Metodología de la gammagrafía con leucocitos marcados en el diagnóstico de infección osteoarticular protésica/no protésica: ¿análisis visual o semicuantitativo? ¿Protocolo de uno o 2 días? / Diagnostic methodology in labelled leukocyte scan for prosthetic / non-prosthetic osteoarticular infection: Visual or semi-quantitative analysis? One- or two-day protocol?

Objetivo: Como hay poca literatura sobre el tema, nos propusimos comparar la utilidad diagnóstica del análisis semicuantitativo versus el análisis visual en la escintigrafía de glóbulos blancos etiquetados (WBCS) para la infección osteoarticular. Se evaluaron protocolos de uno y dos días, en particular en los dispositivos ortopédicos.Material y métodos: Estudio prospectivo de 79 pacientes consecutivos con sospecha de infección osteoarticular. En todos los pacientes, la SCBM se realizó a los 30 min, 4 h, 8 h y 24 h. Las imágenes se analizaron agrupándolas en dos protocolos: protocolo de un día (los expertos evaluaron imágenes planas de 30 min, 4 h y 8 h) y protocolo de dos días (los expertos evaluaron imágenes planas de 30 min, 4 h y 24 h). Las imágenes planas se interpretaron cualitativa y semicuantitativamente y también se compararon agrupando a los pacientes con y sin dispositivos ortopédicos. Para determinar qué valor de corte de la variación porcentual podía predecir la infección osteoarticular, se calcularon múltiples valores de corte en ambos protocolos a partir del índice de Youden. Tres lectores ciegos analizaron las imágenes.Resultados: Comparando el diagnóstico final, el análisis visual del protocolo de un día proporcionó mejores resultados con una sensibilidad del 95,5%, una especificidad del 93% y una precisión diagnóstica del 93,7% (p < 0,01) que el protocolo de dos días con valores del 86,4%, 94,7% y 92,4%, respectivamente (p < 0,01). Para el análisis semicuantitativo, el protocolo de un día también obtuvo mejores resultados con una sensibilidad del 72,7%, una especificidad del 78,9% y una precisión del 77,2% (p < 0,01) que el protocolo de dos días (sin resultados significativos; p = 0,14), especialmente en el grupo de pacientes con aparatos ortopédicos (sensibilidad del 100%, especificidad del 79,5% y precisión del 82,7%; p < 0,01)

Objective: As scarce literature on the topic is available, we aimed to compare diagnostic utility of semi-quantitative versus visual analysis in labelled white blood cell scintigraphy (WBCS) for osteoarticular infection. One-day and two-day protocols were assessed, particularly in orthopaedic devices.Material and methods: Prospective study of 79 consecutive patients with suspected osteoarticular infection. In all patients, WBCS were performed at 30min, 4h, 8h and 24h. Images were analysed by grouping in two protocols: one-day-protocol (experts evaluated 30min, 4h and 8h planar images) and two-day-protocol (experts evaluated 30min, 4h and 24h planar images). Planar images were interpreted qualitative and semiquantitatively and also were compared grouping patients with and without orthopaedic devices. To find which cut-off value of the percentage variation could predict of osteoarticular infection, multiple cut-off values were calculated in both protocols from the Youden index. Three blinded readers analysed the images.Results: Comparing final diagnosis visual analysis of the one-day-protocol provided better results with sensitivity of 95.5%, specificity of 93% and diagnostic accuracy of 93.7% (P<.01) than the two-day-protocol with values of 86.4%, 94.7% and 92.4%, respectively (P<.01). For semi-quantitative analysis, the one-day-protocol also obtained better results with sensitivity of 72.7%, specificity of 78.9% and accuracy of 77.2% (P<.01) than two-day-protocol (no significant results; P=.14), especially in the group of patients with orthopaedic devices (sensitivity of 100%, specificity of 79.5% and accuracy of 82.7%; P<.01).Conclusions: Most accurate approach in the diagnosis of osteoarticular infection corresponded to visual analysis in one-day-protocol that showed greater sensitivity and specificity than semi-quantitative analysis. Semi-quantitative analysis only could be useful when visual analysis is doubtful

Evaluation of imaging features of pelvic echinococcosis based on multimodal images.

BACKGROUND: Hydatid disease (HD) is a zoonotic parasitic disease caused by the larvae of Echinococcus, It is mainly prevalent in pastoral areas. Bone echinococcosis is rare, accounting for 0.5 to 4.0% of all echinococcosis. It is likely to miss the diagnosis and misdiagnose due to non-specific early symptoms and the clinical manifestations and imaging features. The clinical data of 15 patients with pelvic cystic echinococcosis were analyzed retrospectively, and the X-ray, CT, and MRI imaging features of the disease were discussed, which are reported below. METHODS: All 15 patients underwent CT scan evaluation. A total of 8 patients underwent coronal, sagittal, and three-dimensional reconstruction with 3-mm-slice thickness, and 4 patients underwent X-ray plain film examination. Five cases underwent MRI scan. Eight cases underwent MRI or CT enhanced scan. RESULTS: X-ray plain film is characterized by continuous cystic bone destruction, irregular low-density shadow when invading soft tissue, and sometimes calcification which can be seen on the wall or inside the cyst. The involved sacroiliac joint or hip joint may narrow or disappear. The involvement of pelvic cystic echinococcosis is relatively wide, and 80% of patients with pelvic cysts in this group had multiple lesions in the same period. Cystic expansive bone destruction was the most common. Pelvic CT revealed a lobulated hypodense lesion of varying size with internal septae, causing cortical thinning and destruction. Most of them had no periosteal reaction. The iliopsoas muscle is most easily invaded. Single cystic echinococcosis of pelvis showed intermediate or low signal intensity on T1-weighted images and hyperintensity on T2-weighted images in the involved bone and surrounding soft tissue on MRI, and the cyst wall showed linear low signal in T1WI, T2WI, and STIR sequences. The polycystic type is characterized by multiple cysts of varying signal intensity (daughter cysts) within a larger cyst is the typical MRI finding, forming "small vesicles" high signal daughter cysts. Osteosclerosis or calcification showed low signal in T1WI and T2WI. CONCLUSIONS: The results of this study suggest that the lesions of pelvic cystic echinococcosis are mostly cystic expansive and osteolytic bone destruction, which is easy to invade the surrounding soft tissue, often accompanied with calcification; among them, multiple cystic lesions are characteristic.

[Masquelet technique combined with flap transplantation for infectious bone and soft tissue defects of lower leg].

OBJECTIVE: To investigate the effectiveness of Masquelet technique combined with flap transplantation in treatment of infectious bone and soft tissue defects of the lower leg. METHODS: Between January 2013 and January 2017, 35 cases of infectious bone and soft tissue defects of lower leg were treated with Masquelet technique combined with flap transplantation. There were 21 males and 14 females, with an average of 31.5 years (mean, 25-55 years). All patients were tibial fractures caused by trauma and the infections occurred after debridement or internal fixation. The time from injury to admission was 1 to 6 months, with an average of 3.2 months. Defect located at the proximal leg in 11 cases, the middle leg in 11 cases, and the distal leg in 13 cases. The length of tibia defect after debridement ranged from 5.6 to 11.2 cm, with an average of 7.1 cm. The size of soft tissue defect ranged from 14.2 cm×6.9 cm to 17.3 cm×8.7 cm. Bacterial culture of purulent secretion of wound was positive in 18 cases. After debridement, the bone cement was used to fill the bone defect and the flap transplantation was used to repair the wound. The bone cement was taken out at 8 to 12 weeks after the one-stage operation, and the bone defect was repaired with autogenous iliac bone or combined with artificial bone. RESULTS: Three cases had necrosis at the distal edge of the flap after one-stage operation, and survived after dressing change. The other flaps survived successfully, and the wounds healed by first intention. All incisions healed by first intention after two-stage operation. All patients were followed up 24-32 months, with an average of 27 months. The color of the flap was similar to that of the surrounding normal tissue, and its texture was good. X-ray reexamination showed that all bone defects healed after 6-8 months, with an average of 6.7 months. At 9 months after two-stage operation, according to the revised Edwards tibial fracture evaluation standard, 19 cases were excellent, 14 cases were good, and 2 cases were poor, the excellent and good rate was 94.3%. The American Orthopedic Ankle Association (AOFAS) score was 60-98, with an average of 81.3. And 21 cases were excellent, 11 were good, and 3 were fair, with an excellent and good rate of 91.4%. CONCLUSION: Masquelet technique combined with flap transplantation is an effective treatment for infectious bone and soft tissue defects of lower leg.

A Rare Case of Chromoblastomycosis in a 12-year-old boy.

Chromoblastomycosis is a chronic fungal infection of the subcutaneous tissue. The infection usually results from a traumatic injury and inoculation of the microorganism by a specific group of dematiaceous fungi, resulting in the formation of verrucous plaques. The fungi produce sclerotic or medlar bodies (also called muriform bodies or sclerotic cells) seen on direct microscopic examination of skin smears. The disease is often found in adults due to trauma. We report a case of chromoblastomycosis in a 12-year-old child in whom the infection started when he was only 4 years old with secondary involvement of bones, cartilage, tongue and palatine tonsils. The child was not immunosuppressed.

Microwaves increase the effectiveness of systemic antibiotic treatment in acute bone infection: experimental study in a rat model.

BACKGROUND: Osteomyelitis is a challenge for orthopedic surgeons due to its protracted treatment process. Microwaves (MWs) can increase blood perfusion due to their thermal effect. Furthermore, MWs demonstrated significant bactericidal effects in vitro. In the present study, we assumed that the application of a 2450-MHz-frequency MW together with systemic antibiotic treatment would provide synergy for the treatment of acute osteomyelitis. METHODS: The medullary cavity of the right tibia was inoculated with 107 CFU of methicillin-sensitive Staphylococcus aureus (MSSA-ATCC 29213) in 40 rats, and the rats were randomly divided into four groups according to treatment: group I, saline (control); group II, saline + MW therapy; group III, systemic cefuroxime; and group IV, systemic cefuroxime + MW therapy. MWs were applied for 20 min per day to the infected limbs, and all rats were sacrificed on the 7th day. The severity of tibial osteomyelitis was assessed by quantitative culture analysis. RESULTS: Bacterial counts in groups III and IV were significantly reduced compared with those in the control (p = 0.001 and < 0.001, respectively). Furthermore, significant differences were detected between groups III and IV (p = 0.033). However, the difference between groups I and II was nonsignificant (p = 0.287). CONCLUSION: Our experimental model suggests that MW therapy provides a significant synergy for systemic antibiotic treatment. However, further clinical trials are required to safely use this treatment modality in patients.

Diagnosis of peripheral bone and prosthetic joint infections: overview on the consensus documents by the EANM, EBJIS, and ESR (with ESCMID endorsement).

OBJECTIVES: Peripheral bone infection (PBI) and prosthetic joint infection (PJI) are two different infectious conditions of the musculoskeletal system. They have in common to be quite challenging to be diagnosed and no clear diagnostic flowchart has been established. Thus, a conjoined initiative on these two topics has been initiated by the European Society of Radiology (ESR), the European Association of Nuclear Medicine (EANM), the European Bone and Joint Infection Society (EBJIS), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). The purpose of this work is to provide an overview on the two consensus documents on PBI and PJI that originated by the conjoined work of the ESR, EANM, and EBJIS (with ESCMID endorsement). METHODS AND RESULTS: After literature search, a list of 18 statements for PBI and 25 statements for PJI were drafted in consensus on the most debated diagnostic challenges on these two topics, with emphasis on imaging. CONCLUSIONS: Overall, white blood cell scintigraphy and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities for the diagnosis of PBI and PJI. However, the choice of which advanced diagnostic modality to use first depends on several factors, such as the benefit for the patient, local experience of imaging specialists, costs, and availability. Since robust, comparative studies among most tests do not exist, the proposed flowcharts are based not only on existing literature but also on the opinion of multiple experts involved on these topics. KEY POINTS: • For peripheral bone infection and prosthetic joint infection, white blood cell and magnetic resonance imaging have individually demonstrated the highest diagnostic performance over other imaging modalities. • Two evidence- and expert-based diagnostic flowcharts involving variable combination of laboratory tests, biopsy methods, and radiological and nuclear medicine imaging modalities are proposed by a multi-society expert panel. • Clinical application of these flowcharts depends on several factors, such as the benefit for the patient, local experience, costs, and availability.

Copper Bead Therapy in Severe Bone Infection: A Rabbit Tibial Model.

OBJECTIVE: We investigated the benefits of a local preventive therapy based on copper beads against severe bone infection using a rabbit open tibial fracture model. MATERIALS AND METHODS: Cotton mesh balls soaked in a very high concentration of Staphylococcus aureus ATCC 6538 culture were inoculated in drilled holes of the tibiae of treated and control groups. The treated group was also implanted with small copper beads simultaneously, as prevention therapy. RESULTS: Survival rate in the treated group was 67% compared with 25% in the control group (difference 40%, for a 95% confidence interval: 40%, 93.4%). The few remaining animals in the control group had bone lesions which developed into osteomyelitis, while the tibiae of treated group had clear signs of reparatory processes. Sixty days after inoculation, signs of local-only toxicity were observed in healthy tibia of a separate non-infected control group. Drawbacks of copper toxicity were weighed against the threat of septicaemia and also against prolonged use of powerful systemic antibiotic medications in severe bone contamination. CINICAL SIGNIFICANCE: It was found that the proposed therapy prevented septicaemia and the spread of infection, and it also induced reparatory processes. The findings of this study may be relevant in antisepsis of open fractures in less appropriate medical settings (such as military camps or remote locations), as well as in severe bone infections.

Protocolo de un día vs protocolo de dos días de adquisición mediante gammagrafía con leucocitos marcados in vitro para el diagnóstico de infección osteoarticular / One-day protocol versus two-day protocol in acquisition of scintigraphy with "in vitro" labelled white blood cells for diagnosis of osteoarticular infection

Introducción: Resulta difícil determinar la infección osteoarticular y diferenciar entre inflamación e infección mediante procedimientos de laboratorio e imagen (TC, RM, US). La gammagrafía con leucocitos marcados (GLM) constituye la prueba de medicina nuclear de elección, pero su duración es de dos días, y a veces es difícil diferenciar entre tejido blando e infección, por lo que se produce una variabilidad interobservador que hace disminuir su especificidad. Objetivo: Demostrar la utilidad del protocolo de un día de GLM con corrección por decaimiento del tiempo de adquisición para diagnosticar la infección osteoarticular y reducir la variabilidad interobservador. También se evaluó la función de SPECT/TC en GLM en la localización del foco de infección. Métodos: Se estudiaron prospectivamente 110 pacientes con sospecha de infección osteoarticular. Se obtuvieron imágenes planares con corrección por decaimiento del tiempo de adquisición a 30min, 4h, 8h y 24h. Las imágenes planares de GLM se agruparon en dos protocolos: Protocolo de un día: los expertos evaluaron imágenes de 30min, 4h y 8h. Protocolo de dos días: los expertos evaluaron imágenes de 30min, 4h y 24h. Ambos protocolos fueron clasificados como: Negativos: ausencia de migración leucocitaria. Positivos: persistencia o incremento de la captación con el tiempo. Inflamación aséptica: disminución de la captación con el tiempo. La SPECT/TC se realizó en 72 pacientes. Se calculó el índice kappa para evaluar la variabilidad interobservador. Resultados: Se confirmó infección en 34 casos. Los valores de sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo y precisión diagnóstica fueron del 97,1, del 97,4, del 94,3, del 98,7 y del 97,3% para el protocolo de un día, y del 94,1, del 97,4, del 94,1, del 97,4 y del 96,4 para el protocolo de dos días, respectivamente. SPECT/TC contribuyó al diagnóstico en 45 de 50 pacientes con GLM planar positiva. Índice kappa: 0,8 para el protocolo de un día y 0,79 para el protocolo de dos días. Conclusión: El protocolo de un día de GLM con corrección por decaimiento del tiempo de adquisición y SPECT/TC permite el diagnóstico precoz y preciso de la infección osteoarticular

Introduction: It is difficult to determine osteoarticular infection and differentiate inflammation from infection with laboratory and imaging procedures (CT, MRI, US). Labelled white-blood-cell scintigraphy (WBCS) is the nuclear medicine test of choice but it takes two days, sometimes finds it difficult to differentiate soft tissue from bone infection and therefore causes interobserver variability, which decreases its specificity. Objective: To demonstrate the usefulness of the one-day protocol with time decay-corrected acquisition in WBCS to diagnose osteoarticular infection and to reduce interobserver variability. The role of SPECT/CT in WBCS in locating the infected focus was also evaluated. Methods: 110 patients with suspected osteoarticular infection were studied prospectively. Planar images were obtained with time decay-corrected acquisition at 30min, 4h, 8h and 24h. WBCS planar images were grouped in two protocols: One-day protocol: experts evaluated 30min, 4h and 8h images. Two-day protocol: experts evaluated 30min, 4h and 24h images. Both protocols were classified as: Negative: absence of leukocyte migration. Positive: uptake persisted or increased over time. Aseptic inflammation: uptake decreased over time. SPECT/CT was performed in 72 patients. Kappa index was calculated to evaluate interobserver variability. Results: Infection was confirmed in 34 cases. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 97.1%, 97.4%, 94.3%, 98.7%, and 97.3% for the one-day protocol and 94.1%, 97.4%, 94.1%, 97.4%, and 96.4% for two-days-protocol. SPECT/CT contributed to diagnosis in 45/50 patients with planar WBCS positive. Kappa index: 0.8 for one-day protocol and 0.79 for two-day protocol, respectively. Conclusion: One-day protocol with time decay-corrected acquisition WBCS and SPECT/CT enables early and accurate diagnosis of osteoarticular infection

Axial sesamoiditis in the horse: A review.

Axial sesamoiditis or osteitis of the proximal sesamoid bones (PSBs) in the horse is described as a rare condition. The cause remains unknown and speculative, with vascular, infectious, and traumatic aetiologies implicated. It is specifically associated with injury of the palmar or plantar ligament (PL), also known as the intersesamoidean ligament. Imaging findings are generally rewarding and radiological changes are typical, if not pathognomonic, for the condition. Lesions consist of bone lysis at the apical to mid-body axial margins of the PSBs, with variable degrees of joint effusion. Radiographic technique warrants careful attention to make a diagnosis, and exposure factors may need to be adjusted. Perineural, intra-articular and intra-thecal anaesthesia does not seem to provide consistent improvement of lameness in these cases, with literature reporting inconsistent findings. Ultrasonographic findings include digital flexor sheath effusion, loss of the normal fibre structure of the PL at its attachment to the PSBs, abnormal echogenicity or change in thickness of the PL, and irregular hyperechoic cortical margins of the axial margins of the PSBs. Scintigraphy, computed tomography and magnetic resonance imaging, although not necessary to make a diagnosis, may add valuable information regarding the location and extent of lesions. The prognosis remains guarded to poor for return to athletic function. The focus of this paper is a comprehensive review of the proposed aetiopathogenesis of the condition, the prognosis, and a summary of the literature findings with focus on the notable diagnostic imaging features, including radiography, ultrasonography, scintigraphy, computed tomography and magnetic resonance imaging.

High diagnostic accuracy of white blood cell scintigraphy for fracture related infections: Results of a large retrospective single-center study.

INTRODUCTION: White blood cell (WBC) scintigraphy for diagnosing fracture-related infections (FRIs) has only been investigated in small patient series. Aims of this study were (1) to establish the accuracy of WBC scintigraphy for diagnosing FRIs, and (2) to investigate whether the duration of the time interval between surgery and WBC scintigraphy influences its accuracy. PATIENTS AND METHODS: 192 consecutive WBC scintigraphies with 99mTc-HMPAO-labelled autologous leucocytes performed for suspected peripheral FRI were included. The golden standard was based on the outcome of microbiological investigation in case of surgery, or - when these were not available - on clinical follow-up of at least six months. The discriminative ability of the imaging modalities was quantified by several measures of diagnostic accuracy. A multivariable logistic regression analysis was performed to identify predictive variables of a false-positive or false-negative WBC scintigraphy test result. RESULTS: WBC scintigraphy had a sensitivity of 0.79, a specificity of 0.97, a positive predicting value of 0.91, a negative predicting value of 0.93 and a diagnostic accuracy of 0.92 for detecting an FRI in the peripheral skeleton. The duration of the interval between surgery and the WBC scintigraphy did not influence its diagnostic accuracy; neither did concomitant use of antibiotics or NSAIDs. There were 11 patients with a false-negative (FN) WBC scintigraphy, the majority of these patients (n = 9, 82%) suffered from an infected nonunion. Four patients had a false-positive (FP) WBC scintigraphy. CONCLUSIONS: WBC scintigraphy showed a high diagnostic accuracy (0.92) for detecting FRIs in the peripheral skeleton. Duration of the time interval between surgery for the initial injury and the WBC did not influence the results which indicate that WBC scintigraphy is accurate shortly after surgery.

Pyogenic infection of the hip joint as a complication of a femoral artery vascular access for percutaneous coronary intervention.

A rare case of clinical complication following a percutaneous coronary intervention is presented. A femoral vascular access was chosen to treat a coronary lesion with a stent implantation. This femoral vascular access, however, resulted in a pyogenic infection of the ipsilateral hip joint that was not properly diagnosed for an extended post-interventional period. The hip joint completely deteriorated before its underlying cause was identified. This case report illustrates the importance of recognizing potential endovascular complications independently of their frequency.

Diagnostic challenges in pyogenic spinal infection: an expanded role for FDG-PET/CT.

In a preliminary investigation of FDG-PET/CT for assessment of therapy response of pyogenic spine infection, it was concluded that activity confined to the margins of a destroyed or degenerated joint with bone-on-bone contact represents nonseptic inflammation, regardless of the intensity of uptake. Only activity in bone, soft tissue, or within the epidural space represents active infection. The purpose of this investigation was to assess the performance of these pattern-based interpretation criteria in a series of problem cases of proven or suspected spine infection. Eighty-two FDG-PET/CTs were done for initial diagnosis because other imaging failed to provide a definitive diagnosis and 147 FDG-PET/CTs were done to assess treatment responses. Pattern-based interpretations were compared with the clinical diagnosis based on bacterial cultures and outcomes after cessation or withholding of antibiotic therapy. Pattern-based interpretation criteria achieved a sensitivity and specificity of 98 and 100%, respectively, for initial diagnosis and a specificity of 100% for assessment of treatment response. The same data was analyzed using intensity of activity as the primary factor. Sensitivity and specificity using the intensity-based criteria were 93 and 68%, respectively, for initial diagnosis, and the specificity of a negative interpretation for therapy response was 55%. Differences from pattern-based criteria are highly significant. Pattern-based criteria perform well in problem cases with equivocal MR and for treatment response because they correctly eliminate activity from nonspecific inflammation associated with destroyed joints with bone-on-bone contact. Response occurs within a timeframe that is useful for managing antibiotic therapy.

Mandibular Coronoidectomy Could Significantly Accelerate the Healing Process of Infratemporal Fossa Abscess.

PURPOSE: Management of an infratemporal fossa abscess (IFA), which is a specific form of severe and advanced deep fascial space infection (DFI), is based mainly on traditional methods. The purpose of this study was to investigate the role of mandibular coronoidectomy in accelerating IFA healing. PATIENTS AND METHODS: This research is a single-center retrospective study composed of 23 patients with IFA. The predictor variables were gender, age, diabetes, severity score, and mandibular coronoidectomy. The outcome variables included hospitalization time (HT) and irrigating time (IT). A comparison of treatment outcomes between the improved and traditional surgical interventions for IFA was performed. RESULTS: Compared with patients who did not receive mandibular coronoidectomy (NC group; HT, 17.54 ± 1.80 days; IT, 38.54 ± 3.73 days), patients who underwent mandibular coronoidectomy (AC group) had significantly decreased HT (7.20 ± 1.19 days) and IT (15.10 ± 1.27 days; P < .01). In addition, 4 patients (31%) in the NC group received reoperation for osteomyelitis, whereas no osteomyelitis and DFI recurrence occurred in the AC group. CONCLUSIONS: Mandibular coronoidectomy with extra intraoral drainage could considerably accelerate the healing process of IFAs and obviously decrease the reoperation rate for osteomyelitis.

Treatment of infected non-unions of the femur and tibia in a French referral center for complex bone and joint infections: Outcomes of 55 patients after 2 to 11 years.

INTRODUCTION: An infected non-union is a major complication following bone fracture. While bone union can be obtained in 70% to 100% of cases, treatment of osteomyelitis is less predictable, with reported healing rates ranging from 40% to 100%. The primary aim of this study was to assess the success rate of treating infected non-unions of the tibia and femur by a team specializing in complex bone and joint infections. MATERIAL AND METHODS: This single-center retrospective study included all patients operated between 2002 and 2012 due to an infected non-union of the femur or tibia using standardized surgical methods. The procedure was typically done in two phases: excision of the infected site and stabilization, followed by bone reconstruction after a waiting period. Additional procedures (lavage and/or bone grafting) were performed in some cases. A minimum 6-week course of antibiotic therapy was given. The primary endpoint was successful medical and surgical treatment after a minimum 2 years' follow-up defined as healing of the infection (no local clinical signs of infection, ESR≤20mm and CRP≤10mg/L, no mortality attributed to the infection) and radiological and clinical bone union, with the lower limb spared. RESULTS: Fifty-five patients (39 men, 16 women) were included with an average age of 37±11 years. There were 40 tibial fractures and 15 femur fractures. A polymicrobial infection was present in 47% of cases. Repeat surgery was required in 56.4% of patients. At an average of 4±2 years from the first surgical procedure, the treatment was successful in 49 patients (89%): 36 tibia (90%) and 13 femur (87%). The mean time to union was 9±4 months. There were six failures: 3 amputations at 5, 6 and 16 months; 1 mechanical and infection-related failure; 2 failed union. CONCLUSION: This study found that 89% of patients with an infected tibial or femoral non-union treated by a team specialized in complex bone and joint infections using a standardized surgical protocol had bone union and healing of the infection in an average of 9 months. LEVEL OF EVIDENCE: IV, retrospective study.

Diagnostic Imaging and Invasive Fungal Diseases in Children.

Invasive fungal disease (IFD) is a life-threatening condition, especially in immunocompromised children. The role of diagnostic imaging in children at risk for an IFD is multifactorial, including initially detecting it, evaluating for dissemination of infection beyond the primary site of disease, monitoring the response to antifungal therapy, and assessing for potential relapse. The objective of this review was to synthesize the published literature relevant to the use of various imaging modalities for the diagnosis and management of IFD in children.