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Loro A, Fulvio F, Alt V. Treatment of bone infections in children in low-income countries - A practical guideline based on clinical cases. Injury 2023; 54:111066. [PMID: 37856924 DOI: 10.1016/j.injury.2023.111066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 09/24/2023] [Indexed: 10/21/2023]
Abstract
In low-income countries (LIC), the management of bone infections is a huge challenge. A high number of patients are in the pediatric age group. Children and adolescents exhibit good bone healing potential offering treatment options that mainly rely on the biological response of the infected bone. The purpose of this article is to highlight treatment options for these patients in LIC, which is based on clinical cases that illustrate the principles of the treatment, focusing on bone reaction and healing potential. First, identification of emergency cases is of importance. Sepsis of the patient due to bone infections is a life-threatening disease that requires immediate surgical attention with abscess incision. It should be tailored to the surgeon's experience and local conditions to avoid unwanted complications, such as excessive bleeding, fracture or bone loss. In non-septic patients, uncomplicated cases should be distinguished from complicated cases as the first might often require only abscess incision, particularly in small children, without any other major surgical intervention. Biomechanical stability and bone formation capacity, soft tissue conditions and joint involvement are decisive factors differentiating uncomplicated from complicated cases. Central treatment column is the immobilization of the infected bone with simple methods, such as plaster of Paris, braces or external fixation. This is intended to provide sufficient stability to allow for new bone formation that subsequently downsizes the infection site and that can bridge previously infected non-union sites or bone defects. In most cases, antibiotic treatment is not performed as antibiotics are not available or affordable. Severe soft tissue defects remain a major challenge as microvascular surgical experience is often required for reliable coverage, for which referral to one of the very few specialized centers is recommended. Major bone defects should also be treated in centers with sufficient expertise for bone reconstruction procedures. Regular follow-ups are important to ensure healing and to avoid aggravation of the disease. Encouraging success rates can be achieved by these treatment principles. However, it should not be forgotten that poverty in these countries, including limited access to health care, remains one of the world's most important problems.
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Affiliation(s)
- Antonio Loro
- Orthopedic Department, CoRSU Rehabilitation Hospital, Kisubi, Uganda
| | | | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.
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Abbas A, Laverde R, Yap A, Stephens CQ, Samad L, Seyi-Olajide JO, Ameh EA, Ozgediz D, Lakhoo K, Bickler SW, Meara JG, Bundy D, Jamison DT, Klazura G, Sykes A, Philipo GS. Routine Pediatric Surgical Emergencies: Incidence, Morbidity, and Mortality During the 1st 8000 Days of Life-A Narrative Review. World J Surg 2023; 47:3419-3428. [PMID: 37341797 PMCID: PMC10694096 DOI: 10.1007/s00268-023-07097-z] [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] [Accepted: 05/31/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Many potentially treatable non-congenital and non-traumatic surgical conditions can occur during the first 8000 days of life and an estimated 85% of children in low- and middle-income countries (LMICs) will develop one before 15 years old. This review summarizes the common routine surgical emergencies in children from LMICs and their effects on morbidity and mortality. METHODS A narrative review was undertaken to assess the epidemiology, treatment, and outcomes of common surgical emergencies that present within the first 8000 days (or 21.9 years) of life in LMICs. Available data on pediatric surgical emergency care in LMICs were aggregated. RESULTS Outside of trauma, acute appendicitis, ileal perforation secondary to typhoid fever, and intestinal obstruction from intussusception and hernias continue to be the most common abdominal emergencies among children in LMICs. Musculoskeletal infections also contribute significantly to the surgical burden in children. These "neglected" conditions disproportionally affect children in LMICs and are due to delays in seeking care leading to late presentation and preventable complications. Pediatric surgical emergencies also necessitate heavy resource utilization in LMICs, where healthcare systems are already under strain. CONCLUSIONS Delays in care and resource limitations in LMIC healthcare systems are key contributors to the complicated and emergent presentation of pediatric surgical disease. Timely access to surgery can not only prevent long-term impairments but also preserve the impact of public health interventions and decrease costs in the overall healthcare system.
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Affiliation(s)
- Alizeh Abbas
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ruth Laverde
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Ava Yap
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - Caroline Q Stephens
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Lubna Samad
- Global Surgery Programs, Interactive Research & Development, Karachi, Pakistan
| | | | - Emmanuel A Ameh
- Division of Pediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
| | - Doruk Ozgediz
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Kokila Lakhoo
- Department of Pediatric Surgery, University of Oxford and Oxford University Hospitals, Oxford, UK
| | - Stephen W Bickler
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego School of Medicine, 9500 Gilman Drive #0739, La Jolla, San Diego, CA, 92093-0739, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Donald Bundy
- Global Research Consortium for School Health and Nutrition, London School of Hygiene and Tropical Medicine, London, UK
| | - Dean T Jamison
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Greg Klazura
- Loyola University Medical Center, Chicago, IL, USA
| | - Alicia Sykes
- Naval Medical Center San Diego, San Diego, CA, USA
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Moorthy GS, Boutzoukas AE, Benjamin DK, Polgreen PM, Beekmann SE, Bradley JS, Dehority W. Defining Variability in Evaluation and Management of Children with Chronic Osteomyelitis. J Pediatric Infect Dis Soc 2023; 12:226-229. [PMID: 36688512 PMCID: PMC10146934 DOI: 10.1093/jpids/piad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/20/2023] [Indexed: 01/24/2023]
Abstract
Pediatric chronic osteomyelitis is a rare, debilitating condition lacking management guidelines. In a national survey of 162 pediatric infectious disease physicians through the Emerging Infections Network, tremendous variability in diagnostic approaches and management was noted, highlighting a need for a prospective study to better define the spectrum of pathogens and disease.
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Affiliation(s)
- Ganga S Moorthy
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Angelique E Boutzoukas
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Philip M Polgreen
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Susan E Beekmann
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - John S Bradley
- Department of Pediatrics, Division of Infectious Diseases, University of California at San Diego, La Jolla, California, USA and Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Walter Dehority
- Department of Pediatrics, Division of Infectious Diseases, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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Subramanyam KN, Mundargi AV, Prabhu MV, Gopakumar KU, Gowda DSA, Reddy DR. Surgical management of chronic osteomyelitis: Organisms, recurrence and treatment outcome. Chin J Traumatol 2023:S1008-1275(23)00003-2. [PMID: 36828768 PMCID: PMC10388580 DOI: 10.1016/j.cjtee.2023.01.003] [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: 07/12/2022] [Revised: 12/20/2022] [Accepted: 01/25/2023] [Indexed: 02/01/2023] Open
Abstract
PURPOSE The study aimed to identify the risk factors of recurrence in chronic osteomyelitis (COM) and to document the microbiological patterns pre- and intra-operatively and at recurrence, if any. METHODS We performed retrospective review on COM patients treated with surgical debridement and a six-week course of antibiotics. The patients with symptoms of osteomyelitis for at least six weeks, present or past episodes of discharging sinus, documentation of bone sequestration in operative notes or preoperative images were included in the study. Patients with symptoms of osteomyelitis < 6 weeks, lack of history of discharging sinus or lack of evidence of sequestration in preoperative images or intraoperative notes were excluded. Logistic regression models were used to assess the impact of risk factors of recurrence. Cohen-Kappa scores were derived to see the concordance between pre-operative and intra-operative isolates and at recurrence. RESULTS Totally, 147 COM patients (115 males and 32 females, mean age (33 ± 19) years) were included in this study. Recurrence was noted in 28 patients (19.0%). Polymicrobial growth and extended spectrum beta-lactamase producing Enterobacteriaceae increased the chance of recurrence. Cierny-Mader stage-1, hematogenous aetiology and negative intraoperative culture reduced the chance of recurrence. Concordance between pre-operative and intra-operative cultures was 59.85% (Kappa score 0.526, p < 0.001) and between index surgery and at recurrence was 23.81% (Kappa score 0.155, p < 0.001). Lack of knowledge of causative organism preoperatively did not affect outcome. At mean follow-up (42 ± 15) months, all patients were apparently infection free for at least one year. CONCLUSION Polymicrobial growth and multi-drug resistant organisms increase the risk of recurrence in COM. Patients' age, gender, diabetes mellitus, previous failed treatment, duration of symptoms, haemoglobin, white cell count, C-reactive protein and erythrocyte sedimentation rate at presentation did not have any impact on the recurrence of infection. Preoperative isolation of organism is of questionable value. Recurrences of infections do occur and are more of re-infections than relapses. Diligent isolation of organism must be attempted even in re-debridements. Even patients with recurrences do well with appropriate debridement and antibiotic therapy.
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Affiliation(s)
- Koushik Narayan Subramanyam
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India.
| | - Abhishek Vasant Mundargi
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India
| | - Milind Vittal Prabhu
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India
| | - K U Gopakumar
- School of Liberal Arts, Indian Institute of Technology, Jodhpur, Rajasthan, 342001, India
| | - D S Ankush Gowda
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India
| | - Devagiri Raviteja Reddy
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India
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Shi J, Yang X, Song M, Zhang X, Xu Y. Clinical effects of early debridement, internal fixation, and Masquelet technique for childhood chronic haematogenous osteomyelitis of long bones. J Orthop Surg Res 2023; 18:11. [PMID: 36604689 PMCID: PMC9814301 DOI: 10.1186/s13018-022-03478-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/25/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Childhood chronic haematogenous osteomyelitis (CCHOM) is a severe condition in paediatric patients. The optimal timing of debridement and the subsequent method of bone reconstruction in CCHOM patients remain controversial. The purpose of this study was to assess the treatment efficacy of Masquelet technique with early debridement and internal fixation in CCHOM of long bones. METHODS Between January 2016 and January 2021, a total of 21 patients (18 males, 3 females) with CCHOM of long bone were included. The mean age was 10.4 years (range, 2-18 years). All cases were treated by a two-stage surgical protocol of Masquelet technique. In the first stage, aggressive debridement, sequestrectomy, and inducing membrane by bone cement spacer were performed after definite diagnosis. In the second stage, cement spacer was removed, and autologous and allogeneic bone was grafted. Internal fixation was used for the first and/or second stage depending on stability requirements. The patients' clinical and imaging results were retrospectively analysed. RESULTS The mean follow-up was 31.7 months (range, 21-61 months). None of the patients experienced recurrence of infection. Radiographic bone union time was 4.3 months (range, 2.5-11 months). Five cases underwent re-operation due to complications such as bone resorption or refracture. By the last follow-up visit, bones had healed and all of the patients had resumed daily living and sports activities. CONCLUSION The Masquelet technique with early debridement and internal fixation is a viable surgical method for the management of large long bone defects of CCHOM patients.
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Affiliation(s)
- Jian Shi
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032 China
| | - Xiaoyong Yang
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032 China
| | - Muguo Song
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032 China
| | - Xijiao Zhang
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032 China
| | - Yongqing Xu
- Department of Orthopaedics, 920 Hospital of the Joint Logistics Support Force of the PLA, 212 Daguan Road, Kunming, 650032 China
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Mulualem B, Belay G, Bogale EK. Magnitude of chronic osteomyelitis and its associated factors in children as diagnosed on X-ray visiting at Felege Hiwot Comprehensive Specialized Hospital, Northwest Ethiopia: A cross-sectional study. SAGE Open Med 2023; 11:20503121231161191. [PMID: 36949827 PMCID: PMC10026118 DOI: 10.1177/20503121231161191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/15/2023] [Indexed: 03/19/2023] Open
Abstract
Objectives To assess the magnitude of chronic osteomyelitis and its associated factors in children at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Ethiopia, in 2022. Methods A hospital-based cross-sectional study was done between April 15, 2022 and August 15, 2022, in children with an age of 18 years or below, who visited Felege Hiwot Comprehensive Specialized Hospital. A total sample size of 168 participants was involved in the study. The random sampling technique was applied to select the study participants. The data were collected from the patients, their charts, and X-ray requests. The data were cleaned, stored, checked for completeness, and entered into EpiData Version 3.1, which were then exported to SPSS Version 23 for analysis. Descriptive analysis was done, and bivariable and multivariable logistic regression were used for analysis. Results The prevalence of chronic osteomyelitis was found to be 86.3%. The tibia and femur were the most commonly involved bones, and metaphyseal involvement was very common. The most common radiological findings were sequestrum (56%) and involucrum (53%). Of the total patients with radiological evidence of chronic osteomyelitis, 16.6% had complications, the most common of which was a pathologic fracture (12.4%). Being male (adjusted odds ratio = 6.162, 95% confidence interval: 1.12-34.147), being over 10 years old (adjusted odds ratio = 4.048, 95% confidence interval: 1.032-15.886), living in a rural area (adjusted odds ratio = 4.046, 95% confidence interval: 1.236-13.364), having a discharging sinus (adjusted odds ratio = 5.237, 95% confidence interval: 1.393-19.693), having a clinical complaint lasting more than 1 year (adjusted odds ratio = 5.189, 95% confidence interval: 1.247-21.588), and a preceding event of trauma (adjusted odds ratio = =10.363, 95% confidence interval: 1.101-97.509) were the factors associated with chronic osteomyelitis. Conclusion The prevalence of chronic osteomyelitis is high. In this study, being male, being in the age group above 10 years, having rural residency, having a discharging sinus, having a clinical complaint duration of more than 1 year, and having a preceding event of trauma were the factors associated with chronic osteomyelitis. Therefore, healthcare providers should have a high index of suspicion of chronic osteomyelitis in older male children from rural areas with a chronic discharging sinus following trauma.
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Affiliation(s)
- Biruk Mulualem
- School of Medicine and Health Sciences,
Department of Dermatovenereology, Bahir Dar University, Bahir Dar, Amhara,
Ethiopia
| | - Genetu Belay
- School of Medicine and Health Sciences,
Department of Dermatovenereology, Bahir Dar University, Bahir Dar, Amhara,
Ethiopia
| | - Eyob Ketema Bogale
- Health Promotion and Behavioral
Sciences Department, Bahir Dar University, Bahir Dar, Amhara, Ethiopia
- Eyob Ketema Bogale, Health Promotion and
Behavioral Sciences Department, Bahir Dar University, Bahir Dar, Amhara,
Ethiopia.
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Lazzeri S, Montagnani C, Zanardi A, Beltrami G, Galli L. Bioactive glass in the treatment of chronic osteomyelitis in children: Description of four consecutive cases and literature review. Injury 2022; 53:3317-3321. [PMID: 35817607 DOI: 10.1016/j.injury.2022.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/20/2022] [Accepted: 07/02/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Chronic osteomyelitis in children is a rare condition. Debridement surgery, along with appropriate antibiotic therapy, is widely agreed to represent the best procedure in the treatment of chronic osteomyelitis but can result in an extensive dead space formation. In this study, we evaluated the use of bioactive glass to address dead space management. METHODS Four consecutive cases of chronic osteomyelitis treated with antibiotic therapy, one stage- surgical debridement and bioglass implantation between September 2016 and February 2017 were prospectively followed for a minimum of three years. Two cases followed acute hematogenous osteomyelitis, two cases followed fracture fixation. Clinical, histology, laboratory and radiographic findings were recorded. Primary endpoint was eradication of infection. Possible complication related to bioglass application were investigated. RESULTS All patients achieved healing at the latest follow-up of minimum three years. No successive surgical treatments were required at any time. No complications related to the bioglass were detected. Radiographic reconstruction of normal anatomy progressed through the years. CONCLUSIONS Bioglass for the treatment of dead space after surgical debridement appears a viable option in the treatment of chronic osteomyelitis in children.
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Affiliation(s)
- Simone Lazzeri
- Department of Orthopaedics and Traumatology, Meyer Children's Hospital, Viale Pieraccini, 24, Firenze, Italy.
| | | | - Alessandro Zanardi
- Department of Orthopaedics and Traumatology, Meyer Children's Hospital, Viale Pieraccini, 24, Firenze, Italy
| | - Giovanni Beltrami
- Department of Orthopaedics and Traumatology, Meyer Children's Hospital, Viale Pieraccini, 24, Firenze, Italy
| | - Luisa Galli
- Infectious Disease Unit, Meyer Children's Hospital, Firenze, Italy
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Meroni G, Tsikopoulos A, Tsikopoulos K, Allemanno F, Martino PA, Soares Filipe JF. A Journey into Animal Models of Human Osteomyelitis: A Review. Microorganisms 2022; 10:1135. [PMID: 35744653 PMCID: PMC9228829 DOI: 10.3390/microorganisms10061135] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 12/24/2022] Open
Abstract
Osteomyelitis is an infection of the bone characterized by progressive inflammatory destruction and apposition of new bone that can spread via the hematogenous route (hematogenous osteomyelitis (HO)), contiguous spread (contiguous osteomyelitis (CO)), and direct inoculation (osteomyelitis associated with peripheral vascular insufficiency (PVI)). Given the significant financial burden posed by osteomyelitis patient management, the development of new preventive and treatment methods is warranted. To achieve this objective, implementing animal models (AMs) of infection such as rats, mice, rabbits, avians, dogs, sheep, goats, and pigs might be of the essence. This review provides a literature analysis of the AMs developed and used to study osteomyelitis. Historical relevance and clinical applicability were taken into account to choose the best AMs, and some study methods are briefly described. Furthermore, the most significant strengths and limitations of each species as AM are discussed, as no single model incorporates all features of osteomyelitis. HO's clinical manifestation results in extreme variability between patients due to multiple variables (e.g., age, sex, route of infection, anatomical location, and concomitant diseases) that could alter clinical studies. However, these variables can be controlled and tested through different animal models.
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Affiliation(s)
- Gabriele Meroni
- One Health Unit, Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Via Pascal 36, 20133 Milan, Italy; (F.A.); (P.A.M.)
| | - Alexios Tsikopoulos
- Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | | | - Francesca Allemanno
- One Health Unit, Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Via Pascal 36, 20133 Milan, Italy; (F.A.); (P.A.M.)
| | - Piera Anna Martino
- One Health Unit, Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Via Pascal 36, 20133 Milan, Italy; (F.A.); (P.A.M.)
| | - Joel Fernando Soares Filipe
- Department of Veterinary Medicine and Animal Sciences, University of Milan, Via dell’Università 6, 26900 Lodi, Italy;
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McNeil JC, Joseph M, Sommer LM, Vallejo JG. The Contemporary Epidemiology, Microbiology and Management of Chronic Osteomyelitis in US Children. Pediatr Infect Dis J 2021; 40:518-524. [PMID: 33902075 DOI: 10.1097/inf.0000000000003067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While the majority of pediatric osteomyelitis cases are acute in nature, a significant subset present with prolonged symptoms often associated with substantial morbidity. Little data exist to guide clinicians in the management of these infections. We sought to describe the epidemiology, clinical features and management of chronic osteomyelitis (CO) in children. METHODS We reviewed hospital admissions for CO from 2011 to 2018 at Texas Children's Hospital. Cases were included if symptoms lasted ≥28 days on presentation. Cases were classified as those associated with: (1) a contiguous focus of infection; (2) penetrating trauma; (3) orthopedic hardware; (4) postacute CO (PACO, those occurring after ≥28 days of therapy for acute osteomyelitis); and (5) primary hematogenous CO. RESULTS One hundred fourteen cases met inclusion criteria. The median patient age was 11.8 years and 35.9% had comorbidities. 70.2% of patients underwent ≥1 surgical procedure. A microbiologic etiology was identified in 72.8% of cases and Staphylococcus aureus was most common (39.4%). Contiguous focus of infection was more often associated with polymicrobial disease with or without Pseudomonas. Postacute CO was caused by S. aureus in 95%. The median duration of total therapy was 210 days. 26.3% of patients experienced treatment failure of which 46% underwent repeat hospital admission/surgery. There was no association between duration of intravenous therapy for CO and treatment failure. CONCLUSIONS Children with CO represent a diverse group both in terms of pathogenesis and microbiology. Pathogenesis and clinical presentation can provide clues to microbiologic etiology. Prolonged intravenous therapy does not appear to improve outcomes in CO.
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Affiliation(s)
- J Chase McNeil
- From the Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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10
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Treatment of Chronic Hematogenous Osteomyelitis in Children With Antibiotic Impregnated Calcium Sulphate. J Pediatr Orthop 2021; 41:127-131. [PMID: 33284138 DOI: 10.1097/bpo.0000000000001723] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical and radiologic outcome of chronic hematogenous osteomyelitis (CHOM) in children, treated with single-stage debridement and dead space management using antibiotic impregnated calcium sulphate pellets. METHODS The authors retrospectively evaluated a consecutive series of 34 patients who presented with CHOM from 2011 to 2017. In each case, CHOM was classified according to the Beit CURE classification. Following thorough surgical debridement, the resulting dead space in the bone was filled with the antibiotic impregnated beads before primary closure. RESULTS Of the 31 patients available for follow up, effective regeneration of bone was confirmed in all cases, with radiographic bone healing typically observed at around 12 weeks. None of the children required reoperation for infection and none had recurrence of infection at the time of final review. The beads were completely absorbed within 3 months. No systemic adverse reactions to the local delivery of antibiotics were observed in this study. CONCLUSIONS The authors found that single-stage debridement in conjunction with antibiotic impregnated calcium sulphate was an effective means of treating CHOM in children, with effective eradication of infection in every case. LEVEL OF EVIDENCE Level IV-Retrospective case series. See instructions for authors for a complete description of levels of evidence.
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Gornitzky AL, Kim AE, O’Donnell JM, Swarup I. Diagnosis and Management of Osteomyelitis in Children. JBJS Rev 2020; 8:e1900202. [DOI: 10.2106/jbjs.rvw.19.00202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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12
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Abstract
Background: Pyogenic osteomyelitis is an important child health problem in developing countries. It is a one-disease state with a spectrum of pathological features and clinical forms ranging from acute to chronic presentation. Its pattern of presentation varies from and within subregions. The aim of this study was to determine the pattern and outcome of childhood pyogenic osteomyelitis in a low-resource environment. Materials and Methods: This was a retrospective study of all the children aged 18 years and under seen with pyogenic osteomyelitis in Federal Teaching Hospital Abakaliki between January 2005 and December 2015. Results: In 76 patients, there was pyogenic osteomyelitis involving 85 bones. Female-to-male ratio was 1:1.7, and the mean age was 9.9 ± 5.1 years. The clinical forms of presentation were acute in 16 (21.1%), subacute in 10 (13.2%), and chronic in 50 (65.8%) patients. Acute osteomyelitis was the more likely form of presentation among infants (P < 0.001) and urban children (P < 0.011) whereas subacute and chronic osteomyelitis were more likely among the older children (P < 0.001) and rural residents (P < 0.011). Staphylococcus aureus was the most common isolated pathogen. Anemia, septic arthritis, and pathological fractures were the three top complications observed. Fifty patients (65.8%) recovered and adjudged cured, 9 (11.8%) were lost to follow-up, and 17 (22.4%) were unable to afford the financial cost of the treatment. Conclusion: In our environment, chronic pyogenic osteomyelitis sequel to acute hematogenous bone infection in childhood is common. Poverty is also a limiting factor in its definitive treatment. These calls for a policy response aimed at improved care and preventive strategies based on the observed pattern.
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Affiliation(s)
- Njoku Isaac Omoke
- Department of Surgery, Ebonyi State University/Federal Teaching Hospital, Abakaliki, Nigeria
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13
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Geurts J, Hohnen A, Vranken T, Moh P. Treatment strategies for chronic osteomyelitis in low- and middle-income countries: systematic review. Trop Med Int Health 2017; 22:1054-1062. [PMID: 28665557 DOI: 10.1111/tmi.12921] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To identify a standard treatment regime or highly successful procedure for chronic osteomyelitis in low- and middle-income countries. METHODS Systematic review following PRISMA guidelines. RESULTS The initial search resulted in 102 studies of which nine met the inclusion criteria and were analysed qualitatively. The included studies involved 1173 patients from Africa and Asia. All patients were diagnosed with chronic osteomyelitis. Surgical and antibiotic treatment regimens differed substantially. No better judgement than moderate risk of selection bias could be made due to the study designs. CONCLUSIONS The evidence is not sufficiently robust to identify the most effective treatment, or to even allow a recommendation of the best suitable treatment of chronic osteomyelitis in low-income countries.
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Affiliation(s)
- J Geurts
- Department of Orthopaedic Surgery, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - A Hohnen
- Department of Orthopaedic Surgery, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - T Vranken
- Department of Orthopaedic Surgery, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - P Moh
- St.John of God Hospital, Duayaw Nkwanta, Ghana
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Cruickshank JA, Graham SM, Harrison WJ. Immediate bone transport: a novel technique for the management of bone defects after chronic osteomyelitis in children. Trop Doct 2017; 48:64-66. [PMID: 28678002 DOI: 10.1177/0049475517717361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Simon Matthew Graham
- 2 Specialist Registrar in Orthopaedics and Trauma, Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, UK
| | - William J Harrison
- 3 Consultant Orthopaedic Surgeon, The Countess of Chester Hospital, Chester, Cheshire, UK.,4 Beit CURE International Hospital, Blantyre, Malawi
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15
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Zimmerli W, Sendi P. Orthopaedic biofilm infections. APMIS 2017; 125:353-364. [PMID: 28407423 DOI: 10.1111/apm.12687] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 01/10/2017] [Indexed: 02/01/2023]
Abstract
Many infections of the musculoskeletal system are biofilm infections that develop on non-living surfaces. Microorganisms adhere either on dead bone (sequesters) or implants. As a rule for a curative concept, chronic osteomyelitis or implant-associated bone infection must be treated with a combination of surgery and antimicrobial therapy. If an implant is kept in place, or a new device is implanted before complete healing of infection, a biofilm-active antibiotic should be used. Rifamycins are active against biofilms of staphylococci, and fluoroquinolones against those of Gram-negative bacilli. In this review, the management of chronic osteomyelitis, periprosthetic joint infection and implant-associated osteomyelitis of long bones is presented.
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Affiliation(s)
- Werner Zimmerli
- Kantonsspital Baselland, Basel University Medical Clinic and Interdisciplinary Unit for Orthopaedic Infections, Liestal, Switzerland
| | - Parham Sendi
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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16
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Abstract
BACKGROUND Osteomyelitis shows a strong predilection for the tibia in the pediatric population and is a significant source of complications. The purpose of this article is to retrospectively review a large series of pediatric patients with tibial osteomyelitis. We compare our experience with that in the literature to determine any factors that may aid diagnosis and/or improve treatment outcomes. METHODS A 10-year retrospective review was performed of clinical records of all cases of pediatric tibial osteomyelitis managed at the 2 children's orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007, at Starship Children's Hospital, and 1998 and 2008 at Middlemore's Kids First Hospital. RESULTS One hundred ninety-one patients fulfilled the inclusion criteria, and had a review of clinical notes and relevant investigations. The average duration of symptoms before presentation to hospital was 5.7 days. Less than 40% of patients had a recent episode of trauma. Almost 60% of patients could not bear weight on admission. Over 40% of patients had a temperature above 38°C. Erythrocyte sedimentation rate was elevated in 78% and the C-reactive protein was elevated in 90% of patients. In total, 42% of blood cultures and almost 75% of tissue cultures were positive, with Staphylococcus aureus being the most commonly cultured organism. X-rays, bone scans, and magnetic resonance imaging were all used to aid the diagnosis. About 43% of patients had surgery. Treatment length was an average of 2 weeks 6 days of intravenous antibiotics followed by 3 weeks 2 days of oral treatment. Six postsurgical complications and 46 readmissions were noted: 25 for relapse, with the remainder due to social and antibiotic-associated complications. CONCLUSIONS Although generally diagnosed on presentation, pediatric tibial osteomyelitis can require more sophisticated investigations and prolonged management. Treatment with intravenous and oral antibiotics and surgical debridement where indicated can lead to a good clinical outcome, although complications are often noted. LEVEL OF EVIDENCE Level IV-Prognostic study.
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Affiliation(s)
- Brad Stone
- *Department of Orthopaedics, Auckland City Hospital, Grafton†Department of Orthopaedics, Middlemore Kids First Hospital, Papatoetoe‡Department of Orthopaedics, Starship Childrens' Hospital, Grafton, Auckland, New Zealand
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17
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Stevenson AJ, Jones HW, Chokotho LC, Beckles VLL, Harrison WJ. The Beit CURE Classification of Childhood Chronic Haematogenous Osteomyelitis--a guide to treatment. J Orthop Surg Res 2015; 10:144. [PMID: 26384208 PMCID: PMC4573297 DOI: 10.1186/s13018-015-0282-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/27/2015] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Andrew J Stevenson
- FRCS (T&O), North Bristol NHS Trust, 8 Mervyn Road, Bristol, BS7 9EL, UK.
| | - Henry Wynn Jones
- FRCS (T&O), Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, UK.
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Jyoti A, Singh S, Mukhopadhyay B, Gavel R, Mishra SP. Free radicals and antioxidant status in chronic osteomyelitis patients: a case control study. J Clin Diagn Res 2015; 9:BC08-10. [PMID: 26046017 PMCID: PMC4437059 DOI: 10.7860/jcdr/2015/11950.5781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/24/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Osteomyelitis (OM) is a local or generalized infection of the bone and bone marrow which may be multifactorial in its causation. Chronic infection is characterised by sequestrum and involucrum formation. AIM The present study has been carried out for assessing the oxidative stress in chronic OM by measurement of serum oxidants {such as malondialdehyde (MDA), protein carbonyl (PC), nitrite} and the serum antioxidants {such as ascorbic acid, superoxide dismutase (SOD), ceruloplasmin (Cp), blood glutathione} by spectrophotometric method. MATERIALS AND METHODS This was a case control study. About 5 ml of venous blood was collected for the estimation of biochemical parameters. This study comprised of 50 OM patients diagnosed at SSLH Hospital, Varanasi and 50 healthy ages (15-35 y) and sex matched individuals. RESULTS Significantly increased (p<0.0001) levels of serum oxidants and significantly decreased (p<0.0001) levels of all serum antioxidants except ceruloplasmin indicated significantly increased (p<0.0001) levels in response to infections in chronic OM patients as compared to the healthy controls. CONCLUSION These results suggest that there occurs an imbalance between oxidants and antioxidants, especially an increase in oxidative stress, as measured by the levels of the parameters: serum MDA, serum protein carbonyl and serum nitrite.
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Affiliation(s)
- Abha Jyoti
- Assistant Professor, Department of Biochemistry, Banaras Hindu University Varanasi, Uttar Pradesh, India
| | - Saurababh Singh
- Associate Professor, Department of Orthopaedics, Banaras Hindu University Varanasi, Uttar Pradesh, India
| | - Bedabrata Mukhopadhyay
- Resident, Department of Biochemistry, Banaras Hindu University Varanasi, Uttar Pradesh, India
| | - Roshni Gavel
- Resident, Department of Biochemistry, Banaras Hindu University Varanasi, Uttar Pradesh, India
| | - Surendra Pratap Mishra
- Assistant Professor, Department of Biochemistry, Banaras Hindu University Varanasi, Uttar Pradesh, India
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Baldan M, Gosselin RA, Osman Z, Barrand KG. Chronic osteomyelitis management in austere environments: the International Committee of the Red Cross experience. Trop Med Int Health 2014; 19:832-7. [DOI: 10.1111/tmi.12311] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Marco Baldan
- International Committee of the Red Cross; Geneva Switzerland
| | - Richard A. Gosselin
- International Committee of the Red Cross; Geneva Switzerland
- Institute for Global Orthopaedics and Traumatology; University of California; San Francisco CA USA
| | - Zaher Osman
- International Committee of the Red Cross; Geneva Switzerland
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20
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Pääkkönen M, Peltola H. Simplifying the treatment of acute bacterial bone and joint infections in children. Expert Rev Anti Infect Ther 2014; 9:1125-31. [DOI: 10.1586/eri.11.140] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Rousseau M, Anderson DE, Niehaus AJ, Miesner MD, Nichols S. Osseous sequestration in alpacas and llamas: 36 cases (1999–2010). J Am Vet Med Assoc 2013; 243:430-6. [DOI: 10.2460/javma.243.3.430] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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22
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Nthumba P, George S, Jami M, Nyoro P. Reconstruction of the distal humerus and elbow joint using a pedicled scapular flap: case report. J Hand Surg Am 2013; 38:1150-4. [PMID: 23707015 DOI: 10.1016/j.jhsa.2013.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 03/08/2013] [Accepted: 03/08/2013] [Indexed: 02/02/2023]
Abstract
Loss of elbow function resulting from major bone loss negatively affects quality of life and leaves limited options for reconstruction and restoration of function. To overcome this disabling problem, we reconstructed the distal humerus of a child in a single stage using a scapular flap based on the angular branch of the thoracodorsal artery as a pedicled flap. We also reconstructed the proximal ulna using an iliac crest bone graft with dermal graft interposition arthroplasty, which enabled the restoration of useful elbow function.
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Affiliation(s)
- Peter Nthumba
- Plastic, Reconstructive, and Hand Surgery Unit, AIC Kijabe Hospital, Kijabe, Kenya.
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Sequestrectomy in primary osteomyelitis of the humerus: a new indication for posterior approach. Tech Hand Up Extrem Surg 2012; 16:247-9. [PMID: 23160561 DOI: 10.1097/bth.0b013e318270a450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Surgical treatment for primary osteomyelitis of the humerus is not well standardized; guidelines come from the scientific literature on osteomyelitis of the femur and tibia. Commonly deltopectoral approach is used for the proximal humerus and posterior approach for the distal humerus. Sequestrectomy alone or the use of antibiotic cement (bead pouch technique) is advised in case of chronic osteomyelitis. Berger and Buckwalter described a posterior approach to the proximal part of the humerus for an excisional biopsy of an osteoid-osteoma. We found that this approach is also useful for sequestrectomy in primary osteomyelitis of the humerus. We describe the technique and make a review of the literature.
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25
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Pääkkönen M, Kallio MJT, Kallio PE, Peltola H. Shortened hospital stay for childhood bone and joint infections: Analysis of 265 prospectively collected culture-positive cases in 1983–2005. ACTA ACUST UNITED AC 2012; 44:683-8. [DOI: 10.3109/00365548.2012.673729] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jones HW, Beckles VLL, Akinola B, Stevenson AJ, Harrison WJ. Chronic haematogenous osteomyelitis in children: an unsolved problem. ACTA ACUST UNITED AC 2011; 93:1005-10. [PMID: 21768620 DOI: 10.1302/0301-620x.93b8.25951] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
From a global point of view, chronic haematogenous osteomyelitis in children remains a major cause of musculoskeletal morbidity. We have reviewed the literature with the aim of estimating the scale of the problem and summarising the existing research, including that from our institution. We have highlighted areas where well-conducted research might improve our understanding of this condition and its treatment.
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Affiliation(s)
- H Wynn Jones
- Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, WN6 9EP, UK.
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Abstract
The imaging approach to osteomyelitis has evolved in the past two decades. Advances in MRI allow for whole body imaging, decreasing the need for scintigraphy when symptoms are not localized or the disease may be multifocal. There is an increasing clinical need for depiction of abscesses in the soft tissues and subperiosteal space, particularly because methicillin-resistant Staphylococcus aureus infections constitute more than one-third of all the infections. The increasing emphasis on radiation dose reduction has also led away from scintigraphy and computed tomography. MR imaging has become the advanced imaging modality of choice in osteomyelitis. There is an increasing understanding of the appropriate role for gadolinium enhancement, which is not indicated when the pre-gadolinium images are normal. Other related infections, including pyomyositis, are best imaged with MRI.
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