Abstract: Sterile bone inflammation is the hallmark of autoinflammatory bone disorders, including chronic nonbacterial osteomyelitis (CNO) with its most severe form chronic recurrent multifocal osteomyelitis (CRMO). Autoinflammatory osteopathies are the result of a dysregulated innate immune system, resulting in immune cell infiltration of the bone and subsequent osteoclast differentiation and activation. Interestingly, autoinflammatory bone disorders are associated with inflammation of the skin and/or the intestine. In several monogenic autoinflammatory bone disorders mutations in disease-causing genes have been reported. However, regardless of recent developments, the molecular pathogenesis of CNO/CRMO remains unclear. Here, we discuss the clinical presentation and molecular pathophysiology of human autoinflammatory osteopathies and animal models with special focus on CNO/CRMO. Treatment options in monogenic autoinflammatory bone disorders and CRMO will be illustrated.

Abstract: Chronic recurrent multifocal osteomyelitis is a rare auto-inflammatory condition that primarily affects children and adolescents. It presents with recurrent episodes of pain related to the presence of foci of sterile bone inflammation. The long bones of the lower extremities are more frequently affected and the spine can also be involved. Imaging studies, including whole-body magnetic resonance, are important for diagnosis and detection of asymptomatic lesions. Bone biopsies may be necessary to exclude other diseases, including malignancy and infections. Non-steroidal anti-inflammatory drugs cause relief of symptoms in the majority of cases. Bisphosphonates and TNF-α blockers are alternatives for patients who do not respond or who have spinal involvement.

Abstract: Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Abstract: Langerhans cell histiocytosis (LCH) represents a disorder characterised by an abnormal accumulation of histiocytes in miscellaneous tissues. The bone is commonly affected, especially the flat bones, the spine and the long bones. Some lesions in children such as a “vertebra plana” or a solitary lytic lesion of the skull may be suggestive for LCH, whereas others can be confused with a malignant tumour or osteomyelitis. This pictorial essay presents the main usual and unusual skeletal manifestations observed in LCH. • Osseous involvement in children with LCH is very similar to that seen in multiple myeloma. • A solitary lytic lesion of the cranial vault is a typical radiographic finding of LCH. • A vertebra plana appearance in the spine is another typical radiographic finding. • Extensive signal intensity changes within bone marrow on MRI are a helpful sign for the diagnosis. • In long bones, endosteal scalloping may be responsible for a “budding appearance”.

Abstract: This study aimed to explore the in vitro antibacterial activity of the bioglass BAG S53P4 against multi-resistant microorganisms commonly involved in osteomyelitis and to evaluate its use in surgical adjunctive treatment of osteomyelitis. In vitro antibacterial activity of BAG-S53P4 against methicillin resistant Staphylococcus aureus and Staphylococcus epidermidis, Pseudomonas aeruginosa and Acinetobacter baumannii isolates was evaluated by means of time kill curves, with colony counts performed after 24, 48 and 72 hours of incubation. In vivo evaluation was performed by prospectively studying a cohort of 27 patients with a clinically and radiologically diagnosed osteomyelitis of the long bones in an observational study. Endpoints were the absence of infection recurrence/persistence at follow-up, no need for further surgery whenever during follow-up and absence of local or systemic side effects connected with the BAG use. In vitro tests regarding the antibacterial activity of BAG S53P4 showed a marked bactericidal activity after 24 hrs against all the tested species. This activity continued in the subsequent 24 hrs and no growth was observed for all strains after 72 hrs. Results of the clinical study evidenced no signs of infection in 24 patients (88.9%) at the follow-up, while 2 subjects showed infection recurrence at 6 months from index operation and one more needed further surgical procedures. BAG-S53P4 was generally well tolerated. The in vitro and in vivo findings reinforce previous observations on the efficacy of BAG-S53P4 for the treatment of chronic osteomyelitis of the long bones, also in the presence of multi-resistant strains and in immunocompromised hosts, without relevant side effects and without the need for locally adding antibiotics. Deutschen Register Klinischer Studien (DRKS) unique identifier: DRKS00005332 .

Abstract: Background Early diagnosis of Acute Osteomyelitis (OM) and Septic Arthritis (SA) is of vital importance to avoid devastating complications. There is no single laboratory marker which is sensitive and specific in diagnosing these infections accurately. Total Count, ESR and CRP are not specific as they can also be elevated in non pyogenic causes of inflammation. Pus Culture and sensitivity is not a true gold standard due to its varied positivity rates (40 – 70%). Serum Procalcitonin (PCT), at 0.5 ng/ml is found to be an accurate marker for pyogenic infections. The objectives of this study were to show that PCT is an accurate marker in differentiating Acute Osteomyelitis and Septic Arthritis from viral and non infective inflammatory bone and joint conditions.

Abstract: Osteomyelitis is challenging for orthopedic surgeons. The fundamental basis of osteomyelitis treatment is wide surgical debridement. A variety of operative techniques exist for soft tissue coverage and segmental bony stabilization; however, extensive resection remains the crucial starting point in a comprehensive treatment plan. Antibiotic therapy continues to be a cornerstone of adjuvant therapy; nevertheless, the length of treatment is still debated. With ever-increasing antimicrobial resistance rates, targeted therapy based on accurate cultures has become imperative. Osteomyelitis requires a multidisciplinary team prepared to formulate an individualized surgical and medical plan for each patient. The aim of the current article is to highlight and summarize the current concepts in the management of long bone osteomyelitis.

Abstract: The mechanisms underlying the destruction of bone tissue in osteomyelitis are only now being elucidated. While some of the tissue damage associated with osteomyelitis likely results from the direct actions of bacteria and infiltrating leukocytes, perhaps exacerbated by bacterial manipulation of leukocyte survival pathways, infection-induced bone loss predominantly results from an uncoupling of the activities of osteoblasts and osteoclasts. Bacteria or their products can directly increase osteoclast formation and activity, and the inflammatory milieu at sites of infection can further promote bone resorption. In addition, osteoclast activity is critically regulated by osteoblasts that can respond to bacterial pathogens and foster both inflammation and osteoclastogenesis. Importantly, bone loss during osteomyelitis is also brought about by a decline in new bone deposition due to decreased bone matrix synthesis and by increased rates of osteoblast apoptosis. Extracellular bacterial components may be sufficient to reduce osteoblast viability, but the causative agents of osteomyelitis are also capable of inducing continuous apoptosis of these cells by activating intrinsic and extrinsic cell death pathways to further uncouple bone formation and resorption. Interestingly, bacterial internalization appears to be required for maximal osteoblast apoptosis, and cytosolic inflammasome activation may act in concert with autocrine/paracrine death receptor-ligand signaling to induce cell death. The manipulation of apoptotic pathways in infected bone cells could be an attractive new means to limit inflammatory damage in osteomyelitis. However, the mechanism that is the most important in bacterium-induced bone loss has not yet been identified. Furthermore, it remains to be determined whether the host would be best served by preventing osteoblast cell death or by promoting apoptosis in infected cells.

Abstract: Atraumatic vertebral compression fractures are a common clinical problem, especially in elderly population. Metastases are the most frequent source of bone tumors, and the spine is a common site of metastatic disease; in case of cortical involvement or osteolysis, they may result in pathological compression fractures. Atraumatic compression fractures may result from other primary neoplasms of vertebrae and also from osteomyelitis, Paget’s disease, hyperparathyroidism and other metabolic processes. Osteoporosis is a common source of vertebral compression fractures in elderly population, which may be indistinguishable from those of metastatic origin. The differentiation between osteoporotic compression fractures and malignant fracture is necessary to establish an appropriate staging and a therapeutic planning, especially in the acute and subacute stages. Anamnestic data about preexisting disease can be useful to individuate the potential cause of vertebral collapse. Plain radiography shows some difficulties in distinguishing whether the fracture represents a consequence of osteoporosis, a metastatic lesion or some other primary bone neoplasm. Computed tomography is one of the most suitable imaging techniques for the evaluation of bone structure and fragments and to establish the degree of cortical bone destruction; MR imaging (MRI) is the most helpful radiological investigation in order to provide the basis for the distinction between metastatic and acute osteoporotic compression fractures. The most relevant MRI findings to establish a differential diagnosis are described.

Abstract: OBJECTIVE Successful treatment of osteomyelitis is more likely with accurate diagnosis and identification of the causative pathogens. This typically requires obtaining a specimen of bone, usually by image-guided biopsy. We sought to develop a simpler bedside method for definitively diagnosing osteomyelitis. RESEARCH DESIGN AND METHODS Over 2 years, we enrolled consecutive patients presenting to our diabetic foot clinic with a foot ulcer and clinically suspected osteomyelitis but without soft tissue infection. Each underwent hybrid 67 Ga single-photon emission computed tomography and X-ray computed tomography (SPECT/CT) imaging; those with a positive scan underwent bedside percutaneous bone puncture. Patients with a positive bone culture received culture-guided antibiotic therapy. Patients with negative 67 Ga SPECT/CT imaging or with positive imaging but negative bone culture were not treated with antibiotics. All patients were followed up for ≥1 year. RESULTS Among 55 patients who underwent 67 Ga SPECT/CT imaging, 13 had negative results and all of their foot ulcers resolved without antibiotic therapy. Among 42 with positive imaging, 2 were excluded (for recent antibiotic therapy) and 40 had bone punctures (3 punctured twice): 19 had negative results, 3 of which were likely false negatives, and 24 had positive results (all gram-positive cocci). At follow-up, 3 patients had died, 3 had undergone amputation, and 47 had no evidence of foot infection. The sensitivity and specificity of this combined method were 88.0 and 93.6%, respectively, and the positive and negative predictive values were 91.7 and 90.7%, respectively. CONCLUSIONS Coupling of 67 Ga SPECT/CT imaging and bedside percutaneous bone puncture appears to be accurate and safe for diagnosing diabetic foot osteomyelitis in patients without signs of soft tissue infection, obviating the need for antibiotic treatment in 55% of suspected cases.

Abstract: Background:To evaluate the prevalence of osteomyelitis in different areas of the foot and the possible correlation between localization and outcome of major amputation.Methods:From January 2008 to ...

Abstract: Infection imaging has been challenging over the past four decades, which provided an excellent playing field for researchers working in this area, and till date the quest continues to find an ideal imaging agent. Labelled leukocytes were first developed in the 1970s for imaging infection lesions such as osteomyelitis, cellulitis, diabetic foot, Crohn’s disease, inflammatory bowel disease, fever of unknown origin, etc. Subsequently labelled antibiotics such as 99mTc-labelled ciprofloxacin have emerged for directly identifying live bacterial infections. From the early 1970s through the mid-1980s, 67Ga-Citrate was the prime radionuclide for imaging of inflammation and infection of musculoskeletal origin. Although 68Ga-PET was described in 1960s for tumour imaging, recent reports described 68Ga-Citrate and 68Ga-transferrin as possible agents for PET-imaging of infection due to successful application of 67Ga-Citrate SPECT in the past, despite its limitations. It is important to establish a faster imaging method for 68Ga, as its half-life is 68 min compared to 78.3 hrs for 67Ga. Preparation of 68Ga-Citrate and 68Ga-transferrin is described, with very high yield and high radiochemical purity (RCP), which is ideally suited for routine clinical studies. Biodistribution of 68Ga-Citrate-PET images were characterised with high blood pool, high liver and bone (growth plate) uptake with low soft-tissue activity. 68Ga-Citrate or 68Ga-transferrin was able to detect infected lesions in rats within 5–10 min post injection but a focal intense uptake at the lesion (SUVmax) was visualized only at 30 min, which increased for up to 6 hrs post injection with concomitant decrease in the cardiac blood pool activity. The liver and bowel activity decreased after 90 min then stabilised. In the patient studies, infection lesions were detected within 30 min post injection of 68Ga-Citrate. Cardiac blood pool and liver activities decreased during the period of study. Interestingly, there was persistent high vascular activity in the thigh region. One of the major limitations of 67Ga-Citrate SPECT is the delayed post injection waiting time of 48 hrs, in contrast to 60 min post injection waiting with 68Ga-Citrate. The distinct difference in imaging time is intriguing, although there is no chemical difference between 67Ga-Citrate and 68Ga-Citrate, except for the radiolabel. No literature is available on early imaging times using 67Ga-SPECT. When compared 68Ga/67Ga-Citrate images at 60 min post injection in normal rats, 68Ga-PET showed better images with low background activity than 67Ga-SPECT agent. This may be due to short half-life of 68Ga (68 min), as it would have decayed one half-life at 60 min post-imaging time, compared to the SPECT agent (67Ga), which would require 76 hrs to undergo one half-life. Therefore, the visual difference in background can be attributed to the difference in the half-lives of these two agents. Similarly, uptake of 68Ga by liver, cardiac blood pool activity is much lower than 67Ga at 60 min post injection period, may be attributed to the faster decay of 68Ga than 67Ga. High background activity of 68Ga-Citrate in the thorax and upper abdomen at 60 min post-injection may interfere with detecting lesions in these regions; therefore, 68Ga-PET is more suitable for imaging lesions in the lower abdomen and the extremities. The short half-life of 68Ga (68 min) may be advantageous from low dosimetry to the patients, but disadvantageous for longer periods of study. Since 68Ga-Citrate was capable of detecting infection within 60 min, the need for imaging for longer periods may not be warranted. The functional imaging was not limited to diagnosing infection but it could be extended to surgical planning and antibiotic therapy monitoring of osteomyelitis and in distinguishing prosthetic infection from loosening of prosthesis. 18F-FDG is sensitive but has the limitation of giving false positive results in patients with bone prosthesis, even if there is no infection or mobilisation. But the available literature clearly indicated 68Ga-Citrate was positive only in cases of infection. In summary, preliminary reports suggest 68Ga-Citrate PET/CT is useful in the diagnosis of suspected bone infections with reliable sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy. Preliminary reports with 68Ga-Transferrin showed it is capable of detecting both Gram-positive Staphylococcus aureus (Staph A) and Gram-negative Proteus mirobilis. This is an incidental finding but gives an insight into the potential of this agent to detect more than one bacterial infection.

Abstract: Sporadic chronic nonbacterial osteomyelitis (CNO) is the most common auto-inflammatory bone disorder The clinical picture is highly variable ranging from nonsymptomatic monofocal lesions to chronic recurrent multifocal disease Symptoms include pain, local swelling and warmth in the absence or presence of fever A subset of CNO patients exhibits additional symptoms of psoriatic skin involvement, palmoplantar pustulosis and inflammatory bowel disease Novel insights into the pathogenesis of CNO link the failure to produce IL-10 and the resulting imbalance toward pro-inflammatory IL-6 and TNF-α with disease expression Treatment is empiric and includes NSAIDs, corticosteroids, sulfasalazine, methotrexate, TNF inhibitors and bisphosphonates Laboratory studies and clinical trials are warranted to: establish biomarkers that predict flares and clinical outcomes, identify patients that require additional treatment on top of NSAIDs, establish evidence-based treatment regimens, allow a risk-benefit assessment for the available therapeutic strategies, and identify novel therapeutic targets

Abstract: Objective To find and evaluate characteristic magnetic resonance imaging (MRI) patterns for the differentiation between Ewing sarcoma and osteomyelitis. Materials and methods We identified 28 consecutive patients referred to our department for MRI (1.5 T) of an unclear bone lesion with clinical symptoms suggestive of Ewing sarcoma or osteomyelitis. MRI scans were reevaluated by two experienced radiologists, typical MR imaging features were documented and a diagnostic decision between Ewing sarcoma and osteomyelitis was made. Statistical significance of the association between MRI features and the biopsy-based diagnosis was assessed using Fisher’s exact test. Results The most clear-cut pattern for determining the correct diagnosis was the presence of a sharp and defined margin of the bone lesion, which was found in all patients with Ewing sarcoma, but in none of the patients with osteomyelitis (P<0.0001). Contrast enhancing soft tissue was present in all cases with Ewing sarcoma and absent in 4 patients with osteomyelitis (P=0.0103). Cortical destruction was found in all patients with Ewing sarcoma, 4 patients with osteomyelitis did notpresentanycorticalreaction(P=0.0103).Cysticornecrotic areas were identified in 13 patients with Ewing sarcoma and in 1 patient with osteomyelitis (P=0.004). Interobserver reliability was very good (kappa=1) in Ewing sarcoma and moderate (kappa=0.6) in patients with osteomyelitis. Conclusions A sharp and defined margin, optimally visualized on T1-weighted images in comparison to short tau inversion recovery (STIR) images, is the most significant feature of Ewing sarcoma in differentiating from osteomyelitis.

Abstract: Results: Most patients (76%) received prior antibiotic treatment, and first-line treatment failure was the most frequent reason to start daptomycin. Common sites of infection were the knee (22%) or hip (21%), and the most frequently isolated pathogens were Staphylococcus aureus (33%) and coagulase-negative staphylococci (32%). Overall, 52% of patients had surgery, 55% received concomitant antibiotics and 29% received a proportion of daptomycin therapy as outpatients. Clinical success was achieved in 75% of patients. Among patients with prosthetic device-related osteomyelitis, there was a trend towards higher success rates if the device was removed. Daptomycin was generally well tolerated. Conclusions: This analysis suggests that daptomycin is an effective and well-tolerated treatment option for osteomyelitis and highlights the importance of optimal surgical intervention and appropriate microbiological diagnosis for clinical outcomes.

Abstract: Purpose Detection of osteomyelitis beneath a diabetic foot ulcer is imperative for proper management; however, accurate and noninvasive diagnosis of osteomyelitis remains a challenge. Ubiquicidin 29-41 (UBI 29-41) is a synthetic antimicrobial peptide fragment reported to be highly infection-specific. 99mTc-UBI 29-41 has recently been reported to be a promising radiotracer for infection imaging. The aim of this prospective study was to evaluate the utility of 99mTc-UBI 29-41 scintigraphy in diabetic patients with suspected osteomyelitis of the foot.

Abstract: Background The gram-negative organism, Burkholderia pseudomallei, is responsible for the disease melioidosis. Septic arthritis and osteomyelitis due to B. pseudomallei are rare but recognised presentations of the disease.

Abstract: Bone loss from trauma, neoplasia, reconstructive surgery and congenital defects remains a major health problem. The long-term clinical goal is to reconstruct bony tissue in an anatomically functional three-dimensional morphology. In the extremities, bone grafts are used for the treatment of non-unions and necrotic lesions, for skeletal structural support and for the reconstruction of defects resulting from trauma, tumor excision, osteomyelitis, congenital pseudarthrosis, or radiation necrosis. In all cases their use is successful provided that the host bed has adequate vascularization. In cases of decreased blood supply, a vascularized bone graft should be applied. The intrinsic blood supply of the vascularized bone grafts leads to higher success rates and to acceleration of the repair process in the reconstruction of defects and necrotic lesions of the skeleton.

Abstract: The treatment of osteomyelitis induced by Gram-negative bacilli is rarely reported in the literature. This study established a rabbit tibia model of osteomyelitis induced by the Gram-negative bacillus Escherichia coli. Using this model, pellets composed of a chitosan-bonded mixture of borate bioactive glass and gentamicin were evaluated in vitro and in vivo for the treatment of osteomyelitis induced by Escherichia coli. Our results showed that the pellets in phosphate-buffered saline released gentamicin continuously over 26 days. Without the simultaneous use of a systemic antibiotic, the implantation of the gentamicin-loaded pellets into the osteomyelitis region of the tibia resulted in the eradication of 81.82% of infections, as determined by microbiological, histological and radiographic evaluation, and supported the ingrowth of new bone into the tibia defects after 6 weeks of implantation. The results indicate that the gentamicin-loaded borate bioactive glass implant, combining sustained drug release with the ability to support new bone formation, could provide a method for treating osteomyelitis induced by Gram-negative bacilli.

Abstract: Infection of the bone (osteomyelitis) remains one of the most challenging problems in the field of orthopedic surgery. The limitations of systemic antibiotics administration include undesired side effects, systemic toxicity, patient discomfort, and development of bacterial resistance. In this study, we developed a bactericidal gentamicin-doped beta-tricalcium phosphate (TCP) scaffold reinforced with a gelatin/genipin hydrogel (G-TCP). Our data showed that the gentamicin-doped G-TCP had a much longer drug releasing period, while the gentamicin was completely released from pure TCP cements (B-TCP) within one day. In addition, the release profile of G-TCP exhibited an initial burst followed by a zero-order release. One standard strain, Staphylococcus aureus (S. aureus, ATCC25923) was selected to evaluate the antibacterial activity and therapeutic effect of this scaffold. G-TCP significantly inhibited growth of S. aureus both in vitro and in vivo. In a rat osteomyelitis model, osteomyelitis could be totally cured after implantation of G-TCP for three weeks. We propose that the gelatin/genipin–gentamicin TCP scaffold represents one of the promising gentamicin releasing bone scaffolds in treating osteomyelitis.

Abstract: This paper presents a review of the current literature discussing topics of Charcot osteoarthropathy, osteomyelitis, diagnosing osteomyelitis, antibiotic management of osteomyelitis, and treatment strategies for management of Charcot osteoarthropathy with concurrent osteomyelitis.

Abstract: Sir, A middle-aged male presented to the emergency department with fever and 1 week of sharp right hip pain worsening over the past 2 days. His past medical history included uncontrolled diabetes and chronic active hepatitis C. The patient also had a history of multiple methicillin-resistant Staphylococcus aureus (MRSA) infections, including bacteraemia 1 month prior, for which he was treated with vancomycin (MIC ≤0.5–1 mg/L). Three sets of blood cultures were collected before the patient received a single dose of vancomycin and piperacillin/tazobactam. The blood Gram stain showed Gram-positive cocci. The infectious diseases team was consulted, and given recent vancomycin treatment and recurrent bacteraemia, we recommended high-dose daptomycin (8 mg/kg intravenously every 24 h). Dual therapy with rifampicin was considered, but due to limited in vivo data as well as concomitant hepatic dysfunction, we decided against it. Initial blood cultures grew MRSA (3/3 bottles) on hospital day 3, with susceptibility tests showing a daptomycin MIC of 0.38 mg/L (Etest; AB Biodisk, Solna, Sweden) and a vancomycin MIC of 1 mg/L by broth microdilution. Repeat blood cultures on day 4 (2/2 bottles) showed no growth. On hospital day 2, a transoesophageal echocardiogram (TEE) demonstrated no evidence of vegetations. On day 3, a contrast CT of the hip showed bone and retroperitoneal abscesses along with evidence highly suggestive of osteomyelitis. An MRI was less conclusive about the presence of early osteomyelitis. The surgical team was consulted and recommended that the patient to undergo CT-guided drainage of the retroperitoneal abscess as opposed to any surgical treatment, citing difficult surgical access, a high-risk patient with comorbidities and likelihood of the abnormal synovium in radiographic studies being reactive synovitis as opposed to osteomyelitis and septic arthritis. Drainage proceeded on day 7, though there was continued debate about the diagnosis and need for surgical intervention. Research letters

Abstract: Osteopetrosis is a rare hereditary bone disorder presenting with variable clinical features and is characterized by an increase in bone density and reduction of marrow spaces that result from a defect in the function of osteoclasts and, consequently, a decrease in bone turnover. This disease is generally divided into three types: severe infantile malignant autosomal recessive, intermediate mild autosomal recessive, and benign autosomal dominant. The prognosis of the first two types is very poor and is characterized by an early onset, usually within the first decade of life, and early death. The benign-type is characterized by a later onset and a longer life span. Ten percent of osteopetrosis cases develop osteomyelitis that usually involves the mandible. The osteomyelitis is generally caused by tooth extraction or pulpal necrosis. The leading cause of the increased rate of infection is thought to be a lack of adequate bone vasculature. Treatment of osteomyelitis secondary to osteopetrosis is controversial. Treatment regimens include high-dose systemic antibiotics coupled with thorough debridement of necrotic bone and primary closure of soft tissues, if possible. Hyperbaric oxygen has been used for the treatment of chronic osteomyelitis.

Abstract: Introduction Mandibular fractures are frequent, and treatment for these fractures involves rigid fixation. Complications can occur after treatment and may require a new surgical procedure; however, there are limited studies evaluating surgical retreatment. Aim The purpose of this retrospective study was to evaluate the characteristics and the types of treatment carried out in patients requiring surgical retreatment of mandibular fractures. Materials and methods From all patients with mandibular fractures treated by rigid internal fixation at a trauma hospital during a 7-year-period, 20 patients (4.7% of the cases) required a second surgery. Results The most common complaints were pain, infection with the presence of fistula, and abnormal mobility. There was a predominance of Staphylococcus aureus in the bacterial culture. The most frequent radiographic images were diffuse bone resorption, loosening of screws, and a visible fracture line. The diagnoses were nonunion in 10 (50%) cases, soft tissue infection associated with screw loosening or plate exposure in 7 (35%) cases, osteomyelitis in 2 (10%) cases, and malunion in 1 (5%) case. Seven cases of nonunion presented with fistula, and four of these patients had bone sequestration. The required procedures included new fixation in 6 (30%) patients, removal of bone sequestration and new fixation in 4 (20%) patients, surgical exploration and removal of fixation material in 7 (35%) patients, removal of bone sequestration in 2 (10%) patients, and refracture in 1 (5%) patient. Conclusion It was concluded that most cases requiring surgical retreatment of mandibular fractures comprised nonunion or soft tissue infection associated with screw loosening or plate exposure. Consequently, the main procedures needed were new fixation or surgical exploration with the removal of fixation material.