Abstract: We evaluated the results of reconstruction of a skeletal defect with use of a vascularized bone graft from the iliac crest or fibula in 160 patients who had been managed consecutively between 1979 and 1989. The indications for the procedure were a skeletal defect including non-union, resulting from resection of a tumor; traumatic bone loss; osteomyelitis; or a congenital anomaly. The average duration of follow-up was forty-two months (range, twelve to 112 months). For the entire series, the rate of union after the primary procedure was 61 per cent and the over-all rate at the latest follow-up examination (including the patients who had a secondary procedure) was 81 per cent. In a subgroup of seventy-six patients who had union after the primary procedure and did not have additional treatment, the average interval until union was six months and the average interval until full activity was sixteen months. The results were more favorable for the patients who had had reconstruction for resection of a tumor (of sixty-nine patients, fifty-six had union), for a congenital anomaly (of six patients, five had union), or for a non-union without infection (of twenty-five patients, twenty-three had union). The results were less satisfactory for patients who had had the reconstruction for bone loss due to osteomyelitis (of sixty patients, forty-six had union). Our data suggest that vascularized bone transfer for the reconstruction of large skeletal defects is a valuable procedure in appropriately selected patients.

Abstract: Osteomyelitis is a serious health problem that results in multiple limb amputations annually. This article reviews the current scintigraphic procedures used in the diagnosis of osteomyelitis and discusses some of the newer radiopharmaceuticals now being developed. The goal is to understand the strengths and weaknesses of each method so that the procedure most effective for specific clinical settings can be selected. In general, the three-phase bone scan is the procedure of choice if the suspected osteomyelitis is not superimposed on another disease that causes increased bone remodeling (i.e., findings on the radiograph are normal). If the suspected osteomyelitis is superimposed on a disease that causes increased bone remodeling, the combined 111In-labeled leukocyte-99mTc bone scan is the procedure of choice in the non-marrow-containing skeleton and the 111In-labeled leukocyte and 99mTc bone marrow scans are the procedures of choice in the marrow-containing skeleton.

Abstract: Fifteen pediatric patients with biopsy- or culture-proved nonspinal osteomyelitis were studied with magnetic resonance (MR) imaging. Osteomyelitis was acute in seven patients, subacute in three, and chronic in five. Four patients had subperiosteal abscesses, one had a large associated soft-tissue abscess, and one had an intraosseous (Brodie) abscess. Areas of active inflammation had decreased marrow signal intensity on T1-weighted images, increased signal intensity on T2-weighted images, and enhancement on T1-weighted images obtained after gadopentetate dimeglumine administration (n = 10). Abscesses were rim enhancing (n = 3) or not (n = 2) with gadolinium-enhanced MR imaging. Nonenhancing areas presumably represented necrotic material. Gadolinium-enhanced MR imaging assisted in definition of the presence and extent of nonvascularized fluid collections within the bone and/or adjacent soft tissues and the extent of bone involvement in patients with chronic osteomyelitis. It also helped guide surgical debridement of intraosseous disease (n = 7) and open or percutaneous drainage of subperiosteal or soft-tissue fluid collections (n = 5).

Abstract: Over a 5-year period, iliopsoas abscesses were found in 11 patients. Although the most common underlying condition was Crohn's disease (3 of 11 patients), 5 abscesses resulted from hematogenous spread from a distant site. Each of these five patients was elderly, severely malnourished, or had an underlying chronic disease. Fever was a presenting sign in 8 of 11 patients, whereas all 4 patients who presented with back pain had nontuberculous lumbar osteomyelitis or disk space infections. No patient presented with the classic triad of fever, back pain, and anterior thigh or groin pain. Computed tomographic (CT) scans accurately established the clinical diagnosis in 10 of 11 patients. Two of the patients died. One patient was an intravenous drug abuser, whereas the other patient was being treated with steroids for systemic lupus erythematosus. Elderly patients, diabetics, and patients with chronic disease are susceptible to this kind of occult infection and may present with minimal clinical findings. Aggressive diagnosis using CT scanning and treatment with resection of involved bowel, complete drainage of the abscess, and prolonged antibiotics are required to salvage these patients.

Abstract: We reviewed 275 cases and calculated the prevalence of bacteriologically or radiologically confirmed acute haematogenous osteomyelitis in children under 13 resident in Greater Glasgow during 1970 to 1990. In the 20-year period there was a fall of over 50%, mainly involving cases of long-bone infection, and those due to Staphylococcus aureus. There was a reduced incidence of complications. The proportion of cases involving long bones decreased from 84% to 57%, and those of Staphylococcus aureus infection from 55% to 31%. These changes, in what is becoming a rare disease, need to be known to ensure early diagnosis and adequate treatment, particularly of subacute non-staphylococcal infection at unusual sites.

Abstract: OBJECTIVE To compare the accuracies of MRI and leukocyte scanning in diagnosing clinically unsuspected osteomyelitis in diabetic foot ulcers. RESEARCH DESIGN AND METHODS A prospective study of 16 diabetic foot ulcers in 12 patients, including both ambulatory and hospitalized patients, was performed at a university medical center. Pedal images were obtained by leukocyte scanning with [ 111 In]oxyquinoline and MRI. Definitive diagnosis of osteomyelitis then was determined by bone biopsy for culture and histology. RESULTS Biopsy-proven osteomyelitis was present in 7 (44%) of the 16 foot ulcers. The diagnosis was suspected clinically in 0%. Leukocyte scanning was 100% sensitive, whereas MRI was only 29% sensitive in diagnosing osteomyelitis in diabetic foot ulcers. Specificities were 67 and 78%, respectively. The positive and negative predictive values (70 and 100%, respectively) for the leukocyte scan also were > those of MRI (50 and 58%, respectively). CONCLUSIONS Leukocyte scanning is superior to MRI in detecting clinically unsuspected osteomyelitis in diabetic foot ulcers.

Abstract: Antibiotics were delivered to chronically infected tissues by regional limb perfusion in three horses with osteomyelitis associated with orthopedic implants. Two infections were resolved with implants in place; in one, a sequestrum was resorbed. In one horse, regional antibiotic perfusion was applied to treat progressively worsening bone infection after initial implants loosened and were removed.

Abstract: Ten episodes of musculoskeletal sepsis have been seen in nine patients with HIV infection. Seven patients had AIDS, circulating CD4-positive lymphocyte counts being less than 0.1 x 10(9)/l in six. Septic arthritis recurred in seven patients, osteomyelitis in three and pyomyositis and bursitis each occurred in one patient. Staphylococcus aureus was isolated from four patients, atypical micro-organisms being found in three. Presentation of musculoskeletal infection in this patient group may be atypical but rapid diagnosis is important as early antimicrobial therapy is often successful.

Abstract: We treated 96 cases of pyogenic arthritis from January 1, 1980, to December 31, 1990, 16 of whom had adjacent osteomyelitis. Presenting symptoms in the latter were indistinguishable from those in 80 cases of primary pyogenic arthritis with regard to involved joints, aspirate findings and pathogens; however, adjacent osteomyelitis patients tended to be younger and were more likely to be symptomatic more than 7 days and to have received prior antibiotics. Prompt joint drainage was done in 15 of 16 cases but adjacent osteomyelitis was recognized in only 5. Bone scan was misleading in 3 of the 4 cases where it was performed as part of the initial evaluation. Persistent pain, swelling and/or fever occurred in 9 patients, 6 of whom underwent further joint drainage. Radiographs were diagnostic in 1 patient at admission, 10 during hospitalization and in 5 at follow-up. Sequelae were found in 8 of 13 patients with bone and joint infections vs. 8 of 41 patients with primary joint infection. Patients with a positive culture from the hip or shoulder who had been pretreated with antibiotics had the worst prognosis. Osteomyelitis should be considered in patients who present with symptoms and signs of pyogenic arthritis for longer than 1 week, especially if they have received prior antibiotics. Earlier recognition and bone debridement may improve outcome.

Abstract: Three cases of osteomyelitis of the skull base with associated problems in diagnosis and therapy are discussed. Patients with atypical skull base osteomyelitis are difficult to diagnose as they have no ear abnormalities, but they often develop multiple cranial nerve deficits mimicking symptoms of a posterior fossa mass. We conclude that computed tomographic scans, magnetic resonance imaging studies, bone scans indium-labeled white blood cell scans, and gallium scans are useful in making the diagnosis. A biopsy of the bony lesion often is needed to identify the causative organism and to rule out a tumor. Intravenously administered antibiotics are the mainstay of therapy and should be continued until 1 week after the gallium scan shows no abnormalities. Follow-up gallium scans then are done at 1 week and 3 months after the cessation of antibiotic therapy to search for a recurrence.

Abstract: An unusual case ofMycobacterium marinum cutaneous infection is described. As a result of marked delay in the diagnosis, extensive local inflammation and destructive osteomyelitis occurred together with cutaneous dissemination in an immunocompetent host. Pathologic fractures in the infected bone necessitated amputation of the involved digit. The most striking feature of this case was the development of multiple widespread cutaneous lesions for several months following amputation of the infected digit and initiation of appropriate antimicrobial therapy. These new cutaneous lesions may reflect local immune and inflammatory reactions to previously disseminated microorganisms.

Abstract: We reviewed the applications of CT, sonography, and MR imaging in diseases of the musculoskeletal system in children. Unique advantages of each technique are discussed, and common disease entities and practical applications of the three imaging methods are stressed. Evaluation of congenital dysplasia of the hip, hip effusion, and soft-tissue foreign bodies with sonography are emphasized. The role of CT in imaging patients with congenital dysplasia of the hip, tarsal coalition, osteomyelitis, and benign and malignant bone tumors is stressed. Common applications of MR that are emphasized include imaging of osteomyelitis, musculoskeletal tumors, normal bone marrow, and avascular necrosis. Innovations are briefly discussed, including evaluation of dermatomyositis with MR and imaging sternoclavicular dislocation, congenital vertical talus, and fractures and dislocations with sonography.

Abstract: Osteomyelitis of the foot is a well-known complication of diabetes mellitus. In this study, the validity of 111In-labeled human nonspecific immunoglobulin G (IgG) scintigraphy was studied in 16 diabetic patients with foot ulcers, gangrene or painful Charcot joints. In all patients, plain radiographs, conventional bone scan images and 111In-IgG images were recorded. The results were verified by histologic examination of surgical specimens in patients who did not respond to antibiotic treatment within 2-3 wk (10 lesions) or long-term clinical follow-up of at least 6-mo (16 lesions). On the bone scans, all seven osteomyelitic foci were detected. However, 19 additional foci not due to osteomyelitis were seen. The absence of true-negative bone scans in this study resulted in a specificity of 0%. On the plain radiographs, four of seven osteomyelitis foci were detected; for 111In-IgG scintigraphy, six of seven (sensitivity 57% and 86%, respectively). Plain radiographs correctly ruled out osteomyelitis in 15 of 19 lesions, 111In-IgG scintigraphy in 16 of 19 (specificity 79% and 84%, respectively). All imaging procedures gave false-positive results in penetrating ulcers over the calcaneus in two patients and in one patient with a Charcot joint, most likely due to recent fractures. A false-negative 111In-IgG study was observed in a patient with severe arterial angiopathy. Accurate estimation of probable osteomyelitis was not possible from the results of soft-tissue cultures, since in only 6 of 12 positive cultures, osteomyelitic foci could be proven. Indium-111-IgG scintigraphy can contribute to adequate evaluation of osteomyelitis in diabetic foot complications because it improves specificity when compared to bone scan and radiographic findings and improves sensitivity in comparison to plain radiographs.

Abstract: Experience with infected pseudarthrosis with segmental osseous defect, treated by debridement and microvascular bone transfer, is reported. Fourteen patients form the basis for the study, including 12 males and two females. Patient age at the time of operation averaged 35.1 years. Follow-up averaged 52 months. The affected site included tibia (10), femur (2), and ulna (2). A total of 15 vascularized bone graft transfers were carried out for the 14 patients, with the donor bone fibula (8) and ilium (7). Bony union was ultimately obtained in all patients. In 11 patients, primary union was obtained at both ends of the transferred bone segment. In the remaining three patients, a secondary procedure, consisting of onlay nonvascularized bone autografting at one end of the vascularized transferred bone segment, was required to obtain union. Recurrent infection following union occurred in one patient. One of the two patients with active osteomyelitis at the time of vascularized bone transfer had complications from recurrent sepsis, leading to the authors' caveat that vascularized bone transfer should be deferred until such time as sepsis is inactive. Criteria used in this series for determining inactive sepsis (absence of sinus tracts, negative bacterial cultures, negative c-reactive protein, and a sedimentation rate of less than 15 mm per hour) seem appropriate. The study suggests that vascularized bone transfer is a useful procedure for the treatment of infected segmental osseous defects of long bones, of more than 3 cm extent and one month or more after inactive sepsis.

Abstract: Part 1 Introduction to orthopaedic radiology: the role of the orthopaedic radiologist imaging techniques in orthopaedics growth and development of bones. Part 2 Trauma: radiologic evaluation of trauma upper limb - shoulder girdle, elbow, distal forearm, wrist, hand lower limb - pelvic girdle, proximal femur, knee, ankle, foot spine. Part 3 Arthritides: radiologic evaluation of arthritides degenerative joint diseases inflammatory arthritides miscellaneous arthritides. Part 4 Tumours and tumour-like lesions: radiologic evaluation of tumours and tumour-like lesions benign tumours and tumour-like lesions - osteoblastic and chondroblastic lesions, fibrous, fibro-osseous, fibrohistiocytic lesions and other benign conditions malignant bone tumours. Part 5 Infections: radiologic evaluation of musculoskeletal infections osteomyelitis, infectious arthritis and soft tissue infections. Part 6 Metabolic and endocrine disorders: radiologic evaluation of metabolic and endocrine disorders osteoporosis, rickets and osteomalacia hyperparathyroidism Paget's disease miscellaneous metabolic and endocrine disorders. Part 7 Congenital and developmental anomalies: radiologic evaluation of skeletal anomalies anomalies of the upper and lower limbs scoliosis.

Abstract: Patients with sickle cell disease are more susceptible to osteomyelitis and septic arthritis than the population at large. Seventy eight patients with these conditions were admitted to our hospital from April 1988 to March 1991. Thirty had sickle cell disease, 14 had the sickle cell trait and 34 had normal electrophoresis. The tibia, followed by the femur and humerus were the bones most commonly affected, and the knee was the joint most often involved. Salmonella was the commonest organism in osteomyelitis and septic arthritis in sickle cell disease, whereas staphylococcus was commonest in normal patients and those with the sickle cell trait. Antibiotics that cover these two organisms must be considered in patients with sickle cell disease who are suspected of having osteomyelitis or septic arthritis.

Abstract: The use of ultrasound in osteomyelitis has been studied in 25 patients clinically suspected of osteomyelitis. A sonographic diagnosis of osteomyelitis was made if fluid was present in direct contact with the bone, without intervening soft tissues. This was thought to represent an inflammatory exudate dissecting in a subperiosteal and/or extraperiosteal location. Ultrasonographically 15 patients were found to have osteomyelitis, proved either by surgical drainage or needle aspiration. Seven patients had soft-tissue abscesses, one had cellulitis and two patients had no abnormality.

Abstract: During a 4-year period from November 1985 to November 1989, Aeromonas was isolated from wounds and soft tissues with clinical evidence of infection in 28 patients at our institution. Of the 28 patients, 23 (82%) had sustained an acute open or penetrating injury, more than half of which (13 of the 23) were water-related trauma. One patient had Aeromonas osteomyelitis. Five patients had no history of trauma, and three of these five had an underlying chronic disease. Treatment included debridement and antimicrobial agents. Susceptibility testing on 25 isolates from 23 patients showed uniform resistance to ampicillin and considerable resistance to cefazolin sodium (68%), but all isolates were sensitive to gentamicin sulfate, cefuroxime sodium, and the third-generation cephalosporins

Abstract: Purpose:To determine the diagnostic performance of technetium bone scanning in the setting of possible osteomyelitis in the foot of a patient who has diabetes or other vasculopathy.

Abstract: Anaerobic bacteria were isolated from 18 of 28 animals (64%) with osteomyelitis. The bones most commonly infected with anaerobic bacteria were radius and ulna, mandible, and tympanic bulla. Fights or abscesses commonly preceded the osteomyelitis. Seven anaerobic genera were isolated. Mixed infections of anaerobic and aerobic organisms occurred in 16 animals. Staphylococci were isolated in only one such mixed infection, but they were isolated commonly when there were aerobic bacteria only. Staphylococcal infections were often single.

Abstract: Objective Difficulties involved in diagnosis and response to antimicrobial therapy are described in detail for two cases of biopsy-proven osteomyelitis caused by Mycobacterium haemophilum in AIDS patients. Setting Two large, private teaching hospitals in New York City, New York, USA. Patients, participants A 31-year-old woman with previous diagnoses of candida esophagitis and peripheral neuropathy (patient 1), and a 37-year-old man with Kaposi's sarcoma (patient 2). Interventions One patient was treated with a combination of rifampin, ethambutol, clofazimine, and ciprofloxacin, while the other received rifampin, ciprofloxacin and doxycycline. Both patients also received a short course of intravenous amikacin. Main outcome measures Disease activity was monitored clinically by observing resolution of skin ulcers, lymphadenopathy, and pain and swelling in areas affected by osteomyelitis. Results Both patients experienced complete resolution of signs and symptoms of M. haemophilum infection. Patient 1 was treated for 17 months and remains well after 10 months without therapy. Patient 2 shows no evidence of infection after 14 months of therapy. Conclusions M. haemophilum infection must be considered in the differential diagnosis of osteomyelitis in AIDS patients, although specialized culture techniques are required to isolate and identify this pathogen. Excellent clinical response can be achieved with oral antimicrobial therapy.

Abstract: The treatment of 25 tibias in 25 patients with posttraumatic chronic osteomyelitis was reviewed. The approaches to soft tissue management fell into three groups: 1) muscle flap coverage; 2) primary closure with suction irrigation; and 3) open cancellous bone grafting. Treatment success was judged by the presence or absence of drainage and the local signs or symptoms of infection, and by the status of the tibial nonunion. Overall, 19 of 25 tibias (76%) had successful treatment. We found flap coverage to have a higher success rate (80%) than either primary closure with suction irrigation (45.5%) or open cancellous bone grafting (40%). These results further attest to the refractory nature of chronic osteomyelitis.

Abstract: Pasteurella multocida, a small gram-negative bacterium, is part of the normal mouth flora of many animals, including domestic cats and dogs. While commonly associated with infections in animals, it is a rare cause of human disease. The majority of Pasteurella infections in humans occur with percutaneous inoculation of the organism following a bite by a cat or dog, although disease without antecedent animal exposure or with causal animal contact does occur. The spectrum of disease produced ranges from localized, including abscess, cellulitis, lymphadenopathy, and osteomyelitis, to systemic, with septicemia, septic arthritis, respiratory, and central nervous system involvement. Altered host defenses and underlying chronic disease, such as rheumatoid arthritis, corticosteroid therapy, and severe hepatic or renal disease, may predispose to more serious systemic manifestations of infection. The authors report a case of P. multocida infection in a total knee arthroplasty as a result of a dog scratch and review the literature reporting P. multocida infections in total knee arthroplasty.

Abstract: PNEUMOCYSTIS CARINII is a well-known pulmonary pathogen that has been increasingly identified in extrapulmonary sites in patients with the acquired immunodeficiency syndrome (AIDS).1 2 3 4 5 6 7 We describe a case of pneumocystis osteomyelitis that occurred in a patient with common variable immunodeficiency. It was striking that the patient appeared to have normal cell-mediated immunity, including a blastogenic response to pneumocystis antigen. Case Report A 27-year-old black woman with common variable immunodeficiency presented with a one-month history of increasing pain in the left buttock. Common variable immunodeficiency had been diagnosed five years earlier after an evaluation for recurrent infections of the upper and lower . . .