EC Paediatrics

Objective: To evaluate the results of surgical treatment based on the creation of several cortical holes and continuous irrigation with antibiotics in the treatment of hemorrhagic tibial osteomyelitis in children.

Materials and Methods: The analysis was performed on data collected from 268 patients (276 bones), from September 1994 to December 2014. The mean age at the time of surgery was 4 years and 5 months. Information on the diagnosis of osteomyelitis was collected such as clinical examination, plain radiography and ultrasound. Paraclinical tests including bacterial culture, white blood cell count, erythrocyte sedimentation rate and C-reactive. Osteomyelitis was classified into 3 stages: acute, intermediate and chronic osteomyelitis. Surgical techniques: Cortical bone fenestrations with continuous antibiotic irrigation for long bone; and debridement for flat bone.

Results: There were 268 patients (276 bones); 106 (39.6%) female and 162 (60.4%) male. Unilateral lesions were most common, with the left bone affected in 87 (32.5%) and the right bone in 173 (64.5%) patients. Both bones were affected in 8 (3.0%) patients. There were 284 bones, including Humerus 61 (21.5%), Femur 92 (32.4%), Tibia 114 (40.2%) were long bone; and Fibula 17 (5.9%) were flat bone. All patients were classified as having intermediate stage of osteomyelitis. Overall, we achieved good results in 215 tibiae (77.9%), fair results in 59 tibiae (21.4%) and poor results in 2 (0.7%) tibiae with progressive chronic osteomyelitis 1, and pathologic fracture 1.

Conclusion: Overall, all Intermediate Osteomyelitis, and surgical treatment of osteomyelitis of the bone is safe and effective. We suggest that this treatment method can be applied to osteomyelitis of the bones.

 Keywords: Debridement; Osteomyelitis; Tibia; Infection; Children

1. Krogstad P. “Osteomyelitis”. In: Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL, eds. Pediatric infectious diseases. 6^th Philadelphia: Saunders (2009): 725-742.
2. Gillespie WJ and Mayo KM. “The management of acute haematogenous osteomyelitis in the antibiotic era: a study of the outcome”. Journal of Bone and Joint Surgery. British Volume 63-B.1 (1981): 126-131.
3. Peltola H., et al. “Short-versus long-term antimicrobial treatment for acute hematogenous osteomyelitis of childhood: prospective, randomized trial on 131 culture-positive”. Pediatric Infectious Disease Journal 12 (2010): 1123-1128.
4. Dartnell J., et al. “Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature”. Journal of Bone and Joint Surgery. British Volume 5 (2012): 584-595.
5. Paakkonen M., et al. “Antibiotic treatment and surgery for acute hematogenous calcaneal osteomyelitis of childhood”. Journal of Foot and Ankle Surgery 5 (2015): 840-843.
6. Horst SA., et al. “A novel mouse model of Staphylococcus aureus chronic osteomyelitis that closely mimics the human infection: an integrated view of disease pathogenesis”. American Journal of Pathology 4 (2012): 1206-1214.
7. Brandt SL., et al. “Innate immunity to Staphylococcus aureus: evolving paradigms in soft tissue and invasive infections”. Journal of Immunology 12 (2018): 3871-3880.
8. Inzana JA., et al. “A novel murine model of established Staphylococcal bone infection in the presence of a fracture fixation plate to study therapies utilizing antibiotic-laden spacers after revision surgery”. Bone 72 (2015): 128-136.
9. de Mesy Bentley KL., et al. “Evidence of Staphylococcus aureus deformation, proliferation, and migration in canaliculi of live cortical bone in murine models of osteomyelitis”. Journal of Bone and Mineral Research 5 (2017): 985-990.
10. Josse J., et al. “Staphylococcus aureus osteoblast: relationship and consequences in osteomyelitis”. Frontiers in Cellular and Infection Microbiology 5 (2015): 85.
11. Rigby KM and DeLeo FR. “Neutrophils in innate host defense against Staphylococcus aureus infections”. Seminars in Immunopathology 2 (2012): 237-259.
12. Jensen LK., et al. “Specific antibodies to Staphylococcus aureus biofilm are present in serum from pigs with osteomyelitis”. In Vivo5 (2015): 555-560.
13. Croes M., et al. “Inflammation-induced osteogenesis in a rabbit tibia model”. Tissue Engineering, Part C: Methods 11 (2017): 673-685.
14. Gaida MM., et al. “Polymorphonuclear neutrophils in osteomyelitis: link to osteoclast generation and bone resorption”. European Journal of Inflammation 10 (2012): 413-426.
15. Antoni D., et al. “Three-dimensional cell culture: a breakthrough in vivo”. International Journal of Molecular Sciences 3 (2015): 5517-5527.
16. Karve SS., et al. “Intestinal organoids model human responses to infection by commensal and Shiga toxin producing Escherichia coli”. PLoS One6 (2017): e0178966.
17. Lew Daniel., et al. "Osteomyelitis". New England Journal of Medicine14 (1997): 999-1007.
18. Mader Jon T., et al. "Staging and staging application in osteomyelitis". Clinical Infectious Diseases6 (1997): 1303-1309.
19. Ramos OM. “Chronic osteomyelitis in children”. Pediatric Infectious Disease Journal 5 (2002): 431-432.
20. Schlumpf R. “Tibial shaft: anterior approach”. In: Rüedi T, von Hochstetter AHC, Schlumpf R, eds. Surgical Approaches for Internal Fixation. Berlin: Springer-Verlag (1984): 155-156.
21. Matzkin EG., et al. "Chronic osteomyelitis in children: Shriners Hospital Honolulu experience”. Journal of Pediatric Orthopaedic B 5 (2005): 362-366.
22. Lew DP and Waldvogel FA. “Osteomyelitis”. Lancet 9431 (2004): 369-379.
23. Monsalve J., et al. "Septic arthritis in children: Frequency of coexisting unsuspected osteomyelitis and implications on imaging work-up and management”. American Journal of Roentgenology 6 (2015): 1289-1295.
24. Paakkonen M., et al. "C-reactive protein versus erythrocyte sedimentation rate, white blood cell count and alkaline phosphatase in diagnosing bacteraemia in bone and joint infections”. Journal of Paediatrics and Child Health 3 (2013): E189-E192.
25. Henninger B., et al. "Ewing sarcoma versus osteomyelitis: Differential diagnosis with magnetic resonance imaging”. Skeletal Radiology 8 (2013): 1097-1104.
26. Principi N and Esposito S. “Kingella kingae infections in children”. BMC Infectious Diseases 15 (2015): 260.
27. Baron EJ., et al. "A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a)”. Clinical Infectious Diseases 4 (2013): e22-e121.
28. Zaoutis T., et al. "Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children”. Pediatrics 2 (2009): 636-642.
29. Keren R., et al. "Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute”. JAMA Pediatrics2 (2015): 120-128.
30. Faust SN., et al. "Managing bone and joint infection in children”. Archives of Disease in Childhood 6 (2012): 545-553.
31. Ratnayake K., et al. "Pediatric acute osteomyelitis in the postvaccine, methicillin-resistant Staphylococcus aureus era”. American Journal of Emergency Medicine 10 (2015): 1420-1424.
32. Peltola H., et al. "Clindamycin vs. first-generation cephalosporins for acute osteoarticular infections of childhood—A prospective quasi-randomized controlled trial”. Clinical Microbiology and Infection 6 (2012): 582-589.
33. Pezone I and Leone S. “Role of trimethoprim-sulfamethoxazole for treatment of acute osteomyelitis in children”. Pediatric Infectious Disease Journal 6 (2012): 660-661.
34. Atkins BL., et al. "Salmonella osteomyelitis in sickle cell disease children in the east end of London”. Journal of Infection 2 (1997): 133-138.
35. Fogel I., et al. "Dexamethasone therapy for septic arthritis in children”. Pediatrics4 (2015): e776-e782.
36. Vassena C., et al. "Photodynamic antibacterial and antibiofilm activity of RLP068/Cl against Staphylococcus aureus and Pseudomonas aeruginosa forming biofilms on prosthetic material”. International Journal of Antimicrobial Agents 1 (2014): 47-55.
37. Peltola H and Pääkkönen M. “Acute osteomyelitis in children”. New England Journal of Medicine 4 (2014): 352-360.
38. Grimbly C., et al. "Parenteral and oral antibiotic duration for treatment of pediatric osteomyelitis: A systematic review protocol”. Systematic Reviews 2 (2013): 92.
39. Jagodzinski NA., et al. "Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children”. Journal of Pediatric Orthopaedics 5 (2009): 518-525.
40. Peltola H., et al. “Prospective, randomized trial of 10 days versus 30 days of antimicrobial treatment, including a short-term course of parenteral therapy, for childhood septic arthritis”. Clinical Infectious Diseases 9 (2009): 1201-1210.
41. Arnold JC., et al. “Acute bacterial osteoarticular infections: Eight-year analysis of C-reactive protein for oral step-down therapy”. Pediatrics4 (2012): e821-e828.
42. Pääkkönen M and Peltola H. “Simplifying the treatment of acute bacterial bone and joint infections in children”. Expert Review of Anti-infective Therapy 12 (2011): 1125-1231.
43. Pääkkönen M and Peltola H. “Management of a child with suspected acute septic arthritis”. Archives of Disease in Childhood 3 (2012): 287-292.
44. Thompson RM and Gourineni P. “Arthroscopic treatment of septic arthritis in very young children”. Journal of Pediatric Orthopaedics 1 (2017): e53-e57.
45. Hatzenbuehler J and Pulling TJ. “Diagnosis and management of osteomyelitis”. American Family Physician 9 (2011): 1027-1033.