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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 1  |  Page : 26-33

Study to evaluate the role of surgical management in acute osteomyelities in children


Department of Orthopaedics, SDM Medical College and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka, India

Date of Submission06-Dec-2021
Date of Decision18-Dec-2021
Date of Acceptance20-Dec-2021
Date of Web Publication24-Jan-2022

Correspondence Address:
Dr. Shrihari L Kulkarni
Department of Orthopaedics, SDM Medical College and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_352_21

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  Abstract 

INTRODUCTION: Acute hematogenous osteomyelitis is predominantly seen in children, accounting for 1% of all hospital admissions. It is a limb-and life-threatening condition with variable presentation, requiring prompt diagnosis and immediate treatment. Sequential intravenous and oral antibiotics, immobilization, surgical drainage and symptomatic measures are main treatment modalities for management of this condition. The aim of this study is to evaluate the role of surgical management in acute osteomyelitis.
MATERIALS AND METHODS: Twenty-five children with acute hematogenous osteomyelitis were included in this cross-sectional retrospective study. Clinical, laboratory, and radiological data were collected and examined. Follow-up records of patients were analyzsed to note the status of healing, complications, and functional outcome. Data were analyzed using SPSS version 20, paired t-test, and Chi-square test. The chosen level of significance was P < 0.05.
RESULTS: Sixty percent of the patients were male with average age of 7 years. The median duration of symptoms was 10 days. Sixty percent of the patients had a history of trauma. Tibia was most commonly involved followed by femur. Staphylococcus aureus was the most common organism isolated from the culture. Twenty-one patients were managed surgically. Average follow-up period was 4.2 months. At 3 weeks' follow-up, majority of the patients had reduction in pain and swelling. Twenty-two patients had a complete recovery. Three patients developed chronic osteomyelitis, two of them developed deformity. It was observed that surgical treatment was significantly associated with better outcome as compared to conservative management for acute osteomyelitis (P = 0.011).
CONCLUSION: Surgical intervention is of at most importance in patients with acute osteomyelitis in the presence of abscess. Prompt surgical decompression with sequential intravenous-oral antibiotics gives an excellent outcome in the management of acute osteomyelitis in children.

Keywords: Acute osteomyelitis, infection, pediatric orthopedics, surgical management


How to cite this article:
Kulkarni SL, Mannual S, Patil N, Daragad M. Study to evaluate the role of surgical management in acute osteomyelities in children. Indian J Health Sci Biomed Res 2022;15:26-33

How to cite this URL:
Kulkarni SL, Mannual S, Patil N, Daragad M. Study to evaluate the role of surgical management in acute osteomyelities in children. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 May 22];15:26-33. Available from: https://www.ijournalhs.org/text.asp?2022/15/1/26/336307




  Introduction Top


Osteomyelitis is the inflammation of the bone and bone marrow secondary to infection by pyogenic organisms. Depending upon the mode of presentation and clinical course, osteomyelitis can be acute, subacute, or chronic. In acute osteomyelitis, the duration of symptoms is usually < 2 weeks. The most common source of infection in children is hematogenous, from foci of infection elsewhere in the body. Direct seeding of infection in the bone by trauma or surgical intervention are other rare sources of infection. The ends of the long bones are most commonly affected compared to flat bones. Usually, the infection begins in the metaphysis of the long bone, as this region has rich blood supply with sluggish flow due to the hairpin bend arrangement of the arterioles.[1],[2],[3]

Acute hematogenous osteomyelitis is predominantly seen in children with overall prevalence estimated at 1 case per 5000 children as per western studies.[4] The incidence is expected to be much higher in developing countries with low socioeconomic status, high rates of infection in children, malnutrition, and poor access to primary health care.[5] This is compounded by variable clinical presentation and radiological findings across different age groups. The bacterial culture reports can be frequently negative even in histopathologically proven cases.[6]

The treatment largely includes supportive measures, splinting of the limb, antibiotics, and surgical drainage with debridement of necrotic material wherever indicated.[7] Despite the advances in radiological imaging, antibiotic therapy, and surgical techniques the disease continues to have a significant morbidity due to delay in diagnosis and inadequate treatment.[8],[9] This can lead to various complications such as sepsis, chronic osteomyelitis, pathological fracture, joint stiffness, and deformity due to growth disturbances.[10],[11],[12]

Moreover, the topic being so common, there are very few original articles on acute osteomyelitis in children and very less data regarding this is available with respect to our population. The presentation of acute osteomyelitis has been drastically altered after the advent of the new advanced antibiotics. Most of the patients present late to us and would have already received antibiotics in the periphery hence masking most of the classical features. Therefore, this study was planned to evaluate the occurrence, clinical presentation, role of surgical management, and outcome of treatment in children presenting with acute osteomyelitis.


  Materials and Methods Top


This was a retrospective cross-sectional study conducted on all children with acute osteomyelitis admitted from January 2015 to January 2020, presenting to a tertiary care medical teaching hospital. Data was collected from our hospital database. Ethical committee clearance was obtained for the retrieval of the records. Patients were contacted to obtain informed consent.

Clinical and radiological records of twenty-five children diagnosed with acute osteomyelitis were examined. Clinical details regarding age, sex, duration of symptoms, history of trauma, limb involved, and history of prior treatment with primary care physician in the form of oral or intravenous antibiotics were recorded.

The investigations examined were complete blood counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), blood culture, bone aspirate for microscopy, culture, and sensitivity. Radiographs of the affected extremity were examined to look for signs of soft tissue swelling and periosteal reaction which was a valuable indicator of delayed presentation. It was noted that depending on the presentation of the child, high-resolution ultrasonography (HRUSG) or magnetic resonance imaging (MRI) was done. In very sick and/or noncooperative children only HRUSG was performed.

The empirical intra-venous antibiotic of choice was injection cefuroxime which was started in all cases until reports of culture and sensitivity were obtained. Later medication and dose were modified based on the results. The diseased limb was immobilized. Operative management consisting of drainage of abscess, debridement of necrotic material along with decompression of the medullary canal by drilling of affected bone or a cortical window depending on the size of the bone was done in very sick children with abscess or when HRUSG or MRI showed the subperiosteal collection. Postoperatively, the limb was immobilized for 3 weeks, intravenous antibiotics were given for initial 5 days followed by oral antibiotics which were given for a minimum of 3 weeks and maximum of 6 weeks. Patients who were managed conservatively were given intravenous antibiotics for 10 days followed by oral antibiotics which were given for minimum of 6 weeks along with immobilization of the affected limb for 3 weeks. Follow-up records of patients were analyzed to note the status of healing, complications, and functional outcome.

The data collected were subjected to statistical analysis using IBM Corp, Released 2020. IBM SPSS statistics for windows version 27.0. (Armonk, NY: IBM Corp.), paired t-test, Chi-square test. The chosen level of significance was P < 0.05. Suitable descriptive statistical methods (mean, median, and standard deviation [SD]) were employed for data analysis.

Ethical clearance

Ethical Clearance was obtained from SDM Medical College and Hospital, SDM University, Institutional Ethical Committee with Ref no SDMIEC/2022/152 dated 08.01.2022.


  Results Top


The study group was comprised of 15 males (60%) and 10 females (40%). Age distribution was fairly even, ranging from 1 year to 15 years with an average age being 7 years (SD 4.50). Majority of the patients were aged <6 years (56%) reflecting the role of trivial trauma while playing in the occurrence of the condition. Most of them had symptoms for <1 week (48% <1 week and 32% 1–2 weeks) and the median duration of symptoms was 10 days. Sixty percent (15 patients) had a history of fall/trauma before presenting to us. All children had single bone involvement. The most common site was tibia (60%) followed by femur (16%) and pelvis (8%). Humerus, radius, fibula, and calcaneum were involved in one patient each. Twenty percent of the patients had already received antibiotics before presenting to us [Table 1].
Table 1: Demographic profile of the study participants

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All the children who presented to us had fever, pain, and tenderness around the affected site. Patients also presented with swelling over the affected area (84%), decreased use of the affected limb (88%), and adjacent joint pain (24%). A small proportion of patients had presented with vomiting (8%) and headache (4%) [Figure 1].
Figure 1: Distribution of signs and symptoms at presentation

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All of the patients had recorded temperature spikes, 56% (14 patients) had recorded temperature of more than 100°F. The white blood cell (WBC) count ranged from 6000 to 24,700 cells/ml with 14,070 cells/ml being the average (SD 4728.22). ESR was obtained in all the patients after admission. ESR ranged from minimum of 20 mm/h to maximum value of 95 mm/h. The mean ESR was 47.5 mm/h with the SD of 24.5 mm/h. The magnitude of the WBC counts and ESR did not correlate with an increased chance of obtaining a positive culture. We noticed higher WBC count and ESR when the patient presented early, i.e., within a week of onset of symptoms. The difference in mean levels of WBC count (P = 0.041) and ESR (P = 0.041) was statistically significant considering the duration of symptoms within a week and later. CRP was done in twenty patients and mean CRP level was 54.12.

X-ray of the involved bone was done in all the patients. In 72% of the patients, there was no evidence of acute osteomyelitis or any bony changes, whereas, 28% of patients showed soft tissue swelling and periosteal reaction. MRI was done in 48% of patients and HRUSG was performed in 32% of patients to confirm the diagnosis and to know the extent of the abscess.

Blood culture sent in all the patients before starting antibiotics was found to be positive in 22 cases (88%). Culture and sensitivity from the bone was also sent in all patients either intra-operatively or through USG guided aspiration. In 68% of our cases, cultures from the affected bone were sent intra-operatively, 88% of those yielded growths. Whereas, only 50% of those sent by USG guided aspiration (32%) yielded growth. Staphylococcus aureus (52%) was the most common organism isolated followed by Group A Streptococcus (16%). Six patients (24%) showed no growth on culture. More number of cultures were positive when patients presented early as compared to those presenting after 10 days. Duration of symptoms was significantly associated with outcome of the culture report (P = 0.029).

All children were given intravenous antibiotics at admission and affected extremity was immobilized. Twenty-one (84%) patients were managed operatively with drainage of pus after all the investigations. Depending on the size of the bone either cortical drill holes or cortical window was made to decompress the medullary canal. Pus was drained with debridement of the necrotic tissue. After thorough lavage, the incision was closed with drain in situ, which was kept for 24–48 h. Four patients (16%) were managed conservatively with immobilization and antibiotic therapy [Table 2].
Table 2: Summary of investigations and treatment administered

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Patients were followed up for an average of 4.2 months after discharge. The symptomatic response was noted at the follow-up at 3 weeks of treatment. The majority of patients had reduction in pain (84%) and swelling (92%) at 3 weeks. Three patients (12%) developed chronic osteomyelitis, one among them was a patient with calcaneum osteomyelitis who also developed heel varus. One patient with humerus osteomyelitis had a pathological fracture which was managed conservatively, which further led to shortening of the upper limb. Knee stiffness was seen in one of the patients with tibia osteomyelitis which resolved with physical therapy. Twenty-two (88%) patients had complete recovery from the illness. All three patients with chronic osteomyelitis developed sequestrum and draining sinus [Table 3]. It was observed that surgical treatment was significantly associated with better outcome as compared to conservative management for acute osteomyelitis (P = 0.011).
Table 3: Patient's response to treatment and outcome

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  Discussion Top


Acute hematogenous osteomyelitis has a dramatic presentation in children with the organisms reaching the bone through the bloodstream. The unique architecture of the metaphysis and its vascular supply makes the bones in children more susceptible to infection as compared to adults. Majority of the cases occur in younger children <5 years with males affected nearly twice as that of females. In our study, 56% of the children were <6 years with a male to female ratio of 1.5:1. A study by Funk and Copley noted the mean age of presentation to be 6 years while in our study, it was 7 years.[5],[13],[14]

Most of the patients will have symptoms for <2 weeks. Nearly half of our patients (48%) had presented within 1 week with the median duration of complaints prior to presentation being 10 days. Our observations concur with the findings of Scott et al., whereas, Ogunlade et al. and Dahl et al. noted the median duration of presentation to be 8 days and 4 days respectively.[12],[15],[16] The duration between onset and presentation depends on the socio-economic status of the family, prompt access to primary care, and early recognition by the primary care physician. It is to be noted that very few children primarily and promptly present to the orthopedic surgeon in our set-up.

History of fall or trivial trauma leading to the formation of hematoma in the metaphyseal region of the long bones enhancing bacterial infection has been implicated as an important etiological factor for acute osteomyelitis.[17] Trauma is further complicated by a history of massaging the injured part as part of traditional treatment methods. In our study, 60% of the cases had a history of fall or trauma. Typically, the infection involves the metaphysis of a single bone while multifocal infection is seen in neonates and immunocompromised children. The long bones of lower limb (tibia and femur) are the most common sites involving up to 50% of the cases.[18] Nontubular bones are involved in <20% cases, calcaneum and pelvis being the most common sites. Infection involving flat bones (skull, scapula, ribs, and sternum) and spine are rare.[19] Ogunlade et al. reported that the tibia was the most common bone involved in their study.[15] Tibia was involved in 60% of the cases in our study followed by femur (16%) and pelvis (8%). Calcaneum, radius, humerus, and fibula were involved in one patient each.

Clinical features and severity of acute osteomyelitis vary depending on the site of infection, age of the child, and virulence of the responsible pathogen.[1] Fever, pain, and inability to use the extremity are the most common clinical findings of acute osteomyelitis. Examination signs are often age-dependent. As a result of the thin periosteum which is easily penetrated by infective organisms, neonates will have swelling at the site of infection and irritability on the movement of the limb. Toddlers present with point tenderness with the inability to bear weight or use the extremity. Older children will have more subtle symptoms due to thicker metaphyseal cortex and adherent periosteum.[12],[18],[20] In a systematic review involving more than 12,000 patients with acute and subacute osteomyelitis, Dartnell et al. found the commonest presenting features were pain (81%), swelling and erythema (70%), fever (62%), reduced joint movements or pseudo-paralysis (50%) and limp (49%).[3] Pain, fever, bony tenderness, swelling, and decreased use of extremity were seen in more than 85% of patients who presented to us. Adjacent joint pain, vomiting, and headache were rare presenting features.

The mainstay of evaluation of a child with suspected hematogenous osteomyelitis is complete blood counts, ESR, CRP, and microbiological studies such as blood culture and pus culture, wherever available. A blood picture would suggest a neutrophilic leukocytosis with raised ESR and CRP. The rise in ESR peaks in 3–5 days. CRP levels are also useful in making the diagnosis and following the response to treatment in acute osteomyelitis. CRP rises more rapidly than ESR after the onset of infection.[3],[21] We found neutrophilic leucocytosis in 80% of our patients, ESR was elevated in all the patients, and CRP was elevated in 95%. Blood culture before starting antibiotics is a very useful guide to detect the causative organism and the culture-sensitivity pattern. Since in majority of the cases, the infection is hematogenous, blood culture will be positive. We noted positive blood culture in 88% our patients. Direct culture from the site of infection is also useful and in general correlates with the blood culture report in terms of the causative organism and the culture sensitivity. The organism is isolated only in 50% to 80% of cases mainly due to the initiation of antibiotics at the level of primary care physician. S. aureus was the causative organism in 52% of our patients and streptococci in 16%. We noted no growth in 24% of our patients. Our findings were similar to many other studies.[1],[12],[15],[16]

Plain radiography has limited utility in the diagnosis of acute osteomyelitis. Radiographic findings, if at all would be seen only after 2 weeks. In the acute setting, an indirect evidence of inflammation in the form of soft tissue swelling is the only finding. We had 72% of cases without any X-ray changes as most of our patients had presented within 2 weeks of onset of symptoms. The remaining 28% of our patients had soft tissue swelling and periosteal reaction secondary to the elevation of periosteum.[22],[23] Bone scan using technetium-99 m is more sensitive than plain radiographs in detecting early osteomyelitis. Due to the disadvantages such as low specificity, difficulty in differentiating osteomyelitis from cellulitis or septic arthritis, radiation exposure, and expense it has been replaced by MRI. In about half of our patients (48%) MRI was done. MRI is the imaging study of choice for the evaluation of acute osteomyelitis as it has high sensitivity and specificity. In addition, it is useful in defining the soft tissue involvement, delineating bone and soft tissue abscesses, detection of effusion, and to plan surgical intervention.[24] MRI is safe as it carries no radiation risk; however, young children often require sedation or general anesthesia before the procedure can be carried out. Further, it also has additional drawbacks of being less useful in monitoring the course of the disease, higher costs, and prolonged imaging time.[13] HRUSG was carried out in 32% of our patients. Juxtacortical soft tissue swelling and periosteal thickening/collection are the earliest signs of acute osteomyelitis on USG. Fluid collection in direct contact with bone is highly suggestive of acute osteomyelitis. It is cheap, safe, noninvasive, and portable. USG can be utilized in cases where access to other modalities is not readily available or is contraindicated, such as a very sick child in intensive care where transfer to MRI scan is unsafe. However, the lack of specificity, dependence on operator skill, and inability to image marrow or show cortical detail of bone have limited the usefulness of USG compared with MR imaging.[25]

Immobilization of the affected limb helps in pain relief and prevention of pathological fracture. All children require analgesics and antipyretics along with care of nutrition and hydration.[26] Recent studies in the management of acute osteomyelitis emphasize a course of parenteral, followed by oral antibiotics. Previously, the duration of intravenous therapy ranged from 4 to 8 weeks. At present, intravenous antibiotics are used for 5–7 days followed by oral antibiotics. Generally, oral therapy is started with the settling of the temperature, improvement in the clinical signs, and normalizing of CRP. A minimum of 3 weeks oral antibiotics regimen has been accepted widely to reduce the rate of relapse. Prolonged antibiotic treatment beyond 3 weeks is often needed if there has been delay in presentation or an incomplete surgical evacuation of pus or if there are other foci of infection as in disseminated staphylococcal disease.[5],[27],[28]

If the clinical and radiological findings suggest the presence of pus in the soft tissues, subperiosteal space, or the metaphysis, surgical drainage is mandatory. The role of surgical management in acute osteomyelitis is to improve the local environment for antibiotic delivery by removing devitalized tissue and decompressing the subperiosteal abscess cavity thereby preventing the progression of infection to chronic osteomyelitis. As the infection is in the vicinity of the growth plate, care must be taken to avoid iatrogenic damage to the physics leading to limb length discrepancy or angular deformities.[8],[27],[29],[30] In our study, 21 patients (84%) were managed surgically, as they presented late, the average duration of symptoms was 10 days (SD 5.57). In a similar study done by Ogunlade et al. the average duration of symptoms prior to presentation was 8 days and all the patients were managed surgically.[15] Five among our 21 patients managed surgically, required emergency drainage of the abscess. One of them had involvement of distal radius extending into the whole of the forearm with impending compartment syndrome [Figure 2]. Another patient was a 3-year-old boy with humerus involvement with severe swelling causing compressive symptoms requiring emergency surgery. Other three patients were sick and had involvement of tibia with large abscess collection. Four patients (involving fibula, iliac crest, femur, and tibia) were managed without surgery as they had presented early and responded well to the intravenous antibiotics [Figure 3]. At 3 weeks follow-up, pain was reduced in 84% of patients, and swelling subsided in 92% of patients.
Figure 2: (a) X-ray of forearm showing no abnormality. (b) Magnetic resonance imaging showing involvement of distal radius with abscess extending up to mid forearm. (c) Intra operative picture of abscess drainage. (d) Immediate postoperative X-ray, drill holes in the distal radius can be seen. (e) X-ray at 1 year follow-up

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Figure 3: (a) X-ray pelvis with both hips at presentation shows no abnormality. (b) Magnetic resonance imaging showing features suggestive of right iliac bone osteomyelitis with mild collection. (c) Follow-up x-ray of the same patient following conservative management

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Three of our patients progressed to chronic osteomyelitis. A 5-year-old boy with fibula osteomyelitis, who was managed with antibiotics and immobilization came back to us with sinus and sequestrum. It was treated surgically by sequestrectomy [Figure 4]. Another patient with calcaneum osteomyelitis had chronic infection and deformity (decreased calcaneal height and heel varus) which were managed conservatively. Calcaneum being a cancellous bone, osteomyelitis has a high incidence of complications presenting difficulty in diagnosis and management [Figure 5].[31] A 1-year-old patient with acute femur osteomyelitis managed conservatively went on to develop a pathological fracture which was managed conservatively by a hip spica. At the age of 2.5 years, the child presented again with chronic osteomyelitis with sinus and sequestrum, which was managed with debridement and sequestrectomy [Figure 6]. A 3-year-old boy who underwent emergency surgery for humerus osteomyelitis developed pathological fracture which was managed conservatively with immobilization [Figure 7]. One patient with proximal tibia osteomyelitis had knee stiffness which was managed with physical therapy. The final outcome of this study was satisfactory, with infection resolving completely in 88% of patients.
Figure 4: (a) Chronic osteomyelitis of fibula with sequestrum. (b) Postsequestrectomy X-ray

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Figure 5: (a) X-ray of left calcaneum. (b) Magnetic resonance imaging showing the abscess collection and bony changes in the calcaneum. (c) Follow-up X-rays at 2 months. (d) Follow-up at 7 months showing progression of the infection leading to deformity

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Figure 6: (a) X-ray of pelvis with both femur of a one-year-old child showing no abnormality. (b) X-ray at 3 weeks after patient was managed conservatively. (c) Patient developed pathological fracture at 3 months. (d) X-ray of the child at 2.5 years showing features of chronic osteomyelitis (sequestrum). (d) Postsequestrectomy x rays

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Figure 7: (a) X-ray of left upper limb shows no abnormality. (b) Postoperatively at 3 months follow up patient developed pathological fracture of the humerus shaft (c) Follow-up X-ray at 2 years showing shortening and deformity of the humerus

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Our study was not without limitations. The number of cases in our study was 25. A study with a higher number of cases would yield better findings regarding the efficacy of surgical management in acute osteomyelitis. Our average follow-up period of 4.2 months is less in terms of identifying delayed complications such as angular deformities and limb length discrepancies. There is a recent trend towards monitoring the efficacy of antibiotics by measuring the antibiotic concentration in blood. We do not have such a facility in our setup.


  Conclusion Top


Surgical treatment is of at most importance in patients with acute osteomyelitis with subperiosteal, soft tissue, or bone abscess who present late after the onset of symptoms. Prompt surgical decompression with sequential intravenous-oral antibiotics gives an excellent outcome in the management of acute osteomyelitis in children. It calls for awareness in the community on the importance of bringing children with bone pain, fever, and a recent history of fall to the hospital for early diagnosis and treatment.

Acknowledgments

The authors would like to acknowledge Dr. Deepti Shettar from the Department of Community Medicine, SDM Medical College and Hospital, Dharwad, for her assistance with the statistical analysis of the data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
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