Treatment of Chronic Osteomyelitis in Children Resistant to Previous Therapy

Abstract

Patients admitted to the authors' institution with tibial osteomyelitis between 1978 and 1998 were reviewed. The purpose of this study was to determine the incidence, etiology, treatment, and outcome in chronic pediatric tibial osteomyelitis. The authors describe their treatment of chronic osteomyelitis in children resistant to previous therapeutic modalities. Thirty patients were identified with a mean age of 8.5 years at diagnosis. Mean age at admission was 9.6 years, indicating more than a 1-year duration of disease. Follow-up averaged 2.3 years. Patients underwent 97 procedures, averaging 3.2 procedures per patient. Hospital stay ranged from 2 weeks to 18 months, with an average stay of 4.7 months. Seventy-seven percent of patients were culture-positive, and 78% of positive cultures identified Staphylococcus aureus as the causative pathogen. Eighty percent of patients had a good outcome, 13% had a fair outcome, and there were no poor results. Patients with large tibial defects obtained good results with both tibiofibular synostosis and Ilizarov distraction osteogenesis. The authors describe the only reported group of pediatric patients successfully treated using Ilizarov bone transport for bony tibial defects due to osteomyelitis.

Comparative Severity of Pediatric Osteomyelitis Attributable to Methicillin-Resistant Versus Methicillin-Sensitive Staphylococcus aureus

“…Surgical specimens provided a positive culture in 85.5% of the cases, which again is comparable to previous reports. 29,30 Whereas other studies have reported culturenegative specimens in 15% to 47% of cases diagnosed primarily using bone scans, 1,17,18,33,34 only 15.5% of our surgical specimens failed to produce bacterial growth.…”

“…17,30 We used multiple irrigation and debridement procedures in addition to intravenous antibiotics as an aggressive therapeutic means. Most patients seen at the Children's Hospital were treated according to similar protocols combining antibiotic chemotherapy and surgical procedures.…”

“…Average length of treatment with intravenous antibiotics was 5.7 weeks, consistent with current recommendations for the treatment of subacute osteomyelitis. 30 Arnold et al 13 reported antibiotic coverage for a median of 28 days, which was decided upon by the individual treating physician. Invasive treatment, as conducted in this study, for subacute osteomyelitis is not uniformly recommended.…”

Pediatric Tibial Osteomyelitis

“…C-reactive protein (CRP) was recorded in 137 (71.7%) patients with a mean of 80 mg/L (range, <1 to 380 mg/L). In 10 Table 2. Rates of MRSA (5.1%) and extended spectrum beta lactamase (3.4%) were low (Table 3).…”

“…The literature contains many pediatric series of acute hematogenous osteomyelitis (AHO), [1][2][3][4][5][6][7][8][9] but few recent studies focus solely on tibial infection. 10 Osteomyelitis can result from hematologic spread or from direct inoculation. The tibia is predisposed to infection due to the characteristics of its metaphyseal blood supply, 11 and because it is the most frequent site of open fractures.…”