Management in the wound-care center outpatient setting of a diabetic patient with forefoot osteomyelitis using Cerament Bone Void Filler impregnated with vancomycin: off-label use

Several nonbiodegradable and biodegradable antibiotic cement delivery systems are available for the delivery of antibiotics for adjunctive therapy in the management of osteomyelitis. A major nonbiodegradable delivery system is polymethylmethacrylate beads. Antibiotics that can be incorporated into this delivery system are limited to the heat-stable antibiotics vancomycin and aminoglycosides, tobramycin being the most popular. Calcium sulfate and hydroxyapatite (Cerament Bone Void Filler) is a unique biocompatible and biodegradable ceramic bone void filler that can successfully deliver heat-stable and heat-unstable antibiotics in musculoskeletal infections. The use of Cerament as antibiotic beads has not been previously reported. An off-label case of diabetic foot osteomyelitis successfully managed with surgical bone resection and vancomycin Cerament antibiotic beads is presented. Subsequent surgery for the bone infection and staged removal of the antibiotic beads was not necessary.     

抗生素骨水泥及念珠预防和治疗骨科感染

局部使用抗生素防治骨科感染由来已久。随着关节置换术的广泛开展，应用抗生素骨水泥预防和治疗关节置换术术后感染重新被重视，抗生素骨水泥念珠也被用于慢性骨髓炎的预防和治疗及修复开放性骨折时的感染预防。目前，被关注的问题主要有两个：(1)各种新的抗生素加入骨水泥后的有效性和安全性；(2)抗生素对骨水泥物理性质的影响。     

慢性骨髓炎的治疗

目的:介绍慢性骨髓炎的治疗经验。方法:术前停用一切抗生素2周,有窦道或创面者连续3天行分泌物细菌培养及药敏试验。术中取髓腔内脓液、炎性肉芽组织或死骨再次送培养,然后彻底清创,清除失去活力的一切组织。若脓液较多,行滴注引流2～4周。脓液较少骨量不足者,1期植骨,否则3～6个月后2期植骨。再依软组织缺损情况,采用局部皮瓣或肌瓣转移修复。结果:68例患者均获治愈,行皮瓣修复者全部成活;植骨者全部愈合,愈合时间6～12个月。随访6个月～16年,无1例复发,皮瓣质地好、功能佳、外形满意。结论:彻底清创、依细菌培养结果选择敏感抗生素、恰当选择植骨时机并及时以皮瓣或肌瓣覆盖创面改善局部血运,是根治慢性骨髓炎的关键。     

Biological analysis of an innovative biodegradable antibiotic eluting bioactive glass/gypsum composite bone cement for treating experimental chronic MRSA osteomyelitis

A multi-barrier antibiotics loaded biodegradable composite bone cement for resolving chronic osteomyelitis has been studied to understand the physico-mechanical properties, drug loading/eluting efficiency, and different merits and demerits prior to clinical application. After successful induction of bone infection in 28 rabbits using methicillin-resistant Staphylococcus aureus (MRSA) strains, calcium sulfate/bioactive glass based composite cement was implanted in 12 defects to assess its performance over parenteral therapy with microscopic and radiological examination for 90 days. The composite cement revealed acceptable physico-mechanical properties and controlled drug elution kinetics. Furthermore, the antibiotics concentrations in bone up to 42 days were sufficient to kill MRSA without eliciting adverse drug reactions. The striking feature of platelets aggregation by composite cement could assist bone healing. The controlled degradation with simultaneous entrapment of composite cement within the osteoid tissues and complete repair of infected cortical defects (holes) in rabbit tibia at 6 weeks indicated the excellent anti-infective and osteoconductive properties of composite cement. Thus, the animal study demonstrated the superiority of composite over injectable antibiotic therapy based on infection resolution and bone regeneration. We thereby conclude that the composite cement can be effectively applied in the treatment of resistant cases of chronic osteomyelitis.     

Diagnostic value of sinus-tract cultures in chronic osteomyelitis.

Sinus-tract cultures were compared with cultures of operative specimens from 40 patients with chronic osteomyelitis. Thirty-five patients (87.5%) had a single pathogen isolated from their operative specimens. Only 44% of the sinus-tract cultures contained the operative pathogen. Isolation of Staphyloccus aureus from sinus tracts correlated with the presence of S aureus in the operative specimen. However, less than half of the sinus-tract cultures obtained from patients with S aureus osteomyelitis contained this organism. Isolation of bacteria other than S aureus from sinus tracts had a low likelihood of predicting the pathogen isolated from bone. A presumptive diagnosis of S aureus osteomyelitis is justified if S aureus is isolated from an associated sinus tract. A bacteriologic diagnosis of chronic osteomyelitis based on isolation of common pathogens other than S aureus from sinus tracts must be verified by an appropriate operative culture.     

Disseminated donovanosis (granuloma inguinale) with osteomyelitis of both wrists

Donovanosis is a sexually transmitted infection which presents with genital ulceration and inguinal lymphadenopathy. Rarely, it presents with extra-genital manifestations. We present a case of disseminated donovanosis with cervical ulceration, massive pelvic lymphadenopathy, osteomyelitis of the wrists and septic arthritis of the knees and right elbow. A 23-year-old gravida two presented with wasting, oedema, ascites, bilateral iliac lymphadenopathy, anaemia and a large ulcer of the cervix uteri. Two months later in the outpatient clinic, she was much improved but still had post-coital bleeding and a hyperaemic cervix, suggestive of persistent infection. The course of antibiotics was therefore repeated. Histopathological examination of a specimen from colposcopic biopsy of the cervix uteri revealed granuloma inguinale. She improved after several courses of antibiotics, blood transfusion, surgical débridement and aspiration of affected joints.     

Through the looking glass; bioactive glass S53P4 (BonAlive®) in the treatment of chronic osteomyelitis

Background

In terms of eradication, osteomyelitis represents one of the most challenging infective conditions in medicine and surgery. In recent years, the use of bioactive glass in conjunction with antimicrobial therapy has emerged as a viable new treatment.

Aim

We present a short study, from a regional orthopaedic unit, demonstrating its successful use in three patients with chronic osteomyelitis.

Methods

Between September 2010 and May 2011, bioactive glass S53P4 was used in conjunction with intravenous and oral antibiotics to treat chronic osteomyelitis in three patients (two male, one female). All patients underwent debridement and sequestrectomy procedures with the insertion of bioactive glass followed by antimicrobial regimens tailored to isolated pathogen sensitivities. Patient age ranged from 28 to 68 years, with a mean age of 44.7 years. The presentation period, from time of initial diagnosis to treatment, varied from 16 months to 16 years and all three patients had underwent multiple previous debridements and antimicrobial regimens to no avail.

Results

A follow-up of 14–21 months has been achieved with a mean follow-up of 17.3 months. We have seen excellent results in all three patients. All haematological and biochemical parameters have returned to normal, pain has ceased and function has returned in the affected limbs. All antibiotics have stopped and there is no radiological evidence of osteomyelitis. The bioactive glass has integrated with the surrounding bone.

Conclusions

Though a relatively recent development, bioactive glass used in concurrence with antibiotic therapy has significant potential in the treatment of chronic osteomyelitis.     

皮质骨钻孔、一期植骨治疗慢性骨髓炎(附26例临床分析)

作者自1984年起应用自行设计的皮质骨钻孔、一期植骨治疗慢性骨髓炎的新方法治疗了26例病人,有效率为88.5%。本方法打破了传统的在有窦道的骨髓炎中不能植骨、必须凿除硬化骨的观念,既治愈了骨髓炎,又不破坏骨的牢固性,使硬化骨密度减低、皮质变薄。     

腓肠肌肌皮瓣治疗胫骨创伤性慢性骨髓炎伴骨与软组织缺损

目的探讨应用多种腓肠肌肌皮瓣转移治疗胫骨创伤性慢性骨髓炎伴骨与软组织缺损的临床选择及效果。方法 2005年6月—2008年6月,对16例胫骨慢性创伤性骨髓炎合并骨缺损骨外露的患者,采用病灶清除,骨质缺损较多行Ⅰ期或Ⅱ期植骨,外固定支架固定,分别应用腓肠肌内侧头肌皮瓣、腓肠肌外侧头肌皮瓣、腓肠肌内外侧头联合肌皮瓣、腓肠肌内或外侧头肌瓣加植皮,术后常规滴注引流进行治疗。男14例,女2例,年龄17～59岁。皮瓣面积6 cm×4 cm～18 cm×9 cm。结果随访6～24月,全部转移皮瓣一期存活。Ⅰ期植骨2例,Ⅱ期植骨4例1,例慢性骨髓炎复发,植骨失败,经3次清创后感染治愈;其余病例感染均未复发,植骨愈合好,植骨愈合时间3.4～6.7月,平均4.6个月。结论腓肠肌肌皮瓣具有血供丰富、操作简单、成活率高以及不牺牲重要血管等特点。治疗胫骨创伤性慢性骨髓炎并骨与软组织缺损,既可以改善病灶局部血液循环、又可以进行创面覆盖,同时还可以进行滴注引流,提高疗效,缩短病程,减少费用,是一种切实可行的有效方法。     

慢性多灶性骨髓炎1例及文献回顾

分析1例慢性多灶性骨髓炎病例的临床表现、血清学及影像学检查、诊断依据、治疗方案、出院后随访评估等,了解慢性复发性多灶性骨髓炎的发病机制、诊断、鉴别诊断、治疗,并进一步了解自身炎症性骨病的特点。本例患者青少年起病,伴有严重皮损,有进行性加重的脊柱关节疼痛,结合临床表现及辅助检查,符合慢性多灶性骨髓炎的诊断。经过抗炎、止痛效果不佳,后换用肿瘤坏死因子α(tumor necrosis factor α,TNF-α)抑制剂后疼痛缓解,炎症指标恢复正常,皮疹及影像学检查明显改善。慢性复发性多灶性骨髓炎属于自身炎症性骨病中多基因疾病的一种,又称慢性非细菌性骨髓炎,是一种罕见的非感染性炎性疾病,可引起多灶性溶骨性病变,以周期性加重和缓解为特征。该病发病率低,发病机制不清楚,可能与促炎及抗炎失衡有关,诊断无特异性指标及统一的诊断标准,常易与代谢性骨病、感染、肿瘤等疾病相混淆,临床表现为骨痛、发热、皮疹、骨折等,实验室检查可见炎症指标明显增高,影像学检查有溶骨性或硬化性改变,MRI在识别骨病变和组织水肿上更有效,而且比骨发射型计算机断层扫描(emission computed tomography,ECT)更准确。治疗用药方面,多数开始使用非甾体类抗炎药,但易复发并出现新发病灶,还可选择其他治疗方案,如糖皮质激素、TNF-α抑制剂及双磷酸盐、甲氨蝶呤等改善病情的抗风湿药物(disease-modifying anti-rheumatic drugs,DMARDs)。对慢性多灶性骨髓炎的早期诊断和治疗可以预防和减少疾病的并发症,改善患者预后。     

Unsuspected osteomyelitis in diabetic foot ulcers. Diagnosis and monitoring by leukocyte scanning with indium in 111 oxyquinoline

OBJECTIVE. The prevalence of osteomyelitis in diabetic foot ulcers is unknown. Early diagnosis of this infection is critical, as prompt antibiotic treatment decreases the rate of amputation. We therefore assessed the prevalence of osteomyelitis in 35 diabetic patients with 41 foot ulcers. We compared results of roentgenograms, leukocyte scans with indium In 111 oxyquinoline, and bone scans with the diagnostic criterion standards of bone histologic and culture findings. Leukocyte scans were repeated at 2- to 3-week intervals during antibiotic treatment. DESIGN. Cohort study. SETTING. Institutional and private, ambulatory and hospitalized patients. PATIENTS. Consecutive sample of 54 diabetic patients. Thirty-five patients with 41 foot ulcers were included. RESULTS. As determined by bone biopsy and culture, osteomyelitis was found to underlie 28 (68%) of 41 diabetic foot ulcers. Only nine (32%) of the 28 cases were diagnosed clinically by the referring physician. Underscoring the clinically silent nature of osteomyelitis in these ulcers, 19 (68%) of 28 occurred in outpatients, 19 (68%) of 28 occurred in ulcers not exposing bone, and 18 (64%) of 28 had no evidence of inflammation on physical examination. All patients with ulcers that exposed bone had osteomyelitis. Of the imaging tests, the leukocyte scan had the highest sensitivity, 89%. In patients with osteomyelitis, the leukocyte scan image intensity decreased by 16 to 34 days of antibiotic treatment and normalized by 36 to 54 days. CONCLUSION. The majority of diabetic foot ulcers have an underlying osteomyelitis that is clinically unsuspected. Leukocyte scans are highly sensitive for diagnosing osteomyelitis in diabetic foot ulcers and may be useful for monitoring the efficacy of antibiotic treatment. We recommend that diabetic patients with foot ulcers that expose bone should be treated for osteomyelitis. Diabetic patients with foot ulcers that do not expose bone should undergo leukocyte scanning, which eliminates the risk of bone biopsy in diagnosing osteomyelitis and allows for the diagnosis and treatment of this well-known but often silent precursor of lower extremity amputation.     

Osteomyelitis and infective endocarditis.

Osteomyelitis is thought to occur as a complication of infectious endocarditis in as many as 6% of cases of endocarditis. We describe this association in three patients. Osteomyelitis may be difficult to diagnose in patients with endocarditis because symptoms such as fever, bone pain and stiffness are common to both illnesses, therefore physicians need to have a high index of suspicion to avoid missing this important complication. We recommend that patients with endocarditis and persistent or localized musculoskeletal symptoms should be investigated to exclude osteomyelitis. Plain radiographs can be normal in 50% of cases of osteomyelitis in the early stages or show only minor abnormalities, but bone scans are highly sensitive. We suggest that a bone scan is performed if radiography is unhelpful, since a diagnosis of osteomyelitis can effectively be excluded if the bone scan is normal. We advocate close follow-up of these patients with prolonged antibiotic treatment consisting of at least 6 weeks of intravenous therapy, and 3 months or longer of oral therapy.     

Management of childhood haematogenous osteomyelitis in a rural Papua New Guinean hospital

Haematogenous osteomyelitis, especially in its more common chronic stage, is an important cause of morbidity in children in the Southern Highlands Province. Hospital stays are lengthy and the incidence of fractures is high. While awaiting, or in the absence of, culture and sensitivity results, cloxacillin 200 mg/kg/day plus probenecid 40 mg/kg/day is an appropriate first choice antibiotic when it is available. Antibiotic therapy in chronic disease should be limited to the specific settings of associated soft tissue infection; pre- and post-sequestrectomy; and radiological signs of ongoing bone necrosis and systemic signs of active infection. Surgical drainage of subperiosteal pus and possibly the medullary canal is required in all but the very early (less than 48 hours) cases of acute osteomyelitis that sometimes respond to antibiotics alone. Sequestrectomy should be reserved for cases where a sequestrum and adequate involucrum can be seen on X-ray. Effective management of this disease is possible only if ongoing communication exists between hospital-based medical staff and the staff of health centres or subcentres, including the network of aid post orderlies and their supervisors. Since the majority of patients present to facilities other than hospitals, any campaign directed at improving management must involve co-workers in rural areas, namely the health extension officer, nurse and aid post orderly. Only in this way can we hope to achieve earlier appropriate treatment and more systematic long-term follow-up.     

不典型骨髓炎的X线诊断与鉴别

目的分析不典型骨髓炎的X线表现,以与良(恶)性骨肿瘤和肿瘤样病变鉴别。方法回顾性分析13例不典型骨髓炎的X线及临床表现,并与病理结果对照。结果13例中,急性骨髓炎2例,慢性骨髓炎6例,骨脓肿5例,术前诊断正确仅5例,4例误诊为恶性骨肿瘤,4例误诊为良性骨肿瘤或肿瘤样病变。结论全面分析不典型骨髓炎的X线及临床表现,了解病变的病理特征及演变趋势,对本病的诊断和鉴别诊断很有帮助。     

慢性化脓性骨髓炎12例的手术治疗

目的:研究慢性化脓性骨髓炎的手术方法及其疗效。方法:将2008年8月~2010年9月我院收治的慢性化脓性骨髓炎患者共12例作为研究对象。采用碟形手术、置管冲洗引流术、肌瓣填塞术等方法进行治疗,观察骨愈合情况。结果:12例患者中有11例骨愈合,占91.67%。其中2例实行碟形手术,骨愈合1例;4例实行置管冲洗引流术,骨愈合3例;6例实行肌瓣填塞术,骨愈合5例。结论:根据骨髓炎病灶情况和部位选择适当的手术方法,可有效治疗骨髓炎。     

万古霉素骨水泥治疗骨髓炎的临床分析

目的研究万古霉素骨水泥对骨髓炎患者的临床效果.方法将72例骨髓炎患者随机分为两组各36例,对照组采用常规治疗方式,治疗组采用万古霉素骨水泥治疗.结果治疗组患者骨髓炎症状治疗效果明显优于对照组;症状控制时间和住院治疗时间明显短于对照组.结论应用万古霉素骨水泥对骨髓炎实施治疗的临床效果非常明显.     

骨搬移治疗创伤性胫骨慢性骨髓炎并发对合端不愈合的危险因素分析

［摘要］ 目的探讨骨搬移治疗胫骨慢性骨髓炎并发对合端不愈合的危险因素。 方法回顾性分析138例行骨搬移治疗的创伤性胫骨慢性骨髓炎患者的临床资料。对可能影响对合端愈合的因素进行单因素分析,并进一步采用Logistic 回归进行多因素分析,筛选危险因素。 结果138例患者获得8~48个月随访,平均随访(24.76±8.49)个月。术后对合端愈合81例;对合端不愈合57例,发生率为41.3%,其中对合端骨质硬化21例（15.2%）,线位不良18例（13.0%）,折端骨质吸收萎缩13例（9.4%）,软组织嵌顿5例（3.6%）。单因素分析结果显示,患者年龄、是否吸烟、局部软组织条件、骨块搬移距离、搬移方向是骨搬移治疗创伤性胫骨慢性骨髓炎术后并发对合端骨不愈合的影响因素（P＜0.05）。多因素Logistic回归分析显示,患者年龄、是否吸烟、局部软组织条件、骨块搬移距离是骨搬移治疗创伤性胫骨慢性骨髓炎术后并发对合端不愈合的危险因素（P＜0.05）。 结论骨搬移技术是治疗创伤性胫骨慢性骨髓炎合并大段骨缺损的有效方法,术后并发对合端不愈合的概率高,年龄、是否吸烟、局部软组织条件、骨块搬移距离是其危险因素。     

ACPC载药核心块状同种异体骨修复小段感染性骨缺损研究

目的：探讨自固化磷酸钙人工骨（ACPC）载药核心块状同种异体骨治疗小段创伤性骨髓炎骨缺损的临床意义.方法：应用ACPC载药核心块状同种异体骨治疗36例小段创伤性骨髓炎患者,观察患者手术前后的全身及局部组织反应、ESR及CRP、X线摄片和CT扫描;随访时间为13 ～24个月,平均18.5个月.结果：全部患者未见明显全身反应,31例局部软组织愈合好,窦道消除,X线显示ACPC与骨髓炎清除区局部骨质直接愈合,CT示界面处未见间隙存在,基本恢复骨缺损处的解剖形状,I期治愈率为86.1％.另5例需要第二次清创、ACPC载药核心块状同种异体骨植入填充手术后获治愈.结论：ACPC载药核心块状同种异体骨对小段创伤性骨髓炎骨缺损具有治疗彻底、骨缺损修复好、能较好恢复负重肢体功能的优点.     

负压引流法联合开放植骨治疗创伤性骨髓炎的临床效果

目的：观察负压引流法联合开放植骨治疗创伤性骨髓炎（ TO）的临床效果。方法选取80例TO患者，随机分为对照组和干预组各40例。对照组患者给予常规治疗方法，干预组患者给予负压引流法联合开放植骨。对比两组的治疗效果、复发情况、骨愈合所需时间及住院时间。结果与对照组比较，干预组总有效率较高，复发率低，治愈时间及住院时间缩短（均P＜0．05）。结论对TO患者采用负压引流法联合开放植骨技术治疗的临床效果显著，值得在临床上推广应用。     

不同时相抗生素骨水泥的释放特性研究

目的:观察骨水泥不同时相混入抗生素时的释放特性,研究抗生素混合骨水泥的最佳时相,为抗生素骨水泥临床应用提供实验依据.方法:分别将1 g万古霉素、2 g硫酸庆大霉素、1.5 g头孢呋辛钠在不同时相加入40 g骨水泥中,制成负载抗生素的骨水泥,置于实验兔骨髓腔,在不同时间点测定局部抗生素的释放量.结果:3种抗生素在兔体内均能持续释放,骨水泥固相与液相混合后加入抗生素的释放总量明显高于混合前加入抗生素的各组(P<0.05),混合后加入万古霉素组的释放总量高于其他各组(P<0.05).结论:骨水泥固相与液相混合后加入抗生素的混合方法更有利于抗生素的释出,万古霉素的释放效果好于其他抗生素.