Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory condition. The lesions are reported to present most frequently in the long bones. This study aimed to review the presenting features of CRMO in a cohort of children diagnosed as having CRMO and to compare the level of agreement between the clinical and published diagnostic criteria.
A case notes review was undertaken of patients with a clinical diagnosis of CRMO. Patients were younger than 16 years at the time of diagnosis. Features were identified in each patient that agreed or disagreed with the published diagnostic criteria. The location of bone lesions in the lower limb at onset and disease progression was recorded.
A total of 37 patients were included. There was a high prevalence in white individuals. Agreement with the diagnostic criteria of Jansson et al and El-Shanti and Ferguson was poor, with levels of agreement of 40.5% and 43%, respectively, and low kappa scores (κ = 0.07 and 0.09, respectively). The lower limb was affected in 49% of patients at onset and in 72% overall.
This study presents one of the largest published cohorts of pediatric patients with CRMO and also presents racial/ethnic group data that have not previously been reported in other studies. Despite being a condition considered to affect the metaphysis of long bones, the ankle area and foot bones were also frequently affected. The agreement between the clinical diagnosis and the published diagnostic criteria was weak.
Osteomyelitis often complicates a diabetic neuropathic foot, leading to amputation, decreased function, and quality of life. Therefore, early detection and treatment are paramount. Furthermore, neuroarthropathic (Charcot) changes in the foot often resemble infection and must be differentiated. Currently, the Tc-99m HMPAO Labeled Leukocytes Scan is considered to be the most reliable noninvasive imaging modality of choice in determining Charcot foot changes versus osteomyelitis. The purpose of this article is to alert the clinician that although the Tc-99m HMPAO Labeled Leukocytes Scan may be the second most reliable test next to bone biopsy for determining osteomyelitis, false positives do occur. (J Am Podiatr Med Assoc 91(7): 365-368, 2001)
Squamous cell carcinomas are often seen on the sun-exposed areas of the skin and are rarely observed on the digits of the foot. However, there have been incidences of squamous cell carcinoma developing in the presence of chronic wounds with osteomyelitis, thus complicating the treatment. We present a patient with osteomyelitis who developed invasive squamous cell carcinoma of the third digit. We conclude that wounds with osteomyelitis may have underlying pathologic abnormalities that are not obvious on initial presentation.
Osteomyelitis of the distal tibia with involvement of the distal physis can lead to various deformities around the ankle and foot. Calcaneus deformity of the foot is usually secondary to paralytic disorders. A 14-year-old boy presented with calcaneus deformity as a result of osteomyelitis of the distal tibia. Involvement of the distal tibial epiphysis as a result of osteomyelitis of the distal tibia can lead to calcaneus deformity. This deformity has not been reported in the literature. Osteomyelitis of the distal tibia should also be included as a differential diagnosis of calcaneus deformity.
We aimed to evaluate surrogate markers commonly used in the literature for diabetic foot osteomyelitis remission after initial treatment for diabetic foot infections (DFIs).
Thirty-five patients with DFIs were prospectively enrolled and followed for 12 months. Osteomyelitis was determined from bone culture and histologic analysis initially and for recurrence. Fisher exact and χ2 tests were used for dichotomous variables and Student t and Mann-Whitney U tests for continuous variables (α = .05).
Twenty-four patients were diagnosed as having osteomyelitis and 11 as having soft-tissue infections. Four patients (16.7%) with osteomyelitis had reinfection based on bone biopsy. The success of osteomyelitis treatment varied based on the surrogate marker used to define remission: osteomyelitis infection (16.7%), failed wound healing (8.3%), reulceration (20.8%), readmission (16.7%), amputation (12.5%). There was no difference in outcomes among patients who were initially diagnosed as having osteomyelitis versus soft-tissue infections. There were no differences in osteomyelitis reinfection (16.7% versus 45.5%; P = .07), wounds that failed to heal (8.3% versus 9.1%; P = .94), reulceration (20.8% versus 27.3%; P = .67), readmission for DFIs at the same site (16.7% versus 36.4%; P = .20), amputation at the same site after discharge (12.5% versus 36.4%; P = .10). Osteomyelitis at the index site based on bone biopsy indicated that failed therapy was 16.7%. Indirect markers demonstrated a failure rate of 8.3% to 20.8%.
Most osteomyelitis markers were similar to markers in soft-tissue infection. Commonly reported surrogate markers were not shown to be specific to identify patients who failed osteomyelitis treatment compared with patients with soft-tissue infections. Given this, these surrogate markers are not reliable for use in practice to identify osteomyelitis treatment failure.
A percutaneous antibiotic delivery technique (PAD-T) used for the adjunctive management of osteomyelitis is presented.
This surgical technique incorporates a calcium sulfate and hydroxyapatite (calcium phosphate) bone void filler acting as a carrier vehicle with either an antibiotic or an antifungal medicine, delivering this combination directly into the area of osteomyelitis.
The benefit of the PAD-T is reviewed with a case presentation of a successfully treated calcaneal osteomyelitis.
No previously reported PAD-T using a simple bone cortex incision in the adjunctive treatment of osteomyelitis has been reported. The PAD-T safely and effectively uses a calcium sulfate and hydroxyapatite bone void filler carrier vehicle to deliver either an antibiotic or an antifungal medicine directly into the area of osteomyelitis.
External thermoregulation using noncontact normothermic wound therapy accelerates wound closure by second intention in areas of existing osteomyelitis before surgical excision compared with standard wound care. This pilot study consisted of two arms. The control arm received standard wound care, which resulted in complete ulcer healing at an average of 127 days. The treatment arm received noncontact normothermic wound therapy, which resulted in complete ulcer healing at an average of 59 days, or 54% faster than in the control arm. This new treatment allows the physician to decrease the rate of limb loss and recurrent osteomyelitis by decreasing the morbidity of bone reinfection through the wound bed. There have been no published studies or case presentations addressing thermoregulation in the management of wounds associated with osteomyelitis. Although noncontact normothermic wound therapy is not a direct treatment for osteomyelitis, this new treatment option results in significantly accelerated healing of wounds associated with osteomyelitis. (J Am Podiatr Med Assoc 93(1): 18-22, 2003)
Osteomyelitis secondary to diabetic foot infections can lead to proximal amputation if not diagnosed in a timely and accurate manner. The authors have found no studies to date that correlate a specific erythrocyte sedimentation rate with osteomyelitis. A retrospective chart review of 29 diabetic patients admitted to the hospital with diagnoses of osteomyelitis or cellulitis of the foot during a 1-year period was performed. Of the various lab values and demographic factors compared, erythrocyte sedimentation rate was the only measure that differed significantly between the two groups. A receiver operating characteristic curve was used to obtain the optimal cutoff value of 70 mm/h, a level above which osteomyelitis was present with the highest sensitivity (89.5%) and highest specificity (100%), along with a positive predictive value of 100% and a negative predictive value of 83%. This study shows that in combination with clinical suspicion in diabetic foot infections, the erythrocyte sedimentation rate is highly predictive of osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the presence or absence of bone infection. (J Am Podiatr Med Assoc 91(9): 445-450, 2001)
Diabetic foot osteomyelitis is common and causes substantial morbidity, including major amputations, yet the optimal treatment approach is unclear. We evaluated an approach to limb salvage that combines early surgical debridement or limited amputation with antimicrobial therapy.
We conducted a retrospective cohort study of patients treated between May 1, 2005, and May 31, 2007. The primary end point was cure, defined as not requiring further treatment for osteomyelitis of the affected limb. The secondary end point was limb salvage, defined as not requiring a below-the-knee amputation or a more proximal amputation.
Fifty patients with diabetic foot osteomyelitis met the study criteria. Initial surgical management included local amputation in 43 patients (86%) and debridement without amputation in seven (14%). Most infections (n = 30; 60%) were polymicrobial, and Staphylococcus aureus was the most common pathogen (n = 23; 46%). Parenteral antibiotics were used in 45 patients (90%). Patients who had pathologic evidence of osteomyelitis at the surgical margin received therapy for a median of 43 days (interquartile range [IQR], 36–56 days), whereas those without evidence of residual osteomyelitis received therapy for a median of 19 days (IQR, 13–40 days). Overall, 32 patients (64%) were considered cured after a median follow-up of 26 months (IQR, 12–38 months). Fifteen of 18 patients (83%) who failed initial therapy were treated again with limb-sparing surgery. Limb salvage was achieved in 47 patients (94%), with only three patients (6%) requiring below-the-knee amputation.
In patients with diabetic foot osteomyelitis, surgical debridement or limited amputation plus antimicrobial therapy is effective at achieving clinical cure and limb salvage. (J Am Podiatr Med Assoc 102(4): 273–277, 2012)