williams J, Galvin S. Role of bone biopsy and deep tissue culture for antibiotic stewardship in diabetic foot osteomyelitis. J Antimicrob Chemother 2022; 77:3482-3486. [PMID: 36214165 DOI: 10.1093/jac/dkac345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/16/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To describe organisms most frequently identified on bone biopsy or deep tissue culture and determine how culture data impacted antibiotic management in patients with diabetic foot osteomyelitis (DFO). METHODS We retrospectively reviewed patients admitted with a diabetic foot ulcer (DFU) between 3 March 2018 and 31 December 2019 and selected for patients diagnosed with infectious osteomyelitis (OM) of the lower extremity. We stratified patients by whether a bone biopsy or deep tissue culture was obtained and compared rates of antibiotic utilization with chi-squared and Fisher's exact tests. RESULTS Of 305 patients with a DFU, 152 (50%) were clinically diagnosed with DFO. Forty-seven patients received 41 deep tissue cultures and 29 bone biopsy cultures for a total of 70 cultures. Of 45 (64%) positive cultures, 36 (80%) had Gram-positive organisms and 19 (42%) had Gram-negative organisms. MDR organisms were isolated in 7 (15%) patients. Culture data resulted in antibiotic changes in 41 (87%) patients. Therapy was narrowed in 29 (62%) patients and broadened due to inadequate empirical coverage in 4 (9%) patients. Culture data from 18 (40%) patients showed susceptibility to an oral treatment regimen with high bioavailability. There was no significant difference in rates of antibiotic utilization at discharge between patients who underwent bone biopsy or deep tissue culture relative to those who did not (77% versus 75%, P = 0.86), although less MRSA coverage was used (34% versus 50%, P = 0.047). CONCLUSIONS In patients with DFO, deep tissue and bone biopsy cultures were infrequently obtained but resulted in targeted therapy changes in most patients. Culture data usually allowed for narrowing of antibiotics but revealed inadequate empirical coverage in a subset of patients.
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Affiliation(s)
- Sara M Hockney
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Danielle Steker
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ajay Bhasin
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Hospital Based Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen M Krueger
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Janna Williams
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shannon Galvin
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Cui Y, Mi C, Wang B, Zheng B, Sun L, Pan Y, Lin Y, Shi X. Manual Homogenization Improves the Sensitivity of Microbiological Culture for Patients with Pyogenic Spondylitis. Infect Drug Resist 2022; 15:6485-6493. [DOI: 10.2147/idr.s386148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
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Ahmad S, Jhaveri MD, Mossa-Basha M, Oztek M, Hartman J, Gaddikeri S. A Comparison of CT-Guided Bone Biopsy and Fluoroscopic-Guided Disc Aspiration as Diagnostic Methods in the Management of Spondylodiscitis. Curr Probl Diagn Radiol 2022; 51:728-732. [DOI: 10.1067/j.cpradiol.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/14/2022] [Accepted: 02/27/2022] [Indexed: 11/22/2022]
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:11552. [PMID: 34768982 PMCID: PMC8584017 DOI: 10.3390/ijms222111552] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 12/27/2022] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Andrew P. Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA;
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Robert W. Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Dane K. Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Orhan K. Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
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11
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:ijms222111552. [PMID: 34768982 DOI: 10.3390/ijms222111552.pmid:34768982;pmcid:pmc8584017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 05/27/2023] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Andrew P Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Robert W Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Dane K Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Orhan K Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
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12
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Best Practices: CT-Guided Percutaneous Sampling of Vertebral Discitis-Osteomyelitis and Technical Factors Maximizing Biopsy Yield. AJR Am J Roentgenol 2021; 217:1057-1068. [PMID: 33336581 DOI: 10.2214/ajr.20.24313] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Vertebral discitis-osteomyelitis is an infection of the intervertebral disk and vertebral bodies that may extend to adjacent paraspinal and epidural soft tissues. Its incidence is increasing, likely because of improved treatments and increased life expectancy for patients with predisposing chronic disease and increased rates of IV drug use and intravascular intervention. Because blood cultures are frequently negative in patients with vertebral discitis-osteomyelitis, biopsy is often indicated to identify a causative microorganism for targeted antimicrobial therapy. The reported yield of CT-guided percutaneous sampling is 31-91%, which is lower than the reported yield of open biopsy of 76-91%. However, the less invasive approach may be favored given its relative safety and low cost. If paravertebral fluid collections are present, CT-guided aspiration should be performed. If aspiration is unsuccessful or no paravertebral fluid collections are present, CT-guided percutaneous biopsy should be performed, considering technical factors (e.g., anatomic approach, needle selection, and needle angulation) that may improve microbiologic yield. Although antimicrobial therapy should be withheld for 1-2 weeks before biopsy if clinically feasible, biopsy may still be performed without stopping antimicrobial therapy if needed. Because of the importance of targeted antimicrobial therapy, repeat biopsy should be considered after 72 hours if initial biopsy does not identify a pathogen.
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13
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Sousa R, Carvalho A, Santos AC, Abreu MA. Optimal microbiological sampling for the diagnosis of osteoarticular infection. EFORT Open Rev 2021; 6:390-398. [PMID: 34267930 PMCID: PMC8246105 DOI: 10.1302/2058-5241.6.210011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Infection is a dire complication afflicting every field of orthopaedics and traumatology. If specific clinical, laboratory and imaging parameters are present, infection is often assumed even in the absence of microbiological confirmation. However, apart from confirming infection, knowing the exact infecting pathogen(s) and their antimicrobial susceptibility patterns is paramount to help guide treatment. Every effort should therefore be undertaken with that goal in mind.Not all microbiological findings carry the same relevance, and knowing exactly how and where a sample was collected is key. Several different sampling techniques are available, and one must be aware of both advantages and limitations. Microbiological sampling alternatives in some of the most common clinical scenarios such as native and prosthetic joint infections, osteomyelitis and fracture-related infections, spinal and diabetic foot infections will be discussed.Orthopaedic surgeons should also be aware of basic laboratory sample processing techniques as they have a direct impact on the way specimens should be dealt with and transported to the laboratory. Only by knowing these basic principles will surgeons be able to participate in the multidisciplinary discussion and decision making around how to interpret microbiological findings in each specific patient. Cite this article: EFORT Open Rev 2021;6:390-398. DOI: 10.1302/2058-5241.6.210011.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal
| | - André Carvalho
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Cláudia Santos
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Miguel Araújo Abreu
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
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14
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Abstract
AbstractMusculoskeletal infection can be an urgent or emergent clinical issue. Accurate imaging diagnosis is an essential part of the treatment algorithm. This review addresses advantages of available imaging modalities and radiologic appearance of the various manifestations of infection. Controversies are addressed, including the use of the term “osteitis.” Finally, the differential diagnosis of infection is reviewed, such as inflammatory arthropathies and tumors that can simulate infection on imaging exams.
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15
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Onsea J, Pallay J, Depypere M, Moriarty TF, Van Lieshout EMM, Obremskey WT, Sermon A, Hoekstra H, Verhofstad MHJ, Nijs S, Metsemakers WJ. Intramedullary tissue cultures from the Reamer-Irrigator-Aspirator system for diagnosing fracture-related infection. J Orthop Res 2021; 39:281-290. [PMID: 32735351 DOI: 10.1002/jor.24816] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/04/2023]
Abstract
Fracture-related infection (FRI) is a serious complication following musculoskeletal trauma. Accurate diagnosis and appropriate treatment depend on retrieving adequate deep tissue biopsies for bacterial culture. The aim of this cohort study was to compare intraoperative tissue cultures obtained by the Reamer-Irrigator-Aspirator system (RIA)-system against standard tissue cultures obtained during the same surgical procedure. All patients had long bone fractures of the lower limbs and were assigned to the FRI or Control group based on the FRI consensus definition. The FRI group consisted of 24 patients with confirmed FRI and the Control group consisted of 21 patients with aseptic nonunion or chronic pain (in the absence of other suggestive/confirmatory criteria). Standard tissue cultures and cultures harvested by the RIA-system showed similar results. In the FRI group, standard tissue cultures and RIA cultures revealed relevant pathogens in 67% and 71% of patients, respectively. Furthermore, in four FRI patients, cultures obtained by the RIA-system revealed additional relevant pathogens that were not found by standard tissue culturing, which contributed to the optimization of the treatment plan. In the Control group, there were no false-positive RIA culture results. As a proof-of-concept, this cohort study showed that the RIA-system could have a role in the diagnosis of FRI as an adjunct to standard tissue cultures. Since scientific evidence on the added value of the RIA-system in the management of FRI is currently limited, further research on this topic is required before its routine application in clinical practice.
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Affiliation(s)
- Jolien Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Jan Pallay
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - An Sermon
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
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16
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Abstract
The Society of Skeletal Radiology (SSR) Practice Guidelines and Technical Standards Committee identified musculoskeletal infection as a White Paper topic, and selected a Committee, tasked with developing a consensus on nomenclature for MRI of musculoskeletal infection outside the spine. The objective of the White Paper was to critically assess the literature and propose standardized terminology for imaging findings of infection on MRI, in order to improve both communication with clinical colleagues and patient care.A definition was proposed for each term; debate followed, and the committee reached consensus. Potential controversies were raised, with formulated recommendations. The committee arrived at consensus definitions for cellulitis, soft tissue abscess, and necrotizing infection, while discouraging the nonspecific term phlegmon. For bone infection, the term osteitis is not useful; the panel recommends using terms that describe the likelihood of osteomyelitis in cases where definitive signal changes are lacking. The work was presented virtually to SSR members, who had the opportunity for review and modification prior to submission for publication.
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17
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Extensive multifocal emphysematous osteomyelitis: fatal outcome in a patient with psychiatric history. Skeletal Radiol 2020; 49:1487-1493. [PMID: 32447471 DOI: 10.1007/s00256-020-03470-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/09/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023]
Abstract
Emphysematous osteomyelitis is a rare entity with potentially devastating consequences, even after prompt and aggressive intervention. It is characterized by intraosseous gas and may be complicated by adjacent abscess formation. There are a handful of previously reported cases of emphysematous osteomyelitis, but none to the degree as reported here. Specifically, we report an extremely rare case of extensive multifocal emphysematous osteomyelitis involving both the axial and appendicular skeleton in a 20-year-old woman.
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18
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Schechter MC, Ali MK, Risk BB, Singer AD, Santamarina G, Rogers HK, Rajani RR, Umpierrez G, Fayfman M, Kempker RR. Percutaneous Bone Biopsy for Diabetic Foot Osteomyelitis: A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2020; 7:ofaa393. [PMID: 33134407 PMCID: PMC7590897 DOI: 10.1093/ofid/ofaa393] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/24/2020] [Indexed: 12/30/2022] Open
Abstract
Background Diabetes is the leading cause of lower extremity nontraumatic amputation globally, and diabetic foot osteomyelitis (DFO) is usually the terminal event before limb loss. Although guidelines recommend percutaneous bone biopsy (PBB) for microbiological diagnosis of DFO in several common scenarios, it is unclear how frequently PBBs yield positive cultures and whether they cause harm or improve outcomes. Methods We searched the PubMed, EMBASE, and Cochrane Trials databases for articles in any language published up to December 31, 2019, reporting the frequency of culture-positive PBBs. We calculated the pooled proportion of culture-positive PBBs using a random-effects meta-analysis model and reported on PBB-related adverse events, DFO outcomes, and antibiotic adjustment based on PBB culture results where available. Results Among 861 articles, 11 studies met inclusion criteria and included 780 patients with 837 PBBs. Mean age ranged between 56.6 and 71.0 years old. The proportion of males ranged from 62% to 86%. All studies were longitudinal observational cohorts, and 10 were from Europe. The range of culture-positive PBBs was 56%-99%, and the pooled proportion of PBBs with a positive culture was 84% (95% confidence interval, 73%-91%). There was heterogeneity between studies and no consistency in definitions used to define adverse events. Impact of PBB on DFO outcomes or antibiotic management were seldom reported. Conclusions This meta-analysis suggests PBBs have a high yield of culture-positive results. However, this is an understudied topic, especially in low- and middle-income countries, and the current literature provides very limited data regarding procedure safety and impact on clinical outcomes or antibiotic management.
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Affiliation(s)
- Marcos C Schechter
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia, USA
| | - Mohammed K Ali
- Emory University, Rollins School of Public Health, Department of Global Health and Epidemiology, Atlanta, Georgia, USA
| | - Benjamin B Risk
- Emory University, Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Atlanta, Georgia, USA
| | - Adam D Singer
- Emory University School of Medicine, Grady Memorial Hospital, Department of Radiology and Imaging Sciences, Division of Musculoskeletal Imaging, Atlanta, Georgia, USA
| | - Gabriel Santamarina
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, Georgia, USA
| | - Hannah K Rogers
- Emory University, Woodruff Health Sciences Center Library, Information Services, Atlanta, Georgia, USA
| | - Ravi R Rajani
- Emory University School of Medicine, Grady Memorial Hospital, Department of Surgery, Division of Vascular Surgery, Atlanta, Georgia, USA
| | - Guillermo Umpierrez
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, Georgia, USA
| | - Maya Fayfman
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta, Georgia, USA
| | - Russell R Kempker
- Emory University School of Medicine, Grady Memorial Hospital, Department of Medicine, Division of Infectious Diseases, Atlanta, Georgia, USA
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19
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Sax AJ, Halpern EJ, Zoga AC, Roedl JB, Belair JA, Morrison WB. Predicting osteomyelitis in patients whose initial MRI demonstrated bone marrow edema without corresponding T1 signal marrow replacement. Skeletal Radiol 2020; 49:1239-1247. [PMID: 32130445 DOI: 10.1007/s00256-020-03396-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 01/20/2020] [Accepted: 02/05/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE We endeavored to determine which characteristics of diabetic ulcers portend the strongest risk for osteomyelitis in patients whose initial T1-weighted imaging was normal. By determining which features have a greater risk for osteomyelitis, clinicians can treat patients more aggressively to reduce the sequela of inadequately treated osteomyelitis. MATERIALS AND METHODS We performed a retrospective analysis of MR imaging from 60 pedal ulcers with suspected osteomyelitis. Ulcer dimensions and depth were measured. Ratios of marrow ROI/joint fluid ROI on T2/STIR sequences were obtained. Progression to osteomyelitis on subsequent MRI was characterized by loss of normal marrow signal on T1-weighted images. Statistical analysis was performed with a two-sample t test and Cox proportional hazard model. A p value < 0.05 was used as the threshold for statistical significance. RESULTS Sixty MR exams were identified. Thirty-four progressed to osteomyelitis. Marrow ROI/joint fluid ratios averaged 65% in the osteomyelitis group, and 45% in the non-osteomyelitis group, p < 0.001. ROI ratios > 53% had a 6.5-fold increased risk of osteomyelitis, p < 0.001. Proximity to bone averaged 6 mm in the osteomyelitis group and 9 mm in the non-osteomyelitis group, p = 0.02. Ulcer size averaged 4 cm2 in the osteomyelitis group versus 2.4 cm2 in the non-osteomyelitis group, p = 0.07. Ulcers greater than 3 cm2 has a 2-fold increase in the risk of osteomyelitis, p = 0.04. CONCLUSION Increasing bone marrow ROI signal/joint fluid ratios on T2/STIR images were the strongest risk factors for developing osteomyelitis, while ulcer size and depth are weaker predictors.
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Affiliation(s)
- Alessandra J Sax
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA.
| | - Ethan J Halpern
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
| | - Adam C Zoga
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
| | - Johannes B Roedl
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
| | - Jeffrey A Belair
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
| | - William B Morrison
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
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20
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Abstract
OBJECTIVE. The purpose of this article is to provide a step-by-step guide for bone imaging-guided percutaneous core needle biopsy, including the armamentarium available and the most recent advances. CONCLUSION. Bone imaging-guided percutaneous core needle biopsies are well-established, minimally invasive, cost-effective interventions for histologic characterization of bone lesions with an excellent safety profile and diagnostic outcomes; they play a crucial role in management of patients. Radiologists involved in the care of patients with bone lesions must be familiar with the various steps involved in such procedures and their role in patient management.
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21
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Govaert GAM, Kuehl R, Atkins BL, Trampuz A, Morgenstern M, Obremskey WT, Verhofstad MHJ, McNally MA, Metsemakers WJ. Diagnosing Fracture-Related Infection: Current Concepts and Recommendations. J Orthop Trauma 2020; 34:8-17. [PMID: 31855973 PMCID: PMC6903359 DOI: 10.1097/bot.0000000000001614] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 02/02/2023]
Abstract
Fracture-related infection (FRI) is a severe complication after bone injury and can pose a serious diagnostic challenge. Overall, there is a limited amount of scientific evidence regarding diagnostic criteria for FRI. For this reason, the AO Foundation and the European Bone and Joint Infection Society proposed a consensus definition for FRI to standardize the diagnostic criteria and improve the quality of patient care and applicability of future studies regarding this condition. The aim of this article was to summarize the available evidence and provide recommendations for the diagnosis of FRI. For this purpose, the FRI consensus definition will be discussed together with a proposal for an update based on the available evidence relating to the diagnostic value of clinical parameters, serum inflammatory markers, imaging modalities, tissue and sonication fluid sampling, molecular biology techniques, and histopathological examination. Second, recommendations on microbiology specimen sampling and laboratory operating procedures relevant to FRI will be provided. LEVEL OF EVIDENCE:: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Geertje A. M. Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Richard Kuehl
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Bridget L. Atkins
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland
| | - William T. Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Michael H. J. Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; and
| | - Martin A. McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
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