Acute hematogenous osteomyelitis in children: diagnostic and treatment

Abstract

Purpose – to analyze treatment results and to improve algorithms of diagnostic, treatment and rehabilitation of children with acute hematogenous osteomyelitis (AHO). Materials and methods. A study of 884 patients with AHO, who were treated at the Zhytomyr Regional Children’s Clinical Hospital and O. F. Gerbachevsky Zhytomyr Regional Hospital surgical department (child surgical department has been at the adult regional hospital until 1986) in the period from 1978 to 2019. 60.5% patients were boys, the vast majority – 488 (55.1%) – villagers. School-age children (7–15 years) – 353 (39.9%), first-year children – 228 (25.8%). General clinical and laboratory tests, X-ray, ultrasound, CT and MRI, microbiological and immunological test were used to control the course of the disease and the treatment effectiveness. Results. The most common AHO pathogen remains the same – Staphylococcus aureus, however it’s frequency dropped from 60.4% to 46.1% because of increased Kl. pneumoniae, sticks of blue-green pus, to a lesser extent – Klebsiella and mixed flora. Also we established dependence AHO form from the pathogens number and age. The most often AHO determinants (provocation or trigger) were limb traumas (352 patients – 39.8%), lesser – respiratory diseases, skin and soft tissue inflammation. In 37.4% cases (341 patients) there was no such symptoms. Differences in the immunological characteristics of the three clinical forms of AHO disease become clear only during comparative assessment of the dynamics of immunological parameters by stages of the disease. The main subpopulations of T lymphocytes and their interrelated indicator, the helper-suppressor index, are the structural basis for the formation of differences in the immune response. Phlegmon disclosure (subperiosteal, paraosal, periarticular) in total was performed in 863 patients (97.6%), of which 84 children (9.5%) had recurrence. Bone needles puncture was performed in 613 patients (69.3%), of which osteoperforation – in 589 (66.5%). In newborns, antibiotic administration into the bone (metaepiphysis, close to the affected joint) and into the joint was performed by puncture 1–2 times a day for 7–10 days. In young children, decompression of the inflammatory focus in the bone was achieved by setting Dufox needles. Soft tissue abscesses were opened as they appeared, and in purulent pleurisy and pyopneumothorax (in 25 of 52 patients) pleural cavities were drained. There was reduction of local edema, hyperemia in children of experimental groups with generalized forms (septicopia and toxicoseptic) during the first week in 44.4% and 45.4% in the control group – 0.0%-15.9%, p<0.05). The reparation activity increased in 2.5–4.5 times. During the first week, right after starting liposomal therapy, body temperature in children with generalized AHO normalized, while in the control group it occurred only in 12.5–23.1% of patients. The duration of hospital treatment was reduced In the experimental group: 90.0% patients with local forms were treated less than 32 days, 88.9% patients with toxicoseptic and 72.7% of patients with septicopiaemic forms (in the control group, accordingly 92.8%, 37.5%, 38.5%, p1<0.05, p2–3<0.05). Conclusions. Diagnosis of AHO requires today a comprehensive examination: history, local changes and generalization of the process, MRI, ultrasound, radiography at a later date. Decisive in the treatment of AHO in children is the timely and complete irrigation of the lesion area, so the leading specialists in the treatment of acute hematogenous osteomyelitis should be pediatric surgeons. Consultation of related specialists proceeding if necessary. Empirical antibiotic therapy should be planned with consideration of sterile body fluid cultures in patients with various forms of the disease and their antibiotic sensitivity. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: hematogenous osteomyelitis, children, diagnostic, treatment and rehabilitation.