Recomendaciones de práctica clínica: diagnóstico de osteomielitis en pie diabético / Clinical practice recommendations for the diagnosis of osteomyelitis in the diabetic foot

La osteomielitis (OM) es una complicación de las úlceras en pie diabético que habitualmente es subdiagnosticada y tratada en forma tardía e inadecuada. La demora en el tratamiento de estos pacientes aumenta el riesgo de amputación. En esta revisión, se analiza la bibliografía actual acerca del diagnóstico de OM y se realizan recomendaciones en base a la misma, y a las características de los pacientes, los insumos y las posibilidades en nuestro medio.

Diabetic foot osteomyelitis (OM) is a diabetic foot ulcer complication. Usually, it is misdiagnosed and the treatment is delayed and inadequate. Delaying the treatment of these patients rises the risk of amputation. In this revision, current bibliography about this topic is updated and clinical practice recommendations are done, based on the publications and adapted to the characteristics of our country

Recomendaciones de práctica clínica: diagnóstico de osteomielitis en pie diabético / Clinical practice recommendations for the diagnosis of osteomyelitis in the diabetic foot

Resumen La osteomielitis (OM) es una complicación de las úlceras en pie diabético que habitualmente es subdiagnosticada y tratada en forma tardía e inadecuada. La demora en el tratamiento de estos pacientes aumenta el riesgo de amputación. En esta revisión, se analiza la bibliografía actual acerca del diagnóstico de OM y se realizan recomendaciones en base a la misma, y a las características de los pacientes, los insumos y las posibilidades en nuestro medio.

Abstract Diabetic foot osteomyelitis (OM) is a diabetic foot ulcer complication. Usually, it is misdiagnosed and the treatment is delayed and inadequate. Delaying the treatment of these patients rises the risk of amputation. In this revision, current bibliography about this topic is updated and clinical practice recommendations are done, based on the publications and adapted to the characteristics of our country.

Distribution characteristics of pathogen and antibiotic susceptibility in diabetic foot osteomyelitis / 中华内分泌代谢杂志

Objective@#To retrospectively analyze distribution characteristics of pathogenic bacteria and their antimicrobial susceptibility in patients with diabetic foot osteomyelitis(DFO).@*Methods@#Sixty cases of suspected DFO were collected from the Endocrinology Department of Henan Provincial People′s Hospital. After admission, bone biopsy was carried out to confirm the pathological diagnosis, and the pathogenic bacteria and drug sensitivity were determined by bone culture. In addition, bacterial culture was carried out in the basal tissue of the wound, and the results of bacterial culture were compared with those of bone culture.@*Results@#Sixty patients were diagnosed as DFO after bone biopsy. Among the 60 patients, 45 patients underwent bone culture and basal tissue culture. There are 24 patients of whom the results were consistent, accounting for 53.3%. The positive rate of bone culture was 55.0%, there were 16 strains of gram-positive bacteria and 22 strains of gram-negative bacteria. Staphylococcus aureus(9 strains) occurrence was the most, common finding, followed by Escherichia coli(6 strains). The course of diabetic foot, albumin(ALB), and antibiotic usage rate before admission were lower in bone culture positive group than those in bone culture negative group, while white blood cell(WBC) and C-reactive protein(CRP) were higher in bone culture negative group(P<0.05). There was no significant difference in gender, age, course of diabetes, HbA1C, and creatinine(CREA) levels between the two groups(P>0.05). The results of bone culture showed that Staphylococcus aureus was the main Gram-positive bacteria, which was more sensitive to vancomycin, tigecyclin, linezolid, etc. Escherichia coli was the main Gram-negative bacteria, which was more sensitive to tigecyclin, carbapenems, amikacin, etc.@*Conclusion@#Bone biopsy and bone culture should be carried out in cases for suspected DFO patients to identify the pathogenic bacteria, and the bone tissue should be preserved and obtained according to the operation specification before the application of antibiotics, and the appropriate antibiotics should be selected according to the drug sensitivity results.

Age-related changes in bone architecture / Alterações na estrutura óssea relacionadas à idade

ABSTRACT Objective : to evaluate the histologic and morphometric characteristics of bone biopsies of the anterior iliac crest of patients of different age groups. Methods : we studied 30 bone samples from the iliac crest, using brightfield optical microscopy. We divided the samples by donors' age groups in three groups: Group 1 (n = 10), subjects aged between 25 and 39 years; Group 2 (n = 10), subjects aged between 40 and 64 years; Group 3 (n = 10), individuals aged 65 years and over. We randomly divided the samples into two sets with 15 specimens. In the first study segment (n = 15), we used histological to assess the osteogenic property of the graft, through the analysis of cell reserve in the periosteum, the number of osteocytes in the lacunae and the number of Haversian and Volkmann's canals. In the second study segment (n = 15), we investigated the morphology of osteoconductive property of the graft, through quantification of the trabecular meshwork (Vv) and trabecular area (Sv). Results : histologically, we observed degeneration of bone occurring with age, characterized by thinning of the periosteum, with gradual replacement of the steogenic layer by fibrous tissue, small amount of Haversian and Volkmann's canals, osteocyte lacunae voids and fine spongy bone trabeculae, allowing ample medullary space, usually occupied by fat cells and adipocytes. Morphologically, with respect to the quantification of the trabecular meshwork (Vv), we found statistically significant differences between Groups 1 and 3 and between Groups 2 and 3, with reduction of the trabecular meshwork of about 45% in the elderly over 65 years old ; there was no statistically significant difference between Groups 1 and 2. There was also no statistical difference between the Groups regarding Sv. Conclusion : the results of this experiment suggest that, in the elderly (over 65 years old), the osteogenic property of autologous bone graft decreases and the osteoconductive property is compromised.

RESUMO Objetivo: avaliar as características histológicas e morfométricas de biópsias ósseas da região anterior da crista ilíaca de pacientes de diferentes faixas etárias. Métodos: foram estudadas 30 amostras de osso da crista ilíaca, utilizando-se microscopia óptica de campo claro. As amostras foram divididas pela faixa etária dos doadores em três grupos: Grupo 1 (n = 10), indivíduos com idade entre 25 e 39 anos; Grupo 2 (n = 10), indivíduos com idade entre 40 e 64 anos; Grupo 3 (n = 10), indivíduos com idade igual ou superior a 65 anos. As amostras foram separadas aleatoriamente em dois conjuntos com 15 peças. No primeiro segmento do estudo (n = 15), foi avaliada histologicamente a propriedade osteogênica do enxerto, através da análise da reserva celular no periósteo, do número de osteócitos nas lacunas e da quantidade de canais de Havers e de Volkmann. No segundo segmento do estudo (n = 15), investigou-se morfologicamente a propriedade osteocondutora do enxerto, através da quantificação da rede trabecular (Vv) e da área trabecular (Sv). Resultados: histologicamente, observou-se que ocorre degeneração do tecido ósseo com a idade, caracterizada pelo adelgaçamento do periósteo, com substituição gradual da camada osteogênica por tecido fibroso, pequena quantidade de canais de Havers e de Volkmann, osteoplastos vazios e trabéculas finas de osso esponjoso, permitindo amplo espaço medular, em geral ocupado por células lipídicas e adipócitos. Morfologicamente, com relação à quantificação da rede trabecular (Vv), foi observada diferença estatisticamente significante entre os Grupos 1 e 3 e entre os Grupos 2 e 3, com redução da rede trabecular de cerca de 45% no idoso acima de 65 anos de idade; não foi observada diferença estatisticamente significante entre os Grupos 1 e 2. Não foi observada diferença estatística entre os grupos quanto à Sv. Conclusão: os achados do presente experimento sugerem que nos indivíduos idosos (acima de 65 anos de idade), a propriedade osteogênica do enxerto ósseo autólogo diminui e a propriedade osteocondutora está comprometida.

Deposição óssea de cálcio e fósforo, densidade radiográfica e desenvolvimento corporal em potros alimentados com minerais orgânicos / Bone deposition of calcium and phosphorus, radiographic density and body development in foals fed with organic minerals

Foi avaliado o efeito da inclusão de minerais orgânicos na alimentação de potros sobre a concentração ossea de cálcio e fósforo, densitometria óssea e variáveis de desempenho de desenvolvimento e crescimento corporal. Foram utilizados dez potros com peso de 240,7 +- 30,2 kg e idade de 10 de 10 +- 0,15 meses, distribuidos em delineamento inteiramente casualizado, em dois tratamentos: dieta formulada com fonte de minerais na forma orgânica ou inorgânica. A dieta foi composta de 40% de volumoso e 60% de concentrado, à qual foi adicionada mistura mineral na forma orgânica ou inorgãnica na quantidade de 3% do concentrado.Não foi observado efeito das fontes minerais orgãnicas durante 90 dias, quando comparada aos potros alimentados com minerais em forma. Os animais alimentados com minerais organicos aprosentaram maior ganho de peso médio e diario em relação aos animais alimentados com com minerais inorgânicos. O uso de minerais em forma orgânico aumenta a densidade e o ganho de peso dos potrosem fase de crescimento.

This study examined the effect of organic minerals in foals diet evaluating the concentration of bone calcium and phosphorus, bone densitometry and growth and development performance variables. Ten horses weighing 240.7 ± 30.2 kg and 10 ± 0.15 months were used in the study, with two treatments: basal diet with minerals in organic or inorganic forms. The diet was composed of 40% forage and 60% concentrate, which was added as mineral mixture in organic or inorganic quantity of 3% of the concentrate. No effect of mineral sources was observed on bone deposition of calcium and phosphorus. At 90 days, the bone density of foals fed with minerals in organic form was higher than that observed in animals fed with minerals in the inorganic form. Animals fed with organic minerals showed greater weight increase compared to animals fed ino.

Bone histomorphometry: a concise review for endocrinologists and clinicians / Histomorfometria óssea: uma revisão concisa para endocrinologistas e clínicos

Bone histomorphometry is a quantitative histological examination of an undecalcified bone biopsy performed to obtain quantitative information on bone remodeling and structure. Labeling agents taken before the procedure deposit at sites of bone formation allowing a dynamic analysis. Biopsy is indicated to make the diagnosis of subclinical osteomalacia, to characterize the different forms of renal osteodystrophy and to elucidate cases of unexplained skeletal fragility. Bone histomorphometric parameters are divided into structural and remodeling subgroups, with the latter being subdivided into static and dynamic categories. Metabolic bone disorders such as osteomalacia, hyperparathyroidism, hypothyroidism, osteoporosis and renal osteodystrophy display different histomorphometric profiles. Antiresorptive and anabolic drugs used for the treatment of osteoporosis also induce characteristic changes in the bone biopsy. Bone histomorphometry is an important research tool in the field of bone metabolism and provides information that is not available by any other investigative approach.

Histomorfometria óssea é uma avaliação histológica quantitativa de uma biópsia óssea calcificada realizada para obter informação sobre a remodelação e a estrutura óssea. Uma análise dinâmica é possível quando substâncias que fazem a marcação do osso são tomadas antes do procedimento e se depositam no local de formação óssea. A biópsia é indicada para diagnóstico de osteomalácia, diferentes formas de osteodistrofia renal e nos casos não explicados de fragilidade esquelética. O preparo e a análise das amostras necessitam de um laboratório especializado. A histomorfometria avalia parâmetros estruturais e de remodelação óssea, sendo o último subdividido em estático e dinâmico. Doenças osteometabólicas como osteomalácia, hiperparatireoidismo, hipoparatireoidismo, osteoporose e osteodistrofia renal apresentam parâmetros histomorfométricos distintos. Medicações antirreabsortivas e anabólicas usadas no tratamento da osteoporose também induzem alterações características na biópsia óssea. A histomorfometria óssea é uma ferramenta importante no metabolismo ósseo e oferece informação que não é possível por nenhum outro método diagnóstico.

Bone damage induced by different cutting instruments: an in vitro study

The aim of this study was to compare the peripheral bone damage induced by different cutting systems. Four devices were tested: Er:YAG laser (2.94 mm), Piezosurgery, high-speed drill and low-speed drill. Forty-five bone sections, divided into 9 groups according to different parameters, were taken from pig mandibles within 1 h post mortem. Specimens were fixed in 10 percent buffered formalin, decalcified and cut in thin sections. Four different parameters were analyzed: cut precision, depth of incision, peripheral carbonization and presence of bone fragments. For statistical analysis, the Kruskal-Wallis test was applied to assess equality of sample medians among groups. All sections obtained with the Er:YAG laser showed poor peripheral carbonization. The edges of the incisions were always well-shaped and regular, no melting was observed. Piezosurgery specimens revealed superficial incisions without thermal damage but with irregular edges. The sections obtained by traditional drilling showed poor peripheral carbonization, especially if obtained at lower speed. There was statistically significant differences (p<0.01) among the cutting systems for all analyzed parameters. Er:YAG laser, gave poor peripheral carbonization, and may be considered an effective method in oral bone biopsies and permits to obtain clear and readable tissue specimens.

O objetivo deste estudo foi comparar o dano ósseo periférico produzido por diversos sistemas de corte. Foram avaliados 4 dispositivos: laser Er:YAG (2,94 mm), Piezo-cirurgia, broca em alta rotação e broca em baixa rotação. Para isto, foram utilizadas 45 seções ósseas retiradas de mandíbulas de suínos, até 1 h post-mortem, divididas em 9 grupos de acordo com diversos parâmetros. As amostras foram fixadas em formalina a 10 por cento tamponada, descalcificadas e cortadas em lâminas finas. Foram analisados 4 parâmetros diferentes: a precisão do corte, a profundidade da incisão, a carbonização periférica e presença de fragmentos ósseos. A análise estatística empregou o teste de Kruskal-Wallis para avaliar a similaridade das medianas entre os grupos. Todas as seções feitas com o laser Er:YAG exibiram pouca carbonização. As margens das incisões foram todas bem acabadas e regulares, sem apresentar pontos de fusão. As amostras obtidas por piezo-cirurgia apresentaram incisões superficiais sem danos térmicos, mas com margens irregulares. As seções obtidas pelas brocas convencionais apresentaram pouca carbonização marginal, particularmente as feitas em baixa rotação. Foram observadas diferenças estatisticamente significantes (p<0,01) entre todos os sistemas de corte para cada um dos parâmetros analisados. O laser Er:YAG apresentou pouca carbonização e pode ser considerado como um método eficaz para biópsias de ossos bucais, produzindo amostras de tecido limpas e fáceis de analisar.

The Effectiveness of Osteoplasty System (Vertebroplasty using Large Cannula-low Pressure Delivery System) in Compression Fracture and other Spinal Pathology

OBJECTIVE: The vertebroplasty is an excellent procedure in spine compression fracture, but there are some problems such as cement leakage and difficulties in bone biopsy. Recently, the osteoplasty system is developed to solve these problems, so we will report the usefulness of the osteoplasty system. METHODS: From January 2003 to November 2003, there are 9patients with simple osteoporotic spine compression fracture, 2 compression fracture patients combined with suspicious spinal metastasis, 1patient with suspicious primary bone tumor, and 2patient with infection on spine. All patients were treated using the osteoplasty system. RESULTS: All 11 compression fracture patients were relived the back pain after the osteoplasty and there is no complication. The bone biopsies in 3 suspicious cancer patients were also effectively performed using the osteoplasty system; negative result in 2patients and positive result in 1patient. The culture result of spontaneous discitis was no growth for 48hours. The spine tuberculosis was confirm using the osteoplasty system. CONCLUSION: The osteoplasty system has distinguished advantages in comparison with the vertebroplasty. That is, the risk of cement leakage is lower than vertebroplasty because of low pressure delivery system. And we can obtain the specimen effectively in bone biopsy because of large cannula. In conclusion, we emphasize that the osteoplasty system is a more useful procedure in spine compression fracture especially in the patient needed bone biopsy for diagnosis.

Correlations between Microcomputed Tomography and Bone Histomorphometry in Korean Young Females

The bone mass and microarchitecture are important determinants of bone strength, with microarchitectural deterioration being one of the specific changes associated with osteoporosis. The purpose of this study was to evaluate and compare the results of microcomputed tomography (micro-CT) and histomorphometry of biopsied specimens. A bone biopsy was performed on the iliac crest of 10 normal premenopausal Korean women. Measurements of the bone mineral density (BMD), micro-CT, and bone histomorphometry were performed. The bone volume, as determined by both micro-CT and histomorphometry, was significantly correlated (r=0.88, p < 0.01). The osteoid surface was correlated with both the bone volume (r=0.84, p < 0.01) and the structure model index (SMI) (r= -0.89, p < 0.01) measured by micro-CT. The SMI was correlated with both the bone volume (r=-0.85, p < 0.01) and the total hip BMD (r=-0.65, p < 0.05). In conclusion, some, but not all of the parameters of the micro-CT, were well correlated with the bone histomorphometric results. Micro-CT and histomorphometry appear to be complementary techniques in the study of bone microarchitecture.

A Case of Adult Fanconi Syndrome with Hypophosphatemic Osteomalacia / 대한내분비학회지

The Fanconi syndrome is characterized by generalized disturbance of tubular function. It leads to excessive losses of amino acids, glucose, phosphate, bicarbonate, and other organic and inorganic substrates handled by the proximal tubules. The metabolic consequences are acidosis, hypophosphatemia, hypocalemia, dehydration, rickets, osteomalacia, osteoporosis, and growth retardation. This syndrome may either be congenital or acquired, primary or secondary. Acquired Fanconi syndrome may result from multiple myeloma, Wilsons disease, primary amyloidosis, light chain nephropathy, and heavy metal poisoning such as lead, mercury, and cadmium. A 33-year-old female presented with multiple bone pain, and progressive proximal muscle weakness for 15 months. The blood urea nitrogen, creatinine, calcium, phosphate, and uric acid were 12.1 mg/dL, 1.5 mg/dL, 8.4 mg/dL, 1.8 mg/dL, and 1.7 mg/dL, respectively. The urine volume, protein, calcium, phosphate, and creatinine clearance were 2,330 ml, 343.7 mg, 146 mg, 424 mg, and 44.6 ml/min, respectively in 24 hour collection urine study. The tubular reabsorption rate of phosphate was decreased. In arterial blood gas analysis study, pH was 7.348, bicarbonate was 17.6 mmol/L, which means metabolic acidosis. In chest X-ray, fracture was seen in eighth and ninth left ribs. The whole body bone scan revealed hot uptake at both first and second ribs, right third rib, both eighth and ninth ribs, left sacroiliac joint and right hip joint. Bone densitometry showed moderate osteopenia in spine and femur neck. After NE4Cl loading, the urine pH was decreased below 5.0 at two and third hour, which means proximal renal tubular acidosis. Amino acid such as, hydroxyproline, threonine, serine, asparagine, glutamine excreted much more than normal in 24 hour urine. Bone biopsy showed the presence of increased osteoid volume and osteoid seam width and marked decreased mineral appositional rate as evidence for osteomalacia. The patients symptoms, including bone pain and proximal muscle weakness, were relieved after supplement of calcitonin, Vitamin D and calcium carbonate. We report a case of Fanconi syndrome with hypophosphatemic osteomalacia with brief review of literature.

Suspension Suture Materials and Suture Carrier in Modified Gittes Bladder Neck Suspension / 대한비뇨기과학회지

We reviewed 42 cases (mean age 48.3+/-7.6 years, range 30 to 63 years) who underwent the modified Gittes bladder neck suspension for female stress urinary incontinence between January 1990 and May 1995 to evaluate the efficacy of two different suspension suture materials and new suspension suture carrier. At first we used the No. 1-0 Prolene as suspension suture in 24 cases (group I) and secondly No. 1-0 Ethibond in 18 cases (group II) with Ostycut bone biopsy needle (Angiomed) as suture carrier Following results were obtained. 1. The patient's ages ranged from 30 to 63 years (mean age 48.3+/-7.6 years), and most patients were multiparous with an average of 3.3+/-1.2 deliveries and we classified the patients according to Blaivas classification and there was statistically no difference of variables in both groups except the parity. 2. The mean values of operative time, postoperative days on catheter, and postoperative hospitalization were 65.5+/-11.4 minutes, 6.9+/-1.6 days, 7.3+/-1.4 days respectively. 3. The postoperative complications were transient urinary retention 8 cases (21.1%), vaginitis or cystitis 5 cases (11.9%), wound bleeding 1 case (2.4%) and deviation of urinary steam 1 case (2.4%). 4. The success rate was 83.3% in the group I, 94.4% in group II with minimum followup of 12 months (mean 24.6+/-5.0 months) but the latter wasn't significantly higher than the former statistically. The overall success rate was 88.1%. 5. The Ostycut bone biopsy needle as suspension suture carrier was simple and safe in the bladder neck suspension treatment. With above results, we recommend the No. 1-0 Ethibond as suspension suture material rather than the Prolene in bladder neck suspension and Ostycut bone biopsy needle as suspension suture carrier.

Percutaneous Needle Bone biopsyscus Repair / 대한정형외과학회잡지

Since modern medical, surgical, and radiation therapy in bony lesions are both specific and complex, as well as having associated risks, tissue diagnosis has been become even more important. Because open surgical biopsy has greater morbidity, takes a longer time to perform, may delay institution of therapy, and is more expensive, closed biopsy techniques have become popular. Between July 1991 and April 1994, 91 percutaneous needle bone biopsies were performed at the Department of Orthopedic Surgery and the Department of Radiology of Seoul National University Hospital. Fluoroscopy guided needle bone biopsies were performed in 81 cases and computerized tomography guided needle bone biopsies in 10 cases. To assess the diagnostic yield, the accuracy of diagnoses, the adequacy of sampling, the incidence of complications associated with the biopsy procedure, we analyzed these 91 percutaneous bone biopsies retrospectively. Ninty-one cases composed of 25 primary malignant bone tumors, 28 metastatic bone tumors, 20 benign bone tumors, 12 infections and 6 miscellaneous bone disorders. The number of cases in which adequate samples for histologic diagnosis were acquired(the adequacy of sampling) was 80(88%) and the number of inadequate samples was 11(12%). The overall diagnostic yield and diagnostic accuracy were 80%, 91% respectively. There was no complication in all cases. In conclusion, percutaneous needle bone biopsy may be a yielding, useful and safe diagnostic tool in bony lesions.

Assessment of CT-Guided Bone Biopsy in Extremities(A Report of 50 Cases) / 实用放射学杂志

Objective In this article we report our methods and effects of CT-guided bone biopsy in extremities.Methods 50 patients with extremital bone lesion were candidates for CT-guided biopsy.Two or more procedures were routinely performed in each case.Ackmann drill was used for 13 patients with sclerotic lesions.Temno core needle was used for 42 cases.Fine needle aspiration was combined for 12 patients with cystic or obviously liquefied lesions.Results In the 50 cases,a diagnosis was possible in 88%(44/50).The six unsatisfactory results were from sclerotic lesions(n=3),liquefied lesions(n=2) and mixed lesion(n=1).50cases were divided into primary malignant tumors(n=23),primary benign tumors and tumor-like lesions(n=12),metastatic tumors(n=8),and bone inflammations (n=7).Their diagnostic accuracies of CT-guided biopsy were 91%,83%,100% and 71% separately.No severe complications were observed in our series.Conclusion CT-guided extremital bone biopsy is a safe,accurate and effective method.Bone drill,needle core and fine needle aspiration should be slected according to the type of bone lesions.In order to increasing its accuracy,the operator should avoid necrotic areas and select more then one point to get samples.One modality can be performed concomitantly with other one in the evaluation of bone lesions,since the three modalities are complementary.