Diagnosis and treatment of chronic osteomyelitis based on nanomaterials

Chronic osteomyelitis is a painful and serious disease caused by infected surgical prostheses or infected fractures.Traditional treatment includes surgical debridement followed by prolonged systemic antibiotics.However,excessive antibiotic use has been inducing rapid emergence of antibiotic-resistant bacteria worldwide.Additionally,it is difficult for antibiotics to penetrate internal sites of infection such as bone,thus limiting their efficacy.New approaches to treat chronic osteomyelitis remain a major challenge for orthopedic surgeons.Luckily,the development of nanotechnology has brought new antimicrobial options with high specificity to infection sites,offering a possible way to address these challenges.Substantial progress has been made in constructing antibacterial nanomaterials for treatment of chronic osteomyelitis.Here,we review some current strategies for treatment of chronic osteomyelitis and their underlying mechanisms.

Subacute osteomyelitis due to Staphylococcus caprae in a teenager:A case report and review of the literature

BACKGROUND Staphylococcus caprae(S.caprae)is a human commensal bacterium which can be detected in the nose,nails,and skin.It can be responsible for heterogeneous infections such as bacteremia,endocarditis,pneumonia,acute otitis externa,peritonitis,and urinary tract infections.Bone and joint infections due to S.caprae have also been reported,but most of them resulted from the infection of orthopedic devices,especially joint prostheses and internal osteosynthesis devices.Rare cases of primary osteoarticular infections caused by S.caprae have been described,including osteitis,arthritis,or spondylodiscitis.CASE SUMMARY We report an unusual case of subacute osteomyelitis in a toe phalanx caused by S.caprae in a 14.5-year-old girl.CONCLUSION Subacute S.caprae osteomyelitis is a little-known and probably underestimated community-acquired infectious disease.This microorganism’s pathogenicity should be seen as more than a classic nosocomial orthopedic device infection.

Non-coding RNAs:an emerging player in osteomyelitis

Osteomyelitis is a debilitating bone infection primarily caused by Staphylococcus aureus.Despite advancements in surgery and chemotherapy,the treatment of osteomyelitis remains unsatisfactory,characterized by antibiotic resistance and recurrent relapses.Numerous studies have confirmed that non-coding RNAs could play an emerging role in regulating gene expression,as well as in the differentiation of osteoblasts and osteoclasts,along with bone formation.In this context,we provide an overview of current knowledge regarding the roles of non-coding RNAs in osteomyelitis and explore the potential therapeutic applications of these molecules in disease management,aiming to uncover novel diagnostic and treatment approaches.

Skull Base Osteomyelitis: A Rare Cause of Multiple Cranial Nerve Palsies—A Case Report from Ghana

Introduction: Skull Base Osteomyelitis (SBO) is an infectious inflammation of the skull bones that is often caused by malignant otitis externa (MOE) and affects the temporal bone. This condition commonly affects immunocompromised individuals and the elderly, particularly those with a history of diabetes mellitus. Diagnosis is challenging because of non-specific symptoms that lead to late detection and complications. This report discusses a case of SBO with multiple bilateral cranial nerve abnormalities and highlights the diagnostic and management challenges in high-risk individuals with subtle clinical signs. Case presentation: This report describes a 63-year-old patient with hypertension and diabetes who underwent surgical debridement of the left ear due to malignant otitis externa 4 months prior to presentation. The patient presented with significant dysarthria, dysphagia, ptosis of the left eye with double vision, and hearing impairment in the left ear. Examination revealed bilateral CN VI palsy, right CN VII palsy, left CN VIII palsy, and a right CN XII deficit. Initial tests were unremarkable, but a high Fungitell assay and a second review of the CT scan and MRI revealed a pathological process in the base of the skull involving bony structures and cranial nerves bilaterally, which helped diagnose SBO. The patient was subsequently discharged with oral voriconazole and continued his usual medications. The patient requested further management abroad, because he did not notice resolution of his symptoms. Surgical treatment was employed abroad to relieve his symptoms, as he recovered slowly. Conclusion: This case report underscores the importance of a multidisciplinary approach to address SBO. Collaboration between specialists in infectious diseases, otolaryngology, radiology, and neurology plays a pivotal role in achieving an accurate diagnosis and developing a tailored treatment plan. Although SBO may be infrequent, this case report highlights the need to maintain heightened clinical suspicion in high-risk individuals.

First Ever Documented Total Calcaneus Replacement with 3D Printed Metallic Implant for Chronic Osteomyelitis after a Calcaneal Fracture in a Young, Healthy Individual—A Literature Review and Preliminary Case Report

Osteomyelitis of the calcaneus can be a limb threatening diagnosis, which is typically treated with antibiotic therapy with or without partial resection of the bone. Extensive infection of the bone commonly results in limb amputation via transtibial or transfemoral amputation, which can increase morbidity and mortality. This case report involves a 29-year-old male who sustained bilateral calcaneal fracture after a fall, who developed osteomyelitis of the right calcaneus after being treated with internal/external fixation and antibiotic therapy. In order to preserve the limb total calcaneal replacement with 3D printed implant was done.

Role of MRI in the diagnosis and treatment of osteomyelitis in pediatric patients

Osteomyelitis is a significant cause of morbidity in children throughout the world. Multiple imaging modalities can be used to evaluate for suspected osteomyelitis, however magnetic resonance imaging(MRI) has distinct advantages over other modalities given its ability to detect early changes related to osteomyelitis, evaluate the true extent of disease, depict extraosseous spread of infection, and help guide surgical manage-ment. MRI has assumed a greater role in the evaluation of osteomyelitis with the increase in musculoskeletal infections caused by methicillin-resistant Staphylococ-cus aureus which have unique imaging features that are well-demonstrated with MRI. This review focuses primarily on the use of MRI in the evaluation of osteo-myelitis in children and will include a discussion of the clinically important and characteristic findings on MRI of acute bacterial osteomyelitis and related conditions.

Chronic traumatic ankle and foot osteomyelitis: a nationwide case-control study

Background: Osteomyelitis(OM) is an atypical consequence of ankle-foot trauma which is associated with long-term mental and physical morbidity and persistent pain. This study aimed to assess the health status of OM patients with war-related ankle-foot injuries.Methods: A total of 1129 veterans with ankle-foot injuries participated in a case-control study(2014–2016). Thirty patients with chronic OM of the ankle-foot were compared with 90 non-OM participants as the control group. Quality of life(QOL), life satisfaction and the ability to perform basic and instrumental activities of daily living were measured using the following questionnaires: short-form health survey(SF-36), satisfaction with life scale(SWLS), activity of daily living(ADL) and instrumental activity of daily living(IADL), respectively. OM patients were categorized according to their risk factors as A, B and C hosts using a modified version of the Cierny and Mader classification system. The one sample t-test, 2-independent sample t-test, ANOVA, Pearson correlation coefficient and multiple linear regression analyses were applied to analyze the data.Results: Ankle-foot pain leading to surgery(P <0.001) and orthosis usage(P =0.039) were more common in OM patients. There was no significant difference between the two groups in the prevalence of pulmonary and cardiovascular diseases or kidney failure and other related diseases. OM patients showed a significantly lower level of mental health compared to non-OM respondents(P=0.025). Approximately, 70.0% of ankle-foot injured veterans were dissatisfied with their life, and there was no difference between the two groups(P>0.05). Mobility was significantly lower in the OM patients than in the control group(P=0.023). Life satisfaction(P=0.001) and the ability to perform daily activities were the determinants for poor physical(P=0.018) and mental health-related quality of life(P=0.012). According to the Cierny and Mader classification system, they were all included in the type C host classification, with one major and/or three or more minor risk factors.Conclusion: A low level of quality and satisfaction of life and ability to perform activities of daily living were observed in OM patients with war-related ankle-foot injuries. Surgeries of the ankle and foot due to pain were much more common in OM patients than in non-OM participants. Since all the participants were classified as the C-host, health policy planning seems to be necessary.

Innovations in osteomyelitis research:A review of animal models

Infection of bone tissue,or osteomyelitis,has become a growing concern in modern healthcare due in no small part to a rise in antibiotic resistance among bacteria,notably Staphylococcus aureus.The current standard of care involves aggressive,prolonged antibiotic therapy combined with surgical debridement of infected tissues.While this treatment may be sufficient for resolving a portion of cases,recurrences of the infection and associated risks including toxicity with long-term antibiotic usage have been reported.Therefore,there exists a need to produce safer,more efficacious options of treatment for osteomyelitis.In order to test treatment regimens,animal models that closely mimic the clinical condition and allow for accurate evaluation of therapeutics are necessary.Establishing a model that replicates features of osteomyelitis in humans continues to be a challenge to scientists,as there are many variables involved,including choosing an appropriate species and method to establish infection.This review addresses the refinement of animal models of osteomyelitis to reflect the clinical disease and test prospective therapeutics.The aim of this review is to explore studies regarding the use of animals for osteomyelitis therapeutics research and encourage further development of such animal models for the translation of results from the animal experiment to human medicine.

Transitioning antimicrobials from intravenous to oral in pediatric acute uncomplicated osteomyelitis

Osteomyelitis is a bone infection that requires prolonged antibiotic treatment and potential surgical intervention.If left untreated,acute osteomyelitis can lead to chronic osteomyelitis and overwhelming sepsis.Early treatment is necessary to prevent complications,and the standard of care is progressing to a shorter duration of intravenous(Ⅳ) antibiotics and transitioning to oral therapy for the rest of the treatment course.We systematically reviewed the current literature on pediatric patients with acute osteomyelitis to determine when and how to transition to oral antibiotics from a short Ⅳ course.Studies have shown that switching to oral after a short course(i.e.,3-7 d) of Ⅳ therapy has similar cure rates to continuing long-term Ⅳ therapy.Prolonged Ⅳ use is also associated with increased risk of complications.Parameters that help guide clinicians on making the switch include a downward trend in fever,improvement in local tenderness,and a normalization in C-reactive protein concentration.Based on the available literature,we recommend transitioning antibiotics to oral after 3-7 d of Ⅳ therapy for pediatric patients(except neonates) with acute uncomplicated osteomyelitis if there are signs of clinical improvement,and such regimen should be continued for a total antibiotic duration of four to six weeks.

Calcium pyrophosphate dihydrate crystals in a 9-year-old with osteomyelitis of the knee:A case report

BACKGROUND Calcium pyrophosphate dihydrate deposition disease(CPPD),or pseudogout,is an inflammatory arthritis common among elderly patients,but rarely seen in patients under the age of 40.In the rare cases presented of young patients with CPPD,genetic predisposition or related metabolic conditions were almost always identified.CASE SUMMARY The authors report the case of a 9-year-old boy with no past medical history who presented with acute knee pain and swelling after a cat scratch injury 5 d prior.Synovial fluid analysis identified calcium pyrophosphate dihydrate crystals.Further MRI analysis identified osteomyelitis and a small soft tissue abscess.CONCLUSION This case presents the extremely rare diagnostic finding of calcium pyrophosphate dihydrate crystals in a previously healthy pediatric patient.The presence of osteomyelitis presents a unique insight into the pathogenesis of these crystals in pediatric patients.More research needs to be done on the role of CPPD in pediatric arthritis and joint infection.

Vertebral Osteomyelitis Due to <i>Candida</i>Species: A Cohort Study and Review of the Literature

Objective: To describe the demographics and outcome of patients with candidal vertebral osteomyelitis (CVO). CVO is a rare and frequently misdiagnosed condition. It may lead to destruction of the vertebral bodies, spinal cord compression and neurological deficits. Methods: The medical records of all patients diagnosed with CVO at our institution between 01/01/1990-12/31/2009 were reviewed. The cumulative probability of treatment success was assessed by the Kaplan-Meier survival method. Patients were followed until death, failure, or loss of follow-up. Results: Nine patients developed CVO during the 20 year study period. The cervical spine was involved in 5 cases. Seven patients presented with mechanical-type pain, while 2 patients had an elevated temperature at diagnosis. A contiguous infection between the upper airways and the cervical spine was present in 4 patients. One patient presented with concomitant candidemia. Candida albicans, Candida parapsilosis, and Candida glabrata were cultured in 3 of 9 cases respectively. Eight of 9 were treated with azole-based therapy. Patients were followed for an average of 20 months (range 1 - 75 months). The cumulative incidence of success was 66% ± 19% at 1 year and 55% ± 20% at 2 years of follow-up. Conclusions: CVO presents insidiously and is associated with a long duration of symptoms. It most frequently affects the cervical spine and is associated with a poor outcome.

Biological analysis of an innovative biodegradable antibiotic eluting bioactive glass/gypsum composite bone cement for treating experimental chronic MRSA osteomyelitis

A multi-barrier antibiotics loaded biodegradable composite bone cement for resolving chronic osteomyelitis has been studied to understand the physico-mechanical properties,drug loading/eluting efficiency,and different merits and demerits prior to clinical application.After successful induction of bone infection in 28 rabbits using methicillin-resistant Staphylococcus aureus(MRSA)strains,calcium sulfate/bioactive glass based composite cement was implanted in 12 defects to assess its performance over parenteral therapy with microscopic and radiological examination for 90 days.The composite cement revealed acceptable physico-mechanical properties and controlled drug elution kinetics.Furthermore,the antibiotics concentrations in bone up to 42 days were sufficient to kill MRSA without eliciting adverse drug reactions.The striking feature of platelets aggregation by composite cement could assist bone healing.The controlled degradation with simultaneous entrapment of composite cement within the osteoid tissues and complete repair of infected cortical defects(holes)in rabbit tibia at 6 weeks indicated the excellent anti-infective and osteoconductive properties of composite cement.Thus,the animal study demonstrated the superiority of composite over injectable antibiotic therapy based on infection resolution and bone regeneration.We thereby conclude that the composite cement can be effectively applied in the treatment of resistant cases of chronic osteomyelitis.

Extensively drug-resistant Salmonella typhi causing rib osteomyelitis: A case report

Rationale:Salmonella(S.)typhi is a rare cause of osteomyelitis in immunocompetent adults.Extensive drug resistance(XDR)may lead to more complicated cases of S.typhi osteomyelitis.Patient concern:A 55-year-old female presented with a persistent low-grade fever and a swelling on her lower left chest with a sinus discharging purulent fluid for the past 8 months.Her symptoms had been unresponsive to previous anti-microbial therapy.Diagnosis:Rib osteomyelitis caused by XDR S.typhi.Interventions:Surgical wound debridement,left 7th-9th rib resection and intravenous Ⅳ meropenem were done.Outcome:Fever resolved and left-sided swelling resected without recurrence.Lessons:The prevalence of XDR S.typhi is growing in South Asia and should be considered as the differential diagnosis of chronic osteomyelitis.

Tuberculous osteomyelitis/arthritis of the first costoclavicular joint and sternum

A young Somali immigrant presents with a two-year history of a large, firm, painful right anterolateral chest wall sternal mass. The patient denied any history of trauma or infection at the site and did not have a fever, erythematous lesion at the site, clubbing, or lymphadenopathy. A lateral chest radiograph demonstrated a low density mass isolated to the subcutaneous soft tissue overlying the sternum, ribs and clavicle. Computed tomography(CT) with contrast demonstrated a cystic lesion in the right anterolateral chest wall deep to the pectoralis muscle. Enhanced CT of the chest demonstrated sclerosis and destruction of the rib and costochondral joint and manubrio-sternal joint narrowing. Ultrasound-guided biopsy and aspiration returned 500 cc of purulent, cloudy yellow, foul-smelling fluid. Acidfact bacilli stain and the nucleic acid amplification test identified and confirmed Mycobacterium tuberculosis. A diagnosis of tuberculous osteomyelitis/septic arthritis was made and antibiotic coverage for tuberculosis was initiated.

Sonographic Diagnosis of Acute Hematogenous Osteomyelitis in the Early Stage

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Disseminated osteomyelitis after urinary tract infection in immunocompetent adult:A case report

BACKGROUND Urinary tract infection(UTI)is one of the most common bacterial infections.Acute pyelonephritis or upper urinary tract infection is often accompanied by bacteremia;however,bacteremia resolves in most cases without complication.Rarely,complications due to bacteremia occur.One of these is osteomyelitis.It mainly affects the lumbar vertebral bodies,and rarely affects other site.CASE SUMMARY An 80-year-old woman presented to the hospital with a two-month history of pain in both legs.Two months ago,she was admitted to the hospital for fever,flank pain,and urinary frequency and was diagnosed with bacteremic UTI.During hospitalization,she complained of pain in both legs;however,the pain resolved shortly after,and no abnormalities were observed on physical examination.Therefore,she was placed on 2-wk antibiotic therapy for UTI without further evaluation for leg pain.However,pain recurred after discharge and persisted;therefore,an imaging test was performed.Bone scan and magnetic resonance imaging suggested osseous infection in both femurs,tibiae and patellae.Surgical treatment was performed,and tissue-and bone cultures revealed Escherichia coli,a previously observed pathogen,which demonstrated same antibiotic sensitivities,as noted in previous UTI.She was diagnosed with disseminated osteomyelitis,as a complication of UTI,and was placed on an 8-wk antibiotic therapy.CONCLUSION Indication for osteomyelitis should be high regardless of bone pain at sites other than lumbar spine after or during UTI.

Isolated cryptococcal osteomyelitis of the ulna in an immunocompetent patient:A case report

BACKGROUND Cryptococcal osteomyelitis is a bone infection caused by cryptococcus.As an opportunistic infection,bone cryptococcosis usually occurs in patients with immunodeficiency diseases or in those undergoing immunosuppressive therapy and often displays characteristics of disseminated disease.Isolated cryptococcal osteomyelitis is extremely unusual in immunocompetent person.The pathogenic fungus often invades vertebrae,femur,tibia,rib,clavicle,pelvis,and humerus,but the ulna is a rare target.CASE SUMMARY A 79-year-old woman complaining of chronic pain,skin ulceration and a sinus on her right forearm was admitted,and soon after was diagnosed with cryptococcal osteomyelitis in the right ulna.Unexpectedly,she was also found to have apparently normal immunity.After treatment with antifungal therapy combined with surgery debridement,the patient’s osteomyelitis healed with a satisfactory outcome.CONCLUSION Although rare,cryptococcal osteomyelitis should be considered in the differential diagnosis of osteolytic lesions even in immunocompetent patients,and good outcomes can be expected if early definitive diagnosis and etiological treatment are established.

Reciprocal hematogenous osteomyelitis of the femurs caused by Anaerococcus prevotii:A case report

BACKGROUND Haematogenous osteomyelitis is an extremely rare disease occurring in adults,especially in developed countries.It is clearly a systemic infection,because bacteraemia spreads over proximal and distal long bones or paravertebral plexuses,resulting in acute or chronic bone infection and destruction.CASE SUMMARY A 46-year-old Caucasian male was complaining of a left thigh pain.It is known from the anamnesis that the patient developed severe pneumonia three months ago before the onset of these symptoms.The patient was diagnosed with haematogenous osteomyelitis,which developed a turbulent course and required complex combination therapy.The primary pathogen is thought to be Anaerococcus prevotii,which caused pneumonia before the onset of signs of osteomyelitis.Unfortunately,due to the complexity of identifying anaerobes and contributing nosocomial infections,the primary pathogen was not extracted immediately.After the manifestation of this disease,pathological fractures occurred in both femurs,as well as purulent processes in the lungs and molars accompanied.The patient received broad-spectrum antibiotic therapy and countless amounts of orthopaedic and reconstructive surgeries,but no positive effect was observed.The patient underwent osteosynthesis using an Ilizarov’s external fixation apparatus,re-fixations,external AO,debridements,intramedullary osteosynthesis with a silver-coated intramedullary nail,abscessotomies.The right femur healed completely after the pathological fracture and osteomyelitis did not recur.Left femur could not be saved due to non-healing,knee contracture and bone destruction.After almost three years of struggle,it was decided to amputate the left limb,after which the signs of osteomyelitis no longer appeared.CONCLUSION To sum it all up,complicated or chronic osteomyelitis requires surgery to remove the infected tissue and bone.Osteomyelitis surgery prevents the infection from spreading further or getting even worse up to such condition that amputation is the only option left.

A Case of Ankle Osteomyelitis Caused by <i>Mycobacterium abscessus</i>

The proportion of non-tuberculous mycobacteria to Mycobacterium tuberculosis cultivated in the laboratory has been recently increasing. Numerous skin and soft tissue infections have been reported, while osteomyelitis is reported very rarely. A delayed diagnosis can cause a wide range of bone destruction and joint contracture, which highlights the importance of early recognition of osteomyelitis. Here we report a case of ankle osteomyelitis caused by Mycobacterium abscessus and treatment failure due to delayed diagnosis.

Osteomyelitis of the pubis in a young athlete revealed by severe abdominal pain

Acute osteomyelitis is a common condition in children. Only early diagnosis prevents complications. The location at the pubic bones is very rare, even exceptional at the pubis symphis. We report a case of osteomyelitis of the pubis in a young athlete of 14 years old whose symptoms were discussing an acute abdomen, to illustrate the unusual clinical presentation, so as not to miss the diagnosis and avoid unnecessary laparotomy.