Konservative und operative Therapie der Klavikulaschaftfrakturen

The imaging diagnostics of osteomyelitis contain a combination of radiological and nuclear medicine procedures. The conventional radiographic image as first choice examination shows structural changes of the bone and also can give information about localization and enlargement of an osseous infection. Positron emission tomography/computed tomography (PET/CT) is the most sensitive verification procedure. It allows a reliable verification of extent and localization of the bone infection, the proof of satellite foci and soft tissue infections as well as the differential diagnostic distinction from a neoplasia. However, PET/CT scans in the diagnostic workup of osteomyelitis are reserved for special issues due to the high examination costs and the usually limited availability. In cases of negative fluorodeoxyglucose (FDG) PET findings, a chronic osteomyelitis is almost ruled out. In daily practice further diagnostic procedures include besides clinical and laboratory findings imaging by CT and magnetic resonance imaging (MRI). If these procedures do not provide verified results, bone scintigraphy can lead to the final diagnosis.     

Die akute und sekundär-chronische Osteomyelitis des Kiefers

Acute and secondary chronic osteomyelitis of the jaws are considered to be true infections caused by pyogenic bacteria, in most cases involving the mandible. The etiology and pathogenesis are mostly in the form of odontogenic infections allowing deep tissue penetration and proliferation of oral pathogens and hence establishment of a bone infection. Systemic and especially local host factors, such as bone vascularization are also considered to be important in determining the natural course of the disease. The diagnosis of acute and secondary chronic osteomyelitis of the jaws is made based on clinical findings and radiological imaging. While the panoramic radiograph is considered to be an appropriate first-line examination, computed tomography CT, digital volume tomography (DVT) and in early stages (acute osteomyelitis) magnetic resonance imaging (MRI) are considered to be the gold standard for imaging studies. Surgery and prolonged antibiotic therapy are considered to be the most important methods in the treatment of acute and secondary chronic osteomyelitis of the jaws. The surgical removal of infected and necrotic tissue is essential to promote healing.     

非典型骨髓炎的影像学表现及治疗

目的 分析非典型骨髓炎的影像学表现探讨诊疗方法.方法观察24例非典型骨髓炎患者影像学表现,并与手术病理结果进行对照.结果 24例患者术后病理均证实为骨髓炎.显示软组织肿胀:X线平片10例,CT 18例,MRI 21例;显示骨膜反应:X线平片15例,CT 18例,MRI未见;显示骨髓腔密度增高:X线平片11例,CT 16例,MRI 24例;显示骨皮质增厚:X线平片10例,CT 14例,MRI 18例.结论 MRI对非典型骨髓炎的早期诊断、鉴别诊断帮助较大,X 线平片仍是基础.X线平片、CT结合MR检查是非典型骨髓炎的早期诊断和鉴别诊断的重要手段.非典型慢性骨髓炎影像学表现不典型,误诊、漏诊率较高,认识其临床及影像学表现可以提高诊疗水平.     

Diagnostic imaging of musculoskeletal infection. Roentgenography; gallium, indium-labeled white blood cell, gammaglobulin, bone scintigraphy; and MRI.

A great deal of effort has been made to evaluate and define the role of various diagnostic imaging techniques in various clinical settings that complicate the diagnosis of osteomyelitis. Except possibly in neonates, bone scintigraphy remains generally recommended when there has been no previous osseous involvement. In other cases of chronic disease, previous fracture or trauma, prosthesis, and diabetic foot, In-WBC scintigraphy is generally accepted as an appropriate imaging technique. MRI will play an increasingly important role in diagnosing osteomyelitis and may prove to be an important adjunct in these cases. Research continues to improve our current diagnostic armamentarium. In-IgG appears to avoid practical deficiencies encountered with 67Ga and In-WBC; it remains to be seen what role this agent will play in routine clinical practice. All agents to date image inflammation, not infection, and most require delayed imaging sessions, usually at 24 hours. These shortcomings necessitate further research to develop new radiotracers that can provide useful images within several hours and that are specific for infection, perhaps ultimately delineating the particular microorganism involved.     

Imaging in osteomyelitis in the growing skeleton

Summary In acute osteomyelitis of childhood a rapid diagnosis and initiation of antibiotic therapy is necessary in order to prevent late sequelae. Thus, diagnostic imaging plays a crucial role. If acute osteomyelitis is suspected in a child, imaging starts with conventional radiography in order to exclude other differential diagnoses. This is followed by sonography for the purpose of diagnosing a subperiosteal abscess or joint fluid from which the causative organism could be isolated. If the diagnosis is unclear, the next step should be either MRI or ^99m Tc-MDP bone scan, depending on the possibility of clinical localization and the site of the suspected lesion. MRI is superior to bone scan in depicting the exact anatomy, which is extremely important in spinal osteomyelitis and preoperatively. The bone scan can show the whole skeleton in one examination and should be favored if there is no definite localization or in suspected multifocal osteomyelitis. Rarely scintigraphy with labeled white blood cells is indicated. The ⁶⁷ Ga scan, however, should not be used in children because of the high level of radiation exposure. The different imaging modalities are described in detail and an imaging diagnostic workup is outlined.      

Magnetic resonance imaging of the shoulder

Magnetic resonance imaging (MRI) is proving to be an effective means for evaluating the shoulder. The use of a surface coil and high resolution scanning techniques have allowed detailed analysis of the normal anatomy of the shoulder. When evaluating for shoulder pathology, the choice of imaging plane and pulse sequencing will be determined by the suspected pathology. In patients with impingement syndrome, subacromial bursitis, supraspinatus tendinitis, and supraspinatus tendon tear can be differentiated, and the offending component of the subacromial are traumatizing these soft tissues can be identified. MRI is also useful in determining the extent of retraction of the supraspinatus musculotendinous junction and the amount of muscle atrophy in cases of massive, chronic tears. Labral tear or attenuation due to glenohumeral instability can be imaged without the injection of contrast material, and MRI can identify those patients with multidirectional instability. Because of the ability to directly depict bone marrow, MRI is the imaging method of choice for the evaluation of early ischemic necrosis of the humeral head.     

Imaging in pelvic osteomyelitis: support for early magnetic resonance imaging

BACKGROUND: Children with pelvic osteomyelitis may present with symptoms that are nonspecific. Conventional imaging modalities including plain radiographs, ultrasound, technetium bone scan, and computed tomography rarely demonstrate pathology that is diagnostic of this condition. As a result, accurate diagnosis is often delayed, and children may undergo surgical diagnostic or therapeutic procedures that may be avoided. We report the radiographic and magnetic resonance imaging (MRI) findings in 23 children admitted with a suspected diagnosis of pelvic osteomyelitis. We are presenting imaging findings in children with suspected pelvic osteomyelitis with emphasis on MRI abnormalities and to propose an anatomical classification based on the patterns of pelvic involvement. METHODS: The medical records and imaging reports of all patients admitted to our institution with a history and physical examination suggestive of pelvic osteomyelitis between July 31, 1992, and March 10, 2003 were reviewed. Criteria were defined for the diagnosis of pelvic osteomyelitis based on criteria used by Farley et al in 1985. Specific attention was paid to the imaging strategies used and the influence of each radiographic method on the ultimate diagnosis. RESULTS: Abnormalities on the MRI included soft tissue inflammation and bone edema. These findings were bright on T2 and short inversion time Short T1 inversion recovery (STIR) images and enhanced after gadolinium administration. Five distinct patterns of pelvic involvement were observed, each corresponding to a cartilaginous epiphysis or apophysis. These were the sacroiliac joint, triradiate cartilage, pubic symphysis, ischium, and iliac apophysis. One patient had a noninfectious cause of presentation with a deep vein thrombosis, whereas another was diagnosed with Hodgkin lymphoma in addition to osteomyelitis of the ischium. CONCLUSIONS: Magnetic resonance imaging is a sensitive technique for evaluation of pyogenic infections involving the pelvis. In patients presenting with clinical findings and laboratory studies suggesting an infectious process, MRI with gadolinium enhancement should be performed as an early study. Magnetic resonance imaging is also effective in identifying other conditions that may resemble pelvic osteomyelitis.     

Möglichkeiten und Grenzen des Gliedmaßenerhalts bei chronischer Osteitis

Chronic osteomyelitis following operative fracture treatment is not only a serious problem for the patient: it also involves high costs to the community.Chronic osteomyelitis may be recognized in various ways: from clinical signs or laboratory values, or by means of imaging techniques. In particular, PET (positron emission tomography) could become the diagnostic procedure of choice for detection of chronic bone infections in the future.Standard therapy is made up of four steps: eradication of infection, closure of soft tissues, bone replacement and rehabilitation of the patient. Hyperbaric oxygen therapy is a valuable complement to the therapeutic schedule of programmed surgical revisions.The extent and limitations of the therapy need to be thoroughly discussed with the individual patient.     

Diagnosis and management of lower limb osteomyelitis

Osteomyelitis is an inflammatory disease of bone, usually caused by bacterial infection, which most commonly affects the lower extremities. Infection occurs either via haematogenous spread, or contiguous spread (including open trauma and orthopaedic procedures). Staphylococcus aureus is the most common infecting organism. It most commonly affects children and susceptible adults. Diagnosis is made by clinical presentation supported by inflammatory markers, tissue sampling for microbiological analysis and relevant imaging including X-rays and MRI. Subacute osteomyelitis is characterized by the presence of Brodie's abscess, whilst chronic osteomyelitis usually involves the characteristic features of sequestrum, involucrum and cloaca. Treatment is multidisciplinary, involving Microbiology, Orthopaedics, Plastics and Vascular (when appropriate). It can be conservative, medical (antibiotics), or surgical, depending on the acuity and severity of infection, in addition to host factors (Cierny & Mader classification). Surgical management consists of: radical debridement of infected bone and soft tissues, removal of metalwork (where relevant), obliteration of dead space, adequate soft tissue coverage, and adequate vascular supply to the affected region. Reconstruction options include bone transport and Masquelet ‘induced membrane’ techniques for large bone defects. Amputation should not be discounted in appropriate cases.     

Chronic recurrent multifocal and aspecific osteomyelitis: a case report

Chronic recurrent multifocal and unspecific osteomyelitis (CRMUO) is a severe form of chronic nonbacterial osteomyelitis. Lesions can be found anywhere in the skeleton, in young patients, such as children or adolescents, chronic nonbacterial osteomyelitis often affects the metaphyses of the long bones. Furthermore, other organs like skin, eyes and gastrointestinal tract can also be affected. Because of symptoms and course of disease vary in significant way, a clinical diagnosis is often difficult. The radiographic appearance suggests subacute or chronic osteomyelitis. CRMUO may mimic acute hematogenous osteomyelitis, but bacterial culture are usually negative and nonspecific histopathological and laboratory findings are present. This kind of osteomyelitis is often diagnosed by exclusion of the two main differential diagnoses-bacterial infections and tumor-by assessing for a characteristic course and the findings by conventional radiography, if necessary supplemented by scintigraphy and magnetic resonance imaging (MRI). The MRI appearance of CRMUO lesions in tubular bones and the spine is often rather characteristic and can support the diagnosis. It is important to diagnose CRMUO to avoid unnecessary diagnostic procedures or therapy, and initiate an appropriate one. We present a case report of a 44-year-old woman diagnosed with CRMUO involving both femurs.     

Magnetic Resonance Imaging of Diabetic Foot Osteomyelitis: Imaging Accuracy in Biopsy-Proven Disease

Magnetic resonance imaging (MRI) is the recommended diagnostic imaging technique for diabetic foot osteomyelitis (DFO). The gold standard to diagnose osteomyelitis is bone biopsy with a positive culture and/or histopathology finding consistent with osteomyelitis. The purpose of this study is to assess the accuracy of MRI readings in biopsy-proven diabetic foot osteomyelitis with a second read done by a blinded, expert musculoskeletal radiologist. A retrospective chart review of 166 patients who received a bone biopsy to confirm the diagnosis of a suspected DFO at a large county hospital between 2010 and 2014. A second, blinded musculoskeletal radiologist reviewed the images for accuracy, once the official reading was recorded. Imaging results were correlated with the final diagnosis of osteomyelitis determined by bone biopsy. In 17 of 58 patients (29.3%), the diagnosis of DFO by MRI was not confirmed by bone biopsy. There were 12 false positives and 5 false negatives. After the second expert read, there were 5 false positives and 4 false negatives. The overall accuracy was 84% for the second read. Our study demonstrated results comparable to the previously reported meta-analysis findings. There is a clear variation on the read of MRI that could lead to an incorrect diagnosis of DFO. An integrated approach with evaluation of clinical findings, communication with radiologist about the MRI results when indicated, and bone biopsy is warranted for accurate diagnosis management of DFO.     

Diagnosis and therapy of haematogen osteomyelitis in children and adolescents

Summary Haematogen osteomyelitis is mostly found in children and adolescents. In western Europe acute haematogen osteomyelitis (AHOM) is a rare disease. This is the cause why AHOM is often diagnosed with delay. The treatment usually is an antibiotic medication and/or surgical interventions. Uncharacteristic pain of extremities in children should always consider the diagnosis of acute osteomyelitis. Investigation should include conventional X-rays, ultrasounds or MRI to prevent the spreading of infection. In cases of multifocale infection radionuclide imaging should be undergone. Differential diagnosis should always include malignant tumor. If under treatment of antibiotics the clinical signs of illness do not decrease within 24 h surgery with fenestration of the involved bone, debridement and local application of antibiotics is indicated. In unusual cases or in cases with clinical signs of AHOM but no bacteria specification a malignant tumor has to be excluded.      

Diagnosis and treatment of infections associated with fracture-fixation devices

The pathogenesis of infections associated with fracture-fixation devices is related to microorganisms growing in biofilms, which render these infections difficult to treat. These infections are classified as early (<2 weeks), delayed (2-10 weeks) or late infections (>10 weeks) according to the implant surgery. Most infections are caused by staphylococci and are acquired during trauma (in penetrating injuries) or subsequent fracture-fixation procedures. A combination of clinical, laboratory, histopathology, microbiology, and imaging studies are usually needed to accurately diagnose infection. Magnetic resonance imaging (MRI) and computed tomography (CT) scans are often used to diagnose infection and plan surgical treatment. Positron emission tomography (PET) and PET-CT are promising new tools for diagnosing implant-associated osteomyelitis. The treatment goal is achieving bone consolidation and avoiding development of chronic osteomyelitis. Successful treatment requires adequate surgical procedures combined with 6-12 weeks of antimicrobial therapy acting on adhering stationary-phase microorganisms. In chronic osteomyelitis, orthopedic and plastic- reconstructive surgery is combined in the same procedure or within a short time span. In this article, pathogenesis, classification, diagnosis, and treatment of infections associated with intramedullary nails, external-fixation pins, plates, and screws are reviewed.     

Efficacy of Magnetic Resonance Imaging in Diagnosing Diabetic Foot Osteomyelitis in the Presence of Ischemia

Magnetic resonance imaging (MRI) has been recognized as the most accurate imaging modality for the detection of diabetic foot osteomyelitis. However, how accurately MRI displays the extent of diabetic foot osteomyelitis in the presence of ischemia is still unclear. We retrospectively compared the preoperative MRI findings with the results of histopathologic examinations of resected bones and studied the efficacy of MRI in the diagnosis of diabetic foot osteomyelitis of different etiologies. A total 104 bones from 18 foot ulcers in 16 diabetic patients (10 men and 6 women; age range 42 to 84 years) treated by surgical intervention from 2008 to 2012 was examined. In 8 neuropathic ulcers, 29 bones were accurately diagnosed in detail using MRI, even those with severe soft tissue infection. Of 75 bones in 10 ischemic ulcers, only 7 bones evaluated by MRI after revascularization were diagnosed accurately; the other 68 could not be diagnosed because of unclear or equivocal MRI findings. On histopathologic examination, all the bones were found to be infected through the bone cortex by the surrounding infected soft tissue, not directly by articulation. Overall, preoperative MRI is effective in the diagnosis of neuropathic ulcers, but less so of ischemic ones.     

Diagnostik und Therapie des Schultertraumas

Blunt trauma of the shoulder needs, after clinical investigation, x-ray examination to exclude fractures. Despite technical progress, radiographs in two planes are still basic diagnostic tools. Computed tomography (CT) is necessary in cases of differential questions for fracture treatment. Magnetic resonance imaging (MRI) or ultrasound is the method of choice in cases of rotator cuff tears and soft tissue injuries. Vascular diseases and injuries can be diagnosed by the use of conventional angiograms or angio-CT and angio-MRI.     

Osteomyelitis im Erwachsenenalter

Osteomyelitis in the adult is a rare disease. In this review we present the diagnostic and therapeutic principles for treatment of chronic osteomyelitis of long bones in adults. The most important step in treating osteomyelitis is the detection of the offending bacteria. The diagnostics should be performed with tissue and fluids from the depth of the wound. Superficial samples and swaps from fistulas should not be used to determine the offending bacteria. The defining criteria of chronic osteomyelitis are necrotic and non vascularized bony tissue. The appropriate therapy includes radical excision of the diseased bone and infected scar tissue, closure of the wound with well vascularized tissue including (muscle) flaps, stabilization of instable situations by external fixation and administration of adequate antibiotics. Remaining necrotic bone tissue is one of the most relevant sources for recurrent infection.     

Successful truncated osteomyelitis treatment for chronic osteomyelitis secondary to pressure ulcers in spinal cord injury patients

Time-tested treatments for chronic osteomyelitis involve prolonged courses of costly antibiotic treatment. Although such treatment remains unquestioned in acute osteomyelitis, it is an excessive regiment for chronic osteomyelitis. With appropriate surgical debridement and careful operative care, antibiotic treatment can be truncated in diagnoses of chronic osteomyelitis. This study represents the clinical practice of the pressure ulcer management program at Rancho Los Amigos National Rehabilitation Center in dealing with this difficult problem. One hundred fifty-seven patients with similar pressure ulcer wounds were studied retrospectively. Three groups of patients with pathologic diagnoses of acute osteomyelitis, chronic osteomyelitis, and negative osteomyelitis were compared for (1) postoperative stay, (2) wound infection, (3) wound breakdown requiring reoperation, and (4) same-site ulcer recurrence. In all cases, shallow bone shavings were sent for diagnosis via histologic study, and deep shavings were also sent to ensure adequate bone debridement and microbiologic study. All ulcers were subsequently closed with muscle and/or myocutaneous flaps. The negative and chronic osteomyelitis groups were treated with 5 to 7 days of IV antibiotics, whereas the acute group underwent a full 6-week course according to bone bacteriological culture and sensitivity. There was no statistical difference between the chronic osteomyelitis group and the control (negative) osteomyelitis group with respect to postoperative stay (70 days for chronic group, 72.4 for control), wound breakdown rate (10.7% for chronic, 10.2% for control), or ulcer recurrence (1.8% for chronic, 4.1 for control). The acute osteomyelitis group incurred longer hospital stays, greater incidence of wound breakdown, and statistically significantly greater ulcer recurrence (78.6 days, 13.2% and 17.0%, respectively). In cases of pressure ulcer management with bony involvement, bone pathologic diagnosis of chronic osteomyelitis allows for a shorter antibiotic course with better results when the offending tissue has been adequately debrided and closed with viable tissue flap coverage, than simple long-term (4-6 weeks) antibiotic treatment. Because of the extreme contaminated nature of these wounds, if such therapy works in these patients, it may be applicable to chronic osteomyelitis in more varied contaminated surgical cases involving bone.     

Critically evaluating the role of diagnostic imaging in osteomyelitis

Early diagnosis, essential for timely appropriate treatment and reduction of complications, can be difficult. This article aims to give an overview of the role that different imaging modalities have to play in the diagnosis of osteomyelitis. Osteomyelitis is a heterogeneous disease in its pathophysiology, clinical presentation, and management. It infers inflammation of bone and marrow, whereas osteitis is inflammation of the bone only. Thus, a soft-tissue infection that reaches the bone surface but has not infected the marrow is osteitis and not osteomyelitis. Chronic osteomyelitis is divided into active and inactive forms. Newly appearing periosteal reaction or bone destruction within the chronic involucrum are indicators of activation. Imaging modalities represent different underlying pathophysiological processes that may be represented in differing types and differing phases of osteomyelitis. Sequential selection of appropriate imaging modalities requires a thorough understanding of the disease processes and the process by which each modality visualizes this dynamic disease process.     

抗生素骨水泥链珠结合骨搬移技术分期治疗下肢长骨慢性骨髓炎

目的 探讨应用抗生素骨水泥链珠结合骨搬移技术分期治疗下肢长骨慢性骨髓炎的临床疗效,寻找有效解决长骨慢性骨髓炎的治疗方案。方法 选自我院2012年1月至2016年1月行手术治疗的股骨及胫骨慢性骨髓炎患者32例,采用分期治疗,一期进行彻底清创、去除死骨、放置万古霉素骨水泥链株,安装环形外固定延长架,二期取出万古霉素抗生素链珠,进行截骨延长、骨搬移,定期拍片检查骨搬移情况,骨搬移结束后视断端对合情况决定是否植骨。结果 32例患者治疗结束后炎症完全控制,且均达到骨性愈合,其中12例在搬移结束后行自体骨移植,20例断端对合后骨性愈合,所有患者均恢复了日常生活。结论 抗生素链珠结合骨搬移技术分期治疗下肢长骨慢性骨髓炎临床疗效肯定,慢性骨组织炎症经局部使用抗生素链珠后感染被控制,而后行骨搬移技术进行缓慢骨搬移,最终达到骨性愈合,为临床上治疗较为棘手的慢性骨髓炎提供一种有效的方法。     

Effect of preoperative magnetic resonance imaging diagnosis of osteomyelitis on the surgical management and outcomes of pressure ulcers

Despite advances in imaging technology, it is unclear whether preoperative MRI diagnosis of osteomyelitis influences surgical management and improves surgical outcome. The purpose of this retrospective study was to determine whether preoperative diagnosis of osteomyelitis by pelvic MRI influenced the surgical management of pressure sores and flap outcomes. The characteristics, pre- and intraoperative management, and surgical outcomes of the most recent flap surgery in 2 groups were compared: 26 patients diagnosed with osteomyelitis by preoperative MRI and 21 patients diagnosed by culture growth from an intraoperative bone specimen postoperatively. Patients with osteomyelitis diagnosed by MRI had 10 ulcer recurrences at the same site (39%) versus 6 (29%) among patients with osteomyelitis diagnosed by bone culture (odds ratio = 2.4, P = 0.22). We found that patients with a diagnostic preoperative MRI did not differ significantly in rates of antibiotic administration, ostectomy, dehiscence, revision, or infection.