Objective

A clinical investigation into a new bone void filler is giving first data on systemic and local exposure to the anti-infective substance after implantation.

We reviewed all patients with a clinically infected foot ulcer attending a specialised neuropathic foot clinic. Neuropathy was confirmed by the inability to feel a 5.07 Semmes-Weinstein hair, areflexia and impaired vibration sense, as measured by a biothesiometer.

Of 40 patients who attended the clinic over a two-year period, six with ischaemic ulcers were excluded. The remaining 34 had plain radiographs of the foot followed by a ^99mTc-MDP bone scan. If the latter was positive, an ¹¹¹In-labelled WBC scan was performed with planar and/or tomographic dual-isotope studies where appropriate. Bone and WBC scans were performed in 31 patients. In ten, isotope imaging showed infection localised to the soft tissues only and conservative treatment was successful in them all. Eighteen patients were treated surgically with excision of the involved bone, which was sent for culture and histological examination.

Dual-isotope scans had a sensitivity of 93% and a specificity of 83%. ^99mTc-MDP bone scans with the appropriate ¹¹¹In-labelled WBC scans can reliably determine the site and extent of osteomyelitis in the neuropathic diabetic foot.

1. The dominant role of pathogenic staphylococci in surgical infections has been confirmed by positive isolations in 89·9 per cent of a wide variety of lesions in a hospital infective unit. Of 150 staphylococci isolated, 147 were sensitive to fusidic acid, two were slightly sensitive and only one was resistant.

2. Fusidic acid was administered as sodium fusidate to 100 patients with staphylococcal infections (including seventy-two with chronic post-traumatic osteomyelitis). Sterile swabs were achieved in seventy-seven of these patients and in the remaining twenty-three a change of flora was detected.

3. Bone samples were taken at operation from twenty-nine patients with chronic osteomyelitis who had been treated for at least five days with fusidic acid. Depending on dosage, the mean fusidic acid concentrations were 7·3 and 9·8 micrograms per gram. Corresponding levels in non-inflammatory bone samples from thirty-one patients were, depending on the duration of treatment, 12·3, 2l·3 and 25·4 micrograms per gram. The fusidic acid levels in cancellous bone were almost twice as high as those in compact bone.

4. The relevance of these findings to the use of fusidic acid therapy as an adjunct to surgical management of chronic osteomyelitis is discussed.

1. The treatment of twenty-nine consecutive patients suffering from chronic osteomyelitis is reviewed. With the advent of an antibiotic, Fucidin, which has the ability to penetrate in significant amounts into tissues carrying a poor blood supply, a more limited surgical procedure has become possible.

2. A successful outcome, as judged by primary healing, was achieved in 86 per cent of patients treated with a combination of surgery and Fucidin with penicillin. This compares favourably with the results achieved in a previous series in which more radical surgery was undertaken.

3. Although Fucidin has advanced the treatment of chronic osteomyelitis, it is still essential to use surgery as well.

4. Fucidin caused no toxic effects despite an average total dose of seventy to eighty grammes. Resistance of the staphylococcus developed in vitro in one patient, without affecting a satisfactory clinical outcome.

A case of salmonella osteitis of the spine is described. It is thought to be the first case reported due to the serotype Salnionella muenchen.

1. The three age types of acute haematogenous osteomyelitis are conditioned in their respective clinical features by the differing nature of their vascular bone pattern.

2. In the infant the condition causes severe and often permanent epiphysial damage and joint infection, a large involucrum but only transient damage to the shaft and metaphysis.

3. In the child the condition is responsible for extensive cortical damage with involucrum formation, but, except for some stimulation of growth, permanent damage to the growth cartilage and to joints is exceptional. Chronicity of the disease is rare if treatment has been effective.

4. In the adult acute osteomyelitis of the long bones is rare. It causes very frequent joint infection; the cortex is absorbed instead of sequestrating. The whole of the bone is invaded and frequently leaves chronic infection in the bone marrow.

5. The vascular characteristics of the bones in each age group and their relation to the onset of infection are described.

6. Some general directives for management based on these facts are suggested.

1. The clinical findings and results in seventeen patients under two years of age, suffering from acute osteomyelitis, have been studied and compared with forty-eight similar cases treated without penicillin.

2. The results in the penicillin-treated group were not greatly superior to those in the control group and did not justify the high hopes that have been entertained for penicillin as a certain cure for osteomyelitis.

1. Forty-five cases of acute osteomyelitis have been reviewed with the object of determining the causes of relapse. The importance of an early diagnosis and prompt treatment is stressed, and the question of when to stop antibiotic drugs is discussed.

2. The provisional diagnosis was anterior poliomyelitis in seventeen out of forty-five patients; acute osteomyelitis was diagnosed in twelve only. The criteria for making an early diagnosis are discussed, including the value and limitation of blood culture.

3. The place of operation is discussed and certain conclusions are set out.

The treatment of chronic osteomyelitis often includes surgical debridement and filling the resultant void with antibiotic-loaded polymethylmethacrylate cement, bone grafts or bone substitutes. Recently, the use of bioactive glass to treat bone defects in infections has been reported in a limited series of patients. However, no direct comparison between this biomaterial and antibiotic-loaded bone substitute has been performed.

In this retrospective study, we compared the safety and efficacy of surgical debridement and local application of the bioactive glass S53P4 in a series of 27 patients affected by chronic osteomyelitis of the long bones (Group A) with two other series, treated respectively with an antibiotic-loaded hydroxyapatite and calcium sulphate compound (Group B; n = 27) or a mixture of tricalcium phosphate and an antibiotic-loaded demineralised bone matrix (Group C; n = 22). Systemic antibiotics were also used in all groups.

After comparable periods of follow-up, the control of infection was similar in the three groups. In particular, 25 out of 27 (92.6%) patients of Group A, 24 out of 27 (88.9%) in Group B and 19 out of 22 (86.3%) in Group C showed no infection recurrence at means of 21.8 (12 to 36), 22.1 (12 to 36) and 21.5 (12 to 36) months follow-up, respectively, while Group A showed a reduced wound complication rate.

Our results show that patients treated with a bioactive glass without local antibiotics achieved similar eradication of infection and less drainage than those treated with two different antibiotic-loaded calcium-based bone substitutes.

Cite this article: Bone Joint J 2014; 96-B:845–50.

Aims. There is a lack of biomaterial-based carriers for the local delivery of rifampicin (RIF), one of the cornerstone second defence antibiotics for bone infections. RIF is also known for causing rapid development of antibiotic resistance when given as monotherapy. This in vitro study evaluated a clinically used biphasic calcium sulphate/hydroxyapatite (CaS/HA) biomaterial as a carrier for dual delivery of RIF with vancomycin (VAN) or gentamicin (GEN). Methods. The CaS/HA composites containing RIF/GEN/VAN, either alone or in combination, were first prepared and their injectability, setting time, and antibiotic elution profiles were assessed. Using a continuous disk diffusion assay, the antibacterial behaviour of the material was tested on both planktonic and biofilm-embedded forms of standard and clinical strains of Staphylococcus aureus for 28 days. Development of bacterial resistance to RIF was determined by exposing the biofilm-embedded bacteria continuously to released fractions of antibiotics from CaS/HA-antibiotic composites. Results. Following the addition of RIF to CaS/HA-VAN/GEN, adequate injectability and setting of the CaS/HA composites were noted. Sustained release of RIF above the minimum inhibitory concentrations of S. aureus was observed until study endpoint (day 35). Only combinations of CaS/HA-VAN/GEN + RIF exhibited antibacterial and antibiofilm effects yielding no viable bacteria at study endpoint. The S. aureus strains developed resistance to RIF when biofilms were subjected to CaS/HA-RIF alone but not with CaS/HA-VAN/GEN + RIF. Conclusion. Our in vitro results indicate that biphasic CaS/HA loaded with VAN or GEN could be used as a carrier for RIF for local delivery in clinically demanding bone infections. Cite this article: Bone Joint Res 2022;11(11):787–802

Aims

To assess the diagnostic value of C-reactive protein (CRP), leucocyte count (LC), and erythrocyte sedimentation rate (ESR) in late fracture-related infection (FRI).

Achieving arthrodesis of the ankle can be difficult in the presence of infection, deformity, poor soft tissues and bone loss. We present a series of 48 patients with complex ankle pathology, treated with the Ilizarov technique. Infection was present in 30 patients and 30 had significant deformity before surgery. Outcome was assessed clinically and with patient-reported outcome measures (Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and the Short-Form (SF-36)).

Arthrodesis was achieved in 40 patients with the Ilizarov technique alone and in six further patients with additional surgery. Infection was eradicated in all patients at a mean follow-up of 46.6 months (13 to 162). Successful arthrodesis was less likely in those with comorbidities and in tibiocalcaneal fusion compared with tibiotalar fusion.

These patients had poor general health scores compared with the normal population before surgery. The mean MAOFAS score improved significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to 90) post-operatively, but there was only a modest improvement in general health; the mean SF-36 improved from 44.8 (19 to 66) to 50.1 (21 to 76). There was a major benefit in terms of pain relief.

Arthrodesis using the Ilizarov technique is an effective treatment for complex ankle pathology, with good clinical outcomes and eradication of infection. However, even after successful arthrodesis general health scores remain limited.

Cite this article: Bone Joint J 2013;95-B:371–7.

Primary subacute haematogenous osteomyelitis (PSHO) of the small bones of the foot is a rare and infrequently considered cause of a limp in children. We describe 11 patients with PSHO, of whom nine were under three years of age, who had a limp with few symptoms. The talus was involved in 36%. Bone scans were positive in all patients and led to localisation of the lesion in two. The radiological features included soft-tissue swelling, an osteolytic lesion in the talus and the calcaneus and a sclerotic appearance of the cuboid and the navicular bones. All patients except one were cured with antibiotics.

1. Fifteen patients who had had osteomyelitis of the lower femur or upper tibia during infancy have been studied. The cases of four patients showing particular features of the disease are presented in detail and the remainder are summarised.

2. It is suggested that damage to the epiphysis may be due to an abscess, or to ischaemia following occlusion of the blood supply. In the latter instance the prognosis may be better.

3. In the early stages the radiographic appearances may be deceptive, suggesting that damage to the epiphysis is irreparable.

4. Significant recovery of the epiphysis may occur in some patients after a delay of several years. This, together with the often good function which is preserved at the joint, should deter the surgeon from early destructive operation on the limb.

5. Deformity, which was present to some extent in all cases, appeared early and was not well controlled by conservative treatment. Operations were performed in twelve patients.

6. Shortening of the limb occurred in all patients and in some it was severe.

1. In chronic osteomyelitis grafting a cavity with split skin is a reliable method of treatment. The skin cover so obtained is durable.

2. The method may be used with good prospects of success even when the cavity is large and there is extensive disease of bone.

3. Operation is indicated for the relief of pain, to close a sinus or sinuses, to obtain healing of an ulcer or to prevent recurrent episodes of acute infection.

4. The technique of operation employed in eleven cases is described and illustrative case reports are given.

A series of ten infants is reported, seven of whom showed evidence of osteomyelitis of the upper end of the femur; the remaining three did not, but presented with an acute subluxation of the hip in a febrile illness. Four sequelae among the seven more severe cases were: 1) destruction of the capital epiphysis with dislocation at the hip; 2) destruction of the capital epiphysis, the femoral neck remaining in the acetabulum; 3) destruction of the epiphysial plate with the femoral head, remaining in the acetabulum, connected to the femoral neck by a fibrous union; 4) recovery with coxa magna but no other deformity.

The streptococcus plays a greater part in this osteomyelitis of infancy than in osteomyelitis of older children, but various other organisms were identified. The organism should be sought by blood culture as well as from the local lesion.

Aspiration of the hip, treatment of the hip in abduction and the use of the appropriate antibiotic are recommended. If there is marked swelling and induration, freer release of the pus is strongly advised.

Controlled abduction osteotomy plays a useful part in stabilising the femoral neck in the acetabulum or in stabilising the femoral neck beneath the capital epiphysis, but may usefully be preceded by an arthrograph because late ossification of a detached head sometimes occurs.

1. Vascular anatomical studies of the spine are described and the possibility of spread of infection from pelvis to spine through the paravertebral venous plexus is discussed.

2. Though a venous route does exist, our studies do not support the supposition that infection is likely to spread by this route; nor is there any clear clinical, pathological or anatomical evidence that such spread occurs.

3. Nineteen cases of pyogenic osteomyelitis of the spine are recorded, six of which followed urinary infections. The condition is compared with osteomyelitis as it occurs in the other bones of adults.