Ankylosis of the knee after septic arthritis following anterior cruciate ligament reconstruction in a 13-year-old male.

We present the case of an adolescent male developing an ankylosis of the knee after septic arthritis following anterior cruciate ligament reconstruction (ACLR). The patient was shifted to our institution with postoperative septic arthritis associated with a systemic septic condition. Before, repeated arthroscopic surgery had been conducted without any improvement. MRI showed a concomitant osteomyelitis. The infection (Gächter IV, Staphylococcus aureus) was controlled by an open surgical approach and graft removal. An increasing joint stiffness was documented. X-rays showed an ankylosis at 30° of flexion and early closure of growth plates. Functional knee scores showed significantly worse results. Early diagnosis and a stage-adapted treatment in septic arthritis following ACLR are mandatory. In advanced stages or concomitant osteomyelitis an open approach and graft removal may be appropriate. The antibiotic treatment should be adapted consistently.

[Validation of the Osteomyelitis Diagnosis Score on the Basis of a Retrospective Analysis of 100 Patients with Non-Union of the Tibia]. / Validierung des Osteomyelitis-Diagnose-Scores anhand einer retrospektiven Analyse von 100 Patienten mit Tibiapseudarthrose.

Background: The accurate diagnosis of "osteomyelitis" is difficult and is often delayed. However, early and radical therapy of osteomyelitis is essential. The osteomyelitis diagnosis score (ODS) was developed to predict the probability of osteomyelitis. The aim of our study was to validate the ODS and to investigate its practicability in daily routine. Material and Methods: The ODS is based on five diagnostic procedures: 1. clinical history/risk factors, 2. clinical examination/laboratory results, 3. diagnostic imaging, 4. microbiology and 5. histopathology. Each diagnostic procedure includes numerous individual findings, which are rated with 1-6 points, depending on their relevance. If the sum of the five diagnostic criteria is ≥ 17 points, the diagnosis "osteomyelitis" can be viewed as safe, between 8-17 points as probable and between 2-7 points as possible. This retrospective study included 100 patients with non-union of the tibia (2002-2010). The patients were classified into two groups: septic non-union of the tibia (experimental intervention; gold standard: positive detection of bacteria and/or positive histology) and aseptic non-union of the tibia (control intervention; no detection of bacteria and/or histology). Epidemiological data, the score's total number of points and the number of points of the score's five diagnostic procedures were analysed. Results: 71 patients exhibited aseptic non-union of the tibia, 29 patients septic non-union. Patients with septic non-union obtained a mean of 20.8 points, and 24 at least 18 points; the diagnosis "osteomyelitis" is then presumed to be certain. Patients with aseptic non-union obtained a mean of 11.3 points, and only 3/71 patients received > 17 points. Both groups obtained the majority of points in the diagnostic procedure "clinical history". The difference between the two groups is highly significant (p < 0.001). The score's sensitivity is 82.8 %, with a specificity of 95.8 %. Conclusion: The ODS was proved to be a valid score. Patients with septic non-union were identified, even if bacteria were not detected. However, the use of the ODS is demanding, as there are 104 individual findings. Many of these individual findings were negative in all patients. It would be desirable to optimise ODS, by reducing the number of queried parameters, without reduction sensitivity.

[Transosseous Muscle Transfer of the Medial Head of the Gastrocnemius Muscle for Successful Therapy of Refractory Tibial Head Osteomyelitis: a Case Report]. / Der transossäre Transfer des medialen M. gastrocnemius von dorsal nach ventral zur Behandlung einer nicht beruhigbaren Tibiakopfosteitis--ein Case Report.

The primary objective of osteomyelitis treatment is disinfection. Therapies can be protracted and expensive. The basic approach is to use radical debridement with antibiotics. However, radical debridement often results in major osseous defects, so it may be necessary to restore bone structures. Several different therapies have been described. Disinfection may be influenced by tissue perfusion. A muscle flap may effectively make good the loss of osseous tissue. In any case, autologous material is limited and the procedure must be adapted to the individual patient. We now report the successful therapy of refractory tibial head osteomyelitis with large osseous defects with a transosseous muscle flap. The caput mediale of the gastrocnemius muscle was used for dorsal to ventral muscle transfer through the proximal tibia.

[Non-unions. From diagnosis to healing]. / Pseudarthrosen. Von der Diagnose bis zur Ausheilung.

Non-unions are a relevant medical and socio-economic problem. Hyper-, oligo- and atrophic non-unions as well as septic and aseptic non-unions are differentiated. Correct classification is essential for the selected therapy. The "diamond concept" describes five pillars, on which bone healing is based and that have to be considered in the treatment of non-unions: osteogenic cells (mesenchymal stem cells), osteoinduction (growth factors), osteoconduction (scaffolds), mechanical stability, and vascularization. Factors that predispose to non-union also influence fracture healing. The gold standard of therapy are still resection of the non-union, decortication and autologous bone grafting. No advantage could be proven for any of the numerous procedures in monotherapy. But the combination of various procedures - polytherapy - seems to be promising. The aim is to optimize these concepts.

[Definition of the Diagnosis Osteomyelitis-Osteomyelitis Diagnosis Score (ODS)]. / Zur Definition der Diagnose Osteomyelitis - Osteomyelitis-Diagnose-Score (ODS).

AIM: The disease "osteomyelitis" is characterised by different symptoms and parameters. Decisive roles in the development of the disease are played by the causative bacteria, the route of infection and the individual defense mechanisms of the host. The diagnosis is based on different symptoms and findings from the clinical history, clinical symptoms, laboratory results, diagnostic imaging, microbiological and histopathological analyses. While different osteomyelitis classifications have been published, there is to the best of our knowledge no score that gives information how sure the diagnosis "osteomyelitis" is in general. METHOD: For any scientific study of a disease a valid definition is essential. We have developed a special osteomyelitis diagnosis score for the reliable classification of clinical, laboratory and technical findings. The score is based on five diagnostic procedures: 1) clinical history and risk factors, 2) clinical examination and laboratory results, 3) diagnostic imaging (ultrasound, radiology, CT, MRI, nuclear medicine and hybrid methods), 4) microbiology, and 5) histopathology. RESULTS: Each diagnostic procedure is related to many individual findings, which are weighted by a score system, in order to achieve a relevant value for each assessment. If the sum of the five diagnostic criteria is 18 or more points, the diagnosis of osteomyelitis can be viewed as "safe" (diagnosis class A). Between 8-17 points the diagnosis is "probable" (diagnosis class B). Less than 8 points means that the diagnosis is "possible, but unlikely" (class C diagnosis). Since each parameter can score six points at a maximum, a reliable diagnosis can only be achieved if at least 3 parameters are scored with 6 points. CONCLUSION: The osteomyelitis diagnosis score should help to avoid the false description of a clinical presentation as "osteomyelitis". A safe diagnosis is essential for the aetiology, treatment and outcome studies of osteomyelitis.