One hundred years of orthopedics in the Netherlands. IX. The treatment of chronic osteomyelitis

Chronic osteomyelitis is characterized by cicatrization of the focus of infection with deteriorating vascularization, which makes the disease increasingly difficult to treat. The treatment in chronic osteomyelitis consists primarily in surgical debridement of the scarified focus of infection; stabilization with external fixation allows better treatment. Following debridement, local antibiotic treatment is possible with gentamicin containing cement beads, if necessary combined with systemic antibiotic treatment. If the infection heals well, a reconstruction may, if necessary, be carried out: bone defects frequently necessitate bone transplantation, bone segment shifting (Ilizarov method) or free muscle flap grafts. In the future, resistant bacteria will make healing harder. There will be more possibility to use resorbable antibiotic vehicles and bone-replacing biomaterials.     

Osteomyelitis, therapy and prognosis (author's transl)

The application of antibiotics at the treatment of osteomyelitis resulted in a rise of the permanent successful treatment rate. This is especially true for the acute hematogenous osteomyelitis, to a certain extent also for the chronic exogenous one, at which even today the antibiotical therapy is not as important as a surgical intervention. Under consideration of the generally accepted therapeutical principles the special importance of a much individualized treatment adjusted to the clinical picture and disease stage is pointed out. The advantages and disadvantages of an application of antibiotics at the osteomyelitis are mentioned and we try to explain the reasons for occasional therapy failures. A special chapter is devoted to the methods of filling and sterilization of the osteomyelitis bone hollows. Our own experiences with an operative combination process are reported.     

Omentum flap versus pectoralis major flap in the treatment of mediastinitis

The outcome of mediastinal reconstruction during the past 10 years at the "Instituto Nacional de Cardiología Ignacio Chávez" (INCIC), Mexico City was compared. A total of 7136 patients were submitted to open heart surgery. Eighty-two patients (1.15 percent) developed mediastinitis, and 33 patients (0.46 percent) developed sternal osteomyelitis. Only patients who developed mediastinitis with sternal osteomyelitis were included in the study. Reconstruction was performed either with a major omentum flap (12 patients) or a pectoralis major flap (21 patients). The sepsis-related mortality rate was higher in the pectoralis group (28.6 percent) than in the omentum group (0 percent) (p < 0.05). All of the postoperative deaths of the pectoralis group were caused by septic shock; in the omentum group, there were no such deaths. It is concluded that mediastinal reconstruction using the omentum flap in patients with mediastinitis secondary to open heart surgery is associated with fewer septic complications than using the pectoralis major flap.     

Osteomyelitis of the jaws: a 50-year perspective

The incidence of osteomyelitis of the jaws has decreased dramatically, except for a few subsets of individuals. This has been due, in no small part, to the availability of bacteriocidal antimicrobial therapy. The pathogenesis of osteomyelitis of the jaws is predominately due to odontogenic microorganisms rather than the classic skin contaminant, Staphylococcus. This causative relationship relegates the classification of osteomyelitis of the bimaxillary skeleton to predominately that of contiguous foci. These may be regionally progressive, secondary to microvascular compromise brought about by inherent flaws in regional anatomic calcified tissue vascular perfusion as well as by inflammatory metaplastic processes. Diagnosis is based on the presence of painful sequestra and suppurative areas of tooth-bearing jaw bone unresponsive to debridement and conservative therapy. This is usually accompanied by regional or systemic compromise of the immune response, microvascular decompensation, or both. Treatment of both acute and chronic forms of the disease, as outlined in Table 5, is successful if surgically supported. Sustained bacteriocidal antibiotic therapy is pertinent, especially in the face of potentially refractory virulent microorganisms and compromised regional vascular penetrance. The use of adjunctive hyperbaric oxygen therapy also may be included in the more refractory forms of osteomyelitis of the jaws to enhance the local and regional immune response of the jaws as well as to produce microvascular neoangiogenesis for reperfusion support. With resolution of infection, hard and soft tissue reconstruction may be necessary to augment the reparative process.     

Fluorine-18-FDG PET and technetium-99m antigranulocyte antibody scintigraphy in chronic osteomyelitis

The aim of this study was to assess the usefulness of PET with 2-18F-fluoro-2-deoxy-D-glucose (FDG), as compared to immunoscintigraphy (IS) with 99mTc-labeled monoclonal antigranulocyte antibodies (AGAbs), in the detection of chronic osteomyelitis. METHODS: Fifty-one patients suspected of having chronic osteomyelitis in the peripheral (n = 36) or central (n = 15) skeleton were evaluated prospectively with static FDG PET imaging and combined 99mTc-AGAb/99mTc-methylene diphosphonate (MDP) bone scanning within 5 days. FDG PET and IS were evaluated in a blinded and independent manner by visual interpretation, which was graded on a five-point scale of two observers' confident diagnosis of osteomyelitis. Receiver operating characteristic (ROC) curve analysis was performed for both imaging modalities. The final diagnosis was established by means of bacteriologic culture of surgical specimens and histopathologic analysis (n = 31) or by biopsy and clinical follow-up over 2 yr (n = 20). RESULTS: Of 51 patients, 28 had osteomyelitis and 23 did not. According to the unanimous evaluation of both readers, FDG PET correctly identified 27 of the 28 positives and 22 of the 23 negatives (IS identified 15 of 28 positives and 17 of 23 negatives, respectively). The area under the ROC curve was 0.97/0.97 (reader 1/reader 2) for FDG PET and 0.87/0.90 for IS, with a high degree of interobserver concordance (K-values were 0.96 for FDG PET and 0.91 for IS). In the central skeleton, the ROC curve area was 0.98/1.00 for FDG PET and 0.71/0.77 for IS (p<0.05). On the basis of ROC analysis, the overall accuracies of FDG PET and IS in the detection of chronic osteomyelitis were 96%/96% and 82%/ 88%, respectively. With regard to the optimal threshold values, sensitivity and specificity were 100%/97% and 95%/95% with FDG PET, compared to 86%/92% and 77%/82% with IS, respectively. CONCLUSION: In the peripheral skeleton, both FDG PET and combined 99mTc-AGAb/99mTc-MDP scanning are appropriate imaging modalities to diagnose chronic osteomyelitis. FDG PET additionally allows reliable differentiation between osteomyelitis and infection of the surrounding soft tissue. In the central skeleton within active bone marrow, FDG PET is highly accurate and superior to AGAb imaging in the diagnosis of chronic osteomyelitis, which frequently presents as a nonspecific photopenic lesion at scintigraphy with labeled white blood cells.     

BG-1 ovarian cell line: an alternative model for examining estrogen-dependent growth in vitro

Between 1.4.96 and 1.3.97 27 patients with acute infections of bone and soft tissues (n = 13), chronic osteomyelitis (n = 8), and chronic wounds (n = 6) were treated by using Instillation-Vacuum-Sealing. Polyvinylalcohol sponges with drainage tubes were used to cover the internal or external wound surfaces which resulted from surgical debridement. Having hermetically covered the wound with a transparent film dressing a vacuum source generated a partial vacuum in the sponge which was modified according to the type of wound between 20 and 80 kPa. Several times daily, the vacuum line was blocked and, in an alternating fashion, antiseptic or antibiotic solution instilled for 30 minutes. Then, the vacuum was reestablished and the fluids drained from the wound. Seven days later, intermittent drug instillation was stopped and there was either immediate or delayed wound closure by secondary suturing (n = 22), skin grafting (n = 3) or spontaneous epithelialization (n = 2). During a follow-up from the beginning of the instillation treatment of 4.2 (3-14) months there was one recurrency of infection in a patient with chronic osteomyelitis.     

Pseudarthroses of the bones of the extremities of gunshot origin

The causes of formation of false joints of shot origin are given in the present paper. The treatment included internal and transosseous osteosynthesis. In presence of fistula form of the chronic osteomyelitis preliminary necr- and sequestrectomy carried out. The shortening was resected by bone osteotomy and distraction by apparatus combined with false joint compression. The most frequent appeared to be purulent complications and nonremoved extremity deformity. Adhesion was achieved after 151 operation.     

Nonbacterial osteomyelitis of the clavicle

Osteomyelitis can be subdivided into a bacterial exogenic (post-traumatic/postoperative), bacterial endogenic (hematogenous) and an abacterial type, including the rare group containing primary chronic sclerosing osteomyelitis, which is typically localized in the clavicle. In a review of the literature, the criteria for the various types of chronic sclerosing osteomyelitis are analyzed. Out of a group of 17 patients with osteomyelitis of the clavicle treated between 1978 and 1996, three cases of primary chronic sclerosing osteomyelitis are demonstrated. In the differential diagnosis, primary chronic sclerosing osteomyelitis of the clavicle has to be taken into consideration despite its rareness. After establishing a diagnosis by biopsy, in contrast to the other forms, drug therapy will be the treatment of choice and not an operation.     

Management of small infected tibial defects with antibiotic-impregnated autogenic cancellous bone grafting

Between January of 1991 and December of 1993, 36 patients who had tibia fractures complicated by small infected tibia defects were treated at the authors' service. The group included 30 men and 6 women whose average age was 36.5 years (range, 18-72 years). The average follow-up period was 3.7 years. By using the Cierney-Mader staging classification of chronic osteomyelitis, 26 of 36 patients (72%) were stage 4A and 10 of 36 patients (28%) were stage 4B. Ten patients required muscle transfer. All patients were treated with a two-stage protocol. In the first stage, antibiotic-impregnated polymethylmethacrylate bead chains were used to obliterate the debrided osseous defect. In the second stage, the beads were removed, and the defects were reconstructed with antibiotic-impregnated autogenic cancellous bone graft. The time between the first and second stage was 2 to 8 weeks for patients without muscle transfer and 8 to 12 weeks for the patients with muscle transfer. The bone defects ranged from 2 to 4 cm. Wound healing and bony union were achieved in all patients. Only two patients had recurrent infections. The infection arrest rate was 94.4%. Minor pin tract infection of the external skeletal fixation was seen in two patients. Two patients developed skin rashes secondary to antibiotic therapy. Radiographs at an average follow-up of 3.7 years showed good consolidation and hypertrophy of grafted bones in all patients. After 3 to 5 years of follow-up, our results suggest that the use of impregnating antibiotics have no adverse effects on autogenic cancellous bone graft incorporation and may help to eliminate infection. This treatment protocol provided rapid recovery from osteomyelitis. The use of antibiotic-impregnated autogenic bone graft seems to be an effective and safe method for the management of small infected tibial defects.     

Bone scintigraphy in the detection of chronic recurrent multifocal osteomyelitis

In this study, we describe the importance of the whole-body bone scan in diagnosing the multifocality of chronic recurrent multifocal osteomyelitis (CRMO) and in distinguishing it from unifocal acute hematogenous osteomyelitis. MATERIALS: The medical records and two-phase, whole-body bone scans of 14 patients (mean age 10.5 yr) with the diagnosis of CRMO, were retrospectively reviewed. The diagnosis of CRMO was based on bone biopsy in 9 patients and clinical course/laboratory findings in 5. Bone scans were evaluated for geographic and anatomic locations of their lesions. Correlative radiographs of areas of abnormal uptake were performed to assess the radiographic appearance of the lesions. RESULTS: The presentation of the disease was localized to one painful, tender and swollen periarticular site 86% of the time. The number of lesions detected by bone scan varied from 1-18 (mean 6). Most lesions were metaphyseal, proximal or distal tibial lesions. Purely sclerotic or mixed (sclerosis and lysis) lesions were found on radiographs. Bilateral lesions were seen in 64% of patients. Biopsies were negative for organisms in all patients and exhibited subacute or chronic histologic changes in most instances. Complications of chronic hyperemia included marked overgrowth (5), diffuse demineralization (1), angular deformity (1) and length discrepancy (1). CONCLUSION: The identification of the multifocal configuration of the disease process by two-phase (soft-tissue and delayed) whole-body bone scintigraphy results in appropriate diagnosis and therapy of CRMO. Additional sites for possible bone biopsy become apparent for exclusion of other diagnoses. Supportive (nonsteroidal, anti-inflammatory medication) instead of antimicrobial therapy can be initiated with significant cost savings.     

Pediatric osteomyelitis in Panama

Two hundred forty-one children who had osteomyelitis during a 19-year period, 1974 through 1992, were identified by chart review. Acute osteomyelitis or chronic osteomyelitis was the diagnosis for 221 (92%) and 20 (8%) of the children, respectively. Bacteriologic etiology was documented in 137 (57%) of the cases. Staphylococcus aureus, Pseudomonas aeruginosa, Salmonella species organisms, and Haemophilus influenzae type b were isolated from 97 (40%), 10 (4%), 8 (3%), and 7 (3%) of the children, respectively. S. aureus was the predominant microorganism in all age groups, whereas H. influenzae occurred only in children younger than 2 years of age. P. aeruginosa was recovered predominantly from children with a penetrating injury of the foot, while salmonella bone infections were diagnosed in patients with sickle cell disease. These data provide guidelines for the initial work-up for and management of osteomyelitis in children living in developing Latin American countries.     

The significance of T-loop change in Frank''s lead exercise electrocardiography

Addition of antibiotics to bone cement is used more and more in orthopedics and traumatology. Indications are discussed: 1. infection prophylaxis in replacement arthroplasty, 2. therapy and recidive prophylaxis in infected arthroplasty, 3. therapy of chronic osteomyelitis. Our own experiments show release of antibiotics from bone cement Palacos and penetration into cortical bone after experimental osteomyelitis. Carbenicillin and Cephalotin show high level of concentration for 2 weeks, after 3 weeks there is no concentration evident. Lincomycin and Gentamycin in the first days show high tissue levels, after decrease and increase again after second week. Gentamycin was examined during 10 months showing high levels after this time.     

Diagnosis of osteomyelitis. Accuracy and limitations of antigranulocyte antibody imaging compared to three-phase bone scan

Thirty-seven patients with suspected osteomyelitis in conjunction with diabetic gangrene (N = 14, group 1), arthroplasty (N = 8, group 2), and various diseases (N = 15, group 3) were examined. Three-phase bone scans, followed by granulocyte imaging using I-123 labeled anti-NCA 95 monoclonal antibodies, were performed to evaluate and compare the diagnostic accuracy of both procedures. Final diagnosis was established histologically, bacteriologically, or by both methods either through the clinical course or by long-term follow-up in patients in group 1. Osteomyelitis was proven in 17 out of the 37 patients. Bone and antigranulocyte imaging demonstrated positive results in all patients with osteomyelitis (sensitivity 100% for each method). No signs of skeletal infection were found in 20 patients. Fifteen of these patients had no antigranulocyte antibody accumulation, resulting in 75% specificity. Ten patients without infection had normal three-phase bone imaging results (specificity 50%). Antigranulocyte imaging results were negative in 6 out of 10 patients without osteomyelitis in groups 2 and 3 whose bone imaging results were questionable. However, because of identical bone and granulocyte imaging results, no increase of diagnostic accuracy could be obtained by additional granulocyte imaging in patients with diabetic gangrene. Final diagnoses of false-positive antigranulocyte studies were aseptic osteonecrosis (N = 2), loosening of prostheses, gouty arthritis, and pain after arthrolysis. In summary, antigranulocyte antibody imaging offered high sensitivity and acceptable specificity for the diagnosis of osteomyelitis. Diagnostic accuracy can be improved through the adjuvant use of antigranulocyte imaging for patients with suspected osteomyelitis, especially when radiographic and scintigraphic results are questionable or unreliable.     

Childhood sarcoidosis presenting with hypercalcaemic crisis

Squamous cell carcinoma is a rare, but well documented complication of chronic osteomyelitis. Many authors have recommended amputation as the treatment of choice for locally invasive disease. Presented is a patient with squamous cell carcinoma arising in the draining sinus tract of chronic osteomyelitis of the lower extremity that was treated successfully with Mohs micrographic surgery (MMS). After ten year follow-up he remains tumor free and continues to enjoy use of his leg. We propose MMS as a therapeutic option to amputation for control of locally invasive disease.     

Ectopic hematopoietic bone marrow in the appendicular skeleton after trauma

METHODS: Combined bone scanning and immunoscintigraphy (IS) with 99mTc-monoclonal antigranulocyte antibodies were performed in two patients with suspected reactivation of chronic osteomyelitis of the lower extremity. Because bone scanning and IS were strongly positive, both patients underwent surgical intervention. RESULTS: Macroscopic findings did not show purulent infection and microbiologic results remained negative, but histology revealed unexpected ectopic bone marrow, explaining the strong uptake on IS. One patient exhibited active hematopoietic bone marrow at the former fracture site of the tibial bone. The second patient presented with interspersed bone marrow in the cortical bone of the femoral diaphysis after several intramedullary surgical procedures. CONCLUSION: Unexpected ectopic hematopoietic marrow may occur in the appendicular skeleton after trauma and repeated surgical interventions. The bone marrow shows a physiologic uptake with IS and may be misinterpreted as granulocyte accumulation due to infection. This may lead to false-positive diagnosis in cases of suspected osteomyelitis.     

Treatment of experimental staphylococcal osteomyelitis with rifampin and trimethoprim, alone and in combination

Rifampin and trimethoprim were used alone and in combination in the treatment of chronic osteomyelitis due to Staphylococcus aureus in rabbits. Rifampicin levels in infected bone were well above the minimum inhibitory concentration of the infecting strain of S. aureus for at least 4 h after injection. In contrast, trimethoprim levels in diseased bone were below the minimum inhibitory concentration as early as 1 h after injection. Trimethoprim or rifampin, administered alone for 14 days, were ineffective in sterilizing infected rabbit bones. The combination of rifampin plus trimethoprim was significantly more effective (P less than 0.005) than either agents given alone for a comparable duration of time. Staphylococci isolated from the bones of rabbits treated with rifampin alone or rifampin plus trimethoprim were uniformly resistant to rifampin, but retained their susceptibility to trimethoprim.     

Heart rate variability and baroreflex sensitivity in hypertensive subjects with and without metabolic features of insulin resistance syndrome

PURPOSE: The traditional approach to investigating suspected osteomyelitis in children includes conventional radiography and bone scintigraphy. The roles of US, CT and MR imaging are controversial. Our objective was to determine whether the additional use of these modalities would yield information likely to lead to treatment modification. MATERIAL AND METHODS: Sixty-five children with clinically suspected osteomyelitis took part in a prospective study. All patients underwent conventional radiography and bone scintigraphy. In addition to this, US, CT and MR imaging were all performed in 33 patients; the remaining 32 patients were examined with various combinations of these three modalities. The value of the additional information obtained was estimated retrospectively by a pediatric orthopedic surgeon in terms of possible modification of treatment. RESULTS: MR imaging was the modality with the highest sensitivity and specificity for detecting osteomyelitis. MR yielded information likely to influence treatment in the greatest proportion of patients (45%) followed by US (30%). CONCLUSION: The standard investigation protocol with the addition of US (because of its ability to detect subperiosteal abscesses early and simply) is adequate in uncomplicated cases. When additional imaging is required to outline a lesion, or in complicated cases, and when bone scintigraphy is inconclusive, MR imaging should also be performed. CT should be considered when MR investigation is not available or when anesthesia is required but cannot be provided.