[Infected nonunion: diagnostic and therapeutic work-up]. / Infizierte Pseudarthrose: diagnostischer und therapeutischer Ablauf.

BACKGROUND: Septic nonunion is one of the major complications in fracture healing. The challenge is to identify the infection as the cause of nonunion first and then to achieve healing of the infection and the bone. OBJECTIVE: Because of the more heterogeneous appearance of an infected nonunion, the prevalence of germ detection in surgical nonunion revision is often underestimated. MATERIAL AND METHODS: In a retrospective study between 2010 and 2017, 86 patients with radiologically confirmed femoral shaft nonunion without clinical evidence and unremarkable medical history of a florid infection as the cause of nonunion, who had undergone primary single-stage surgical nonunion revision were analyzed. At least four intraoperatively obtained samples were evaluated for microbiological diagnosis. A distinction was made between tissue samples with subsequent 48­h short-term incubation and tissue samples with 14-day long-term cultivation. The finding "germ detection" was made if at least two of the samples demonstrated bacterial growth. RESULTS: In 18 of 86 patients with a nonunion preoperatively judged to be aseptic, positive bacterial evidence was obtained after short-term incubation. After long-term cultivation, positive bacterial detection was possible in 38 of 86 patients with a femoral shaft nonunion initially classified as aseptic. Regarding potential risk factors, the two groups demonstrated no relevant differences. In 29 patients, 1 pathogen was isolated from the obtained samples, whereas in the remaining 9 patients, a mixed culture with an average of 2.9 ± 0.5 different bacteria was detected. Identification revealed mainly low-virulence bacteria, most commonly Staphylococcus epidermidis. CONCLUSION: If the preoperative diagnostics including clinical, laboratory and radiological examination as well as a careful anamnesis reveal indications of a possible infectious event, the surgical nonunion revision should be performed in two stages with specimen collection before definitive nonunion revision. For microbiological diagnosis, several representative tissue samples should independently be obtained from the nonunion site and incubated for 14 days. Only in the absence of evidence of septic nonunion is a single-stage procedure suggested.

Actinomicosis ósea del antepié izquierdo. Presentación de un caso / Bone actinomycosis of the left forefoot. Presentation of a case

RESUMEN Se presentó el caso de una actinomicosis ósea, que se manifestó como una lesión de la piel en la zona correspondiente al segundo metatarsiano izquierdo. Por el antecedente de ser la paciente operada de un tumor de células gigantes, se pensó en una recidiva tumoral. Fue intervenida quirúrgicamente y se realizó exéresis del segundo metatarsiano y de la piel afectada. La biopsia informó actinomicosis. Se trató a la paciente con amoxicilina; evolucionando satisfactoriamente, y dando seguimiento en consulta (AU).

ABSTRACT The authors presented the case of a bone actinomycosis expressed as a skin lesion in the area of the second left metatarsals. Due to the antecedent of having undergone a surgery of a giant cell tumor, a tumor recurrence was thought. Surgical intervention was performed and the excision of the second metatarsals and affected skin was performed. The biopsy reported Actinomycosis. The patient was treated with amoxicillin. She had a satisfactory evolution and is still followed up in consultation (AU).

Osteoarticular infection in children.

AIMS: We aimed to describe the epidemiological, biological, and bacteriological characteristics of osteoarticular infections (OAIs) caused by Kingella kingae. METHODS: The medical charts of all children presenting with OAIs to our institution over a 13-year period (January 2007 to December 2019) were reviewed. Among these patients, we extracted those which presented an OAI caused by K. kingae and their epidemiological data, biological results, and bacteriological aetiologies were assessed. RESULTS: K. kingae was the main reported microorganism in our paediatric population, being responsible for 48.7% of OAIs confirmed bacteriologically. K. kingae affects primarily children aged between six months and 48 months. The highest prevalence of OAI caused by K. kingae was between seven months and 24 months old. After the patients were 27 months old, its incidence decreased significantly. The incidence though of infection throughout the year showed no significant differences. Three-quarters of patients with an OAI caused by K. kingae were afebrile at hospital admission, 11% had elevated WBCs, and 61.2% had abnormal CRPs, whereas the ESR was increased in 75%, constituting the most significant predictor of an OAI. On MRI, we noted 53% of arthritis affecting mostly the knee and 31% of osteomyelitis located primarily in the foot. CONCLUSION: K. kingae should be recognized currently as the primary pathogen causing OAI in children younger than 48 months old. Diagnosis of an OAI caused by K. kingae is not always obvious, since this infection may occur with a mild-to-moderate clinical and biological inflammatory response. Extensive use of nucleic acid amplification assays improved the detection of fastidious pathogens and has increased the observed incidence of OAI, especially in children aged between six months and 48 months. We propose the incorporation of polymerase chain reaction assays into modern diagnostic algorithms for OAIs to better identify the bacteriological aetiology of OAIs. Cite this article: Bone Joint J 2021;103-B(3):578-583.

Lytic lesion of skull: a rare presentation of chronic granulomatous disease.

An 18-month-old boy presented with lytic lesion of skull and recurrent abscesses with Serratia marcescens The extensive work up revealed a gene mutation confirming the diagnosis of chronic granulomatous disease (CGD). This case scenario underscores the importance of exploring the possibility of immunodeficiency if there is a history of recurrent abscesses with atypical organism. The case also demonstrates that CGD can present as lytic lesion of skull.

An innovative strategy to treat large metaphyseal segmental femoral bone defect using customized design and 3D printed micro-porous prosthesis: a prospective clinical study.

Five patients with segmental irregular-shaped bone defect of the femur were recruited in this study from 2017.12 to 2018.11. All patients were treated by customized design and 3D printed micro-porous prosthesis. And the procedure was divided into stages: radical debridement and temporary fixation (the first stage); the membrane formation and virtual surgery (intervening period for 6-8 weeks); definite reconstruction the defects (the second stage). Routine clinical follow-up and radiographic evaluation were done to assess bone incorporation and complications of internal fixation. The weight-bearing time and the joint function of the patients were recorded. The patients were followed up for an average of 16.4 months. The average length of bone defect and the distal residual bone was 12 cm and 6.5 cm. The average time of partial weight-bearing and full weight-bearing was 12.7 days and 2.6 months. X-ray demonstrated good osseous integration of the implant/bone interface. No complications occurred such as implant loosening, subsidence, loss of correction and infection. At the last follow-up, Harris score of hip joint was excellent in 2 cases, good in 2 cases, fair in 1 case; HSS score of knee joint was good in 4 cases, middle in 1 case. From our study, we concluded that meticulous customized design 3D printed micro-porous prosthesis combined with intramedullary nail may be a promising and an alternative strategy to treat metaphyseal segmental irregular-shaped femoral bone defect, especially for cases with massive juxta-articular bone loss.

Frequency of Multifocal Disease and Pyogenic Arthritis of the Hip in Infants with Osteoarticular Infection in Three Neonatal Intensive Care Units.

OBJECTIVE: To describe the clinical features of osteoarticular infection in infants cared for in neonatal intensive care units (NICUs) and to assess the presence of multifocal infection. STUDY DESIGN: Retrospective medical record review with structured data abstraction of infants with osteomyelitis or pyogenic arthritis or both in NICUs at 3 children's hospitals over a 29-year period. RESULTS: Of the 45 cases identified, 87% occurred in prematurely born infants, with a median gestational age of 27.4 weeks (IQR, 26, 31 weeks). Median postnatal age at diagnosis of infection was 33 days (IQR, 20, 50 days). Osteomyelitis was present without joint involvement in 53% and with joint involvement in 44% of cases. Methicillin-susceptible Staphylococcus aureus (71%) was the predominant pathogen, despite prevalent methicillin-resistant S aureus in community-associated infections. More than 1 bone was infected in 34% of cases. The femur (in 50% of patients) was the most frequently involved bone and the hip (in 20% of patients) was the most frequently involved joint. Bacteremia persisted for 4 or more days in 54% of patients with a positive blood culture despite active antimicrobial therapy. CONCLUSIONS: Among infants with osteoarticular infection in NICUs, multifocal disease is common and frequently is unsuspected. Search for additional sites of infection including the hip is warranted following the diagnosis of osteoarticular infection at a single site. Involvement of contiguous joints should be suspected in cases of osteomyelitis; conversely the presence of pyogenic arthritis usually indicates extant osteomyelitis in a contiguous bone.

Characteristics of Pyogenic Musculoskeletal Infections in Older Children and Adolescents.

The characteristics and clinical consequences of pyogenic bone and joint infections in older children and adolescents have received little attention. This study evaluated the presentation and complications of musculoskeletal infections involving the pelvis and extremities in children older than 10 years. Thirty patients 10 to 17 years old (mean, 12.7 years old) were treated for musculoskeletal infections. Mean time to diagnosis was 9.2 days. Prior to correct diagnosis, 83% were assessed by at least 1 outpatient provider. At the time of admission, 55% were weight bearing and 93% were afebrile. Twenty-eight percent had a multifocal infection. More than one-third had serious medical complications or orthopedic sequelae; compared with patients without complications, this group had a significantly higher admission C-reactive protein and longer hospital stay. Symptoms of musculoskeletal infection common among young children may be absent in adolescents. Axial imaging is recommended to identify adjacent or multifocal disease. The Kocher criteria are less sensitive for septic hip arthritis in the adolescent population. Prompt recognition and treatment are critical to avoid medical and musculoskeletal complications. [Orthopedics. 2020;43(4):e291-e298.].

Characteristics of Japanese patients with pustulotic arthro-osteitis associated with palmoplantar pustulosis: a multicenter study.

BACKGROUND: Pustulotic arthro-osteitis (PAO) is a major comorbidity of palmoplantar pustulosis (PPP), which is frequently seen in Japanese patients. To determine the characteristics of Japanese patients with PAO, we conducted a multicenter, retrospective epidemiologic survey at four university hospitals. METHODS: Clinical features including age, gender, duration of disease, extrapalmoplantar lesion, smoking habit, focal infection, site of joint pain, bone scintigraphy with Technetium99 , and therapies were retrospectively evaluated. RESULTS: In total, 165 patients with PAO were identified among 576 patients with PPP (28.6%). The male to female ratio was 1 : 3.7, and the mean age was 50.2 years. The mean disease duration of PAO was 6.0 years. Smoking habit was observed in 104 patients. Focal infection was detected in 74 patients, who developed tonsillar infection (n = 41), sinusitis (8), odontogenic infection (40), and others (2). Fifteen patients had multifocal infection. Technetium bone scintigraphy was performed in 97 cases. Increased uptake was most frequently observed in the sternocostoclavicular regions, followed by wrist and ankle, sacroiliac joint, knee and elbow, finger and toe, lumbar spine, thoracic spine, scapula, and thigh. Patients were mainly treated with nonsteroidal anti-inflammatory drugs, methotrexate, cyclosporine, antibiotics, and biologics, as well as tonsillectomy and dental treatment. CONCLUSION: PAO frequently involves the anterior chest wall of middle-aged women with smoking habit and is closely associated with focal infection.

Potential Clinical Effects of a Novel Rapid Diagnostic Panel for Pediatric Musculoskeletal Infections.

A direct-from-source rapid musculoskeletal diagnostic panel (MDP) was validated recently. We compared clinical measures to theoretical time points had MDP results been available. The MDP would have significantly decreased the time to pathogen identification (7 hours), time to definitive antimicrobial therapy (22 hours), and hospital length of stay (26.4 hours).

Development and challenges in setting up an international bone infection registry.

INTRODUCTION: Osteomyelitis is an increasing burden on the society especially due to the emergence of multiple drug-resistant organisms. The lack of a central registry that prospectively collects data on patient risk factors, laboratory test results, treatment modalities, serological analysis results, and outcomes has hampered the research effort that could have improved and provided guidelines for treatments of bone infections. The current manuscript describes the lessons learned in setting up a multi-continent registry. MATERIALS AND METHODS: This multicenter, international registry was conducted to prospectively collect essential patient, clinical, and surgical data with a 1-year follow-up period. Patients 18 years or older with confirmed S. aureus long bone infection through fracture fixation or arthroplasty who consented to participate in the study were included. The outcomes using the Short Form 36 Health Survey Questionnaire (version 2), Parker Mobility Score, and Katz Index of Independence in Activities of Daily Living were assessed at baseline and at 1 month, 6 months, and 12 months. Serological samples were collected at follow-ups. RESULTS: Contract negotiation with a large number of study sites was difficult; obtaining ethics approvals were time-consuming but straightforward. The initial patient recruitment was slow, leading to a reduction of target patient number from 400 to 300 and extension of enrollment period. Finally, 292 eligible patients were recruited by 18 study sites (in 10 countries of 4 continents, Asia, North and South America, and Central Europe). Logistical and language barriers were overcome by employing courier service and local monitoring personnel. CONCLUSIONS: Multicenter registry is useful for collecting a large number of cases for analysis. A well-defined data collection practice is important for data quality but challenging to coordinate with the large number of study sites.

Musculoskeletal Infection in Pediatrics: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection.

The Second International Consensus Meeting (ICM) on Musculoskeletal Infection was held in July 2018 in Philadelphia, Pennsylvania. This meeting involved contributions from an international multidisciplinary consortium of experts from orthopaedic surgery, infectious disease, pharmacology, rheumatology, microbiology, and others. Through strict delegate engagement in a comprehensive 13-step consensus process based on the Delphi technique, evidence-based consensus guidelines on musculoskeletal infection were developed. The 2018 ICM produced updates to recommendations from the inaugural ICM that was held in 2013, which primarily focused on periprosthetic infection of the hip and the knee, and added new guidelines with the expansion to encompass all subspecialties of orthopaedic surgery. The following proceedings from the pediatrics section are an overview of the ICM consensus recommendations on the prevention, diagnosis, and treatment of pediatric musculoskeletal infection.

Afectación osteoarticular por Streptococcus pneumoniae tras la autorización de las vacunas conjugadas / Osteoarticular infections caused by Streptococcus pneumoniae since authorization of conjugate vaccines

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Calcium hydroxyapatite deposition disease: Imaging features and presentations mimicking other pathologies.

OBJECTIVE: Calcium hydroxyapatite depositional disease (HADD) is usually asymptomatic and self-limiting; however, when there is an associated inflammatory process or HADD occurs in an unusual location, it may mimic trauma, infection, or neoplasm. The purpose of this article is to review the imaging features of HADD and how to distinguish it from more worrisome entities that can have similar appearances. CONCLUSION: An understanding of the presentations of HADD is important to allow early and confident diagnosis. In particular, familiarity with presentations that resemble more ominous pathologies is essential to avoid costly and time-consuming workup or intervention.

Prevalencia de infecciones osteoarticulares por enterobacterias productoras de ß-lactamasas de espectro extendido / Prevalence of osteoarticular infections by Enterobacteria producing extended-spectrum ß-lactamases

Resumen: Introducción: Las infecciones por enterobacterias productoras de β-lactamasas de espectro extendido (BLEEs) ocasionan una gran carga a los sistemas de salud. Poco se conoce de las infecciones osteoarticulares, por lo que este trabajo estudió la prevalencia de estas infecciones en un hospital de tercer nivel. Material y métodos: Estudio de prevalencia en pacientes de un servicio de traumatología durante 2016, con criterios de infección proporcionados por el CDC de Atlanta, Georgia. Se utilizó el sistema VITEK® 2 AST-N272 (bioMérieux) para la identificación bacteriana a nivel de especie y para las pruebas de susceptibilidad antimicrobiana. Resultados: Se reportaron 7.85% (n = 86) con infecciones osteoarticulares; 22.09% (n = 19) fueron por enterobacterias BLEEs. Con un promedio de 77.1 días de hospitalización (DE 37.7) (46-200 días); el aislamiento del microorganismo se produjo 15 días posteriores al ingreso; 16 (84.2%) pacientes presentaron osteomielitis, tres (15.8%) tuvieron infección protésica de rodilla o cadera. El promedio de días de tratamiento fue de 60 días (21-129 días); 18 pacientes (94.7%) fueron dados de alta con resolución de su cuadro infeccioso; un paciente falleció con infección sobreagregada por neumonía debida a K. pneumoniae resistente a carbapenémicos. Discusión: La prevalencia de infecciones osteoarticulares por enterobacterias BLEEs no se pudo calcular con precisión, pero consideramos que se encuentra dentro de lo esperado, las medidas de control de infecciones requieren tener estándares más elevados y falta desarrollar programas de uso racional de antimicrobianos para controlar la aparición de estas patologías.

Abstract: Introduction: Infections of enterobacteria producing extended-spectrum ß-lactamases place a heavy burden on health systems. Little is known in osteoarticular infections, so this work studied the prevalence of these infections in a third-level hospital. Material and methods: Prevalence study in patients of a Traumatology Service during 2016, with infection criteria provided by the CDC in Atlanta, Georgia. The VITEK® 2 AST-N272 (bioMérieux) system was used for bacterial identification at the species level and for antimicrobial susceptibility tests. Results: 7.85% (n = 86) were reported with osteoarticular infections; 22.09% (n = 19) were by enterobacteria BLEEs. An average of 77.1 days of hospitalization (SD 37.7) (46-200 days); isolation of the microorganism occurred 15 days after entry. Sixteen (84.2%) patients had osteomyelitis, three (15.8%) had a prosthetic knee or hip infection. The average number of treatment days was 60 days (21-129 days). Eighteen patients (94.7%) were discharged with resolution of their infectious picture; one patient died with infection over aggregated pneumonia due to carbapenem-resistant K. pneumoniae. Discussion: The prevalence of osteoarticular infections by enterobacteria BLEEs could not be accurately calculated, but we consider it to be within what is expected, infection control measures require higher standards and there is a lack of development programs to use antimicrobials rationally to control the emergence of these pathologies.

What Is the Optimal Method to Perform Bone Biopsy (Method, Location, Imaging Use) for Patients With Foot and Ankle Infections?

RECOMMENDATION: A bone biopsy should generally be performed in a percutaneous fashion, particularly in cases where surgical debridement is not considered necessary. If surgical debridement is considered necessary, then an open biopsy can be performed as part of the debridement. Percutaneous biopsy should be performed under sterile conditions by an interventional radiologist or other physician trained in image-guided techniques. The location of the biopsy will depend upon the clinical and radiographic evaluations, with a goal of maximizing the yield of the biopsy while minimizing the risk of injury to surrounding and/or overlying soft tissue structures. LEVEL OF EVIDENCE: Consensus. DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Microbiological Diagnosis of Skeletal System Infections in Children.

BACKGROUND: If not timely diagnosed and adequately treated, skeletal system infections in children may result in severe and permanent disability. Prompt identification of the etiology of the disease and determination of its antibiotic susceptibility are crucial for the successful management of septic arthritis, osteomyelitis, and spondylodiscitis. However, the bacteriological diagnosis of these infections has been traditionally limited by the low yield of conventional cultures and, on average, one-third of cases of pediatric joint and bone infections remained unconfirmed. OBJECTIVE: To review the medical literature to summarize the current approach diagnosing the pediatric skeletal system infections. METHODS: The relevant publications for the last three decades were reviewed. RESULTS: In recent years, the detection of skeletal system pathogens has been revolutionized by the use of improved laboratory methods, including seeding of synovial fluid and bone exudates into blood culture vials, and the development and implementation of sensitive nucleic acid amplification assays. These advances have resulted in the recognition of Kingella kingae as the predominant etiology of hematogenous infections of bones, joints, intervertebral discs and tendon sheaths in children aged 6-48 months, and reduced the fraction of culture-negative osteoarthritis. CONCLUSION: As the exudate and tissue samples obtained from young children with skeletal system infections are frequently insufficient for a comprehensive laboratory workup, physicians should take in consideration the patient's age, predisposing medical conditions and possible exposure to zoonotic organisms, and use a judicious combination of Gram's stain, culture on blood culture vials, and molecular tests to maximize the microbiological diagnosis of these diseases.

Acute spinal implant infection treated with debridement: does extended antibiotic treatment improve the prognosis?

The study aims to determine whether 8 weeks of antibiotics is non-inferior to 12 weeks in patients with acute deep spinal implant infection (SII). In the retrospective study of all SII cases (2009-2016), patients aged ≥ 15 years with microbiologically confirmed SII treated with debridement and implant retention were included. Whenever possible, tailored antibiotic treatment was used: rifampin/linezolid in gram-positive and quinolones in gram-negative infection. Patients were divided into short treatment course (8 weeks, ST group) and extended treatment (12 weeks, ET group). Primary outcome measure was percentage of cures at 1-year follow-up. One-hundred-twenty-four patients considered, 48 excluded based on the above criteria, leaving 76 patients, 28 ST and 48 ET. There were no differences in patient age, comorbidities, underlying pathologies, infection location, or surgery characteristics between groups. Surgery-to-debridement time was similar (18.5-day ST vs. 19-day ET; P = 0.96). Sixteen SII cases (21.1%) occurred with bloodstream infection. Pathogens found were Enterobacteriaceae (35, 46.1%), Staphylococcus aureus (29, 38.2%), coagulase-negative staphylococci (12, 15.8%), Pseudomonas aeruginosa (12, 15.8%), and Enterococcus faecalis (7, 9.2%). Twenty seven (35.5%) had polymicrobial infection. E. faecalis was more frequent in the ST group (7, 25% vs. 0; P < 0.001), and P. aeruginosa in ET (1, 3.6% vs. 11, 22.9%; P = 0.05). Five patients died of causes unrelated to SII. At 1-year follow-up, cure rates (21/26 ST, 80.8% vs. 39/45 ET, 86.7%; P = 0.52) and recurrences (2/26, 7.7% vs. 2/45, 4.4%; P = 0.62) were similar. Eight-week antimicrobial courses were not inferior to 12 weeks in patients with acute deep SII treated with prompt debridement, proper wound healing, and optimized antibiotics.

Challenges in diagnosis of spinal epidural abscess: A case report.

RATIONALE: Spinal epidural abscess (SEA) is a rare condition that shows a high prevalence in immunocompromised patients. The clinical presentation of SEA includes the "classic triad" of pain, fever, and neurological dysfunction. However, these nonspecific features can lead to a high rate of misdiagnosis. SEA may lead to paralysis or even death; thus, prognosis of these patients remains unfavorable. PATIENT CONCERNS: We report a case of a multilevel (T6-T12) SEA in a 22-year-old woman. DIAGNOSIS: The patient was initially diagnosed with spinal tuberculosis at a local hospital based on a history of tuberculosis exposure, as well as radiography and computed tomography. Histopathological examination of the tissue resected during laminectomy confirmed the diagnosis of SEA in this patient. INTERVENTIONS: The patient underwent multilevel laminectomy combined with long-term antibiotic therapy. OUTCOMES: Physical examination performed 16 months postoperatively revealed that superficial and deep sensation was restored to normal levels in the lower extremities with improvement in the patient's motor function (muscle strength 2/5). LESSONS: This case report indicates that whole spine magnetic resonance imaging is warranted in patients with SEA and that prompt surgical intervention is important at symptom onset. Long-term antibiotic therapy is also essential postoperatively.