Background: Diabetic foot osteomyelitis (DFO) is a major complication and can lead to significant morbidity and mortality. Systemic antibiotic therapy is often initiated first line to achieve quiescence of infection. To perform a multi-centre case review of systemic antibiotic intervention to treat adults with DFO in England and Wales and compare with national guidelines \'Diabetic foot problems: prevention and management\'. Methods: Eight centres from England and Wales retrospectively collated data from a minimum of five adults (aged ≥ 18 years) from electronic case records. All patients were treated with systemic antibiotics following a new diagnosis of DFO (1 June 2021-31 December 2021). Results: 40 patients (35 males and 5 females) were included; the mean age was 62.3 years (standard deviation (SD) 13.0). Patients commenced systemic oral 14 (35%) or intravenous 26 (65%) antibiotic therapy following a new diagnosis of DFO. Twenty-seven (67.5%) patients were medically or surgically managed in the 12-week period with clinical quiescence of infection. Twenty-one patients (52.5%) had no recurrence of DFO infection within 12 weeks; seventeen (42.5%) of these patients had clinical quiescence of infection with systemic antibiotics alone without surgical intervention and nine (22.5%) of these cases had no recurrence of DFO. There were no cases of major amputation or death. All centres showed significant in-centre variability in systemic antibiotic management; variability was reported in the clinical and quantity indicators specifically to antibiotic selection, single versus dual therapy, mode of delivery and duration of treatment. Conclusions: This case review identifies there is existing variation when treating adults with systemic antibiotics for DFO. Further national guidance is required to standardise service delivery and care to improve patient outcomes.

BACKGROUND: Chronic osteomyelitis is a debilitating bone infection, characterized by a persistent infection over months to years, poses diagnostic and therapeutic challenges due to its insidious nature and potential for severe bone and soft tissue destruction. This systematic review and meta-analysis aims to review the literature on the treatment of chronic osteomyelitis in long bones and assess cure rates in single versus two-stage surgery.
METHODS: Following the PRISMA guidelines and registered with PROSPERO (ID: CRD42021231237), this review included studies that reported on the management of chronic osteomyelitis in long bones using either a planned one-stage or two-stage surgical approach in adult patients. Databases searched included Medline, Embase, Web of Science, CINAHL, HMIC, and AMED, using keywords related to osteomyelitis, long bones, and surgical management. Eligibility criteria focused on adults with chronic osteomyelitis in long bones, with outcomes reported after a minimum follow-up of 12 months. The meta-analysis utilized the random-effects model to pool cure rates.
RESULTS: The analysis included 42 studies with a total of 1605 patients. The overall pooled cure rate was 91% (CI 95%) with no significant difference observed between single-stage and two-stage surgeries (X2 = 0.76, P > 0.05). Complications were reported in 26.6% of cases in single-stage procedures and 27.6% in two-stage procedures, with prolonged wound drainage noted as a common issue. Dead space management techniques varied across studies, with antibiotic-loaded calcium sulphate beads used in 30.4% of cases.
CONCLUSIONS: This meta-analysis reveals no significant difference in cure rates between single and two-stage surgical treatments for chronic osteomyelitis in long bones, supporting the efficacy of both approaches. The current treatment strategy should include a combination of debridement, dead space management using local and systematic antibiotics and soft tissue reconstruction if necessary.

BACKGROUND: Heel puncture (HP) in neonates can result in osteomyelitis if done non-aseptically or with incorrect technique. This study summarizes clinical experience with heel puncture-related osteomyelitis of the calcaneus (HP-CO) in newborns.
METHODS: We systematically reviewed studies that examined HP-CO in newborn patients using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search included the PubMed, Embase, and Cochrane Library databases until December 31, 2023. We used the National Institutes of Health (NIH) assessment scale to evaluate the quality of our analyzed studies.
RESULTS: This study analyzed 15 neonatal calcaneal osteomyelitis (CO) cases due to HP conducted in six countries from 1976 to 2016. The average age of the cases was 8.87 ± 6.13 days, with an average birth weight of 2367.27 ± 947.59 g. The infants had undergone an average of 9.00 ± 8.90 HP, with 93.33% exhibiting swelling. Staphylococcus aureus was present in 80% of cases. Beta-lactam antibiotics were used, with satisfactory outcomes in 53.33% of cases. However, in seven cases, three patients had flatfoot due to calcaneal deformity, and other complications were observed in some patients after 7-8 years.
CONCLUSIONS: This study offers valuable insights into a rare condition, including its epidemiology, clinical and laboratory characteristics, and treatment options for infants with HP-CO. To prevent the risk of osteomyelitis in this vulnerable group of patients, increasing awareness and maintaining strict aseptic techniques is necessary. We recommend that infants presenting with tenderness, redness, purulent discharge, erythema, or fever and with a history of repeated HP and swollen ankles should be evaluated for suspicion of osteomyelitis. A graphical abstract is avilable for this article.

UNASSIGNED: Reliable animal models are critical for preclinical research and should closely mimic the disease. With respect to route of infection, pathogenic agent, disease progression, clinical signs, and histopathological changes. Sheep have similar bone micro- and macrostructure as well as comparable biomechanical characteristics to humans. Their use in bone research is established, however their use in bone infection research is limited. This systematic review will summarise the key features of the available bone infection models using sheep, providing a reference for further development, validation, and application.
UNASSIGNED: This systematic review was designed according to the PRISMA guidelines and registered with PROSPERO. Quality was assessed using SYRICLE\'s risk of bias tool adapted for animal studies. PubMed, MEDLINE, Web of Science and EMBASE were searched until March 2022.1921 articles were screened by two independent reviewers, and 25 were included for analysis.
UNASSIGNED: Models have been developed in nine different breeds. Staphylococcus aureus was used in the majority of models, typically inoculating 108 colony forming units in tibial or femoral cortical defects. Infection was established with either planktonic or biofilm adherent bacteria, with or without foreign material implanted. Most studies used both radiological and microbiological analyses to confirm osteomyelitis.
UNASSIGNED: There is convincing evidence supporting the use of sheep in bone infection models of clinical disease. The majority of sheep studied demonstrated convincing osteomyelitis and tolerated the infection with minimal complications. Furthermore, the advantages of comparable biology and biomechanics may increase the success for translating in vivo results to successful therapies.
UNASSIGNED: In the realm of preclinical research, the translation to viable clinical therapies is often perilous, and the quest for reliable and representative animal models remains paramount. This systematic review accentuates the largely untapped potential of sheep as large animal models, especially in bone infection research. The anatomical and biomechanical parallels between sheep and human bone structures position sheep as an invaluable asset for studying osteomyelitis and periprosthetic joint infection. This comprehensive exploration of the literature demonstrates the robustness and translational promise of these models. Furthermore, this article underscores the potential applicability for sheep in developing effective therapeutic strategies for human bone infections.

Chronic osteomyelitis in adults is managed with prolonged courses of intravenous antibiotics in conjunction with surgical debridement of necrotic bone. Over the past 40 years, there has been no paradigm shift in this approach, as randomized controlled trials of this standard of care compared to alternatives such as prolonged oral antibiotics are scarce. However, there have been many small trials, case reports, and review papers evaluating the effectiveness of oral treatment for chronic osteomyelitis. The oral route for infections requiring prolonged treatment is intuitively and practically more favorable due to several advantages, the most important of which is the avoidance of long-term IV antimicrobial therapy with its complications, inconvenience, and cost. In this paper, we review the literature evaluating oral antibiotic therapy in the management of chronic bone infections since 1975. The majority of osteomyelitis infections are caused by Staphylococcus aureus, hence we focus on its treatment using oral antibiotics; however, we also emphasize subpopulations of patients with diabetes, implanted hardware, and with less common bacterial organisms. The primary objective of this review is to promulgate clinical recommendations on the use of oral antibiotics in bone infections in the context of initial therapy, transition from intravenous therapy, and the role of chronic suppression. The secondary objective is to summarize current knowledge of the specific oral antimicrobial agents that are commonly utilized, together with a synopsis of the available literature pertaining to their pharmacokinetic/pharmacodynamic properties and duration of therapy in bone infection.

UNASSIGNED: It is important to consider foot and ankle tuberculosis (TB) as a potential cause of cystic lesion around the ankle, especially in patients with a history of TB. Early diagnosis and treatment with a rifampin-based regimen for a duration of 12 months can lead to good functional and clinical outcomes.
UNASSIGNED: Skeletal TB is an uncommon accounting for 10% of extra-pulmonary TB may present slowly over an extended period of time, making a diagnosis difficult and time-consuming (Microbiology Spectr. 2017;5:5). For the best possible outcome and to reduce the risk of deformity diagnosis must be early (Foot (Edinb). 2018;37:105). For the treatment of drug-susceptible musculoskeletal illness, a rifampin-based regimen lasting 12 months is advised (Clin Infect Dis. 2016;63:e147; J Bone Joint Surg Br. 1993;75:240; Tubercle. 1986;67:243). A 33-year-old female who are working as nurse with diffuse, persistent and low in intensity ankle pain not aggravated relieved by analgesia and swelling over a period of 2 months, static not related to activity. With past medical history of partially treated pulmonary TB 1 year ago. She reported night sweats and low-grade fever during this period, and she denied any history of trauma. The right ankle was globally swollen and tender anteriorly and on the lateral malleolus. The skin over the ankle showed dark discoloration with cautery marks with no discharging sinuses. The range of motion of the right ankle was decreased. The plain x-ray of the right ankle showed three cystic lesion at the distal tibia, one cyst at the lateral malleolus and another one at the calcaneum. Surgical biopsy and expert gene test confirmed the diagnosis of tuberculous osteomyelitis. The patient was planned for surgical curettage of the lesion. After the confirmation of the diagnosis of TB with the biopsy and gene expert test, with consultation of senior chest physician the patient fitted to anti-tuberculous regimen. The patient had good functional and clinical outcome. This case report highlights the importance of considering skeletal TB as a potential cause of musculoskeletal symptoms, especially in patients with a history of TB. Early diagnosis and treatment with a rifampin-based regimen for a duration of 12 months can lead to good functional and clinical outcomes. Further research on the management and prevention of musculoskeletal TB is warranted to improve patient outcomes. The lesson behind this case is that the diagnosis TB osteomyelitis should be on the top of differential diagnosis of multiple cystic lesions around the foot and ankle especially in area where TB is endemic. Early diagnosis and early start of anti-tuberculous therapy can lead to full cure of the patient and in bad situation can minimize the complications.

OBJECTIVE: the focus of this study is to evaluate if the combination of an antibiotic with a ceramic biomaterial is effective in treating osteomyelitis in an infected animal model and to define which model and protocol are best suited for in vivo experiments of local bone infection treatment.
METHODS: a systematic review was carried out based on PRISMA statement guidelines. A PubMed search was conducted to find original papers on animal models of bone infections using local antibiotic delivery systems with the characteristics of bone substitutes. Articles without a control group, differing from the experimental group only by the addition of antibiotics to the bone substitute, were excluded.
RESULTS: a total of 1185 records were retrieved, and after a three-step selection, 34 papers were included. Six manuscripts studied the effect of antibiotic-loaded biomaterials on bone infection prevention. Five articles studied infection in the presence of foreign bodies. In all but one, the combination of an antibiotic with bioceramic bone substitutes tended to prevent or cure bone infection while promoting biomaterial osteointegration.
CONCLUSIONS: this systematic review shows that the combination of antibiotics with bioceramic bone substitutes may be appropriate to treat bone infection when applied locally. The variability of the animal models, time to develop an infection, antibiotic used, way of carrying and releasing antibiotics, type of ceramic material, and endpoints limits the conclusions on the ideal therapy, enhancing the need for consistent models and guidelines to develop an adequate combination of material and antimicrobial agent leading to an effective human application.

Emphysematous Osteomyelitis (EO) is an extremely rare bone infection caused by gas-forming bacteria with few documented cases in the literature. Our study aims to highlight characteristic imaging features, including the novel use of positron emission tomographymagnetic resonance imaging (PET-MRI) in diagnosing this potentially fatal entity.
Radiography and computed tomography (CT) of the pelvis were performed due to complaints of persistent back pain in a 36-year-old male with a history of recent abdominal aorta surgery. Sacroiliac joint aspiration was performed, and a follow-up PET-MRI was subsequently performed.
Radiography and CT demonstrated bilateral sacroiliitis, osteonecrosis and EO in the bony pelvis. Left sacroiliac joint aspiration identified Staphylococcus aureus as the causative organism. PET-MRI revealed EO with left iliopsoas abscess and abdominal aortic graft infection. The patient\'s symptoms resolved following antibiotic therapy and image-guided abscess drainage.
EO is a lethal variant of osteomyelitis with a dearth of published cases. Pertinent imaging characteristics of EO on radiography, CT and PET-MRI are discussed here, along with a review of the literature surrounding this rare condition.

BACKGROUND: Chronic osteomyelitis in children is a rare condition. Debridement surgery, along with appropriate antibiotic therapy, is widely agreed to represent the best procedure in the treatment of chronic osteomyelitis but can result in an extensive dead space formation. In this study, we evaluated the use of bioactive glass to address dead space management.
METHODS: Four consecutive cases of chronic osteomyelitis treated with antibiotic therapy, one stage- surgical debridement and bioglass implantation between September 2016 and February 2017 were prospectively followed for a minimum of three years. Two cases followed acute hematogenous osteomyelitis, two cases followed fracture fixation. Clinical, histology, laboratory and radiographic findings were recorded. Primary endpoint was eradication of infection. Possible complication related to bioglass application were investigated.
RESULTS: All patients achieved healing at the latest follow-up of minimum three years. No successive surgical treatments were required at any time. No complications related to the bioglass were detected. Radiographic reconstruction of normal anatomy progressed through the years.
CONCLUSIONS: Bioglass for the treatment of dead space after surgical debridement appears a viable option in the treatment of chronic osteomyelitis in children.

UNASSIGNED: Calcium sulphate is a recent alternative for delayed antibiotic elution in infected bones and joints. The purpose of this study is to evaluate the use of antibiotic impregnated calcium sulphate (AICS) beads in the management of infected tibia and femur, with regards to patient outcomes and complication rates (including reinfection rate, remission rate and union rate).
UNASSIGNED: Searches of AMED, CINAHL, EMBASE, EMCARE, Medline, PubMed and Google Scholar were conducted in June 2020, with the mesh terms: \"Calcium sulphate beads\" or \"Calcium sulfate beads\" or \"antibiotic beads\" or \"Stimulan\" AND \"Bone infection\" or \"Osteomyelitis\" or \"Debridement\" AND \"Tibia\" or \"Femur\". Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of interventions (ROBINS-i) tool, and quality assessed via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria.
UNASSIGNED: Out of 104 relevant papers, 10 met the inclusion criteria for data extraction. Total infection remission was 6.8%, which was greater than that of polymethylmethacrylate (PMMA, 21.2%). Complication rates varied. The main issue regarding AICS use was wound drainage, which was considerably higher in studies involving treatment of tibia alone. Studies using PMMA did not experience this issue, but there were a few incidences of superficial pin tract infection following surgery.
UNASSIGNED: Where AICS was used, it was consistently effective at infection eradication, despite variation in causative organism and location of bead placement. Wound drainage varied and was higher in papers regarding tibial cases alone.