Serum Calcium Level Combined with Platelet Count May Be Useful Indicators for Assisted Diagnosis of Extremity Posttraumatic Osteomyelitis: A Comparative Analysis

Background. A previous study had reported that patients with osteomyelitis (OM) appeared to be more likely to develop hypocalcemia before and after surgery. Calcium sulfate (CS) is frequently used as a local antibiotic vehicle in the treatment of OM, which may also affect serum calcium level. However, whether changes of serum calcium level are caused by OM and/or local use of calcium sulfate remains unclear. Also, platelet (PLT) count plays a crucial predictive role in periprosthetic joint infections (PJIs), but its role in assisted diagnosis of OM is largely unknown. The purpose of this study was to determine whether serum calcium level and PLT count may be helpful in assisted diagnosis of PTOM. Methods. Between January 2013 and December 2018, we analyzed 468 consecutive patients (392 males and 76 females), including 170 patients with posttraumatic OM (PTOM), 130 patients with aseptic bone nonunion (ABN), and 168 patients recovered from fractures with requirement of implant removal set as controls. Preoperative serological levels of calcium, phosphorus, and PLT were detected, and comparisons were conducted among the above three groups. Additionally, correlations and receiver operating characteristic (ROC) curves were displayed to test whether calcium level and PLT can differentiate patients with ABN and PTOM. Results. Outcomes showed that the incidences of asymptomatic hypocalcemia (PTOM vs. ABN vs. controls = 22.94 % vs. 6.92% vs. 8.82%, χ 2 = 21.098 , P < 0.001 ) and thrombocytosis (PTOM vs. ABN vs. controls = 35.3 % vs. 13.84% vs. 12.35%, χ 2 = 28.512 , P < 0.001 ) were highest in PTOM patients. Besides, the mean serological levels of phosphorus in PTOM and ABN patients were significantly higher than those in the controls ( P = 0.007 ). The Area Under the Curve (AUC) of the ROC curve outcomes revealed that, with the combination of serum calcium level with PLT count, the predictive role was acceptable (AUC 0.730, P < 0.001 , 95% CI 0.681-0.780). Also, serological levels of calcium of 2.225 mmol/L and PLT count of 246.5 × 10 9 / L were identified as the optimal cut-off values to distinguish patients with and without PTOM. However, age- and gender-related differences in serum calcium levels (age, P = 0.056 ; gender, P = 0.978 ) and PLT count (age, P = 0.363 ; gender, P = 0.799 ) were not found to be statistically significant in any groups. In addition, no significant correlations were identified between serum calcium level and PLT count ( R = 0.010 , P = 0.839 ). Conclusions. Asymptomatic hypocalcemia and thrombocytosis appeared to be more frequent in this cohort with PTOM. Serological levels of calcium and PLT count may be useful biomarkers in screening patients suspected of PTOM.

Dynamics of bone tissue metabolism in the complex treatment of chronic posttraumatic osteomyelitis of long bones

Introduction: Chronic post-traumatic osteomyelitis is a complex problem of modern traumatology and orthopedics, affecting, in addition to medical, social and economic aspects of healthcare. When planning treatment, it is necessary to take into account the metabolic state of the bone tissue, since the effect of an infectious pathogen goes far beyond the classical lytic process, disrupting the balance of bone formation and bone resorption in various ways. The study is devoted to the study of the dynamics of parameters reflecting the metabolism of bone tissue in patients receiving complex therapy for chronic post-traumatic osteomyelitis of long bones. Aim: To study the dynamics of metabolic disorders of bone tissue in patients with orthopedic infection of long bones and large joints under conditions of ongoing complex etiotropic and compensatory therapy for 6 months, the timing of bone tissue consolidation within 2 years from the moment of surgery. Materials and methods: The study was prospective, observational, comparative, exploratory, involving 138 patients with post-traumatic chronic osteomyelitis of the long bones. Complex therapy included a combination of surgical treatment with antibacterial, anti-inflammatory therapy and drug correction of the revealed disorders of bone metabolism. The timing of the consolidation of bone defects after treatment and the dynamics of indicators of bone metabolism were studied. Results: The similarity of the periods of consolidation of different segments in the conditions of the described therapy was shown; the time period corresponding to the most pronounced dynamics of changes (correction) of violations was determined (3 months from the beginning of treatment); shows the effectiveness of metabolic therapy for the treatment of osteoarticular infections in various anatomical segments of the extremities. The results corresponds both to the results of the previous study and to the pathophysiological aspects of bone metabolism described in the literature. Conclusion: the timing of consolidation in the treatment of metabolic disorders is generally similar; the greatest changes in the parameters of bone metabolism are recorded within 3 months after the start of therapy. Also, the metabolic therapy regimen can be considered as universal for all segments.

The Dynamics of Immunological Indices in Patients with Posttraumatic Osteomyelitis and Trophic Disoders of the Shin Tissues

Summary. The article deals with the study of immune status of patients with osteomyelitis and trophic disorders of the shin tissues. Objective: to evaluate the immune status of patients with shin-bone osteomyelitis and distrophic processes, and to study dynamics of immunological indices after surgical interventions (clearing and reconstructive restoring surgeries). Materials and Methods. The immune status of 52 patients with posttraumatic osteomyelitis and trophic disorders of the shin tissues was studied. Clinical, immunological, and statistical research methods were used. Results. The study revealed changes in immune defence and in trophic processes in tissues (bones, skin, and muscles) of the damaged extremity. Thus, the presence of changes in the immune status was established: a decrease in the number of T-lymphocytes, T-helpers, cytotoxic T-lymphocytes, as well as changes in the humoral immune system – a decrease in immunoglobulins M and G levels and an increace in the level of circulating immune complexes. Conclusions. Changes in systemic immunity and local trophic disorders revealed in patients mutually aggravate the course of the pathological process and complicate its elimination.

Treatment of posttraumatic patella osteomyelitis with MRSA infection and knee stiffness: a case report

Background Posttraumatic patella osteomyelitis is rare, and the treatment of osteomyelitis remains to be challenging. Control of the infection commonly costs a long time, and it is easily to cause knee stiffness. In addition, there is no unified protocol for the treatment of knee stiffness. Case presentation We reported a case of posttraumatic patella osteomyelitis that successive infected with methicillin-resistant staphylococcus aureus (MRSA) after multiple surgeries. We successfully treated osteomyelitis by one-staged surgery, but the patient present knee stiffness after treatment. Thus Ilizarov external fixation system was further used to gradually adjust the mobility by exerting mechanical stress to the joint. After adjusting the frame under a scheduled plan, the patient successfully restored satisfactory knee function. Conclusions Adequate debridement is the key to control infections of posttraumatic osteomyelitis. Control the infection of posttraumatic patella osteomyelitis by one-staged surgery is achievable and could shorten the knee immobilization period. When knee stiffness occurs, scheduled range of motion (ROM) adjustment using Ilizarov frame with hinges might be a safe and useful method to restore function.

Associations between Interleukin Gene Polymorphisms and Risks of Developing Extremity Posttraumatic Osteomyelitis in Chinese Han Population

This case-control study aimed to investigate potential associations between interleukin (IL) gene polymorphisms and the risks of developing extremity posttraumatic osteomyelitis (PTOM) in Chinese Han population. Altogether, 189 PTOM patients and 200 healthy controls were genotyped of IL-1α (rs17561, rs1800587), IL-1β (rs16944, rs1143627, rs1143634, rs2853550), IL-1RN (rs4251961, rs419598, rs315951), IL-4 (rs2243248, rs2243250), IL-6 (rs1800795, rs1800796, rs1800797), IL-8 (rs4073, rs2227306, rs2227307), IL-10 (rs3024491, rs3024496, rs1800871, rs1800872, rs1800896), IL-17A (rs2275913), and IL-17F (rs763780) using the SNaPshot genotyping method. Statistical differences were observed regarding the genotype distributions of rs16944 (P=0.049) and rs4251961 (P=0.007) between the patients and healthy controls. In addition, significant associations were found between rs16944 and the risk of PTOM development by dominant (OR=1.854, P=0.017), homozygous (OR=1.831, P=0.041), and heterozygous (OR=1.869, P=0.022) models, and of rs1143627 by dominant (OR=1.735, P=0.032) and homozygous (OR=1.839, P=0.040) models. Moreover, significant links were also identified between rs4251961 and the susceptibility to PTOM by dominant (OR=0.446, P=0.005) and heterozygous (OR=0.409, P=0.003) models, and of rs1800796 by dominant (OR=4.184, P=0.029), homozygous (OR=4.378, P=0.026), and heterozygous (OR=3.834, P=0.046) models. The present outcomes demonstrated that rs16944, rs1143627, and rs1800796 associate with increased risks, while rs4251961 links to a decreased risk of PTOM development in Chinese Han population.

ROLE OF CYTOKINE-MEDIATED MECHANISMS IN DEVELOPMENT OF POST-TRAUMATIC MANDIBULAR OSTEOMYELITIS

Osteomyelitis of the lower jaw is one of the urgent problems of modern medicine. There are many reasons for the evolvement of purulent necrotic processes of the jaw bones, including the role of disorders in the systems of innate and adaptive immunity. The aim of the study was to determine the content of TNFα, IL-17, IL-4 in serum and mixed saliva in patients with uncomplicated mandibular fractures and posttraumatic osteomyelitis to determine the possibility of using these indicators for early diagnosis of posttraumatic complications. The article presents the results of a study of tumor necrosis factor α (TNFα), interleukin-17 (IL-17) and interleukin-4 (IL-4) cytokines in serum and mixed saliva in patients with uncomplicated mandibular fracture and post-traumatic osteomyelitis at the first and tenth days of observation. By means of single-layer neural networks, binary classifiers were built, allowing patients to be stratified by the clinical form of the disease and to predict its course. The probability of uncomplicated mandibular fracture is described by the ratio P = 1/(1+e-z), where the index z is determined by the level of TNFα, IL-17, and IL-4 at the first and tenth day of observation. The simulation confirmed high prognostic significance of serum TNFα and IL-17 for early verification of posttraumatic osteomyelitis, which was confirmed by the OTC and ROC indices, which varied from 87 to 100% in different models. Models 4 and 5, where TNFα recorded on the tenth day of the study was used as predictors, and a combination of TNFα and IL-17 obtained on the first day of hospitalization, were the most accurate. Modeling the results of the study of immunological indicators in the mixed saliva showed that the predictive properties have only IL-4 and IL-17, was on the tenth day of hospitalization that distinguishes these binary classifiers from similar indexes, derive from the levels of cytokines in blood serum. The results of the study indicate the important role of disorders in the system of рro- and anti-inflammatory cytokines in pathogenesis of post-traumatic osteomyelitis.

Is Hypercalcemia a Frequent Complication following Local Use of Calcium Sulfate with Antibiotics for the Treatment of Extremity Posttraumatic Osteomyelitis? A Preliminary Study

Background. Previous study had reported hypercalcemia as a frequent complication (20%) following local use of antibiotic-eluting calcium sulfate (CS) during treatment of periprosthetic joint infections (PJIs). However, whether this complication may occur in patients who receive local CS implantation for management of posttraumatic osteomyelitis (OM) remains unclear. Methods. Between April 2016 and May 2017, we included 55 patients with extremity posttraumatic OM who received local antibiotic-loaded CS therapy. Serum calcium levels were detected preoperatively and on the 1st, 3rd, and 7th postoperative days (PODs). Comparisons were performed regarding serum calcium levels among the four time points and between two different CS volume groups (≤ 20 cc group and > 20 cc group). Additionally, potential associations were examined regarding CS volume and preoperative calcium level with postoperative calcium levels, respectively. Results. Altogether 46 males and 9 females were included, with a median CS volume of 20 cc. Outcomes showed that prevalence of asymptomatic hypocalcemia was more frequent, with 16.4% before surgery and 60%, 53.8%, and 25% on the 1st, 3rd, and 7th PODs, respectively. Hypercalcemia was not found in any patients, at any time point. In addition, significant differences were identified regarding serum calcium levels among different time points, suggesting significantly decreased calcium levels on the 1st (P < 0.001) and 3rd PODs (P < 0.001) and back to near preoperative level on the 7th POD (P = 0.334). However, no statistical differences were observed regarding serum calcium levels between the two CS volume groups at any time points (P > 0.05). Moreover, no significant links were identified between CS volume and postoperative calcium levels (P > 0.05). Serum calcium levels on the 3rd (P = 0.019) and 7th PODs (P = 0.036) were significantly associated with the preoperative calcium level. Conclusions. In contrast to what had occurred in PJI patients, asymptomatic hypocalcemia appeared to be more frequent in this cohort with posttraumatic OM. Hypercalcemia may be an infrequent complication before and after local CS use for the treatment of extremity posttraumatic OM.