Aspects des complications ostéo-articulaires de la maladie de Gaucher de type 1 en scintigraphie osseuse planaire (infection exclue) : à propos d’un cas

Type 1 Gaucher disease is an autosomal recessive inheritance lysosome storage disorder, corresponding to an inherited deficiency of glucocerebrosidase. Bone complications are frequently revealing and constitute the main source of morbidity and disability. They can appear on the acute (osseous infarction, acute osteomyelitis) or chronic mode (bone modelling disorders, osteopenia, osteonecrosis, chronic osteomyelitis). The aim of our work is to evaluate the contribution of the 99mTc labeled diphosphonates bone scan in the case of a 28-year-old patient, followed up for type 1 Gaucher disease and presenting for 2 months knees and pelvis inflammatory pain with functional impotence. X-ray had shown a stage IV aseptic osteonecrosis of the right femoral head. The bone scan found other osteo-articular lesions of the left hip, knees and right tibia related to Gaucher disease with a high likelihood. Bone scan is a very sensitive procedure in the early diagnosis and in the follow-up of bone complications of type 1 Gaucher disease. Bone scan allows to clinically silent lesions on the whole skeleton.     

Benzylpenicillin levels in the serum and bone tissue of the lower jaw in patients with chronic traumatic osteomyelitis after intraosseous and intramuscular administration

Penetration of benzylpenicillin into pathological foci was studied in 48 patients with chronic traumatic osteomyelitis of the lower jaw after intramuscular and intraosseous administration of the antibiotic. A group of 10 patients operated for congenital deformations of the lower jaw was used as the control. The results showed that after intramuscular administration benzylpenicillin penetration into the inflammation focus of the lower jaw was better than that into the intact bone only for the first 30 minutes. At later periods it was detected in both the cases as traces. After intraosseous administration of the drug in doses of 50,000 and 200,000 units its accumulation in the bone tissue of the patients with chronic traumatic osteomyelitis of the lower jaw in 30 minutes was respectively 75 and 160 times higher than that after the intramuscular injections. The period of its presence in the pathological focus as the therapeutic levels was also higher i. e. up to 2 hours. Intraosseous route of benzylpenicillin administration is likely to decrease the quantity of the drug needed for treating patients with chronic osteomyelitis of the lower jaw.     

Skeletal Scintigraphy

Skeletal scintigraphy, using phosphates or diphosphonates labeled with technetium 99m, is a sensitive method of detecting bone abnormalities. The most important and most frequent role of bone scanning is evaluating the skeletal areas in patients who have a primary cancer, especially a malignant condition that has a tendency to spread to bone areas. The bone scan is superior to bone radiographs in diagnosing these abnormalities; 15 percent to 25 percent of patients with breast, prostate or lung cancer, who have normal roentgenograms, also have abnormal scintigrams due to metastases. The majority of bone metastases appear as hot spots on the scan and are easily recognized. The incidence of abnormal bone scans in patients with early stages (I and II) of breast cancer varies from 6 percent to 26 percent, but almost invariably those patients with scan abnormalities have a poor prognosis and should be considered for additional therapies. Progression or regression of bony lesions can be defined through scanning, and abnormal areas can be identified for biopsy. The incidence of metastases in solitary scan lesions in patients with known primary tumors varies from 20 percent to 64 percent. Bone scintigraphy shows positive uptake in 95 percent of cases with acute osteomyelitis. Stress fractures and trauma suspected in battered babies can be diagnosed by scanning before there is radiological evidence. The procedure is free from acute or long-term side effects and, except in cases of very young patients, sedation is seldom necessary.Although the test is sensitive, it is not specific and therefore it is difficult to overemphasize the importance of clinical, radiographic, biochemical and scanning correlation in each patient.     

Dilemma in Differentiating between Acute Osteomyelitis and Bone Infarction in Children with Sickle Cell Disease: The Role of Ultrasound

Background

Distinguishing between acute presentations of osteomyelitis (OM) and vaso-occlusive crisis (VOC) bone infarction in children with sickle cell disease (SCD) remains challenging for clinicians, particularly in culture-negative cases. We examined the combined role of ultrasound scan (USS), C - reactive protein and White blood counts (WCC) in aiding early diagnosis in children with SCD presenting acutely with non-specific symptoms such as bone pain, fever or swelling which are common in acute osteomyelitis or VOC.

Methods

We reviewed the records of all children with SCD who were discharged from our department from October 2003 to December 2010 with a diagnosis of osteomyelitis based on clinical features and the results of radiological and laboratory investigations. A case control group with VOC who were investigated for OM were identified over the same period.

Results

In the osteomyelitis group, USS finding of periosteal elevation and/or fluid collection was reported in 76% cases with the first scan (day 0–6). Overall 84% were diagnosed with USS (initial +repeat). 16% had negative USS. With VOC group, USS showed no evidence of fluid collection in 53/58 admissions (91%), none of the repeated USS showed any fluid collection. Mean C-reactive protein (CRP), and white cell count (WCC) were significantly higher in the OM.

Conclusion

The use of Ultrasound in combination with CRP and WCC is a reliable, cost-effective diagnostic tool for differentiating osteomyelitis from VOC bone infarction in SCD. A repeat ultrasound and/or magnetic resonance imaging (MRI) scan may be is necessary to confirm the diagnosis.     

外固定架联合抗感染活性骨治疗下肢创伤性骨髓炎

目的:验证外固定架联合抗感染活性骨(ARBX)治疗下肢创伤性骨髓炎的疗效。方法:25例下肢创伤性骨髓炎患者给予原内固定取出、病灶清除、断端修整、抗感染活性骨植骨、外固定架固定,通过长期随访,分析评价其疗效。结果:随访2-10年,平均6年,感染彻底控制无复发23例,感染治愈率92%;骨不连、骨缺损获得骨性愈合24例,1例残留骨不连,愈合时间6-24月,骨性愈合率96%。结论:外固定架联合抗感染活性骨是治疗下肢创伤性骨髓炎的安全有效手术方法。     

Chronic osteomyelitis of the clavicle

Osteomyelitis of the clavicle is an uncommon disease, but it should be considered in patients who present with pain, cellulitis, or drainage in the sternoclavicular area following head and neck surgery, irradiation, subclavian vein catheterization, or immunosuppression. An idiopathic presentation is possible. In contrast to primary osteomyelitis of the clavicle, which is occasionally seen in children, secondary osteomyelitis is quite rare. It is often mistaken for a fracture or a possible neoplasm on plain x-rays. Tomograms and CT scanning are confirmatory, and in early cases, technetium-99m bone scanning can be helpful. Treatment must include early, aggressive surgical debridement of all affected tissues, followed by wound coverage with a well-vascularized flap and perioperative antibiotics.     

Intraosseous angiosarcoma with secondary aneurysmal bone cysts presenting as an elusive diagnostic challenge

Angiosarcoma of bone is an exceedingly rare primary bone malignancy that can present as an aggressive osteolytic lesion. Histological diagnosis can be extremely challenging, as the pathological features often resemble that of aneurysmal bone cysts. We report an interesting and peculiar case of an intraosseous angiosarcoma that presented as a diagnostic dilemma and discuss the relevant radiological and pathologic findings.     

Gefäßzugang über den Knochen

Intraosseous line In cases of emergency an intravenous line is necessary to administer live‐saving infusions and drugs. In hemorrhagic shock, hypothermia or circulatory arrest it can be difficult to get access to systemic circulation. An alternative is an intraosseous line by inserting a needle into the medullary cavitiy in the epiphysis of a long bone. With a system working with a cordless screw‐driver the canula can be administered save and in a few seconds. Via the osteons drugs and infusions reach the circulation. Pharmacokinetics are comparable to an intravenous line. Anatomical basics of the technique are 300, first practical work nearly 100 years old. New technologies facilitate the easily application of intraosseous lines in medicine.     

The diagnosis of osteomyelitis in patients with pressure sores

A prospective blind trial was undertaken to assess the usefulness of commonly used tests to diagnose osteomyelitis underlying pressure sores. Sixty-one pressure sores were studied, with a histopathologic diagnosis from the ostectomy specimen being available in 52. White cell count, erythrocyte sedimentation rate, plain pelvic x-ray, technetium-99m bone scan, computerized tomography, and Jamshidi needle bone biopsy were studied. The most useful individual test was a needle bone biopsy, with a sensitivity of 73 percent and a specificity of 96 percent. Technetium-99m bone scans and computerized tomography are not indicated in the diagnosis of osteomyelitis associated with pressure sores. Plain pelvic x-ray, white cell count, and erythrocyte sedimentation rate, with a diagnosis of osteomyelitis if any test is positive, is the most sensitive (89 percent), specific (88 percent), noninvasive workup. Jamshidi needle biopsy may be useful where these tests are negative and a clinical suspicion of osteomyelitis remains. Extent of surgical debridement and antibiotic therapy can then be rationally decided on the basis of this information.     

Variability in intraosseous pressure induced by saline flush of an intraosseous cannula by multiple practitioners

Intraosseous cannulation is an accepted means to achieve vascular access when peripheral venous access is not available. It is common practice to flush the intraosseous cannula with saline prior to establishing infusions. The objective of this study was to evaluate changes in intraosseous pressure during the flush procedure and to assess the variability of pressure changes induced by different practitioners. Two intraosseous cannulas were placed in an isolated cadaveric femur collected from a swine. Intraosseous pressure and the rate of change in pressure were recorded continuously during a series of saline flushes into a distal femoral intraosseous cannula by 21 members of the veterinary research staff at the authors' institution. Median peak intraosseous pressures exceeded 600 mmHg, and an inverse relationship was noted between peak intraosseous pressure and the duration of flush. Bone marrow fat emboli were grossly evident in flush effluents and their presence was confirmed by microscopic examination. Until the practitioners were informed of the pressure changes induced by the intraosseous cannula flush, few had appreciated the magnitude of the pressures that they had generated, suggesting that an instrumented intraosseous flush preparation like the one used in this study may prove useful as a training tool for flush procedures.     

Allogeneic materials in complications associated with pre-implantation restoration of maxillary and mandibular alveolar processes. A four case report

There are numerous types of bone replacement materials used to regenerate atrophic alveolar processes before the elective intraosseous implantation. Properties of these materials differ one from another, therefore the choice of material should be thoroughly analysed as well as its type and texture in regard of intraoral conditions and the objective to be achieved. The study involved reconstruction of atrophic alveolar processes with allogeneic bone following unsuccessful use of synthetic and animal materials. The procedure of bone regeneration was performed with frozen bone block (case 1) and allogeneic bone granulate (cases 2, 3, 4) radiation-sterilised with 35 kGy prepared by the Tissue Bank. In all of the presented cases after 3-month implant reorganisation optimal width of the process was obtained, which allowed implant embedment (case 1) or correct implant submergence in the osseous tissue, when implantation took place at the same time (case 2, 3, 4). Allogeneic bone material both, in the form of a block as well as granulate, seems to be an adequate alternative for other materials used in order to widen the bone of the alveolar process, particularly in difficult, complicated cases, where the first regeneration procedure was not successful.     

Nocardiose pulmonaire compliquée d’ostéomyélite

We report a case of a 49-year-old female who developed a bronchopneumonia associated with atelectasis of the upper right lobe and back pain of bone origin. Bronchoscopy revealed an endobronchial mass at the origin of the right upper lobe bronchus. Scintigraphy showed three paravertebral spots of the seventh and eighth thoracic vertebrae, without any radiological modification. Culture of lung tissue obtained by transparietal punction under CT scan control became positive to Nocardia belonging to the pneumoniae complex. Positive diagnosis of pulmonary nocardiosis associated with two rare localisations was set, one was an endobronchial mass, the other was osteomyelitis of the posterior chest wall. The patient was treated with Trimethoprim–Sulfamethoxazole and recovered completely.     

Intraosseous Vascular Access through the Anterior Mandible – A Cadaver Model Pilot Study

Background

Several insertion sites have been described for intraosseous puncture in cases of emergencies when a conventional vascular access cannot be established. This pilot study has been designed to evaluate the feasibility of the mandibular bone for the use of an intraosseous vascular access in a cadaver model.

Methodology/Principal Findings

17 dentistry and 16 medical students participating in a voluntary course received a short introduction into the method and subsequently used the battery powered EZ-IO system with a 15 mm cannula for a puncture of the anterior mandible in 33 cadavers. The time needed to perform each procedure was evaluated. India ink was injected into the accesses and during the anatomy course cadavers were dissected to retrace the success or failure of the puncture. Dental students needed 25.5±18.9(mean±standard deviation)s and medical students 33±20.4 s for the procedure (p = 0.18). Floor of mouth extravasation occurred in both groups in 3 cases. Success rates were 82 and 75% (p = 0.93).

Conclusions/Significance

Despite floor of mouth extravasation of injected fluid into a mandibular intraosseous access might severely complicate this procedure, the anterior mandible may be helpful as an alternative to other intraosseous and intravenous insertion sites when these are not available in medical emergencies.     

Local osteogenic expression of cyclooxygenase-2 and systemic response in porcine models of osteomyelitis

It is suggested that cyclooxygenase 2 (COX-2) derived prostaglandins contributes to the progressive bone loss seen in osteomyelitis lesions. In the present study we examined the expression of COX-2 in bones from 23 pigs with experimental osteomyelitis. Osteomyelitis was induced with Staphylococcus aureus and groups of animals were euthanized following 6 h, 12 h, 24 h, 2 days, 5 days, 11 days and 15 days, respectively. Expression of COX-2 was evaluated immunohistochemically and combined with characterization of morphological changes in bone tissue. Furthermore, the serum concentrations of alkaline phosphatase and haptoglobin were measured. Extensive COX-2 expression by osteoblasts was present 2 days after inoculation together with many activated osteoclasts. Simultaneously, the serum concentration of alkaline phosphatase decreased whereas the haptoglobin concentration increased. This is the first in vivo study showing an early wave of COX-2 mediated bone resorption during osteomyelitis. Therefore, treatment aiming to reduce the break down of bone tissue directed by the COX-2 pathway might be suggested early in the course of the disease.     

Free tissue coverage of chronic traumatic wounds of the lower leg

Thirty-eight consecutive patients who underwent 42 free flaps for chronic wounds of the lower leg were identified over an 11-year period. All wounds were open for a minimum of 1 month (mean, 40 months; median, 8 months; range, 1 month to 30 years). The average age was 37 years (range, 7 to 68 years), there were 31 male patients and seven female patients, and the average follow-up time was 30 months (range, 12 to 72 months). The original injury was an open fracture in 28 patients, wound dehiscence after open reduction and internal fixation of a closed fracture in nine patients, and a shrapnel wound in one patient. A total of 23 patients had osteomyelitis, which was classified as local (involving less than 50 percent of the bone diameter) in 15 patients and as diffuse (involving greater than 50 percent of the bone diameter or infected nonunion) in eight patients. The wounds were treated with sequential debridement, antibiotics, and flap coverage. Ancillary procedures included antibiotic beads in 18 patients, saucerization in 16, Ilizarov bone transport in three, calcanectomy in two, and fibular resection and ankle fusion in one. Thirty-four of 42 flaps survived, four having undergone a repeat free flap. There were three failures out of 25 flaps (12 percent) among those with a normal angiogram and five failures out of 15 flaps (33 percent) among those with an abnormal angiogram (p > 0.05). The failure rate of those with osteomyelitis was six of 26 (23 percent) versus two of 26 (13 percent) for those without osteomyelitis (p > 0.05). Successful reconstruction (bone healed, patient ambulatory and infection-free) was achieved in 33 of 38 patients (87 percent). The failure of reconstruction for those patients with osteomyelitis was four of 23 (22 percent) versus one of 15 (7 percent) for others (p > 0.05). The failure rate of flaps in patients with diffuse osteomyelitis was three of eight (38 percent) versus two of 30 for others (7 percent, p = 0.053). The presence of diffuse osteomyelitis was associated with a lower rate of successful limb reconstruction. An abnormal angiogram and the presence of osteomyelitis both were associated with a lower rate of successful limb reconstruction, but this was not significant, probably because of the small size of the cohort.     

Antibacterial and anti-inflammatory effects of genistein in Staphylococcus aureus induced osteomyelitis in rats

Methicillin-resistant Staphylococcus aureus (MRSA) is a highly infectious Gram-positive pathogen known to cause severe diseases such as endocarditis, food poisoning, pneumonia, osteomyelitis, and septicemia. MRSA is a major public health issue. Among these, osteomyelitis is inflammation of the bone caused by the invasion of the bacterial pathogen in the bones. Its prominent symptoms include fever, pain, and redness of bones. In the case of children, it affects the long bones of arms and legs, whereas in the case of adults it affects the hip, feet, and spine. Bacterial osteomyelitis can trigger pathological remodeling of bones and hence causes substantial morbidity and mortality. The present study aims to evaluate the isoflavone genistein's (5,7-dihydroxy-3-(4-hydroxyphenyl)−4H-1-benzopyran-4-one,4′,5,7 trihydroxyisoflavone) antimicrobial and anti-inflammatory effects against osteomyelitis induced by MRSA in male Wistar rats. Classification of the animals was into the following: sham (Group I), osteomyelitis (Group II, control), genistein (25 mg/kg body weight, Group III), and genistein (50 mg/kg body weight, Group IV). The rats did not receive any treatment for 4 weeks after bacterial inoculation. Genistein was then administered twice daily for 2 weeks. Bacterial growth, mean body weight bone infection status, and side effects of genistein treatment were assessed. Furthermore, lipid peroxidation, superoxide dismutase, glutathione (GSH) peroxidase, catalase, reduced GSH, tumor necrosis factor-α (TNF-α), and interleukin (IL)-6 were also determined. Two days after treatment, it was found that genistein significantly suppressed bacterial growth and reduced serum pro-inflammatory cytokines TNF-α and IL-6. Therefore, the study suggests that genistein could be a promising lead against MRSA-induced osteomyelitis.     

Septic arthritis and osteomyelitis from a cat bite

A 39-year-old man with no prior history of underlying arthritis developed osteomyelitis and septic arthritis in his hand following a cat bite. This case illustrates the virulence of Pasteurella multocida infections associated with animal bites, particularly those of cats, whose teeth can inoculate bone directly. The onset of cellulitis caused by P. multocida infections is often rapid, and the drug of choice for such infections remains penicillin. Appropriate antibiotic therapy, however, does not always prevent complications such as those seen in this patient.     

Sarcome d’Ewing agressif apparaissant comme une lésion froide sur la scintigraphie osseuse

Ewing's sarcoma classically presents as a hot spot on bone scan as a result of increased vascularity of the tumor and new bone formation.PurposeWe report and analyze an uncommon pattern of a “cold” lesion in Ewing's sarcoma on bone scan and its physiopathologic significance.Case reportA 15-year-old boy complaining of thigh pain. CT scan evocated Ewing's sarcoma or osteitis. MRI evocated chronic osteitis. Scintigraphy showed a fairly intense and heterogeneous uptake on the femoral lesion and no abnormal uptake elsewhere. Biopsy showed none pathologic pattern. Three months later, a second biopsy concluded to Ewing's sarcoma. Bone scan showed a larger lesion with peripheral intense uptake centered by enlarged “cold” area in the left femoral diaphysis and no evident bone metastasis. The patient underwent chemotherapy and surgery. Three months later, bone scan showed extensive skeletal metastasis.ConclusionEwing's sarcoma appears usually as an intense lesion on bone scan. Nevertheless, decreased radiopharmaceutical uptake or “cold” lesion may be seen in aggressive Ewing's sarcoma with lytic tumor, growth of which is very rapid and bony reaction is minimal.     

CT characteristics of solitary long bone cysts before and after treatment

Computed tomography was used to study the X-ray morphological characteristics of femoral and humoral bone cysts and the course of a reparative process after surgery in 23 patients with varying activity of solitary bone cysts. Treatment using transosseous osteosynthesis, intraosseous armoring, and therapeutic and diagnostic punctures in patients with solitary bone cysts could yield the most active osteoproductive effect and cause a considerable increase in the density of cyst contents in active and activity-losing stages, which was most evident around the intraosseous wires. Patients with late-stage cysts were found to have an osteogenic effect, mainly in an area of osteotomy.     

TRAIL expression is induced in both osteoblasts containing intracellular Staphylococcus aureus and uninfected osteoblasts in infected cultures

Staphylococcus aureus is the principal etiological agent of osteomyelitis (bone infection), which is characterized by a progressive inflammatory response resulting in extensive damage to bone tissue. Recent studies have demonstrated the ability of S. aureus to invade and persist inside osteoblasts (bone matrix-forming cells) and other eukaryotic cells. The presence of intracellular S. aureus in bone tissue may be relevant to the pathology of osteomyelitis, a disease often refractory to antibiotic treatment and subject to recurrence months and even years after apparently successful therapy. The present study examined the production of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) following S. aureus infection, and whether expression of the molecule was induced by those osteoblasts containing intracellular S. aureus. Results from this study suggest that osteoblasts containing intracellular S. aureus induce TRAIL expression in uninfected osteoblasts present in infected cultures.