Osteoarticular and muscle infectious lesions in patients with the human immunodeficiency virus

Summary Between 1988 and 1995, 1832 HIV positive patients were evaluated in our institution. We studied the epidemiologic, immunologic and bacteriologic data, laboratory tests, and X-Ray films in those with musculoskeletal infection. We reviewed twenty-one cases of musculoskeletal infection in twenty patients aged 23–35 years (mean 28,6 years, M:F=15:5). In all of them risk factor for HIV was intravenous drug abuse. The number of CD4 positive lymphocytes ranged from 0,003 to 0,5 10⁹/l. Staphylococcus aureus was the organism responsible of the infection in twelve cases, all active intravenous drug abusers at the time the diagnosis was done. The remaining causative agents were: Mycobacterium tuberculosis (3 cases), Candida albicans (2 cases), Salmonella subgroup 1 (1 case), Neisseria gonorrhoeae (1 case), Pseudomona aeruginosa (1 case) and Streptococcus agalactiae (1 case). Fifteen infections were diagnosed between 1988 and 1991 and 6 between 1992 and 1995. Musculoskeletal infectious lesions in HIV positive patients in our country are related in the majority of cases to intravenous drug abuse. In the last four years due to a National medical health care plan conducted to educate this group of people the number of musculoskeletal infections is decreasing.     

Long-Term Follow-Up of Bimaxillary Osteomyelitis Associated with Autosomal Dominant Osteopetrosis: A Case Report

Osteopetrosis (OP) is a rare metabolic bone disease characterized by a generalized increase in skeletal mass. The disease is characterized by increased susceptibility to develop osteomyelitis of the jaws. We report a case of clinical and radiological progression of bimaxillary osteomyelitis in a patient with autosomal dominant OP. The patient presented non simultaneous osteomyelitis in both upper and lower jaws with time interval of 10 years. The osteomyelitis of maxilla resulted in oroantral fistula formation and required surgical closure with Bichat fat pad flap. The mandibular osteomyelitis resulted in sequestra formation and pathological fracture and required multiple debridement procedures. Both maxillary and mandibular osteomyelitic foci were persistent and healing required more than 2 years. The case confirms the possibility of development of non simultaneous bimaxillary osteomyelitis in patients with OP. The case enhances the need of close follow- up and preventive measures in patients with OP.     

Chronic sternal osteomyelitis complicating primary manubriosternal septic arthritis

We present a 40-year-old woman complaining of worsening chest pain. She was previously treated with a prolonged course of antibiotics for suspected sternal osteomyelitis. Radiological investigations were suggestive of ongoing inflammation within the manubriosternal joint. Formal surgical debridement yielded evidence corroborating the diagnosis although microbiological samples were negative. Prolonged empirical treatment with intravenous antibiotics leads to a complete resolution of symptoms. Primary culture-negative manubriosternal septic arthritis is rare, and suboptimal treatment, particularly if confused with other conditions such as synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome, compounds its considerable morbidity.     

糖尿病并发慢性骨髓炎的临床治疗方法探讨

目的;通过对39例糖尿病合并慢性骨髓炎治疗的回顾性分析,探讨糖尿病并发慢性骨髓炎的治疗方法。方法;分析2000年至2011年收治的39例糖尿病并发慢性骨髓炎患者,其中男23例,女16例,年龄21～81岁,平均45岁,患者均有不同程度的红肿热痛表现,病程均在3个月以上。其中,25例术前有窦道形成。术前均常规行引流液培养、X线及CT检查。27例行清创Ⅰ期植骨外固定术,12例行清创术,术后均联合抗生素治疗。通过比较治疗前后血沉、C-反应蛋白和血常规测量结果、术前术后穿刺结果及影像学检查综合评定治疗效果。结果:治疗前35例出现血沉增快,治疗后32例转阴;治疗前25例血常规异常,治疗后23例转阴;术前36例C-反应蛋白升高,治疗后33例转阴。治疗后病灶脓液培养均为阴性。39例中,临床治愈33例,4个月至4年内复发6例。结论:在常规慢性骨髓炎治疗的同时,应重视并积极治疗糖尿病,采用综合治疗方法能明显提高糖尿病并发慢性骨髓炎的治愈率。     

Results of non-vascularised fibular grafting in gap non-union of long bones in paediatric age group

BackgroundBone defect has always been a challenge to treat for the orthopaedic surgeon. Fibular grafting is a popular method for bridging the gap in bone defects created by tumour excision, trauma or bone loss as sequelae to infection. Fibula is a popular substitute for this method because of its easy accessibility and minimal donor site morbidity. The present study is aimed at finding the results in paediatric population.Material and methods20 patients with bone defect (19 as a result of chronic osteomyelitis and one as a result of excision of a tumour) were included in the current study. The age of the patients ranged from one year to 12 years. The fibular graft was applied after freshening of bone end and fixed with K wire or plating and cancellous bone graft was also applied at both ends. The limb was immobilized in plaster till union of fibula at both ends.ResultsThe average gap was 8 cm (range 6–12 cm). Out of the twenty cases nine involved the humerus, seven in the tibia, two in radius and one each in femur and ulna. Union was achieved at both ends in 80% of the patients after the first surgery. Three out of six patients with K wire as fixation device failed and one out of fourteen patients with plate as fixation device ended in non-union. Union was achieved in these patients after revision surgery. One patient had stress fracture at distal end of the plate after weight bearing. Union occurred in this patient after plaster immobilization. Range of motion at distal and proximal joint was comparable to normal side. Superficial infection was seen in two patients and they responded to antibiotics.ConclusionNon-vascularised fibular grafting is a good option for bone defects in paediatric population provide adequate fixation and immobilization has been done.Level of evidenceLevel IV (Therapeutic).     

Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement

Aims/hypothesis  We analysed the factors that determine the outcomes of surgical treatment of osteomyelitis of the foot in diabetic patients given early surgical treatment within 12 h of admission and treated with prioritisation of foot-sparing surgery and avoidance of amputation. Methods  A consecutive series of 185 diabetic patients with foot osteomyelitis and histopathological confirmation of bone involvement were followed until healing, amputation or death. Results  Probing to bone was positive in 175 cases (94.5%) and radiological signs of osteomyelitis were found in 157 cases (84.8%). Staphylococcus aureus was the organism isolated in the majority of cultures (51.3%), and in 35 cases (36.8%) it proved to be methicillin-resistant. The surgical treatment performed included 91 conservative surgical procedures, which were defined as those where no amputation of any part of the foot was undertaken (49.1%). A total of 94 patients received some degree of amputation, consisting of 79 foot-level (minor) amputations (42.4%) and 15 major amputations (8%). Five patients died during the perioperative period (2.7%). Histopathological analysis revealed 94 cases (50.8%) of acute osteomyelitis, 43 cases (23.2%) of chronic osteomyelitis, 45 cases (24.3%) of acute exacerbation of chronic osteomyelitis and three remaining cases (1.6%) designated as ‘other’. The risks of failure in the case of conservative surgery were exposed bone, the presence of ischaemia and necrotising soft tissue infection. Conclusions/interpretation  Conservative surgery without local or high-level amputation is successful in almost half of the cases of diabetic foot osteomyelitis. Prospective trials should be undertaken to determine the relative roles of conservative surgery versus other approaches.     

负压封闭引流术应用于糖尿病患者头皮感染及颅骨骨髓炎二例

病例1患者男,39岁,患2型糖尿病3年。头皮感染并溃疡形成半年余,见右颞顶部约8cm×8cm大小类圆形红肿,中央部见-2cm×2cm皮肤缺损溃疡,敏感抗菌药物治疗未愈,形成头皮缺损,常规换药未愈,行负压封闭引流术（vacuum sealingdrainage,VSD）治疗20余天后,皮缘肉芽生长,缺损缩小,皮肤红肿减轻。     

Amputation as a marker of the quality of foot care in diabetes

Strategic targets for the management of foot ulcers focus on reducing the incidence of amputation. While data on the incidence of amputation can be obtained relatively easily, the figures require very careful interpretation. Variation in the definition of amputation, population selection and the choice of numerator and denominator make comparisons difficult. Major and minor amputation have to be distinguished as they are undertaken for different reasons and are associated with different costs and functional implications. Many factors influence the decision of whether or not to remove a limb. In addition to disease severity, co-morbidities, and social and individual patient factors, many aspects of the structure of care services affect this decision, including access to primary care, quality of primary care, delays in referral, availability and quality of specialist resources, and prevailing medical opinion. It follows that a high incidence of amputation can reflect a higher disease prevalence, late referral, limited resources, or a particularly interventionist approach by a specialist team. Conversely, a low incidence of amputation can indicate a lower disease prevalence or severity, good management of diabetes in primary and secondary care, or a particularly conservative approach by an expert team. An inappropriately conservative approach could conceivably enhance suffering by condemning a person to months of incapacity before they die with an unhealed ulcer. The reported annual incidence of major amputation in industrialised countries ranges from 0.06 to 3.83 per 10³ people at risk. Some centres have documented that the incidence is falling, but this is often from a baseline value that was unusually high. Other centres have reported that the incidence has not changed. The ultimate target is to achieve not only a decrease in incidence, but also a low overall incidence. This must be accompanied by improvements in morbidity, mortality, and patient function and mood.     

改良开放植骨技术治疗17例慢性骨髓炎患者的护理

报告了应用改良开放植骨技术治疗17例慢性骨髓炎患者的护理.术前皮肤准备时注意减少皮肤表面损伤;做好床边隔离措施,强调医务人员手卫生,预防院内交叉感染发生.术后保证创面有效负压吸引,及时处理漏气和引流管堵塞;加强外固定器的管理,预防针道感染发生;注意取骨区、植皮区的观察与护理,促进切口愈合.本组植皮后骨髓炎得到控制,创面愈合,缺损骨生长,治疗周期为1～5个月.骨折愈合时间4～18个月,无骨不连、再次骨折发生.     

Infantile Osteomyelitis Secondary to Malignant Osteopetrosis

Osteopetrosis (OP) is a rare congenital disorder (present at birth) in which the bones become over dense. This results from an imbalance between the formation of bone and the resorption of the bone. Thickening of the bones which become abnormally dense due to an inherited defect in bone resorption, the process in which old bone is broken down and removed so that new bone can be added to the skeleton. Osteoclasts are the cells responsible for bone resorption. In osteopetrosis the osteoclasts do not perform normally. This flaw in bone resorption results in bones that are abnormally dense, yet are fragile and easily broken. Osteopetrosis is also known as Albers–Schonberg disease, generalized congenital osteosclerosis, ivory bones, marble bones, osteosclerosis fragilis generalisata. In this article, we have described about the diagnosis and medical and surgical management of osteopetrosis reported case to our hospital.