Analysis of the epidemiological status, microbiology, treatment methods and financial burden of hematogenous osteomyelitis based on 259 patients in Northwest China.

Background: The incidence of hematogenous osteomyelitis is on the rise, and the prognosis is poor. There has been no large-scale epidemiological analysis of hematogenous osteomyelitis in the world, and the treatment method is still controversial. Methods: A retrospective case study method was used to collect and analyze clinical data obtained from patients with hematogenous osteomyelitis in a tertiary hospital in Northwest China from January 1, 2011, to December 31, 2020. The aim of this study was to investigate the epidemiological status, microbiological characteristics, treatment and financial burden of hematogenous osteomyelitis in Northwest China to explore the therapeutic effects of different treatment methods, elucidate the epidemiological characteristics of hematogenous osteomyelitis and to provide a basis for the choice of treatment. Results: We included 259 patients with hematogenous osteomyelitis, including 96 patients with acute hematogenous osteomyelitis and 163 patients with chronic hematogenous osteomyelitis. The cause of the disease was not obvious in most patients, the sex ratio of males to females was 1.98, and the three most common infected sites were the tibia, femur and phalanx. Regarding preoperative serum inflammatory markers, the rate of positivity for ESR was the highest at 67.58%. Among pathogenic microorganisms, Staphylococcus aureus was the most common. Regarding the financial burden, the median total cost per patient was 25,754 RMB, and medications accounted for the largest proportion of the main costs. Conclusions: The most common pathogen associated with HO infection was MSSA. Oxacillin has good PK and PD and is recommended as the first-line drug. Some blood-borne bone infections may lead to complications, such as pulmonary infection through bacteremia, which requires early detection to avoid a missed diagnosis. Regarding surgical intervention, debridement plus absorbable calcium sulfate bone cement and calcium sulfate calcium phosphate bone cement exclusion have achieved good therapeutic effects, but they are worthy of further in-depth research. Regarding the financial burden, the median total cost per patient was 25,754 RMB. The financial burden of blood-borne osteomyelitis was lower than that of traumatic osteomyelitis. Among the main costs, drugs accounted for the largest proportion.

Nationwide epidemiologic study for pediatric osteomyelitis and septic arthritis in South Korea: A cross-sectional study of national health insurance review and assessment service.

Epidemiologic studies of pediatric bone and joint infection have been done mostly by developed Western countries, and such results could be expected to be biased. Therefore, an epidemiologic study to identify the distinct features of an Eastern country would be beneficial to improve their health outcomes and to reduce health care cost. A study was planned to investigate the epidemiology of pediatric osteomyelitis and septic arthritis in South Korea and to find out epidemiologic factors related with the occurrence of surgery.We conducted a cross-sectional study among hospitalized pediatric patients (<18 years old) with osteomyelitis and septic arthritis using nationwide cohort based on the Health Insurance Review and Assessment Service (HIRA) from 2008 to 2016. Percentage of hospitalization was additionally calculated according to several epidemiologic factors including age, month, site of infection, and region of residence. Logistic regression analysis was performed to find out the association between epidemiologic factors and occurrence of surgeryAnnual hospitalization rates (per 100,000) in our country were 7.8 to 9.1 for osteomyelitis, and 11.9 to 20.8 for septic arthritis. Frequent sites of osteomyelitis and septic arthritis were pelvis and lower extremity. The hospitalization rates of osteomyelitis and septic arthritis showed increasing trend with age. After multivariate logistic regression analysis, female gender, children, and adolescents rather than infants, rural area rather than urban area were associated with significantly increased odd ratios for surgery.The hospitalization rate of septic arthritis (11.9 to 20.8 per 100,000) in South Korea was higher than the Western countries (1.1 to 11 per 100,000), and the hospitalization rate of osteomyelitis (peak at 12 years) and septic arthritis (peak at 17 years) showed increasing trend with age, which was different from those of the developed Western countries showing higher incidence in children aged under 5 years. After multivariate logistic regression analysis, our study identified female gender, higher age group including children, and adolescents, and rural residence as epidemiologic risk factors associated with surgery.

Infecciones osteoarticulares en un hospital pediátrico de alta complejidad: epidemiología y características clínicas asociadas con bacteriemia / Osteoarticular infections in a tertiary care children's hospital: Epidemiology and clinical characteristics in association with bacteremia

Introducción. Las infecciones osteoarticulares son una importante causa de morbilidad y pueden presentar bacteriemia. La epidemiología de estas infecciones se ha modificado en los últimos años. Objetivos. Describir las características epidemiológicas, clínicas y evolutivas de los niños con infecciones osteoarticulares y comparar los pacientes con bacteriemia con los que no la presentaron. Población y métodos. Cohorte retrospectiva. Se incluyeron pacientes menores de 18 años, admitidos en el Hospital Juan P. Garrahan entre el 1/1/2016 y el 31/12/2016 con sospecha de infecciones osteoarticulares en quienes se hubiese realizado artrocentesis y/o biopsia articular. Se excluyeron niños con patología previa. Se compararon las características clínicas y de laboratorio según tuvieran bacteriemia o no. Se utilizó Stata 10. Resultados. N: 62. La mediana de edad fue 59.5 meses (rango intercuartilo -RIC- 24-84). Presentaron fiebre 44 pacientes (70%). Predominaron las artritis (54 pacientes, 87%). Se identificó un agente etiológico en 29 pacientes (47%). Predominó Staphylococcus aureus (n: 20, 32%). Tuvieron bacteriemia 15 de ellos (24%). Recibieron clindamicina como tratamiento empírico 56 pacientes (90%). La mediana de tratamiento endovenoso fue 7 días (RIC 5-11) y de internación, 7 días (RIC 4-12). Los pacientes con bacteriemia tuvieron menor edad (26 meses vs. 60, p < 0,05), mayor valor de proteína C reactiva inicial (101 vs. 33 U/L, p < 0,05), menor valor de hemoglobina al ingresar (10,8 g/dl vs. 12.5 g/dl, p 0,04) y mayor frecuencia de fiebre (100% vs. 57%, p < 0,05). Conclusiones. Predominó Staphylococcus aureus. Los niños con bacteriemia tuvieron menor edad, mayor valor de proteína C reactiva, menos hemoglobina al ingresar y, más frecuentemente, fiebre.

Introduction. Osteoarticular infections are an important cause of morbidity and may present with bacteremia. The epidemiology has changed in recent years. Objectives. To describe the epidemiological, clinical, and evolutionary characteristics of children with osteoarticular infections and compare patients with and without bacteremia. Population and methods. Retrospective cohort. Patients younger than 18 years admitted between January 1st, 2016 and December 31st, 2016 suspected of osteoarticular infections who had undergone an arthrocentesis and/or joint biopsy were included. Clinical and laboratory characteristics were compared between patients with and without bacteremia. The Stata 10 software was used.Results. N: 62. Patients' median age was 59.5 months (interquartile range [IQR]: 24-84). Fever developed in 44 patients (70%). Arthritis predominated (54 patients, 87%). An etiologic agent was identified in 29 patients (47%). Staphylococcus aureus was prevalent (n: 20, 32%). Among these, 15 developed bacteremia (24%). Clindamycin was administered to 56 patients (90%) as empirical therapy. The median intravenous treatment duration was 7 days (IQR: 5-11) and the median length of stay, 7 days (IQR: 4-12). Patients with bacteremia were younger (26 months versus 60 months, p < 0.05), had a higher baseline C-reactive protein level (101 U/L versus 33 U/L, p < 0.05), a lower hemoglobin level at the time of admission (10.8 g/dL versus 12.5 g/dL, p = 0.04), and a higher frequency of fever (100% versus 57%, p < 0.05).Conclusions. Staphylococcus aureus was prevalent. Children with bacteremia were younger, had a higher C-reactive protein level, a lower hemoglobin level at the time of admission, and 100% presented fever

Osteoarticular infections in a tertiary care children's hospital: Epidemiology and clinical characteristics in association with bacteremia. / Infecciones osteoarticulares en un hospital pediátrico de alta complejidad: epidemiología y características clínicas asociadas con bacteriemia.

INTRODUCTION: Osteoarticular infections are an important cause of morbidity and may present with bacteremia. The epidemiology has changed in recent years. OBJECTIVES: To describe the epidemiological, clinical, and evolutionary characteristics of children with osteoarticular infections and compare patients with and without bacteremia. POPULATION AND METHODS: Retrospective cohort. Patients younger than 18 years admitted between January 1st, 2016 and December 31st, 2016 suspected of osteoarticular infections who had undergone an arthrocentesis and/or joint biopsy were included. Clinical and laboratory characteristics were compared between patients with and without bacteremia. The Stata 10 software was used. RESULTS: N: 62. Patients' median age was 59.5 months (interquartile range [IQR]: 24-84). Fever developed in 44 patients (70%). Arthritis predominated (54 patients, 87%). An etiologic agent was identified in 29 patients (47%). Staphylococcus aureus was prevalent (n: 20, 32%). Among these, 15 developed bacteremia (24%). Clindamycin was administered to 56 patients (90%) as empirical therapy. The median intravenous treatment duration was 7 days (IQR: 5-11) and the median length of stay, 7 days (IQR: 4-12). Patients with bacteremia were younger (26 months versus 60 months, p < 0.05), had a higher baseline C-reactive protein level (101 U/L versus 33 U/L, p < 0.05), a lower hemoglobin level at the time of admission (10.8 g/dL versus 12.5 g/dL, p = 0.04), and a higher frequency of fever (100% versus 57%, p < 0.05). CONCLUSIONS: Staphylococcus aureus was prevalent. Children with bacteremia were younger, had a higher C-reactive protein level, a lower hemoglobin level at the time of admission, and 100% presented fever.

INTRODUCCIÓN: Las infecciones osteoarticulares son una importante causa de morbilidad y pueden presentar bacteriemia. La epidemiología de estas infecciones se ha modificado en los últimos años. OBJETIVOS: Describir las características epidemiológicas, clínicas y evolutivas de los niños con infecciones osteoarticulares y comparar los pacientes con bacteriemia con los que no la presentaron. POBLACIÓN Y MÉTODOS: Cohorte retrospectiva. Se incluyeron pacientes menores de 18 años, admitidos en el Hospital Juan P. Garrahan entre el 1/1/2016 y el 31/12/2016 con sospecha de infecciones osteoarticulares en quienes se hubiese realizado artrocentesis y/o biopsia articular. Se excluyeron niños con patología previa. Se compararon las características clínicas y de laboratorio según tuvieran bacteriemia o no. Se utilizó Stata 10. RESULTADOS: N: 62. La mediana de edad fue 59.5 meses (rango intercuartilo -RIC- 24-84). Presentaron fiebre 44 pacientes (70%). Predominaron las artritis (54 pacientes, 87%). Se identificó un agente etiológico en 29 pacientes (47%). Predominó Staphylococcus aureus (n: 20, 32%). Tuvieron bacteriemia 15 de ellos (24%). Recibieron clindamicina como tratamiento empírico 56 pacientes (90%). La mediana de tratamiento endovenoso fue 7 días (RIC 5-11) y de internación, 7 días (RIC 4-12). Los pacientes con bacteriemia tuvieron menor edad (26 meses vs. 60, p < 0,05), mayor valor de proteína C reactiva inicial (101 vs. 33 U/L, p < 0,05), menor valor de hemoglobina al ingresar (10,8 g/dl vs. 12.5 g/dl, p 0,04) y mayor frecuencia de fiebre (100% vs. 57%, p < 0,05). CONCLUSIONES: Predominó Staphylococcus aureus. Los niños con bacteriemia tuvieron menor edad, mayor valor de proteína C reactiva, menos hemoglobina al ingresar y, más frecuentemente, fiebre.

Statin use correlates with reduced risk of chronic osteomyelitis: a nationwide case-control study in Taiwan.

BACKGROUND/OBJECTIVE: Potential association between prior statin use and chronic osteomyelitis is examined. METHODS: A nationwide case-control study was conducted based on data taken from the Taiwan National Health Insurance program. The case group includes 2338 subjects aged 20-84 years newly diagnosed for chronic osteomyelitis from 2000 to 2013; the control group included 2338 randomly selected subjects without chronic osteomyelitis matched for sex, age, and index year. Statin use was respectively defined as "current", "recent" or "past" if the most recent statin prescription was filled <3 months, 3-6 months or ≥6 months prior to the chronic osteomyelitis diagnosis. Relative risk of chronic osteomyelitis associated with statin use was measured by the odds ratio (OR) with 95% confidence interval (CI) using the conditional logistic regression model. RESULTS: After controlling for potential confounders, the adjusted ORs of chronic osteomyelitis were 0.57 for subjects with current statin use (95% CI 0.45, 0.72), 0.80 for subjects with recent statin use (95% CI 0.48, 1.33), and 1.00 for subjects with past statin use (95% CI 0.83, 1.20), compared patients with no prior statin use. In further analysis, the adjusted ORs of chronic osteomyelitis were 0.70 for subjects with cumulative statin use <12 months (95% CI 0.47, 1.07), and 0.56 for subjects with cumulative statins use ≥12 months (95% CI 0.41, 0.77), compared with those with no prior statin use. CONCLUSIONS: Current statin use is associated with reduced concurrent diagnosis of chronic osteomyelitis, particularly for a cumulative statin use ≥12 months.

Osteomielitis crónica no bacteriana: experiencia en un hospital terciario / Non-bacterial chronic osteomyelitis: Experience in a tertiary hospital

INTRODUCCIÓN: La osteítis crónica no bacteriana (OCNB) es una enfermedad autoinflamatoria que cursa con brotes de inflamación ósea en ausencia de aislamiento microbiológico. Su diagnóstico es de exclusión. El tratamiento se basaba en la utilización de antiinflamatorios no esteroideos (AINE) y esteroideos aunque cada vez con mayor frecuencia se utilizan bifosfonatos o fármacos contra el factor de necrosis tumoral α (anti-TNFα) con buenos resultados. El objetivo es revisar nuestra experiencia en el diagnóstico y tratamiento de estos pacientes. PACIENTES Y MÉTODOS: Revisión retrospectiva de las historias clínicas de los pacientes diagnosticados de OCNB entre 2008 y 2015 en un hospital terciario. RESULTADOS: De un total de 7 pacientes, 4 eran mujeres, con una mediana de edad de 10 años (RIQ 2). El motivo más frecuente de consulta fue dolor que interfería con el sueño en 5 pacientes. Seis presentaron lesiones multifocales al diagnóstico. En 6 se realizó biopsia ósea que demostró un infiltrado neutrofílico o linfocitario y esclerosis. Cuatro pacientes recibieron tratamiento antibiótico y AINE sin respuesta clínica. Cinco pacientes recibieron prednisona, consiguiéndose control sintomático que solo mantuvo uno tras su suspensión. Cinco recibieron bifosfonatos con remisión de la enfermedad en 3. Dos pacientes presentaron una respuesta insuficiente a pamidronato, por lo que recibieron terapia anti-TNFα (etanercept, infliximab o adalimumab) y se mantienen asintomáticos en la actualidad. CONCLUSIONES: Nuestra serie, aunque limitada, confirma la efectividad y seguridad de la terapia con bifosfonatos y fármacos biológicos en pacientes con OCNB

INTRODUCTION: Non-bacterial chronic osteomyelitis (NBCO) is an autoinflammatory disease that presents with recurrent bouts of bone inflammation in the absence of microbiological isolation. It is a diagnosis of exclusion. Its treatment was classically based on the use of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, although nowadays bisphosphonates or anti-tumour necrosis factor-α (anti-TNF) drugs are frequently used with good results. The objective of the study is to describe our experience in the diagnosis and treatment of patients with NBCO. PATIENTS AND METHODS: Retrospective chart review of patients with NBCO followed up in a tertiary centre between 2008 and 2015. RESULTS: A total of 7 patients with NBCO were recorded. Four were female and the median age was 10 years (IQR 2). The most common complaint was pain that interfered with sleep in 5 of the patients. Six patients had multifocal lesions at diagnosis. Bone biopsy demonstrated neutrophilic or lymphocytic infiltration and sclerosis in 6 patients. Four patients received antibiotics and NSAIDs without clinical response. Five received a short course of prednisone with an adequate control of symptoms, but only one of them maintained remission after corticosteroid suspension. Five patients received bisphosphonates with disease remission in 3 of them. The other 2 showed an inadequate response to pamidronate and were started on anti-TNF therapy (etanercept, infliximab or adalimumab), remaining asymptomatic at present. CONCLUSIONS: Our series, although limited, confirms the effectiveness and safety of bisphosphonate and anti-TNF therapy for children with NBCO

Prophylactic administration of a combined prebiotic and probiotic, or therapeutic administration of enrofloxacin, to reduce the incidence of bacterial chondronecrosis with osteomyelitis in broilers.

Bacteria entering the bloodstream via translocation from the gastrointestinal tract spread hematogenously and can trigger bacterial chondronecrosis with osteomyelitis (BCO) by infecting osteochondrotic microfractures in the epiphyseal-physeal cartilage of the proximal femora and tibiae. In experiment 1, broilers were fed control feed or the same feed containing BacPack 2X, which includes the prebiotic IMW50 (a mannan oligosaccharide beta-glucan yeast cell wall product) plus the probiotic Calsporin (Bacillus subtilis C-3102). Broilers reared on wire flooring consistently developed higher incidences of BCO than hatchmates reared on wood shavings litter (≥24 vs. ≤4%, respectively; P=0.001). Adding BacPack 2X to the feed on d 1 through 56 delayed the age of onset and reduced the cumulative incidence of BCO on wire flooring when compared with broilers fed the control feed (24.0 vs. 40.7%, respectively; P=0.003). In experiment 2, broilers reared on wire flooring received tap water on d 1 through 62 (control group) or therapeutic levels of the potent fluoroquinolone antimicrobial enrofloxacin in the water on d 35 through 54 (enrofloxacin group). During enrofloxacin administration, half as many birds developed BCO in the enrofloxacin group when compared with the control group (8.1 vs. 19.5%, respectively, on d 35 through 54; P=0.001), whereas both groups had similar BCO incidences subsequent to withdrawing enrofloxacin on d 55 through 62 (14.8 vs. 18.2% for the enrofloxacin vs. control groups; P=0.386). Cumulative lameness incidences for d 1 through 62 were higher for the control group than for the enrofloxacin group (39.0 vs. 25.8%, respectively; P=0.003). These results demonstrate that wire flooring imposes a rigorous challenge that leads to high incidences of BCO that can be difficult to suppress, even with therapeutic doses of enrofloxacin. Prophylactically adding BacPack 2X to the feed reduced the incidence of BCO lameness by a proportion similar to that achieved with enrofloxacin, indicating that probiotics potentially can provide effective alternatives to antibiotics for reducing BCO lameness attributable to bacterial translocation and hematogenous distribution.

Increased risk of coronary heart disease in patients with chronic osteomyelitis: a population-based study in a cohort of 23 million.

OBJECTIVES: Chronic inflammatory disease may trigger vascular atherosclerosis. This study aimed to determine whether chronic osteomyelitis (COM) is linked to an increased risk of coronary heart disease (CHD). METHODS: A national insurance claim dataset of more than 23 million enrolees was used to identify 15 054 patients with newly diagnosed COM and 60 216 randomly selected age-matched and gender-matched controls between 2001 and 2009 for comparing the risk and incidence of CHD. The study period was from the entry date to the first date of the following events: the diagnosis of CHD, death, withdrawal from the Taiwan National Health Insurance programme or the end of 2010. The analysis of the CHD risk was performed using Cox proportional hazards regression model. RESULTS: During a follow-up period of 67 927 person-years, the overall incidence rate of CHD in COM cohort was 1.95 times higher than non-COM cohort (16.66 vs 8.52 per 1000 person-years). After controlling age, gender and four comorbidities (hypertension, diabetes, hyperlipidaemia and stroke), the risk remained significantly higher in the COM cohort than the control group (adjusted HR=1.65, 95% CI 1.54 to 1.78, p<0.001). In age-stratified analysis, the younger population had a stronger association between COM and CHD risk than the elderly (from HR=3.42, 95% CI 1.60 to 7.32 in age <35 to HR 1.39, 95% CI 1.15 to 1.68 in age ≥80). CONCLUSIONS: This study demonstrates that COM is an independent risk factor for CHD, particularly in the younger population. Further studies are necessary to explore the underlying mechanisms linking COM and CHD.

Genetic analysis of glycopeptide-resistant Staphylococcus epidermidis strains from bone and joint infections.

Glycopeptide-resistant Staphylococcus epidermidis (GRSE) strains are of increasing concern in bone and joint infections (BJIs). Using multilocus sequence typing and multilocus variable-number tandem repeat analysis, we show that BJI-associated GRSE strains are genetically diverse but arise from related, multiresistant hospital sequence types (STs), mostly ST2, ST5, and ST23.

Clinical outcomes of osteomyelitis patients infected with methicillin-resistant Staphylococcus aureus USA-300 strains.

Methicillin-resistant Staphylococcus aureus (MRSA) USA-300 strains have emerged as an important cause of community-acquired infections. These strains have been recognized as an etiology of osteomyelitis but data on their incidence and outcomes are limited. We retrospectively studied the incidence and clinical outcomes of MRSA USA-300 osteomyelitis in patients at the University of Louisville Hospital and the Henry Ford Health System between January 2007 and March 2008. Pulsed-field gel electrophoresis was used to determine USA type. Clinical outcomes were defined as management success versus failure at 12 months. Chi-square tests, Fisher exact tests, and Mann-Whitney tests were used to compare patient characteristics on the basis of clinical outcomes and USA type. Of the 50 patients with MRSA osteomyelitis, 27 (54%) had the USA-300 strain. Clinical failure was identified in 22% (6/27) of the patients with MRSA USA-300 and in 30% (7/23) of the patients with MRSA non-USA-300 osteomyelitis (P = .509). Our results showed that MRSA USA-300 is a significant etiology of MRSA osteomyelitis. With current surgical and medical management, outcomes of patients with MRSA USA-300 osteomyelitis are similar to those of patients with MRSA non-USA-300 osteomyelitis.

Effects of antiresorptive agents on osteomyelitis: novel insights into the pathogenesis of osteonecrosis of the jaw.

The effects of antiresorptive agents (e.g., alendronate [Aln], osteoprotegerin [OPG]) on bone infection are unknown. Thus, their effects on implant-associated osteomyelitis (OM) were investigated in mice using PBS (placebo), gentamycin, and etanercept (TNFR:Fc) controls. None of the drugs affected humoral immunity, angiogenesis, or chronic infection. However, the significant (P < 0.05 vs. PBS) inhibition of cortical osteolysis and decreased draining lymph node size in Aln- and OPG-treated mice was associated with a significant (P < 0.05) increase in the incidence of high-grade infections during the establishment of OM. In contrast, the high-grade infections in TNFR:Fc-treated mice were associated with immunosuppression, as evidenced by the absence of granulomas and presence of Gram(+) biofilm in the bone marrow. Collectively, these findings indicate that although antiresorptive agents do not exacerbate chronic OM, they can increase the bacterial load during early infection by decreasing lymphatic drainage and preventing the removal of necrotic bone that harbors the bacteria.

The use of implantable bone stimulators in nonunion treatment.

Delayed or failure of bone healing in fracture, osteotomy, and arthrodesis patients continues to be a clinical dilemma. Electromagnetic stimulation is 1 modality demonstrated in many studies to aid bone healing; however, relatively few studies depict the use and complications associated with direct current implantable bone stimulators. Over a 9-year period, we studied a consecutive series of 120 adult patients who underwent implantation of a direct current bone stimulator. The goals of this study were to determine the time until healing, the presence of infection, and the need for additional nonunion surgery or salvage procedure following internal bone stimulator placement for nonunion treatment. Of the factors affecting the time until healing, tobacco smoking was a significant factor associated with increased time until healing. Tobacco smoking and duration of nonunion prior to implantable bone stimulator placement were both significant factors in the need for revision nonunion surgery or salvage procedure after implantable bone stimulator placement. Deep soft tissue infection or osteomyelitis was a significant factor predicting prolonged time to healing, subsequent infection following implantable bone stimulator placement, and the need for revision or salvage surgery. With the relative lack of complications directly attributable to electromagnetic implantable bone stimulators, their use may be an effective adjuvant to stable internal fixation and autogenous bone grafting in healing nonunions. However, the use of implantable bone stimulators in patients with nonunion prior to deep soft tissue infection or osteomyelitis exhibited an increased rate of postoperative infection in this study.

The utility and effectiveness of bone morphogenetic protein in foot and ankle surgery.

UNLABELLED: A review of the use of bone morphogenetic protein in 38 cases in 35 patients at high risk for bone healing complications following foot and ankle surgery was performed. Multiple relevant variables were analyzed with respect to the incidence of healing, including age; diabetes mellitus; Charcot neuroarthropathy; prior infection; type of procedure; and the use of femoral head allograft, electrical bone stimulation, and external fixation. The overall incidence of successful healing was 84.21%. A statistically significant decrease in the incidence of bone healing was observed if the patient was 50 years of age or older (P = .03), and all 16 patients younger than 50 years healed their index operation. If 60 years of age was the benchmark, a statistically significant decrease in the rate of healing was observed (P = .02). Logistic regression showed that a 10-year increase in age almost doubled the risk of not healing (odds ratio = 2.613). Furthermore, 4 (66.66%) of the 6 patients who did not heal had diabetes mellitus and were older than 60 years. This combination of risk factors was associated with a statistically significant decrease in the likelihood of bone healing (P < .01). Of the 10 cases to exhibit postoperative drainage, only 50% of these successfully healed, whereas 96% of the remaining 28 cases successfully healed (P = .0026). The results of this study demonstrate the utility of bone morphogenetic proteins in foot and ankle surgical patients at high risk for bone healing complications. LEVEL OF CLINICAL EVIDENCE: 2.

Role of hyperbaric oxygen therapy in the treatment of bacterial spinal osteomyelitis.

OBJECT: Hyperbaric oxygen therapy (HBO) is used as primary and/or adjunctive therapy in the treatment of various clinical conditions complicated by local hypoxia. It may have therapeutic potential in the treatment of neurosurgical infections such as spinal osteomyelitis that are associated with significant morbidity rates. The purpose of this study was to evaluate the efficacy of HBO therapy in the treatment of spinal osteomyelitis. METHODS: The clinical records of patients diagnosed with spinal osteomyelitis who received HBO therapy during their treatment at the authors' institution over the past 10 years were retrospectively reviewed. Six adult patients were identified. Four patients had recently undergone spinal surgery and secondary spinal osteomyelitis had developed. These patients received adjunctive HBO therapy due to significant comorbidities and risk factors for poor healing. RESULTS: All patients remained symptom and infection free over the subsequent follow-up period. Two patients had primary spinal osteomyelitis that had recurred despite a full course of appropriate antimicrobial therapy. Infection control was achieved after HBO therapy in 1 patient. The mean follow-up period for the study group was 2.9 years (range 5 months to 5 years). CONCLUSIONS: Hyperbaric oxygen therapy enabled infection cure in 5 of 6 patients with spinal osteomyelitis complicated by medical comorbidities or the failure of primary therapy. These results show that HBO may be a useful adjunctive therapeutic modality in the treatment of spinal osteomyelitis, particularly when there are medical comorbidities that increase the risk of poor healing. Hyperbaric oxygen therapy may also be beneficial in patients with relapsing primary spinal osteomyelitis after standard therapy has failed.