Does local implantation of gentamicin impair renal function in patients undergoing surgery for chronic bone infection?

<p><strong>Background: </strong>The treatment of chronic bone infection often involves excision of dead bone and implantation of biomaterials which elute antibiotics. Gentamicin is a preferred drug for local delivery, but its systemic use carries a well-established risk of nephrotoxicity. We aim to establish the risk of acute kidney injury (AKI) with local delivery in a ceramic carrier.</p><p><strong>Methods: </strong>163 patients with Cierny-Mader type 3 or 4 chronic osteomyelitis had a single-stage operation including filling of the osseous defect with a calcium sulphate-hydroxyapatite carrier containing gentamicin. Mean gentamicin dosing was 191.3 mg (maximum 525 mg). Glomerular filtration rate (GFR) was calculated pre-operatively and during the first seven days post-operatively. Renal impairment was graded using the chronic kidney disease (CKD) staging system, and AKI was assessed using the RIFLE criteria.</p><p><strong>Results: </strong>155 cases had adequate data to allow calculation of pre- and post-operative GFR. 7 had pre-existing renal disease. 70 patients (45.2%) had a temporary GFR drop post-operatively, with the greatest decrease occurring at a mean of 3.06 days following surgery. Twenty cases had a &gt;10% decline in GFR, but 12 resolved within 7 days. 7 patients transiently fell into the “Risk” category according to RIFLE criteria, but no patient had a change consistent with “Injury”, “Failure” or “Loss” of renal function and none had clinical signs of new acute renal impairment post-operatively. </p><p><strong>Conclusions: </strong>Renal function is not significantly affected by local implantation of gentamicin up to 525 mg. The presence of pre-existing renal disease is not a contraindication to local gentamicin therapy.</p><p><strong> </strong></p>

Differentiating Brucella Spondylitis from Tuberculous Spondylitis by the Conventional MRI and MR T2 Mapping: A Prospective Study

Background Brucellar spondylitis (BS) and tuberculous spondylitis (TS) which cause initial bacteremia and show granulomatous lesions are the two leading types of spinal inflammatory. BS is easy to miss or maybe misdiagnosed as TS. Our purpose differentiates brucella spondylitis (BS) from tuberculous spondylitis (TS) in conventional MR imaging and MR T2 mapping.Methods We performed on 26 BS and 27 TS patients in conventional MR imaging and MR T2 mapping. We analyzed the features in conventional MR imaging and also measured T2 values of the lesion vertebrae (LV) and unaffected adjacent vertebrae (UAV) in BS and TS patients, respectively.Results There were no significant differences in sex, age, national between BS and TS. It was significantly lower of the severe vertebral destruction, vertebral posterior convex deformity, dead bone, and abscess scope in BS when compared to TS (p < 0.001, p = 0.005, p = 0.048, p < 0.001, p < 0.001, respectively). The vertebral hyperplasia was significantly higher in BS when compared to TS (p < 0.001). The T2 value of the LV with BS was markedly higher than that in the UAV with BS and that in the LV and UAV with TS (p < 0.001, p < 0.037, p < 0.001, respectively). The T2 value of the LV with TS was significantly higher than that of the UAV in TS and BS (p < 0.001, p < 0.001, respectively). There were no significant differences in the T2 value of the UAV between BS and TS (P = 0.568). Conclusions The qualitative and quantitative evaluation may differentiate BS from TS. The conventional MR imaging helps to distinguish BS from TS by several distinctive features. MR T2 mapping has the additional potential to provide quantitative information between BS and TS.

5 Osteomyelitis

Osteomyelitis is a fascinating condition that can affect all parts of the human skeleton. It presents in several distinct ways, but all have varying degrees of inflammation, systemic ill health, bone death, and soft-tissue compromise. Understanding the components of the disease and the interplay between bacteria, biofilm formation, and the host response is critical to successful treatment. Recent advances in diagnostic methods, imaging, local delivery of antimicrobials, and bone reconstruction have greatly improved the outcome for many patients. Surgery remains central to the effective treatment of chronic osteomyelitis and many acute cases. Eradication of infection is largely dependent on the skill of the surgeon in identifying the areas of dead bone and removing them during surgery. Osteomyelitis is challenging and rewarding to treat, and most patients should enjoy prolonged disease-free periods or cure. Holistic care of the patient requires close collaborative working in a multidisciplinary team including physicians, surgeons, nurses, and therapists to achieve the best outcomes.

Atypical fungal thoracic vertebral osteomylitis resembling metastatic tumor and literature review of fungal vertebral osteomylitis

Case DescriptionFungal vertebral osteomylitis is a rare disease that difficult to diagnosis and cure. Because the early specific clinical manifestations of this disease are few and atypical, it is often missed or misdiagnosed, resulting in treatment delay and aggravation of the disease.ObjectiveTo report a rare case of cryptococcal osteomyelitis that resembles metastatic tumor happened in an immunecompromised patient with a history of mantle cell lymphoma and to review cases reported in literature.Study DesignBased on imaging studies, metastatic tumor was highly suspected. For a further examination and therapy, the patient was referred to our spine clinic. After admission to our clinical, chest and abdominal CT were checked to evaluate the disease status.TreatmentsAfter general anesthesia, posterior thoracic pedicle screw fixation (T2.3.5.6) were performed, followed by posterior laminectomy and decompression of T4 vertebral body. The right facet joint of T3/4, costal transverse joint, right pedicle and transverse process of T4 vertebra were fully removed and curetted. After careful hemostasis, posterolateral bone grafting was performed. The nail-rod connection is fixed.OutcomesThe postoperative intercostal neuralgia and chest pain were significantly relieved, without complications. The postoperative pathological results were suppurative inflammation with focal granuloma formation, dead bone formation and fungal (cryptococcal) infection. ConclusionsWhen complicated with vertebral fungal spondylitis, no obvious abnormality and fever can be found. When pain or nerve dysfunction caused by spinal cord compression or nerve root compression occurs, surgical treatment can effectively relieve clinical symptoms.

Technique of Papineau in the Management of Chronic Osteomyelitis in a Low Setting Area. A 12 Years’ Experience

Introduction: Chronic osteomyelitis, a bone infectious pathology is difficult to treat. The authors report their experience in a series of patients treated in a low-income country.Methods: We report a prospective study of 53 patients suffering of chronic osteomyelitis for a long time, covering our experience between January 1998 to December 2010 at the Kinshasa University Hospital in central Africa. We used the technique described by Papineau with success, until the consolidation of the bones and the drying up of the wounds.The following elements were analyzed and taken into account: age and sex of the patients, sites involved, germs, surgical technique, length of stay in the hospital and estimated cost of the treatment.Result: The majority of patients were between 26 and 35 years old with extremes between 15 and 80 years old, with 34 males and 19 females with a sex ratio of 1.7/1. Upper limb was involved with 7 humerus, 6 radius, 6 cubitus and the lower limb with 14 femurs and 20 tibias. Staphylococcus aureus was the germ most found in cultures from dead bone from intraoperative technique. Stay in hospital on average was 17 weeks for upper limb and 28 weeks for the management of lower limb injuries. The average cost for the treatment was estimated for 700 to 800 dollars. Conclusion: Chronic osteomyelitis is a tenacious condition for long-term evolution, but it is nevertheless encouraging to dry up foci, which were the toughest challenges for orthopedics and plastic surgeons. In a low setting region, the management of the disease remains a condition with a high economic cost and it is absolutely useless to begin a Papineau treatment if the patients do not have enough money.

Infected Non Union of Tibia Managed by Limb Reconstruction System- A Prospective Cohort Study

Introduction: Infected non union of Tibia is one of the most commonly faced problem in both compound as well as closed fractures of Tibia, treated surgically. Few patients also present with gap at the fracture site which may be either due to bone loss during trauma or due to debridement of dead bone during previous surgeries. Treatment of infected non union is always challenging with unpredictable outcomes. Limb Reconstruction System (LRS) is one of the systems available to treat this complex situation. Aim: To evaluate the role of LRS in treatment of infected non union of Tibia in terms of union time, total duration of fixator applied and Visual Analouge Score (VAS). Materials and Methods: Twenty one patients of infected gap, non union of tibia were included in the study and were treated with debridement, resection of dead bone and application of LRS and segment transport. The results were evaluated in terms of union time, total duration of fixator applied and VAS. Bony and functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. SPSS statistics 24.0 was used for analysis. Mean, median and mode were used to describe continuous variable. Results: Out of 21 patients, 19 were males and two were females. The mean age of patients was 29.43±14.07 years. The mean limb length discrepancy was 23.3 mm (range, 15-40 mm). The mean duration from injury to LRS application was 7.9 months (range, 6-12 months). Mean duration of follow-up was 29.5 months (range, 16-50 months). Average union time was 44 weeks and average fixator time was 11.2 months. Bony and function results were good and excellent in 90% cases. Conclusion: The use of monolateral rail external fixator LRS is an effective method for the treatment of infected non union of tibia augmented with a fibular strut graft. This provides good results in terms of bony union, subsidence of infection and functional results.