Osteomielitis crònica no bacteriana / Osteomielitis crónica no bacteriana / Chronic non-bacterial osteomyelitis

Introducció. L’osteomielitis crònica no bacteriana (OCNB)és una entitat poc freqüent en pediatria. Es tracta d’unamalaltia inflamatòria no infecciosa de l’os que sol cursaramb remissions i exacerbacions espontànies. Té una etiologia desconeguda. Sol presentar-se com un dolor ossisubagut, acompanyat o no de clínica sistèmica, i és necessari descartar altres causes, com la neoplàstica o la infecciosa. Les proves d’imatge donen suport al diagnòstic.Observació clínica. Es presenten dos casos de pacients ambdolor ossi insidiós a les extremitats inferiors de diversessetmanes d’evolució, amb alteració de la força i la mobilitat. Ambdós casos s’associen a anorèxia. L’analítica presenta elevació dels paràmetres inflamatoris, VSG (velocitatde sedimentació globular) i PCR (proteïna C reactiva). Lagammagrafia òssia i la ressonància magnètica nuclear permeten fer el diagnòstic d’OCNB. En ambdós casos es fatractament amb antiinflamatoris no esteroidals durant quatre setmanes, i es requereix l’addició de bifosfonats a causad’una resposta parcial.Comentaris. L’OCNB és una causa d’inflamació òssia en elsinfants en què un diagnòstic precoç i la instauració d’untractament efectiu permet evitar complicacions. És important tenir-la en compte en fer el diagnòstic diferencial deldolor ossi insidiós. Un coneixement millor en pot disminuirl’infradiagnòstic. (AU)

Introducción. La osteomielitis crónica no bacteriana (OCNB) esuna entidad poco frecuente en pediatría. Se trata de una enfermedad inflamatoria no infecciosa del hueso que suele cursar conremisiones y exacerbaciones espontáneas. Su etiología es desconocida. Suele presentarse como un dolor óseo subagudo, acompañado o no de clínica sistémica, y es necesario descartar otrascausas como la neoplásica o la infecciosa. Las pruebas de imagenapoyan el diagnóstico.Observación clínica. Se presentan dos casos de pacientes con doloróseo insidioso en extremidades inferiores de varias semanas de evolución con alteración de la fuerza y la movilidad. Ambos casosse asocian a anorexia. A nivel analítico presentan elevación de losparámetros inflamatorios, VSG (velocidad de sedimentación globular) y PCR (proteína C reactiva). La gammagrafía ósea y la resonancia magnética nuclear permiten realizar el diagnóstico de OCNB.En ambos casos se realiza tratamiento con antiinflamatorios noesteroideos durante cuatro semanas, requiriendo la adición de bifosfonatos debido a respuesta parcial.Comentarios. La OCNB es una causa de inflamación ósea en losniños en la que un diagnóstico precoz y la instauración de untratamiento efectivo permite evitar complicaciones. Es importantetenerla en cuenta al realizar el diagnóstico diferencial del doloróseo insidioso. Un mayor conocimiento puede disminuir su infradiagnóstico. (AU)

Introduction. Chronic non-bacterial osteomyelitis (CNBO) is a rarecondition in pediatrics. It is a non-infectious inflammatory diseaseof the bone that usually results in spontaneous remissions andexacerbations. Its etiology is unknown. It usually presents as subacute bone pain, with or without systemic signs and symptoms. Itis often necessary to rule out other causes such as neoplastic orinfectious. Imaging tests support the diagnosis.Clinical observation. We present two cases of patients with insidious bone pain in the lower extremities of several weeks of evolution with impaired strength and mobility. Both cases were associated with anorexia nervosa. Laboratory evaluation showed elevatedinflammatory parameters, erythrocyte sedimentation rate andC-reactive protein. Bone scintigraphy and nuclear magnetic resonance imaging allowed the diagnosis of CNBO. In both cases,treatment with nonsteroidal anti-inflammatory drugs was performed for 4 weeks, requiring the addition of bisphosphonates due topartial response.Comments. CNBO is a cause of bone inflammation in children inwhich early diagnosis and effective treatment can prevent complications. It is important to keep this entity in mind when makingthe differential diagnosis of insidious bone pain. Greater knowledgemay decrease its underdiagnosis. (AU)

The Impact of Spray Cryotherapy on Lesion-Induced Osteitis in a New Murine Experimental Model.

Background and Objectives: Endoscopic sinus surgery is considered the gold management strategy for difficult-to-treat chronic rhinosinusitis. The inflammatory bony process is incriminated as being involved in the unfavorable evolution and recurrence of the disease. Osteitis is significantly increased in patients that have been previously submitted to surgery, and it is more often present in patients with extended radiological disease and in patients undergoing revision surgery. The aim of the research is to demonstrate the presence of inflammations and neo-osteogenesis associated with nasal mucosal surgical injury and the correlation between their severity and to evaluate the efficacy of low-pressure spray cryotherapy in reducing inflammation and bone remodeling. Materials and Methods: The experimental murine model was conducted over a period of 80 days and included a total of 60 adult female Wistar rats, with three periods of withdrawal of 20 individuals each from the experiment. After inducing a bilateral mechanical injury by brushing, low-pressure spray cryotherapy application was performed unilaterally, and tissue samples were prepared specifically for histological analysis. The scores for inflammation and osteitis were compared over time and between the two nasal fossae. Results: Osteitis and inflammation were induced by a simple mucosal brushing lesion, similar to surgical injury. We identified the presence of inflammation in 95% of the specimens, and it was present over time. Moreover, criteria for bone remodeling were clearly highlighted in a percentage of 72% of the specimens. There was a direct correlation between the severity of inflammation and neo-osteogenesis, with a statistical significance of p = 0.050. Low-pressure spray cryotherapy was safe and effective in reducing inflammation (p = 0.020) and osteitis (p = 0.000) with a safety profile. Conclusions: Low-pressure cryotherapy reduces the severity of mucosal inflammation and osteitis in lesion-induced neo-osteogenesis.

Osteitis Pubis Treated With Platelet-Rich Plasma: A Case Report.

ABSTRACT: Osteitis pubis is a common source of groin pain in athletes participating in sports requiring kicking, twisting, and pivoting movements. Athletes will present with progressive pain or discomfort in the pubic area or groin. There is usually point tenderness over the pubic symphysis and pain localizing to the adductor or rectus abdominis tendons. Conservative management often includes activity modification, oral medications, progressive rehabilitation, therapeutic ultrasound, steroid injections, and prolotherapy. Osteitis pubis can be refractory to conservative management and can keep an athlete sidelined for as long as 2 years. Platelet-rich plasma (PRP) injections have been used for pubic symphysis pain, but reports have focused on pathology affecting the rectus abdominis or hip adductor muscle tendons. In this article, we present a case of isolated osteitis pubis, without overlapping rectus abdominis or adductor tendon involvement, successfully treated with an ultrasound-guided PRP injection of the fibrocartilage.

Vasoinhibin reduces joint inflammation, bone loss, and the angiogenesis and vasopermeability of the pannus in murine antigen-induced arthritis.

Increased permeability and growth (angiogenesis) of blood vessels play a key role in joint swelling and pannus formation in inflammatory arthritis, a family of diseases influenced by reproductive hormones. The hormone prolactin (PRL) protects against joint inflammation, pannus formation, and bone destruction in adjuvant-induced arthritis and these effects may involve its proteolytic conversion to vasoinhibin, a PRL fragment that inhibits angiogenesis and vasopermeability. Here, we show that the intra-articular injection of an adeno-associated virus type-2 (AAV2) vector encoding vasoinhibin reduced joint inflammation, the hyperplasia, vascular density, and vasopermeability of the pannus, and the loss of bone in mice subjected to antigen-induced arthritis. In agreement, the AAV2 vasoinhibin vector reduced the expression of proinflammatory cytokines (interleukin-1ß, interleukin-6), an endothelial cell marker (platelet endothelial cell-adhesion molecule 1), and proangiogenic molecules [vascular endothelial growth factor (VEGF), VEGF receptor 2, and hypoxia-inducible factor 1α] in the arthritic joint. Also, vasoinhibin reduced the synovial vasopermeability induced by the intra-articular injection of VEGF in healthy mice. Finally, vasoinhibin signals by blocking the phosphorylation/activation of endothelial nitric oxide synthase (eNOS) at Ser1179 and the AAV2 vasoinhibin vector inhibited the enhanced phosphorylation of eNOS Ser1179 in the arthritic joint. We conclude that vasoinhibin reduces joint inflammation and bone loss in arthritis by inhibiting pannus angiogenesis and vasopermeability via the blockage of VEGF-induced eNOS activation. These findings suggest the potential therapeutic benefit of AAV2-mediated vasoinhibin gene delivery in arthritis.

Osteitis condensans ilii: current knowledge and diagnostic approach.

Osteitis condensans ilii is a noninflammatory condition of an uncertain etiology, characterized by sclerotic bone lesions located mainly in the iliac region of the sacroiliac joints. In many patients, osteitis condensans ilii remains an incidental imaging finding; however, it has been associated with lower back pain and may mimic inflammatory rheumatic conditions such as axial spondyloarthritis. The diagnosis is based on the presence of the characteristic sclerotic lesions on radiographs and the exclusion of other conditions that are associated with back pain. Management is usually conservative with the use of physical therapy and analgesics, and it is associated with a favorable prognosis. Herein, we conducted a narrative literature review using the terms osteitis condensans ilii, and we identified case reports, case series, reviews, and original studies associated with the condition. The aim of this article is to raise the awareness of this underrecognized clinicoradiological condition and to enable the health-care providers to recognize clinical and radiological features that should raise suspicion of the osteitis condensans illi, and to describe the treatment options.

Omnipresence of inflammasome activities in inflammatory bone diseases.

The inflammasomes are intracellular protein complexes that are assembled in response to a variety of perturbations including infections and injuries. Failure of the inflammasomes to rapidly clear the insults or restore tissue homeostasis can result in chronic inflammation. Recurring inflammation is also provoked by mutations that cause the constitutive assembly of the components of these protein platforms. Evidence suggests that chronic inflammation is a shared mechanism in bone loss associated with aging, dysregulated metabolism, autoinflammatory, and autoimmune diseases. Mechanistically, inflammatory mediators promote bone resorption while suppressing bone formation, an imbalance which over time leads to bone loss and increased fracture risk. Thus, while acute inflammation is important for the maintenance of bone integrity, its chronic state damages this tissue. In this review, we discuss the role of the inflammasomes in inflammation-induced osteolysis.

Successful treatment and digestive decolonisation of a patient with osteitis caused by a carbapenemase-producing Klebsiella pneumoniae isolate harbouring both NDM-1 and OXA-48 enzymes.

OBJECTIVES: Carbapenem resistance in Klebsiella pneumoniae is an increasing problem worldwide and infections caused by this bacterium can be difficult to treat. This study reported the case of a patient from Romania, who was hospitalised in Bulgaria after an accident trauma. He then came to France for treatment of an osteitis caused by a Klebsiella pneumoniae carrying both blaNDM-1 and blaOXA-48. METHOD: The resistome of this extremely drug-resistant bacterium was analysed both with phenotypic (large antibiotic susceptibility testing) and genomic methods (genome sequencing). The genetic environment of the two carbapenemases was studied. RESULTS: Klebsiella pneumoniae ST307 carrying both a blaNDM-1 and blaOXA-48 gene was located on two different plasmids: Inc L/M and IncFII. The patient was successfully treated by a combination of intravenous colistin (9 MUI, then 4.5 MUI bd), intravenous fosfomycin (4g tds) and oral doxycycline (100mg bd) for 3 months. Faecal microbiota transplantation was successfully conducted for stool carriage. CONCLUSION: The ST307 type is becoming endemic in hospital environments and is frequently associated with carbapenem resistance. Treatment of infection caused by multidrug-resistant bacteria is a clinical challenge, and the use of old antibiotics associated with screening and decolonisation of the reservoirs can be an efficient therapeutic alternative.

MR and ultrasound of the hands and wrists in rheumatoid arthritis. Part II. Added clinical value.

Advanced imaging has become just as vital for diagnosing, staging, and monitoring disease in rheumatoid arthritis (RA) patients as it is for cancer patients. Part 1 of this review discussed synovitis, tenosynovitis, erosions, and osteitis-key imaging findings that occur in patients with RA. Part 2 will now show how these features, in combination with clinical and serologic data, can assist clinical decision-making at various stages of a patient's disease course. Specifically, assessing current disease activity and prognosticating future aggressiveness inform treatment decisions at initial presentation, during medical treatment, and at clinical remission. In addition to summarizing the current literature on advanced imaging in RA, clinical examples from different stages throughout the disease course will illustrate practical approaches for applying these research results. Last, this review will describe potential future roles of imaging in RA patients.

Evaluation of the efficacy of granulocyte and monocyte adsorption apheresis on skin manifestation and joint symptoms of patients with pustulotic arthro-osteitis.

Pustulotic arthro-osteitis, occasionally complicated with palmoplantar pustulosis, affects patients' activities of daily living. Granulocyte and monocyte adsorption apheresis selectively removes activated granulocytes and monocytes by means of extracorporeal circulation. Although the efficacy of granulocyte and monocyte adsorption apheresis in the treatment of generalized pustular psoriasis has been proved, very few reports have assessed its efficacy in the treatment of palmoplantar pustulosis and pustulotic arthro-osteitis. Ten pustulotic arthro-osteitis patients with five palmoplantar skin manifestations were treated with weekly granulocyte and monocyte adsorption apheresis over 5 weeks. Skin manifestations were assessed using palmoplantar pustulosis area and severity index, and joint symptoms were assessed using a visual analog scale of joint pain, tender joint count, swollen joint count and C-reactive protein immediately before, after and at the 3-month follow up of the five granulocyte and monocyte adsorption apheresis sessions. Two out of five patients with skin manifestations achieved more than 50% improvement in their score (remarkably improved). However, in two patients, deterioration was noted, in one of whom the skin manifestations remained unchanged at the 3-month follow up. In five out of the 10 patients, the joint symptoms were assessed as better than improved at the 3-month follow up. No deterioration was noted at the 3-month follow up. In three patients, reduction or cessation of medication for arthralgia was possible. We concluded that granulocyte and monocyte adsorption apheresis is a therapeutic option to consider when pustulotic arthro-osteitis is recalcitrant to conventional therapy.

Clinical Manifestations, Management, and Outcomes of Osteitis/Osteomyelitis Caused by Mycobacterium bovis Bacillus Calmette-Guérin in Children: Comparison by Site(s) of Affected Bones.

OBJECTIVE: To evaluate the clinical manifestations, management, and outcomes of Mycobacterium bovis Bacillus Calmette-Guérin (BCG) osteitis/osteomyelitis. STUDY DESIGN: We reviewed 71 cases of BCG osteitis/osteomyelitis registered in Taiwan's vaccine injury compensation program (VICP) in 1998-2014. Demographic, clinical, laboratory, treatment, and outcome data were compared according to site(s) of infection. RESULTS: Involvement of a long bone of the lower extremity was present in 36.6% of the children, followed by foot bone (23.9%), rib or sternum (15.5%), upper extremity long bone (9.9%), hand bone (7%), multiple bones (4.2%), and vertebrae (2.8%). Children with lower extremity long bone involvement had a longer interval from receipt of BCG vaccine to presentation (median, 16.0 months; P = .02), and those with foot bone infection had higher rates of swelling (94.1%; P = .02) and local tenderness (76.5%; P = .004). Surgical intervention was performed in 70 children, with no significant difference in the number of procedures by site (median, 1.0 procedure per patient). Among the 70 children who received antimicrobial therapy, those with vertebral and multifocal infections had a longer duration of treatment (P < .001) and/or second-line antituberculosis medications (P = .002). Three children with vertebral and multifocal infections had major sequelae with kyphosis or leg length discrepancy. Outcomes were good for children with involvement of the ribs, sternum, and peripheral bones without multifocal involvement. The average time for functional recovery was 6.2 ± 3.9 months. CONCLUSION: Children with BCG osteitis/osteomyelitis in different bones had distinct presentations and outcomes. Pediatricians should consider BCG bone infection in young vaccinated children with insidious onset of signs and symptoms, and consider affected site(s) in the management plan.

Nonoperative Management, Rehabilitation, and Functional and Clinical Progression of Osteitis Pubis/Pubic Bone Stress in Professional Soccer Players: A Case Series.

Study Design Case series. Background Pubic bone stress (PBS) is a common acute or chronic response of the pelvis in sports where sprinting, kicking, twisting, and cutting are the dominant movements. There are few nonoperative rehabilitation strategies for the condition reported in the literature, and the outcome of conservative treatment has not been documented. Case Description Five professional and academy soccer players complaining of pubic symphysis pain, confirmed as PBS on magnetic resonance imaging and objective assessment, were treated with a nonoperative rehabilitation program that featured functional and clinical objective markers as progression criteria. Interventions in the acute phase included pharmacological and physical therapeutic modalities to reduce pain initially. Rehabilitation management focused on improving range of motion at the hips and thorax, adductor strengthening, trunk and lumbopelvic stability, gym-based strength training, and field-based rehabilitation and conditioning. Clinical follow-up was performed at least 8 months following return to play. Outcomes All players demonstrated reduced or resolved pain, increased adductor squeeze strength, and return to pain-free training and match play. Return-to-training time averaged 40.6 days (range, 30-60 days) and return to play averaged 49.4 days (range, 38-72 days) within the 5 players. At final follow-up (mean, 29.6 months; range, 16-33 months), there had been no recurrences. Discussion This report of 5 cases suggests that a nonoperative protocol, using clinical and functional progression criteria, may be successful in rehabilitating athletes with PBS for return to sport within 11 weeks. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther 2017;47(9):683-690. Epub 3 Aug 2017. doi:10.2519/jospt.2017.7314.

Septic Arthritis, Physitis, and Osteomyelitis in Foals.

Despite differences in etiology and diagnostics, the mainstay of therapy in the foal is similar to the adult: local lavage and/or debridement and local antimicrobial therapy. When musculoskeletal infection is concurrent with neonatal sepsis, the prognosis for survival is fair. When musculoskeletal infection is the primary problem, the prognosis is fair to good for survival of synovial, bony, and physeal infections with appropriate and aggressive local therapy. Recent literature may indicate that prognosis for survival and potential athleticism in foals that are treated expediently with local therapies and are without comorbidities may be more favorable than has been previously indicated.

Psoriatic arthritis: lessons from imaging studies and implications for therapy.

INTRODUCTION: Modern imaging may aid in the diagnosis, prognosis and monitoring of therapeutic response in psoriatic arthritis (PsA). Detection of osteitis and technical advances like whole body magnetic resonance imaging (MRI) exemplify the value of this technology. Areas covered: Ultrasound (US) provides a clinic-based tool for evaluating both joint pathologies and extra-articular structures (especially enthesitis) including skin and nail disease. Recent studies have demonstrated subclinical disease in psoriasis without arthritis, as well as in PsA, with implications for diagnosis and treatment classification. Modern imaging can also facilitate decisions on tapering of expensive biologics, though real-world clinical studies are still lacking. Expert commentary: The increase in novel PsA therapies should increase the utilization of modern imaging, providing both increased validation of imaging biomarkers as well as responsive outcome measures.

[Tibial defects and infected non-unions : Treatment results after Masquelet technique]. / Tibiadefekt- und Infektpseudarthrosen : Behandlungsergebnisse nach Masquelet-Technik.

BACKGROUND: The treatment of non-unions with large bone defects or osteitis is a major challenge in orthopedic and trauma surgery. A new concept of therapy is a two-step procedure: Masquelet technique according to the diamond concept. METHODS: Between February 2010 and June 2014, 55 patients with tibia non-unions or infections were treated in a two-step Masquelet technique in our center. The patients' average age was 48 (median 50; minimum 15-maximum 72) with an average BMI (body mass index) of 28 (27; 18-52). There were 10 (18 %) female and 45 (82 %) male patients in the group. All study patients went through a follow up. Bone healing and clinical functional data were collected, as well as data according to subjective patient statements about pain and everyday limitations. RESULTS: In 42 cases (76.4 %) the outcome was a sufficient bony consolidation. On average, the time to heal was 10.3 (8, 5; 3-40) months, defect gaps were 4 cm (3 cm; 0,6-26 cm), and on average the patients had had 6 (median 4; range 1-31) previous operations . In all cases patients received osteosynthesis as well as a defect filling with RIA (reamer-irrigator-aspirator), and growth factor BMP-7 (bone morphogenetic protein-7). In 13 cases (23.6 %) there was no therapeutic success. In the evaluation of the SF12 questionnaire the mental health score increased from 47.4 (49.1; 27.6-65.7) to 49.8 (53.0; 28.7-69.4) and the well-being score from 32.7 (32.7;16.9-55.7) to 36.6 (36.5; 24.6-55.9). CONCLUSION: The two-step bone grafting method in the Masquelet technique used for tibia non-unions according to the diamond concept is a promising treatment option. Its application for tibia shaft non-unions with large bone defects or infections means a high degree of safety for the patient.

Tratamiento de la osteítis condensante en molar: informe de caso / Molar condensing osteitis treatment: Case report

En la actualidad, la principal causa por la que acuden los pacientes al odontólogo es el dolor dental, endonde la mayoría presenta un padecimiento pulpar o periapical irreversibles, que pueden estar asociados a factores traumáticos e irritativos. Sin embargo, pocosde ellos son asintomáticos, como la osteítis condensante que es escasamente mencionada en elámbito de la Endodoncia; por lo tanto, el objetivo de este caso clínico es el de proporcionar información acerca de la osteítis condensante siguiendo los lineamientos internacionales de Case Report (CARE). La osteítis condensante tiene una incidencia muy baja en pacientes y se debe diagnosticar correctamente al momento de tratar este tipo de lesiones con las diferentes herramientas de diagnóstico que se conocen. En este caso, se presenta un paciente del sexo femenino de 58 años de edad con un estado prediabético, que refiere un fractura del segundo molar inferior derecho, al cual radiográficamente se le encontróuna lesión periapical radiopaca en la raíz distal. Se muestra la secuencia del tratamiento, el manejo clínico y la rehabilitación.

At present, the main reason for patients to visit adentist is dental pain, where most of them presenta pulp or periapical irreversible condition, whichmay be associated with traumatic and irritative factors. However, few of them are asymptomatic as osteitiscondensing that is barely mentioned in thefield of endodontics. The aim of this case report isto provide information about the condensing osteitisfollowing international Case Report (CARE)guidelines. Condensing osteitis has a very low incidence in patients and should be correctly diagnosed with the different available diagnostic tools. In thiscase a 58-years-old female patient, with prediabeticstate, referred of a right lower second molar fracturewhich radiographically showed a radiopaque periapicallesion in the distal root of the molar. The sequence of treatment, clinical management and rehabilitation is presented.