Islamic University – Gaza
Master of Health Administration
Osteomyelitis Following Gunshot
Injury: Case Study
Reported by:
Fatma H. Keshta 220202077
Sara A. Kouta
220200010
Suprervised by:
Dr. Abdalkarim S. Radwan
2021
1
Abstract:
The aim of this study is to report on a complex case; osteomyelitis. The patient was
a 21-year-old man exposed to an explosive gunshot that caused a comminuted
fracture at the lower third of the left femur then exposed to osteomyelitis as a
complication. Images of his knee showed osteolysis of the distal left femur bone, it
treated by surgical intervention, After 14 days he presented pain, bad smell, and
developed a yellow abscess in the site of the fracture. A bone biopsy showed
recurrent osteomyelitis treated with surgical procedures and antibiotics IV and
tablets. After all the suffering the patient had to cope with amputation as treatment.
In conclusion, we explained the causes of failure of the treatment of osteomyelitis
regarding our patient and put forward our recommendations to use the surgical
treatment in association with local Antibiotic bone cement for the optimal treatment
based on research along with literature reviews studied.
Key words: osteomyelitis ;amputation ;external fixat ion;gunshot injury;femoral
fractures;femur ; fracture fixation;Osteomyelitis/therapy ; Osteomyelitis/diagnosis.
Introduction
Osteomyelitis is one of the oldest diseases known. As it is, one of most rarest
and serious conditions of bone infections; osteomyelitis. Bone can develop
infection in a variety of ways. Infection in one part of the body may spread through
the bloodstream into the bone or can spread from nearby tissue, or an open fracture
or surgery may expose the bone to infection, as this all leads to development of
osteomyelitis (J.Robinson et al 2019). Infections can also begin in the bone itself if
an injury exposes the bone to germs. The majority of osteomyelitis cases are caused
by staphylococcus bacteria, types of germs generally found on the skin or in the
nose of normal healthy humans.
2
Germs in the blood stream look for weakened spot in a bone to live. Yet not
only but germs adore severe puncture wounds in order to inhibit nearby bone
function, and favour broken bone sticking out of the skin. As such case is difficult to
keep sterility of the injury. As for germs contamination in surgeries, it is usually
when replacing joints or fracture repair. Around 80 percent of cases develop
osteomyelitis because of an open wound Brazier et al 2018 .National organization
for rare disorder states that early diagnosis is very important because fast antibiotic
delivery may prevent permanent bone loss.
Symptoms of osteomyelitis involve deep pain as well as muscle spasms in the
inflammation area, and accompanied with fever, swelling, warmth and redness over
the area of the infection, general fatigue, nausea, and lost range of motion. Walliam
Morrsion, a medical supervisor states that bone infections commonly affect the long
bones in the leg and upper arm, the spine, and the pelvis. It took many years before
the acute infection could be brought under control with antibiotics (L. Klenerma et
al, Emeritus et al 2018). To get a picture of what is going on exactly, doctor’s count
on X-rays, blood tests, MRI, and bone scans (J. Robinson et al 2019). A bone
biopsy helps determine the type of organism, typically bacteria, causing the
infection so the right medication can be prescribed.
However, with aggressively strong treatment the infected bone can be saved
as well as halt the spread of infection. On the other hand, some patients require
surgery to remove dead bone tissue. Nevertheless, if this disease is not nursed with
caution, acute osteomyelitis can advance to a chronic disease. In chronic
osteomyelitis, infection remains active, and periodic drainage to the surface via
sinus tracts may occur(G. Bauer et al 2007). Bone damage may be extensive,
possibly requiring amputation of the affected limb. Osteomyelitis is estimated to
affect 2 out of every 10,000 people in the United States at some times (O. Ganescu,
and M. Anderson et al 2021).
Pathophisiology:
Once bone tissue is infected, the bacterium provokes an acute inflammatory
reaction. The bacteria and inflammation influence the periosteum negatively and
spread inside the bone causing bone necrosis.
Osteomyelitis has a tendency to occlude local blood vessels, hence causing
bone necrosis and limited stretch of infection. Subsequently, infection can develop
throughout the bone cortex and extend beneath the periosteum. Not only that but it
also may form a subcutaneous abscesses that can pass unexpectedly throughout the
rest of the skin.
3
Definition:
The definition of osteomyelitis is normally acknowledged as an inflammatory
process of bone and bone marrow which is caused by an infectious organism like
bacteria, mycobacteria, or fungi. This effects in local bone damage, necrosis and
collocation of new bone. Thus, the term osteomyelitis implies bone or joint
infection. Common symptoms are restricted bone pain and tenderness as mentioned
above. Diagnosis is by imaging studies and cultures. Treatment is with antibiotics
and every so often surgery.
Anatomy and Physiology:
The essential biologic progression active in bone infection are independent of
pathogen type. The entry of an organism into bone is one of the primary steps in
osteomyelitis and evolves by three chief mechanisms: hematogenous seeding,
extension from a contiguous site, and direct implantation.
Hematogenous Osteomyelitis:
Hematogenous osteomyelitis is generally the cause of bacteria and has negative
influence on rapidly growing long bones. It habitually marked as a primary, single
centre of disease. Yet, vitally, could occur as a complication of several localized or
systemic infection. Briefly, metaphyseal blood vessels are responsible for regulating
slow-flowing blood that has high tolerance to bacterial proliferation. The
metaphysis is a common site for haematogenous osteomyelitis. Hematogenous
osteomyelitis is a result of the spread of bacteria through the bloodstream from a
distinct source to the wound. As there is wide variation in the frequency and
appearance of the course of haematogenous osteomyelitis depending on the age
group of the patient. Hematogenous osteomyelitis is the most frequent type and
primarily affects the metaphysis because the bacteria travel through vascular tunnels
and adhere to the bone matrix. In acute osteomyelitis, a collection of pus becomes
surrounded by granulation tissue and reactive bone, forming an intraosseous
abscess(Y. Lee, S. Sadigh, K. Mankad, N. Kapse,and G. Rajeswaran et al 2016).
The increase of intramedullary pressure due to the accumulation of pus results in the
rupture of the cortex; this creates a defect known as a cloaca. Cloaca; drains pus
from the bone to the surrounding tissues. Thus a subperiosteal abscess may be
caused with elevation of the periosteum, in addition to soft tissue abscesses.
In chronic osteomyelitis, disruption of the intraosseous and periosteal blood supply
leads to formation of a necrotic bone fragment, known as a sequestrum, which is
surrounded by pus and granulation tissue. An involucrum, a reactive shell of new
bone forms surronds the sequestrum. A sinus tract, which drains pus from bone to
the skin surface, may be present in both acute and chronic osteomyelitis.
4
Contiguous Spread
Osteomyelitis that results from contiguous spread occurs after organisms from a
neighboring anatomic site gain direct access to the bone (A. Rosenberg, G. Nielsen
et al 2010). This may affect any bone adjacent to a soft tissue abscess. In particular
cases, the inflammatory process ought to first destruct the periosteum or articular
surface prior to accessing the bone. In contrast to hematogenous osteomyelitis, the
cortex instead of the medullary cavity is originally infected; the location is
influenced by the rapidity of spread and extent of disease.
Direct Implantation
Varity of conditions are taken in consideration when approaching direct
implantation of pathogens into bone cases. Generally, the contamination of an open
fracture, penetration of fomites such as shrapnel or orthopaedic hardware into bone,
and exposure of bone during an operation are examples of direct implantation. In
these situations, the causative event and the extent of associated hemorrhage, tissue
fragmentation, and necrosis influences important aspects of the infection (A.
Rosenberg, G. Nielsen et al 2010).
Repeatedly, the pathogens are active and proceed to proliferate in an environment of
necrotic tissue unreachable to the immune response and therapeutic antibiotics. In
this manner, a blistering chronic infection is established that continues the
impending to cause future destruction if treatment is found with the appropriate
time.
Case presentation
H.M Soliman healthy male within the age of 21 years old was exposed to an
explosive gunshot on both lower limbs during the Great March of Return
demonstrations (GMR) in Gaza Strip. He was admitted to the emergency
department of Al-Shifa hospital on 3.7.2018 with a right hamstring tendon cut and
veins rupture. The patient reported that his major injuries were in the left lower limb
he elucidated that the doctors diagnosed him with comminuted fracture in the shaft
of femur with loss 17 cm of the bone continuity, along with complete cut in the
sciatic nerve, soft tissue injury with partial loss of quadriceps muscle, rupture of the
femoral artery and femoral vein. Due to his situation, immediate surgery was
performed for artery repair, tendon repair, fracture fixation by external fixation.
However before this decision was taken the patient lost consciousness, his surgery
was completed but he lay unconscious in the ICU department for 16 days.
Thankfully the patient obtained his consciousness and was referred to European
Hospital according his location. Within his stay at the European hospital, the patient
5
underwent wound debridement for 3 times and external fixation modification done.
Subsequently, the patient was referred to the Doctors without Border Association
"MSF" to perform skin graft surgery.
On 11.11.2018 the patient was referred to Egypt, to undergo an operation that lasted
for 12 hours in order to re-repair the Right hamstring tendon, to also to remove
metal bodies from both lower limbs and to replace the femur external fixation by
dynamic axial external fixator from the upper femur to the lower tibia. During his
ten day stay in the hospital he received physiotherapy rehabilitation and with the
hard effort the patient started to stand for the first time.
On 30.3.2019 another operation performed was taken place in order to modificate
the site of pins around the knee joint to keep the available range of motion as
possible. Yet more operations were done for this patient; on 30.4.2019 bone
transplant was done in the site of fracture. After these operations, the patient was
returned to Gaza.
Next, six months of rehabilitation spent with Doctors without border "MSF" for
wound care, physiotherapy, pain management, and nerve blocking was all covered.
In this period he started walking using axillary crutches non-weight bearing,
however the patient suffered from severe infection at the site of pins. Blood
investigations showed a total white cell count WBC of 11.20 x 109/L (normal range
is 4-9 x 109/L) then increased within a week to 12.50 x 109/L. following blood
samples doctors diagnosed the patient with osteomyelitis , debridement was done
and antibiotic medication were immediately started.
On 15.10.2019 the patient was sent back to Egypt to continue his treatment. CT
scan of the patient showed that the bone healing was completed; only 7 cm of his
normal bone was healed and about 10 cm became infected bone known as
osteomyelitis. Subsequently, the patient was admitted to more surgeries. On
29.11.2019 a surgey was done to remove external fixation and replace it with
internal fixation (plates and scrows ) to fix the fracture after doing debridement for
infected bone and a new bone transplant. Within his 2weeks of post operation the
patient was told to relax at home and on the fifteenth day from the surgery to come
back for follow up. Yet on his fourteenth day, the patient felt pain in the site of the
fracture accompanied with awful odor. By examination, yellow abbesses was found
close to bone filled with fluid and pus, immediately the doctor in Egypt was
prepared for secretion removal via syringe 20 cm. The sample was sent to the
laboratory unit for it to be examined; the result showed the bone bacterial infection
has been established. Another bone debridement surgery was done as well as the
6
removal of the infected tissue were taken for samplings. Not only was that but a
bone biopsy taken for culture and sensitivity.
Microbiological culture result was Staphylococcus aureus bacterial infection.
The doctor prescribed:
Augmentin tablet 1g every 12 hours,
Ciprofloxacin tablet 500mg every 12 hours,
Alphintern tablet, 2 tablets every 8 hours, half-hour before a meal,
Divido 75 mg, 1capsule every 12 hours after a meal,
Clexane 40 IU ready syringe, 20 IU subcutaneous every 24 hours.
While taking the medications still in Egypt the patient started suffering from an
ulcer, in posterior distal leg.
The patient is back in Gaza and continues treatment with MSF the, the ulcer
continued expanding, and a terrible odor began emitting from the ulcer.
Examination was required for the ulcer case, the results happen to showed the
development of necrotic tissue. In response the patient started suffering from
gangrene. MSF referred the patient file to MSF hospital to Jordan and the doctor
decided that amputation is the only available choice as there is no one percent
chance for treating the limb.
In 7.5.2020 amputation was done above the knee, and then patient start
rehabilitation for artificial limb. A second Trans-femoral amputation was performed
on 8/28/2020and the 7cm that the patient healed was also amputated. Then the
patient returned to complete rehabilitation for the prosthesis, but he began to suffer
from another problem; the distribution of muscles (where the muscles were falling
down and the thigh bone remained attached to the skin due to the great loss of tissue
and muscles) in the stump was painful for the patient when putting pressure while
walking. As a result, the patient entered a third surgery in order to repeat of
amputation on 11/26/2020. Unfortunately, the surgery did not elucidate any benefit
to the patient as he still suffered from the same pain. The patient is now awaiting a
transfer to Egypt for the same operation and the installation of the prosthesis there.
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Discussion
Osteomyelitis occurred at a rate of 1% to 5% after closed fractures and 3% to
50% after open fractures depending on severity. In this type of fracture, there is
a risk of osteomyelitis due to severe infection, as well as because the deep open
wound is mixed with contaminated soil at the moment of the gunshot wound,
before the ambulance crews arrive at the place. Osteomyelitis is classified as
acute or chronic, based on its histopathological findings, rather than the duration
of the infection. Acute osteomyelitis is characterized by inflammatory bone
changes which typically present two weeks after bone infection. Whereas,
chronic osteomyelitis is characterized by the presence of bone destruction with
formation of cloaca, sequestrum and involucrum which presents at six or more
weeks after bone infection. In 10% to 30% of patients, acute osteomyelitis
becomes chronic.
The x-rays show a comminuted fracture at the left lower third of the femur and a
clear gap in the continuity of the bone approximately 13 cm, and clearly show
the presence of metal objects in the surrounding tissues. The fracture is well
fixed by an external fixator confined to the femur only, but was later modified to
extend from the top of the femur to the mid of the tibia.
11
Radiographic findings showed a non-union fracture distal third left femur with
features of chronic osteomyelitis such as sequestrum and involucrum. Bone lucency
around external fixator pins indicates an osteolysis as a result of infection.
12
Treatment of chronic osteomyelitis is challenging and unfortunately leads to
significant morbidity and high expenses. The goals of treatment must be fully
understood by the patient, while caregivers should have a clear understanding of
the challenges along the process of a successful recovery.
Surgical principles for osteomyelitis include radical debridement of necrotic and
devitalized tissues, drainage of discharge, managing of resultant dead space,
reconstruction of soft-tissue, commencement of culture-directed antibiotics and
skeletal stabilization or management of skeletal defects .
Debjit Bhowmik et al 2018 suggested that the Treatment focuses on stopping
infection in its tracks and preserving as much function as possible. Most people
with osteomyelitis are treated with antibiotics, surgery, or both. Antibiotics help
bring the infection under control and often make it possible to avoid surgery.
13
People with osteomyelitis usually get antibiotics for several weeks through an
IV, and then switch to a pill form.
The local use of antibiotics to prevent skeletal infections was incorporated into
general practice with the development of joint arthroplasty in Europe in the
1970s. Buchholz and Engelbrecht reported in a sentinel paper that penicillin,
erythromycin, and gentamicin mixed into the cement used to affix prostheses to
bone was found to provide high concentrations of antibiotics for extended
periods of time, facilitating the use of antibiotics in infection prophylaxis for
joint arthroplasty. In addition to this role, local antibiotic therapy has been
instituted for treatment of arthroplasty infections, prophylaxis for open fractures,
and treatment of chronic osteomyelitis. In 1979, Klemm created gentamicinimpregnated beads and used them to occupy dead space after debridement of
infected bone. In more than 100 patients, a cure rate of 91.4% was achieved.
Placement of these beads is a simple procedure and often performed at time of
initial debridement of chronic osteomyelitis or open fracture. Beads are
generally prepared from commercially available cement just prior to placement
in the operating room. Bead placement aids significantly in the management of
large dead-space defects and bathes the hematoma and/or seroma in constantly
high levels of antibiotic. Aside from the possibility of persistent drainage at the
wound site, local antibiotic therapy with beads decreases the risk of
complications of systemic antibiotic therapy including end-organ failure and
gastrointestinal side effects.
In spite of these advantages, bead placement generally requires a second
operation for removal.
In 2021 'Meta-analysis of vacuum-sealing drainage combined with antibiotic
bone cement in the treatment of chronic osteomyelitis" demonastrated that The
combination of vacuum-sealing drainage and antibiotic bone cement in the
treatment of chronic osteomyelitis has a significant advantage over the
traditional treatment, which is worthy of clinical promotion (Tian Lin et al
2021).
In our case, the left femur chronic osteomyelitis was type Contiguous (Bacterial
inoculation from an adjacent focus. E.g.: Post-traumatic Osteomyelitis,
infections related to prosthetic devices) according to Waldvogel classification
with diffused osteomyelitis in a patient without comorbidities.
14
For our patient, treatment started with surgical treatment by perform wound
debridement, removal10 cm of bone defect at fracture site ,and bone
transplanted from the pelvic bone then the fracture fixed by internal fixation
plates and screws. but within 14 days the sign and symptoms of osteomyelitis
appeared again where a localized collection of pus immediately patient
preparation started for secretion removal via syringe 20 cm. and the sample sent
to the laboratory unit for test and the result shows the bone bacterial infection.
new surgery did for bone debridement and removal infected tissue samplings, a
bone biopsy was taken for culture and sensitivity , the result show
Staphylococcus aureus bacterial infection.
After failiar of surgical treatment ,immediately medical treatment with antibiotic
started by use Augmentin tablet 1g ,Ciprofloxacin tablet 500mg ,Alphintern
tablet, Divido 75 mg, Clexane 40 IU ready syringe. but later the patient started
suffering from an ulcer in the posterior distal leg that expanded within few
monthes to mid of posterior leg and a bad smell starts emitting from the
ulcer.in this stage the choice of amputation is taken.
In 1979 a study of Chronic osteomyelitis: open excision and grafting after
saucerization that present 180 cases of chronic osteomyelitis were treated by
the same surgeon in the infection unit of Notre-Dame Hospital in Montreal
From January 1960 to January 1974. Of these cases, 71.4% were treated by
saucerization, followed by secondary closure or by skin grafting. In ten cases
(5.4%) the limb was amputated. However, in 39 cases two similar techniques of
open excision and grafting were used. The infection was mostly traumatic in
origin and a staphylococcus was cultured in 75% of cases. The organism was
sensitive to cloxacillin and dicloxacillin in the majority of cases. Since 50% of
these 39 cases were referred for amputation, the results were much betts. Two
late recurrences were recently seen and treated, one 17 years and one 4 years
after the initial treatment (Papineau LJ et al 1979 ).
Psychosocial
The Differences in psychosocial and functional ability are related to disease
diagnosis, pain, status of fracture healing, and timing of amputation.Our patient
suffers from social impacts, such as loss of work, financial threats, changes, and
loss of partner, social environment and restrictions on leisure activities. The
psychological effects of chronic stress are depressive situations, loss of control
when severe pain occurs, a decrease in sexual needs, and a permanent change of
personality as the patient became overly nervous.
15
In addition, at first he was anxious about the future, or feared that the infection
would "flare up" again or the necessity of amputation. In the end, he chose the
amputation, although his fears increased a little, but he was feeling somewhat
resigned and patient and receptive to get rid of the pain and start preparing to
use an artificial limb.
According to the scientific literature, the presence of chronic pain is the most
dangerous factor affecting a patient's quality of life.The most common reason
for continuing medical and surgical management of nonunion and osteomyelitis
was expectation for cure. and the patients who choose the amputation do that to
avoid further treatment (R K Lerner et al 1991).
Ethical and legal malpractice related to the case
In the second half of 2018, the health system in the Palestinian Ministry of Health
was suffering from a collapse in the health system, as a state of emergency was
declared due to the huge number of injured during the activities of the Great
Return March. These conditions have caused many problems in ethical practices
while providing health care services in hospitals, and here we will talk about our
patient as an example after several interviews with him.
After the patient's condition improved and he was discharged from the intensive
care department, he was placed in the internal medicine department instead of
the surgery department due to the absence of empty beds, the patient was
forgotten due to the emergency and remained closed wound for 4 continuous
days without wound dressing.
Until the patient opened his own wound dressing and see the white worms
coming out of his wound intensively and began to suffer a for two weeks to try
to clean his wound and the wound cleaning operations under anesthesia were
unsuccessful until one of the nurses took pity on him and offered to clean his
wound by using Hydrogen peroxide H2O2 and asked him to endure the pain
and after the patient's approval , the nurse began By cleaning the patient's
wound from worms with H2O2. The patient says that the wound was cleaned
within 4 days, but it was very painful, and it was like putting Nitric acid in his
wound.
preventing osteomyelitis
16
osteomyelitis prevention is a procedure through which individuals, particularly
those with risk factors for an infection, are treated in order to prevent an
osteomyelitis from occurring. Treatment normally begins either before signs
and symptoms of the disease occur, or shortly thereafter. Treatment can include
patient education, lifestyle modification, and drugs.
Patients with a weakened immune system should:
Cleaning and dressing an open wound can prevent infection.
Have a well-balanced healthy diet and suitable exercise, to boost the immune
system.
Avoid smoking, as this weakens the immune system and contributes to poor
circulation.
Practice good hygiene, including regular and proper hand washing.
Have all the recommended shots.
Patients with poor circulation should:
Avoid smoking, as it worsens the circulation.
Maintain a healthy body weight by following a healthy diet.
Exercise regularly to improve your circulation.
Avoid excessive regular alcohol consumption as this raises the risk of
hypertension, or high blood pressure, and high cholesterol.
People who are susceptible to infections should be especially careful to avoid cuts
and scrapes. Any cuts or scrapes should be cleaned at once, and a clean dressing
put over it.
And, as with many infections, Wounds need frequent checking for signs of
infection, keep skin clean to stop the spread of germs. Also be sure that the
patient vaccinations are up to date, where A retrospective cohort study
demonstrated that the vaccination succeeded in eliminating Haemophilus
influenzae type b as an infectious agent in septic septic arthritis and
osteomyelitis (A W. Howard et al 1999).
Diagnosing of osteomyelitis
17
The diagnosis of osteomyelitis may be difficult. If an ulcer is present on exam,
osteomyelitis is present if bone is visible, or if bone is encountered when the
ulcer is probed with a sterile instrument.5 However, the inability to probe to
bone does not rule out osteomyelitis.
Routine laboratory tests are usually nonspecific. The white blood cell count is
often normal even in the setting of acute osteomyelitis. The erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP) are often elevated;
however, they both lack specificity in the absence of other radiologic and
microbiologic data.
To diagnose osteomyelitis, the doctor will first perform a history, review of
systems, and a complete physical examination. In doing so, the physician will
look for signs or symptoms of soft tissue and bone tenderness and possibly
swelling and redness. The doctor will also ask to describe the symptoms and
will evaluate the personal and family medical history. The doctor can then order
any of the following tests to assist in confirming the diagnosis:
Radiographs (X-Rays): These tests can show abnormalities of the bone. The
abnormalities can elucidate a focal decrease in density, that may recommend
bone destruction from bacteria Yet, it includes the demonstration of infected
sections of the bone in response to bacterial infection.
Magnetic Resonance Imaging (MRI): This imaging examination can shows any
fluid contained in the bone with wider sensitivity and precision. MRI is a
practical method in diagnosing the spread of infection, as well as if there is an
infection present.
Blood tests: When testing blood, measurements are taken to verify an infection.
CBC (complete blood count): shows whether a white blood corpuscle count is
gathered or not.
ESR (erythrocyte geological phenomenon rate); serum globulin (C-reactive
protein) within the bloodstream, which functions as a highlighter as it measures
inflammation in the body.
Blood culture: A blood culture is taken in consideration in order to detect
bacterium that is active in the bloodstream. A sample of blood is taken then
placed in environments which influence the expansion of bacteria. authorizing
the bacteria to grow, the representative may be able to identify and examine it
against variant antibiotics in anticipation of verifying primary effective
treatment.
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Needle aspiration: During this test, a needle is used to secrete a sample of fluid
and cells from the bone space, or bony area. The sample is then sent to be
evaluated, by allowing the mediator to grow on the media.
Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for
signs of an incursive organism.
Bone scan: During this test, a small amount of Technetium-99 pyrophosphate, a
high temperature material, is injected intravenously into the body. If the bone
tissue is healthy, the cloth can spread out in a uniform fashion. However, a
tumour or infection contained in the bone will absorb the material and show a
collection of concentration of the radioactive material, that may be seen with a
special camera that produces the images on a laptop screen. The scan may
assist facilitate your doctors view of the abnormalities in the early stages, as
X-ray findings strength exclusively and show usual findings.
Blood cultures are usually obtained as soon as Osteomyelitis is suspected.
However in most cases there are negative expectations for instances in cases like
hematogenous osteomyelitis. Most methods used for diagnosis of osteomyelitis
are histopathology examination and tissue culture. When the patient is clinically
stable, immediate delay of empiric antimicrobial treatment should be stopped
until bone biopsy is performed. Needle biopsy is generally used, and hence the
sensitivity and specificity oppression. This method has been reported useful
with an 87% and 93%, respectively. Yet not only but, the specimens suffer each
aerobic and anaerobic bacterial culture. In addition, flora and mycobacterium
cultures must be performed when clinical suspicion of those organisms is
determined.
Patients with suspected Osteomyelitis typically present with ulcers or debilitate
wounds. A very important not is considered when diagnosing; if no infected
material is present, the site of injury should not be cultured. If bone diagnostic
investigation is difficult to diagnose, then culture of purulent material from not
infected sites is allowed to be obtained. Yet it is very important to keep that as a
last approach and handled with caution. Surface cultures often grow exclusively
on skin flora, and frequently miss the initial infectious agent, or secondary
pathogen(s) in such case; polymicrobial infection. Severe growth of a usual
pathogen is suggestive conversely not diagnostic of its involvement. The
presence of S. aureus in surface cultures has been associated with its presence in
deep cultures.
Radiology
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Several imaging modalities are useful when diagnosing osteomyelitis. (Table 1).
Plain radiographs are the main step in assessment since the are inexpensive and
safe, and will help obtain the appropriate description. Bone destruction and
periosteal reaction regularly seen throughout infection for 10-21 days. Negative
films are not excluded within the diagnosis of osteomyelitis, for the most part in
acute infection.
Table 1
Imaging for Osteomyelitis
Modality
Sensitivity (%)
Specificity (%)
Plain radiographs
43-75
75-83
Computed tomography
65-75
65-75
Magnetic resonance imaging
82-100
75-96
Three-phase bone scan
73-100
73-79
White blood corpuscle scan
80-90
80-90
Bone scintigraphy, conjointly refered to as bone scan, which is useful throughout
development of osteomyelitis. The radio pharmaceutical, naturally technecium99, accumulates in areas of increased blood flow and reactive bone formation.
However, when looking at poor tissue infection with no bone infection, there are
3-phases of bone scan that must only demonstrate the main phases, with usual
uptake on the late (3-hour) images. In cases of osteomyelitis, uptake is seen all
through three phases. Specificity decreases in the setting of recent trauma or
surgery, medical science devices, or diabetes. Radio-labeled white blood
corpuscle scan is an interchange to bone scan, with comparable sensitivity and
specificity, while it requests other technical preparation and time to perform.
Computed imaging (CT) and resonance imaging (MRI) are affordable and useful
to find appropriate diagnosis to diagnosis if osteomyelitis is present or not. Each
technique shows anatomic detail, collectively with animal tissue destruction and
soft tissue extension. CT is complicated method as it is caused by adjacent
metallic implants. Imaging cannot be performed in the presence of some metal
implants, even if some prosthetic implants are MRI-compatible.
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CONCLUSION
In conclusion, treatment of combined critically sized intercalary femur defects
with soft tissue defects remains challenging.
for our patient The treatment with surgical procedure and antibiotic IV and tablets
was failed and in the end he chose the amputation, in Gaza Strip may the
difficulties and long time for referral the patient played active role in late
diagnosis and treatment failure , .
We recommend that the surgical treatment in association with local Antibiotic
bone cement is the best way for the treatment of osteomyelitis where delivering
antibiotics directly to the surgical site using specialized carrier materials which,
after releasing their antibiotics, completely dissolve in the patient. This ability to
release high doses of antibiotics exactly where they are required to achieve early
primary infection control in cases of infected non-union with bone defect, may
improve treatment and prevent the risk of antimicrobial resistance (AMR)
developing.
To prevent and treat infection, patients should given antibiotics which spread
through the body in an attempt to kill the causative bacteria. However, in case of
femur fracture stabilized with external fixation, there is a lack of blood supply to
the surrounding area and the fracture site , which often makes treatment
ineffective as the antibiotics can not successfully reach the surgical site. This
allows the infiltrating bacteria to grow and establish biofilms, large clusters of
bacteria which are extremely difficult to treat with normal antibiotic intervention
strategies. Moreover, poor treatment and an inability to completely eradicate an
infection may also permit the remaining bacteria to develop AMR , further
reducing the chances of successfully clearing the infection.
References
21
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