Abstract: Ciprofloxacin labeled with 99mTc specifically binds to various bacteria. Thus, it potentially constitutes a specific marker allowing discrimination between septic arthritis/osteomyelitis and aseptic osteoarticular diseases. The aim of this prospective study was to evaluate such properties in patients with skeletal diseases. Methods: We prospectively investigated 2 groups of patients: patients with suspected osteoarticular infections (G1, n = 16) and a control group of patients with a presentation of osteoarticular diseases and no sign suggestive of infection (G2, n = 11). All had clinical, biologic, and radiologic evaluations and had 1-, 4-, and 24-h images from 99mTc-ciprofloxacin scintigraphy (370 MBq) before planned biopsy or surgery. For 23 patients, the scintigraphic results were compared with histologic and bacteriologic analyses of biopsy tissue samples; for 4 patients, the scintigraphic results were compared with the findings from 23 ± 5 mo of follow-up. Results: In G1, 99mTc-ciprofloxacin findings were true-positive in all 11 infected sites, true-negative in 2 cases, and false-positive in 3. In G2, 99mTc-ciprofloxacin was true-negative in 4 cases and false-positive in 7. Neither the location of 99mTc-ciprofloxacin activity nor its intensity or kinetics between 1, 4, and 24 h allowed discrimination between infection and aseptic diseases (sterile loosened joint replacement, pseudoarthrosis, or arthrosis). Sensitivity, specificity, and accuracy were 100%, 37.5%, and 63%. Conclusion:99mTc-Ciprofloxacin scintigraphy showed good sensitivity and a high negative predictive value for the detection of bone and joint infection, but it did not discriminate between infected and aseptic osteoarticular diseases in symptomatic patients referred for surgery.

Abstract: BACKGROUND AND PURPOSE: Skull base osteomyelitis typically arises as a complication of ear infection in older diabetic patients, involves the temporal bone, and has Pseudomonas aeruginosa as the usual pathogen. Atypical skull base osteomyelitis arising from the sphenoid or occipital bones without associated external otitis occurs much less frequently and initially may have headache as the only symptom. The purpose of this study was to review the clinical and MR imaging features of central skull base osteomyelitis. METHODS: We retrospectively reviewed MR images obtained in six patients with central skull base osteomyelitis. No patient had predisposing external otitis or osteomyelitis of the temporal bone. RESULTS: All of our patients presented with headache, no external ear pain, and cranial nerve deficits. Five of six patients had a predisposition to infection, and the erythrocyte sedimentation rate was elevated in the five patients in whom it was checked. In each case, the diagnosis was delayed until MR imaging demonstrated central skull base abnormality, and the diagnosis was then confirmed with tissue sampling. The most consistent imaging findings were clival bone marrow T1 hypointensity and preclival soft tissue infiltration. Five of six patients were cured with no recurrence of skull base infection over a 2–4-year follow-up period. CONCLUSION: In the setting of headache, cranial neuropathy, elevated erythrocyte sedimentation rate, and abnormal clival imaging findings, central skull base osteomyelitis should be considered as the likely diagnosis. Early tissue sampling and appropriate treatment may prevent or limit further complications such as intracranial extension, empyema, or death.

Abstract: It is known that following a traumatic fracture or surgical intervention, bone scintigraphy reveals positive results for an extended period of time, posing a challenge when evaluating patients for possible malignancy or superimposed osteomyelitis. Previous reports indicate that acute fractures can also result in increased fluorine-18 fluorodeoxyglucose (FDG) accumulation and therefore cause difficulties when patients are evaluated for other indications by FDG-PET. The purpose of this study was to assess the pattern and time course of abnormal FDG uptake following traumatic or surgical fracture. A total of 1,517 consecutive patients who underwent whole-body FDG-PET imaging were retrospectively studied. A history of fractures or orthopedic intervention was obtained from an interview prior to scanning. The FDG-PET results were compared with the results of other imaging studies, including bone scans, radiographs, CT, and MRI, as well as surgical pathology reports. Thirty-seven patients with a known date of traumatic or surgical fracture were identified. Among these, 14 had fractures or surgery within 3 months prior to FDG-PET, while 23 had fractures or surgical intervention greater than 3 months prior to FDG-PET. FDG-PET showed no abnormally increased uptake at the known fracture or surgical sites in 30 of these patients. Notably, in the 23 patients with fractures more than 3 months old, all but one showed no abnormally increased uptake. Furthermore, the positive FDG uptake in this exception was a result of complicating osteomyelitis. In the 14 patients with a history of fracture less than 3 months old, only six had abnormally increased FDG uptake. Following traumatic or surgical fractures, FDG uptake is expected to be normal within 3 months unless the process is complicated by infection or malignancy.

Abstract: The diagnostic imaging of osteomyelitis can require the confluence of multiple imaging technologies. Conventional radiography should always be the first imaging modality. Sonography is most useful in the diagnosis of fluid collections in a joint or in the extra-articular soft tissues but is not useful for evaluating presence of osseous infection. CT scan can be a useful method to detect early osseous erosion and to document the presence of sequestrum, foreign body, or gas formation but generally is less sensitive than other modalities for the detection of bone infection. Nuclear medicine and MRI are the most sensitive and most specific imaging modalities for the detection of osteomyelitis. Nuclear medicine is particularly useful in identifying multifocal involvement, which is common in children. MRI provides more accurate information of the local extent of the soft tissues and possible soft tissue abscess in patients with musculoskeletal infection.

Abstract: This retrospective study investigated the causative pathogens, complications, and outcome of 58 children who were hospitalized for septic arthritis at a tertiary care hospital in southern Taiwan from July 1988 to December 2000. The mean age was 3 years (range, 12 days-16 years). The males/females ratio was 1.2:1. Ninety percent of the cases involved lower extremities (knee, hip, and ankle) with the hip being the most common site of infection (54%). Joint pain (81%) was the most common clinical presentation, followed by fever (74%), local warmness and swelling (72%), and limitation of motion (64%). Erythrocyte sedimentation rate was elevated (> or = 20 mm/h) initially in 89% of the cases. The predominant causative organism was Staphylococcus aureus (43%, 25/58), 6 isolates of which were methicillin-resistant, followed by coagulase-negative Streptococcus (6), Streptococcus pneumoniae (3), Salmonella spp. (3), Haemophilus influenzae type b (2), and group B Streptococcus (2). The concomitant complications of septic arthritis were sepsis (9%, 5/58) and meningitis (2%, 1/58). Ten patients had sequelae, including limitation of motion (6), limping gait (2), limb-length discrepancy (1), and abnormalities of bone growth (1). This study found that S. aureus was the most common infecting microorganism in septic arthritis in children. Septic arthritis with concomitant osteomyelitis and infection due to methicillin-resistant S. aureus was associated with a significantly increased risk of sequelae (relative risk, 46.4, 95% CI, 2.9-748.8; relative risk, 16. 2, 95% CI, 1.3-204.9, respectively).

Abstract: We studied a 4-year-old boy from Angola who presented with 2 cutaneous ulcerations of the right hip and osteomyelitis of the left knee and right ankle. Mycobacterium ulcerans disease was confirmed by direct smear examination and by polymerase chain reaction. The patient was treated with antimycobacterial drugs, repeated surgical debridement, skin grafting, and daily hyperbaric oxygenation. Despite significant improvement of the local lesions in response to hyperbaric oxygenation, swelling of the right knee, without associated skin lesions, was noted. Radiological evaluation and open biopsy revealed extensive metaphyseal osteomyelitis of the right distal femur. A 99 technetium bone scan revealed an additional focus in the diaphysis of the left humerus, without soft-tissue involvement. This case documents, for the first time (to our knowledge), the systemic spread of M. ulcerans. with subsequent multifocal osteomyelitis and secondary involvement of soft tissues and supports the hypothesis that low tissue oxygen levels promote hematogenous spread of M. ulcerans. Sickle cell anemia, with associated microthrombosis and microinfarction, may have contributed to tissue hypoxia.

Abstract: This retrospective study analyzed the clinical, bacteriological, and radiological features of pediatric patients with acute hematogenous osteomyelitis and septic arthritis. Eighty-four patients with septic arthritis and 39 with acute hematogenous osteomyelitis were enrolled. Their age ranged from 13 days to 17 years. In patients with septic arthritis, the hip joint was the most often infected site. The tibia was the most often involved site in acute hematogenous osteomyelitis. A bacteriological diagnosis was established in 78 (63%) patients. Overall, methicillin-susceptible Staphylococcus aureus (36 cases) was the most common causative organism identified, followed by methicillin-resistant S. aureus (10 cases). The median duration of antibiotic therapy was 33 days. Serum bactericidal titers were obtained for 19 (15%) of the 123 patients. The median duration of hospitalization and antibiotic treatment was not significantly different between patients with and without serum bactericidal titer testing. More patients without serum bactericidal titer testing had symptom relapse which required re-admission for further treatment. In conclusion, the incidence of methicillin-resistant S. aureus as a cause of bone and joint infections has been increasing. Serum bactericidal titer is valuable for the management of patients receiving sequential therapy for acute hematogenous osteomyelitis and septic arthritis.

Abstract: The purpose of the current study was to show the efficacy and safety of an absorbable polymer (polycaprolactone) as an antibiotic delivery vehicle for treatment of osteomyelitis. An intramedullary osteomyelitis was induced in the femur of adult rabbits by Staphylococcus aureus inoculation after use of a sclerosing agent, and then treatment was done with intramedullary irrigation and implantation of a rod made of polycaprolactone, polycaprolactone plus 6% tobramycin, or polymethylmethacrylate plus 6% tobramycin. A control group received irrigation only. At defined intervals, the animals were euthanized and culture of the inoculated site was done. In addition, histologic sections of body tissues were made to look for signs of systemic toxicity of the implant. After 4 weeks of treatment, a statistically significant difference was found between the animals that were treated with irrigation alone and the animals that were treated with antibiotic-laden rods of polycaprolactone or polymethylmethacrylate. There was no difference between the antibiotic rod types. No histologic evidence of toxicity was found. Bioabsorbable rods of polycaprolactone are a safe and effective means of antibiotic delivery for treatment of osteomyelitis.

Abstract: Background The management of infection after intramedullary nailing of the femoral shaft fracture remains a challenge to orthopedic surgeons. The dilemma confronting surgeons concerns the removal or retention of the nail in the presence of infection. Methods The authors treated 23 infections after intramedullary nailing for femoral fractures. All fractures were unhealed at presentation. All patients were followed for at least 1 year after the infection. Acute infection occurred in 13 patients, subacute infection in 5, and chronic infection in 5. The patients were divided into two groups on the basis of the method of the initial treatment. In group I (12 patients), the intramedullary nails were retained, and there were 11 men and 1 woman, with an average age of 36 years (range, 15–55 years). In group II (11 patients), the nails were removed at the time of debridement and the fractures were stabilized with external fixation, and there were nine men and two women, with an average age of 44 years (range, 25–69 years). Results In group I, all fractures healed within an average period of 9 months (range, 5–15 months) after surgical debridement. There was no recurrence of infection at an average follow-up of 25 months (range, 12–76 months). In group II, seven fractures healed within an average of 10 months (range, 4–24 months) after treatment. At an average follow-up of 33.8 months (range, 12–79 months), infected nonunion was noted in two patients. More complications occurred in group II patients in comparison with group I patients. Limited range of motion of the knee joint was usually encountered if a fracture was stabilized with external fixation for a prolonged period of time. Conclusion Retention of the intramedullary nail is performed if the fixation is stable and the infection is under control. External fixation is most suitable for uncontrollable osteomyelitis or infected nonunion. Staged bone grafting is usually necessary when a bone defect is present.

Abstract: Objectives To find diagnostic points and to identify the origin of osteomyelitis in synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome. Methods Fifty-two patients with mandibular suppurative osteomyelitis and 25 patients with mandibular osteomyelitis in SAPHO syndrome were included in the study. Radiographic patterns of the lesion, types of periosteal reaction and the presence of external bone resorption and bone enlargement were investigated in each case and compared between the two entities. Results Suppurative osteomyelitis demonstrated an osteolytic pattern and a lamellated type of periosteal reaction, whereas SAPHO syndrome revealed a mixed-pattern, solid-type periosteal reaction, external bone resorption and bone enlargement. Conclusions Radiographic examination is suggested to be convenient and a useful diagnostic method of differentiating osteomyelitis in SAPHO syndrome from suppurative osteomyelitis. The periosteum is suspected to be the original site of osteomyelitic lesions in SAPHO syndrome.

Abstract: The authors describe their experience with the use of distally based saphenous and sural neurofasciocutaneous flaps for the treatment of calcaneal osteomyelitis in nine cases. Aggressive debridement of all nonviable and poorly vascularized tissue and coverage with a distally based neurofasciocutaneous flap were coupled with a thorough antibiotic course in all cases. The deepithelized peripheral parts of all flaps were buried in the bone cavities after bone debridement. Follow-up periods ranged from 15 to 27 months. All flaps survived completely. All of the wounds except one healed completely. These flaps have adequate blood flow for the management of chronic bone infections. They also have many advantages, such as easy quick elevation, short operative time, and acceptable donor-site morbidity. Moreover, patients treated with neurocutaneous flaps do not require debulking procedures or special shoes. Reconstruction with neurocutaneous flaps after radical debridement is a versatile alternative to the use of local or distant muscle flaps and calcanectomy procedures for patients with osteomyelitis of the os calcis.

Abstract: distal humerus pain. No other symptoms or physical findings were found at the initial evaluation. The results of laboratory tests, including hematocrit concentration, sedimentation rate, leukocyte count, and serum blood chemistry profiles, were normal. The anteroposterior and lateral radiographs showed a rounded osteolytic diaphyseal lesion surrounded by an important sclerotic reaction and associated with mild L E T T E R T O T H E E D I T O R

Abstract: ¶Background. We describe the management of osteomyelitis of the cervical spine, utilizing internal fixation with subsequent removal and culture of the implants. Four out of five patients had evidence of bacterial colonisation in close proximity to the internal fixation device.

Abstract: Osteomyelitis of the maxilla is extremely rare. When it occurs, there is invariably an underlying predisposing condition. We describe a 28-year-old woman whose presentation with osteomyelitis of the maxilla led to a diagnosis of generalized osteopetrosis.

Abstract: A 12-year-old girl with juvenile rheumatoid arthritis presented with signs of infection of the proximal interphalangeal joint of her left great toe 1 week after a flu-like illness. Several joints and one bone were subsequently found to be infected with group A beta-hemolytic streptococci. Despite appropriate antibiotic therapy, synovial fluid cultures remained positive for 2 weeks. We believe that the antiinflammatory medications, including etanercept (a tumor necrosis factor antagonist), used to treat this patient's arthritis contributed to the severity and unusual course of her infection.

Abstract: Since 1980, 64 children with pelvic osteomyelitis (40 boys) were treated at a major pediatric referral center. The average age was 11 years and 6 months. The presenting complaints included pain in 61 children, fever in 30, and altered weight-bearing in 31. The erythrocyte sedimentation rate was elevated in 56 and there was leukocytosis in 19. The most commonly affected sites were the ilium in 21 and the acetabulum in 20, followed by the pubis in 11 and the ischium in 10. Culture results were negative in 32 and positive for Staphylococcus aureus in 26. Treatment consisted of intravenous antibiotics in 62 and irrigation and debridement in five children, all of whom presented since 1990. The infection resolved in 62 children and persisted in two. Three developed complications, including fusion of the sacroiliac joint in one, deformity of the acetabulum in one, and one child with an underlying protein C deficiency developed thromboembolism. Recent patients have demonstrated increased severity, likely due to increased virulence of the organism.

Abstract: To the Editor: Coxiella burnetii, a strict intracellular bacterium, is the etiologic agent of Q fever, a worldwide zoonosis. Humans are infected by inhaling contaminated aerosols from amniotic fluid or placenta or handling contaminated wool (1). The bacterium is highly infectious by the aerosol route. Two forms of the disease are typical: acute and chronic. Acute Q fever is the primary infection and in specific hosts may become chronic (1,2). The major clinical manifestations of acute Q fever are pneumonia and hepatitis. Less common clinical manifestations are aseptic meningitis and/or encephalitis, pancreatitis, lymphadenopathy that mimics lymphoma, erythrema nodosum, bone marrow necrosis, hemolytic anemia, and splenic rupture (2). The main clinical manifestation of the chronic form is culture-negative endocarditis, but infection of vascular grafts or aneurysms, hepatitis, osteomyelitis, and prolonged fever have also been described (1,2). Fluoroquinolones, co-trimoxazole, and doxycycline are active against C. burnetii in vitro, and ceftriaxone has been shown to have a bacteriostatic effect and could be effective in the phagolysosome of C. burnetii–infected cells (3). However, the treatment of choice for Q fever is doxycycline.

Abstract: 13 cases of osteomyelitis caused by Aspergillus nidulans have been previously reported in patients with chronic granulomatous disease (CGD). All of them have been associated with simultaneous pulmonary infection and have had an extremely poor outcome. We report an unusual case of femoral osteomyelitis due to A. nidulans in a 16-year-old male with CGD, without pulmonary involvement. Treatment with liposomal amphotericin B and granulocyte colonystimulating factor as well as extensive surgical debridement followed by prolonged treatment with itraconazole resulted in an excellent clinical response.

Abstract: A 21-year-old male presented with pain in the right thigh of insidious onset and 3 months' duration. He had a history of febrile illness lasting for 15 days, 2 months prior to the onset of pain. Examination revealed swelling over the lower lateral aspect of the right thigh with some induration and tenderness. Initial X-rays of the right femur and the computed tomography scan at 10 weeks after the onset of disease were normal. Magnetic resonance imaging scan showed signal alteration with minimal destruction of the anterior cortex in the mid-diaphyseal region of the right femur. A repeated X-ray taken at 15 weeks after the onset of illness showed erosive changes, along with periosteal reaction in the diaphyseal area. The Widal test was positive. Open biopsy of the lesion revealed inflammatory non-caseating tissue. Culture of the specimen grew Salmonella typhi. The patient was given antibiotic treatment. Both X-rays and the Widal titres were normal on subsequent follow-up at 3 months.

Abstract: A case of tuberculous osteomyelitis of the proximal humerus is described. The relevant literature is reviewed with attention to epidemiologic data. Issues highlighted include the frequent presentation in a subacute course without systemic illness; the value of plain radiography and especially magnetic resonance imaging; the importance of obtaining a tissue diagnosis; and the high rate of cure with medical therapy. Although rare in Western countries, skeletal tuberculosis is not uncommon in endemic areas and in migrants from such areas. With the growing use of biologic therapies, rheumatologists must be familiar with the diagnosis and treatment of tuberculosis in all its forms.

Abstract: Background Puncture wounds in the feet of children present a clinical dilemma. Objectives To evaluate our approach, we reviewed the charts and all available images of 80 children admitted to our institution because of plantar punctures from 1988 to 1999. Methods The charts of 80 children were reviewed retrospectively. Results Three groups of patients were found: 59 with superficial cellulitis, 11 with retained foreign bodies, and 10 with osteoinyelitis and/or septic arthritis. There was a significant presentation delay in patients from the second and third groups. Most common organisms were Staphylococcus aureus or Group A Streptococcus. Of the 80 children, 34 were treated surgically and 46 were treated with antibiotic therapy alone. All patients with osteomyelitis and septic arthritis were re-examined; at follow-up, all but one were asymptomatic apart from residual radiologic sequelae in four. Conclusions Patients with an established infection 24-36 hours after a plantar puncture should be admitted to hospital for parenteral antibiotic therapy. Delayed presentation is a significant marker for deep-seated infection. Further infection or relapse after initial improvement suggests the presence of osteomyelitis or a retained foreign body. A bone scan is advisable in all patients with suspected osteomyelitis: a positive bone scan necessitates aggressive early debridement combined with appropriate antibiotics; while negative bone scan, X-ray and exploration suggest that the infection is due to a foreign body, which can be detected by computed tomography.

Abstract: A 6-yr-old, 130-cm, 20-kg healthy boy (American Society of Anesthesiologists classification I), without preexisting systemic or regional infection, had general anesthesia and a caudal block for circumcision on an outpatient basis. After application of the standard monitoring (pulse oximetry, 5-lead ECG, and noninvasive blood pressure measurement), general anesthesia was induced by inhalational technique (sevoflurane 3 minimum alveolar concentration in 40% N2O with oxygen) and an intravenous access was established. After skin disinfection of the puncture area using a solution of octenidine hydrochloride, the caudal block was performed by single-shot technique with no difficulties. A 22-gauge needle was introduced under aseptic conditions (i.e., sterile gloves, facemask, and operation cap) at a 45-degree angle without lancing the skin. Bony structures were not grazed. Next, 20 ml of 0.125% Bupivacaine with epinephrine 1:200,000 was injected, providing effective intraand postoperative analgesia. The anesthetic and surgical procedures were uncomplicated, and the early postoperative period was uneventful. However, on the third postoperative day, the child presented with immobilizing back pain. He was in good clinical condition and was afebrile. A tender spot in the area of the caudal puncture without signs of local inflammation was detected. Sensibility and motor function of the legs were preserved. Leukocyte count and C-reactive protein level were normal. Blood cultures or local tissue-samples were not taken. Magnetic resonance imaging (MRI) revealed a phlegmonous, subcutaneous inflammation of the sacral region. There was no abscess, but edema at the anteroposterior periosteum of the lower sacrum indicated a beginning osteomyelitis (fig. 1). Amoxicillin-clavulanic acid 120 mg·kg 1 daily initially intravenously for 3 days, then 120 mg·kg 1 daily orally for 46 days, was used as empiric therapy based on the clinical estimation of highest probability for Gram-positive organisms by the infectious disease consultant. The MRI was repeated after 17 days of antibiotic therapy, at which time the acute osteomyelitis of the sacrum with signs of a soft-tissue infection was diagnosed (fig. 2). Antibiotic therapy was continued for another 30 days, and the patient showed complete recovery: The back pain disappeared 7 days after the second MRI, and a follow-up MRI showed no signs of infection in the sacral area.

Abstract: Context.—Decubitus ulcers constitute a serious medical problem, often encountered in association with hospitalization or institutionalization in senior citizens' or nursing homes. Potentially life-threatening sepsis has been reported to originate not only from soft tissue infection, but also from osteomyelitis as a complication of involvement of bone tissue in decubitus ulcers. Objective.—To assess the histopathology of osseous structures involved in grade IV decubitus ulcers. Design.—Autopsy-based histopathologic assessment of the presence and extent of osteomyelitis on os sacrum specimens from 28 deceased individuals with grade IV sacral decubitus ulcers using an undecalcified preparation following plastic embedding (staining with Goldner, Kossa modification, toluidine blue, and Giemsa). Results.—The histologic findings were classified in 4 types of pathomorphologic changes: type 1, decubitus ulcer confined to soft tissue, no inflammation (n = 7); type 2, decubitus ulcer involving bone, no infl...