Clinical features and outcomes in children with bone and joint infections of the ankle or foot.

BACKGROUND: The foot and ankle are uncommon sites of bone and joint infections (BJIs) in children. The objectives of the present study were to determine the clinical and bacteriologic features of BJIs and to assess any associated complications and orthopedic sequelae. METHODS: We performed a retrospective, single-center study of children treated for foot or ankle BJIs between 2008 and 2018 in a French university medical center. A total of 23 children were included. The median age at diagnosis was 9.1 years. Osteomyelitis was noted in 14 cases; it involved the calcaneus in seven cases, the distal fibula in four cases, the first metatarsal in two cases, and the distal tibia in one case. Arthritis affected the ankle in six cases and the cuneiform-cuboidal joint in one case. In two cases, osteoarthritis of the ankle was associated with distal osteomyelitis of the tibia. Clinical, radiological, and bacteriological parameters, surgical procedures, complications, and sequelae were recorded and analyzed. RESULTS: The median (range) time to diagnosis was 3.18 days (0-10), and trauma was reported in four cases. Fever was present on admission in 18 cases, and the serum C-reactive protein level was elevated in 22 cases. Standard X-rays showed osteolysis in one case and bone sequestration in another. Staphylococcusaureus was identified in 10 cases. Surgery was performed in 17 cases. A subperiosteal abscess that required surgical drainage complicated 10 cases of osteomyelitis. No recurrence was observed. At the last follow-up, the median (range) age was 11.9 years (1.5-19). Sequelae (spontaneous tibia-talus fusion, first metatarsal epiphysis fusion, and varus deformity of the hindfoot) were observed in three cases, all of which were initially complicated by an abscess. CONCLUSION: Physicians should be aware that pediatric BJIs of the lower limb may involve the foot and ankle. S. aureus is frequently involved. In cases of osteomyelitis, complications are closely associated with subperiosteal abscesses justifying an early diagnosis. These BJIs must be treated rapidly, and the risk of sequelae justifies long-term follow-up.

Acute osteomyelitis of the distal fibula in children: Treatment options and long-term follow-up.

INTRODUCTION: Acute osteomyelitis of the distal fibula is a rare disease in children and is characterized by special features compared with other sites. The objective of this study was to report the functional outcome at long-term follow-up. METHODS: We reviewed retrospectively, between January 2000 and December 2010, all cases of acute osteomyelitis of the distal fibula. Epidemiological and bacteriological data as well as therapy and outcome factors were analyzed. At the last follow-up, functional outcome was studied based on ankle motion, growth disturbance, and radiological sequelae. RESULTS: Seven cases of acute osteomyelitis of the distal fibula were found. The mean age was patients was 7.71 years and the sex ratio was 2.5. The portal of entry of the pathogen was a skin injury in 57% of cases. Staphylococcusaureus was identified in 71% of cases. The mean duration of antibiotic therapy was 33.2 days. At a mean of 12.85 years of follow-up, no growth disturbance was found. The mean plantar and dorsal flexion was 41° and 27.7°, respectively. The mean postoperative American Orthopedics Foot and Ankle score (AOFAS) was 96.71 points. CONCLUSION: Acute osteomyelitis of the distal fibula in children is scarce and rarely reported in the literature. It occurs more often in boys at an average age of 7 years. Local symptoms are usually more obvious than general symptoms. Surgical debridement of the subperiosteal abscess without bone trepanation seems to lead to a satisfactory outcome. LEVEL OF EVIDENCE: Level IV - case series. IRB: Sahloul Hospital Human Research Ethics Committee.

Early outcome of culture-negative infection in open fractures of the lower limb: A prospective study.

Background: Culture-negative infections in open long bone fractures are frequently encountered in clinical practice. We aimed to identify the rate and outcome of culture-negative infections in open long bone fractures of lower limb. Methodology: A prospective cohort study was conducted from November 2015 to May 2017 on Gustilo and Anderson Grade III open long bone fractures of the lower limb. Demographic data, injury details, time from injury to receiving antibiotics and index surgical procedure were noted. Length of hospital stay, number of additional surgeries and occurrence of complications were also noted. Patients with infected open fractures were grouped as culture positive or culture negative depending on the isolation of infecting microorganisms in deep intraoperative specimen. The clinical outcome of these two groups was statistically analysed. Results: A total of 231 patients with 275 open fractures involving the femur, tibia or fibula were studied. There was clinical signs of infection in 84 patients (36.4%) with 99 fractures (36%). Forty-three patients (51.2%) had positive cultures and remaining 41 patients had negative cultures (48.8%). The rate of culture-negative infection in open type III long bone fractures in our study was 17.7%. There was no statistical difference in the clinical outcome between culture-negative and culture-positive infections. Conclusion: Failure to identify an infective microorganism in the presence of clinical signs of infection is routinely seen in open fractures and needs to be treated aggressively.

Comparative Genomics Study of Staphylococcus epidermidis Isolates from Orthopedic-Device-Related Infections Correlated with Patient Outcome.

Staphylococcus epidermidis has emerged as an important opportunistic pathogen causing orthopedic-device-related infections (ODRI). This study investigated the association of genome variation and phenotypic features of the infecting S. epidermidis isolate with the clinical outcome for the infected patient. S. epidermidis isolates were collected from 104 patients with ODRI. Their clinical outcomes were evaluated, after an average of 26 months, as either "cured" or "not cured." The isolates were tested for antibiotic susceptibility and biofilm formation. Whole-genome sequencing was performed on all isolates, and genomic variation was related to features associated with "cured" and "not cured." Strong biofilm formation and aminoglycoside resistance were associated with a "not-cured" outcome (P = 0.031 and P < 0.001, respectively). Based on gene-by-gene analysis, some accessory genes were more prevalent in isolates from the "not-cured" group. These included the biofilm-associated bhp gene, the antiseptic resistance qacA gene, the cassette chromosome recombinase-encoding genes ccrA and ccrB, and the IS256-like transposase gene. This study identifies biofilm formation and antibiotic resistance as associated with poor outcome in S. epidermidis ODRI. Whole-genome sequencing identified specific genes associated with a "not-cured" outcome that should be validated in future studies. (The study has been registered at ClinicalTrials.gov with identifier NCT02640937.).

Ilizarov bone transport for the treatment of fibular osteomyelitis: a report of five cases.

BACKGROUND: The objective of this study was to evaluate the effectiveness of the treatment of fibular osteomyelitis by Ilizarov bone transport. METHODS: We retrospectively reviewed 5 patients with fibular osteomyelitis treated by Ilizarov bone transport. Our study included 4 males and 1 female with a mean of age 29.2 years. The average length of the bone defects after radical debridement was 7.6 cm (range 6.5-10 cm). RESULTS: The mean follow-up was 24.8 months (range 14-34 months). No patient was lost to follow-up. All the patients had bone union and no recurrence of infection was observed. The mean external fixation time was 8.8 months (range 8-10 months), and the mean external fixation index was 1.18 months/cm (range 0.90-1.43 months/cm). There was no sign of knee or ankle instability by clinical examination in all the patients. According to Association for the Study and Application of the Method of Ilizarov (ASAMI) classification, bone results were excellent in 3 patients, good in 2 patients; functional results were excellent in 3 patients, good in 2 patients. CONCLUSIONS: Our study suggested that Ilizarov bone transport may be a good choice for the treatment of fibular osteomyelitis, especially for the patient with distal fibular loss.

Osteological, biomolecular and geochemical examination of an early anglo-saxon case of lepromatous leprosy.

We have examined a 5th to 6th century inhumation from Great Chesterford, Essex, UK. The incomplete remains are those of a young male, aged around 21-35 years at death. The remains show osteological evidence of lepromatous leprosy (LL) and this was confirmed by lipid biomarker analysis and ancient DNA (aDNA) analysis, which provided evidence for both multi-copy and single copy loci from the Mycobacterium leprae genome. Genotyping showed the strain belonged to the 3I lineage, but the Great Chesterford isolate appeared to be ancestral to 3I strains found in later medieval cases in southern Britain and also continental Europe. While a number of contemporaneous cases exist, at present, this case of leprosy is the earliest radiocarbon dated case in Britain confirmed by both aDNA and lipid biomarkers. Importantly, Strontium and Oxygen isotope analysis suggest that the individual is likely to have originated from outside Britain. This potentially sheds light on the origins of the strain in Britain and its subsequent spread to other parts of the world, including the Americas where the 3I lineage of M. leprae is still found in some southern states of America.

Localized Histoplasma capsulatum osteomyelitis of the fibula in an immunocompetent teenage boy: a case report.

BACKGROUND: Infection of local bone with Histoplasma capsulatum is rare and difficult to diagnosis, and occurs particularly in immunocompetent subjects, who are more likely to be affected by a wide range of organisms. CASE PRESENTATION: An 11-year-old boy presented with localized histoplasmosis osteomyelitis in the left fibula without any evidence of abnormal immunological function or systemic disease. After surgical clearance of the lesion and homologous cancellous bone, the patient was treated orally with voriconazole for 6 months. The patient completely recovered with full function of his left leg during the 5-year follow-up. CONCLUSIONS: Histoplasmosis osteomyelitis can occasionally occur in immunocompetent individuals and can be complete cured by surgical clearance of the lesion and antibiotic treatment.

Isolated tubercular pseudotumour of lateral malleolus.

A 22-year-young adult presented with a painless swelling of distal fibula on right side for 3-month duration. He had no constitutional symptoms and there was full range of painfree ankle movement. Radiographs showed cortical breech with an osteolytic lesion in lateral malleolus. Magnetic Resonance Imaging showed T2W hyperintense signal in the distal fibula. It further revealed involvement of tendo Achilles and paroneal tendons. Fine needle aspiration cytology showed epitheloid granuloma and Langhans giant cells. The Mycobacterium tuberculosis DNA could be identified on polymerase chain reaction. The patient received 18 months of antitubercular treatment and the lesion subsided. There is no recurrence even after 3 years of follow up. A strong suspicion of tuberculosis should be considered in any bony swelling of a patient from endemic area, even at atypical sites. Polymerase chain reaction analysis should be performed in addition to radiological and histological examination of the lesion to establish the diagnosis. Early treatment with antitubercular therapy decreases the morbidity and avoids the possibility of surgical intervention.

Blastomycosis: Case report of an isolated lesion in the distal fibula.

Blastomycosis (Blastomyces dermatitidis) is a fungal infection that occurs primarily in the lungs, but 15% to 60% of patients with systemic blastomycosis have skeletal involvement. Because the symptoms and radiographic appearance of bony lesions are variable, diagnosis and treatment may be delayed if fungal infections are not included in the differential diagnosis for a patient with a lytic bone lesion. We present the case of a man in his late 30s with no local or systemic signs of infection in whom biopsy-curettage of a painful ankle lesion identified budding yeast consistent with North American blastomycosis. After treatment with itraconazole, the patient was symptom-free and had returned to his previous activities without pain or difficulty.

Early congenital syphilis with isolated bone involvement: a case report.

Congenital syphilis is the oldest recognized congenital infection and still represents a serious healthcare problem in the 21st century. It is important to be fully informed regarding the early diagnosis and treatment of congenital syphilis to prevent its devastating complications leading to death. In this manuscript, we report a newborn infant with unusual clinical findings of congenital syphilis such as a non-fluctuant mass surrounding the left calf. She did not have any additional system involvement such as hepatic or skin involvement or lymph nodes. To our best knowledge, there are only a few case reports presented with isolated bone involvement. This case demonstrates that congenital syphilis should be considered in neonates with bone fractures, lytic bone lesions and periostitis.

Tuberculous pseudotumor of the proximal end of the fibula. A case report.

A 72-year-old asian woman who had immigrated from Vietnam 10 years ago presented with a soft tissue mass around the proximal fibula. Conventional radiographs and magnetic resonance imaging demonstrated a destructive lesion of the head of the fibula with an intact superior tibiofibular joint and an abscess surrounding the destroyed bone. Histopathology obtained by a CT-guided needle biopsy revealed necrotizing epithelioid granulomata without demonstrating acid-fast bacilli. However, culture grew Mycobacterium tuberculosis. When tuberculosis affects the end of a long tubular bone, the adjacent synovial joint is usually involved. Cases where joint involvement does not occur are extremely rare and unusual. We report such a case.

Osteomyelitis of the fibula due to septic embolism: a rare complication of a graft enteric erosion. Case report.

We report the case of a 70-year-old female who experienced a graft enteric erosion (GEE) three years after a right aorto-femoral bypass. She was treated by right axillo-femoral bypass, removal of the aortic prosthesis and direct aortic suture. The duodenum was stitched up and separated from the aorta by omentoplasty. Bacteriological culture of the removed graft identified Escherichia coli and Peptostreptococcus. Antibiotic therapy consisting of Amoxicillin and Gentamycin was given for seven days. A month later this patient developed a fibula osteomyelitis due to the same germs. She was then treated by surgical excision of the infected tissues and by antibiotics: Amoxicillin, Metronidazole and Gentamycin for one month. This case of embolism into bone due to GEE is a rare complication which indisputably establishes a link between the spontaneously septic cavity of the bowel and bone tissue by way of blood via the interstices of the fabric. The prosthesis may be responsible for blood seeding infection and not only a mere victim. The prosthesis acts as a porous membrane which allows two opposite flows: the passage of blood from graft to bowel and germ migration from naturally septic bowel to blood. When a GEE is encountered, a rigorous management is required to prevent septic embolism. The precise timing of each step of the surgical procedure remains difficult to codify.

[Recurrent osteitis and Coxiella burnetii: the relation to chronic recurrent multifocal osteomyelitis]. / Ostéites récidivantes et Coxiella burnetti: relation avec l'ostéomyélite chronique récurrente multifocale.

UNLABELLED: Chronic recurrent multifocal osteomyelitis (CRMO) is a disorder of suspected--but unproved-infectious etiology. OBSERVATION: A girl presented with a typical CRMO involving successively the left fibula, radius, humerus and the right carpus. A Coxiella burnetii infection was indicated during the first attack. Two recurrences occurred in spite of suitable antibiotic treatment and with negative infectious investigation. Two months after stopping antibiotic treatment, a new recurrence associated with antibodies increase and positive bone culture occurred. CONCLUSION: Coxiella burnetii can initiate a CRMO. The mechanism involved is probably a delayed hypersensitivity. CRMO would therefore be the first type of reactive osteitis.

Experimental hematogenous osteomyelitis by Staphylococcus aureus.

To assess bone marrow lodgement of bacteria that produce osteomyelitis, 10(6) colony forming units of 16 nonhemolytic strains of Staphylococcus aureus was injected intravenously into mice. Eleven of 16 strains showed bone marrow lodgement without the death of mice. The M-138 strain induced osteomyelitis in 100% of the mice. Furthermore, the difference of compact colony forming active substance activity between bone marrow lodgement and nonlodgement strains was statistically significant. Compact colony forming active substance, which is an alkali stable polysaccharide located on the cell surface of Staphylococcus aureus strain, caused compact formation of the strains in serum soft agar or fibrinogen soft agar, and it clotted animal plasma. These results suggest that bacterial factors are important for bacterial lodgement at the onset of staphylococcal hematogenous osteomyelitis.

Salmonella typhi osteomyelitis in a nonsickle cell patient. A case report.

Few cases of osteomyelitis caused by Salmonella typhi in nonsickle cell patients have been reported. In a 33-year-old woman with a history of chronic, intermittent drainage of the right lower leg, roentgenographs indicated middiaphyseal osteomyelitis of the fibula. Bone cultures obtained at surgical debridement grew S. typhi. The patient responded adequately to four weeks of intravenous antibiotic therapy, and the infection has remained arrested after 18 months. The characteristics of S. typhi osteomyelitis are as follows: All reported cases have affected female patients with no apparent immunocompromise; all had a history of S. typhi infection with long bone involvement; and all had a tendency to recurrence.

Atypical mycobacterium osteomyelitis of the fibula.

Atypical mycobacterium osteomyelitis is rare. An 81 year old woman has been found to have an osteomyelitis of the upper end of the fibula due to mycobacterium avium complex. The occurrence may be related to advanced age and chronic respiratory disease. Treatment by surgery and drugs has been successful over two years of follow-up.

Chronic osteomyelitis located symmetrically to the fibular bones. A case report.

Osteomyelitis isolated to the fibular bones of a patient is described. Cultures from the infected tissue were negative. The patient was successfully treated with surgery.