KAUNAS UNIVERSITY OF MEDICINE
DALIUS MALCIUS
EPIDEMIOLOGICAL AND CLINICAL
STUDIES OF ACUTE HEMATOGENOUS
OSTEOMYELITIS IN CHILDREN
Summary of Doctoral Dissertation Biomedical Sciences, Medicine (07 B)
Dissertation has been prepared at Kaunas University of Medicine during the period of 2004–2008.
Scientific Supervisor
Prof. Dr. Vidmantas Barauskas (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B)
Scientific Advisor
Assoc. Prof. Dr. Almantas Maleckas (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B)
The Dissertation will be defended at the Medical Research Council of Kaunas University of Medicine:
Chairman
Assoc. Prof. Dr. Rytis Rimdeika, (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B.
Members:
Prof. Dr. Habil. Žilvinas Padaiga, (Kaunas University of Medicine, Biomedical Sciences, Public Health – 10 B.
Prof. Dr. Algidas Basevičius, (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B.
Prof. Dr. Habil. Vytautas Usonis, (Vilnius University, Biomedical Sciences, Medicine – 07 B.
Prof. Dr. Jūratė Šiugždaitė, (Lithuanian Veterinary Academy, Biomedical Sciences, Veterinary Medicine – 12 B)
Opponents:
Assoc. Prof. Dr. Alfredas Smailys, (Kaunas University of Medicine, Biomedical Sciences, Medicine – 07 B.
Prof. Dr. Habil. Saulius Petkevičius, (Lithuanian Veterinary Academy, Biomedical Sciences, Veterinary Medicine – 12 B)
The dissertation will be defended at the open session of the Medical Research Council on September 11, 2009, 12:00 AM, in the Symposium Hall of Scientific Laboratory Block of Kaunas University of Medicine.
Address: Eiveniu str. 4, LT-50009, Kaunas, Lithuania.
The summary of the doctoral dissertation was sent for review on August 11, 2009. The doctoral dissertation is available at the Library of Kaunas University of Medicine.
KAUNO MEDICINOS UNIVERSITETAS
DALIUS MALCIUS
VAIKŲ ŪMINIO HEMATOGENINIO
OSTEOMIELITO EPIDEMIOLOGINIAI IR
KLINIKINIAI TYRIMAI
Daktaro disertacijos santrauka Biomedicinos mokslai, medicina (07 B)
Disertacija rengta 2004–2008 metais Kauno medicinos universitete.
Mokslinis vadovas
prof. dr. Vidmantas Barauskas (Kauno medicinos universitetas, biomedicinos mokslai, medicina – 07 B)
Konsultantas
doc. dr. Almantas Maleckas (Kauno medicinos universitetas, biomedicinos moks-lai, medicina – 07 B)
Disertacija ginama Kauno medicinos universiteto Medicinos mokslo krypties taryboje.
Pirmininkas
doc. dr. Rytis Rimdeika, (Kauno medicinos universitetas, biomedicinos mokslai, medicina – 07B)
Nariai:
prof. habil. dr. Žilvinas Padaiga (Kauno medicinos universitetas, biomedicinos mokslai, visuomenės sveikata – 10 B)
prof. dr. Algidas Basevičius, (Kauno medicinos universitetas, biomedicinos moks-lai, medicina – 07 B)
prof. habil. dr. Vytautas Usonis (Vilniaus universitetas, biomedicinos mokslai, medicina – 07 B)
prof. dr. Jūratė Šiugždaitė (Lietuvos veterinarijos akademija, biomedicinos moks-lai, veterinarijos medicina – 12 B)
Oponentai:
doc. dr. Alfredas Smailys, (Kauno medicinos universitetas, biomedicinos mokslai, medicina 07 B)
prof. habil. dr. Saulius Petkevičius, (Lietuvos veterinarijos akademija, biomedici-nos mokslai, veterinarijos medicina – 12 B)
Disertacija bus ginama viešame Medicinos mokslo krypties tarybos posėdyje 2009 m. rugsėjo 11 d. 12 val. Kauno medicinos universiteto Mokomojo laboratorinio korpuso Simpoziumų salėje.
Adresas: Eivenių 4, LT-50009, Kaunas, Lietuva.
Disertacijos santrauka išsiuntinėta 2009 m. rugpjūčio mėn. 11 d.
Disertaciją ir santrauką galima peržiūrėti Kauno medicinos universiteto biblio-tekoje
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CONTENTS
Contents ... 5
Abbreviations ... 6
1 Introduction ... 7
2 Goal and Objectives ... 8
2.1 The Goal ... 8
2.2 The Objectives ... 8
3 Novelty and Originality of the Study ... 9
4 Patients and Methods ... 9
5 Results ... 12
6. Conclusions ... 29
Practical significance of the study ... 29
List of the Author‘s Publications ... 30
Santrauka ... 32
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ABBREVIATIONS
AHO – Acute Hematogenous Osteomyelitis MRI – Magnetic Resonance Imaging
CI – Confidence Interval SD – Standard Deviation CRP – C-reactive Protein
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1 INTRODUCTION
Children‘s Acute Hematogenous Osteomyelitis (AHO) is a serious pediatric age disease. Its diagnosis sometimes is difficult and the treatment is long. Because AHO in children may occur as a life threatening condition, it can present a challenge to pediatricians and pediatric surgeons. Acute Osteomyelitis treated in the correct manner may be just a short episode in a child’s life, but if badly managed it is life threatening at worst and, at best – a debilitating, crippling illness.
In recent years, various authors have observed a decline in the incidence of AHO, as well as a shift from severe forms to subacute or primary chronic forms. Furthermore, an improvement in treatment results has also occurred, and this phenomenon may be due to the disease’s becoming both less common and less severe. The decline in the incidence and severity of AHO over the last 30 years could be linked to improved standards of living and hygiene, as well as to the increasing effectiveness of community-administered antibiotics. Hematogenous pyogenic bone and joint infection is seldom seen in developed countries, but in developing countries it is still a common problem. Over the last decade, there have been fewer cases of AHO treated in our department, and the clinical course of the disease is becoming less severe. The incidence and the clinical course of AHO have not been studied in Kaunas and Lithuania before.
Medical progress and environmental changes had an impact on classical symptoms and course of pediatric osteomyelitis. Physicians see children with AHO earlier; the symptoms are not so obvious because of the initiated treatment with antibiotics, and more patients have subacute forms of AHO. The most important test confirming AHO diagnosis is finding the microbe of the disease. However, this test is of limited value in conservatively treated patients. That is why different noninvasive radiologic techniques are becoming more and more important in AHO diagnosis. Plain x-ray, bone scintigraphy with radionuclide agent, ultrasound, MRI and CT can complement each other in Osteomyelitis diagnosis. It is important to know advantages and disadvantages of each technique, their accuracy and diagnostic value in diagnosis of children‘s AHO.
AHO varies in severity – from a comparatively mild clinical form to an acute fulminating illness. According to many authors, surgery plays a decreasing role in the management of AHO, while conservative antibiotic
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management is a treatment of choice. There are three clinical stages of AHO: the first, when only edema of bone marrow is present; the second, when there is pus in the medulla; and the third, when pus is in the soft tissue of the bone. Open surgery is beneficial to AHO patients with metaphyseal abscesses, subperiosteal abscesses, or suppuration of the bone cavity; therefore, the pus in the soft tissue indicates an undeniable indication for surgery.
Before the year 2000, the diagnosis of AHO was an indication for operation, however, in recent years about a half of AHO patients are being treated conservatively, only with antibiotics. The conservative treatment of AHO is a new method used in our department and it has not been justified by any clinical study before.
It is very important to confirm or deny the subperiostal and soft tissue abscess. In result, some AHO patients can be treated conservatively and the surgery will be indicated only when AHO is complicated. The differences in symptoms and laboratory tests can help distinguish between the patients with complications – those with subperiostal and soft tissue abscess, and uncomplicated patients. The conservative treatment with antibiotics can be started in cases without complications.
Studies of AHO treatment are mostly empiric and based on retrospective data. Many questions on surgical treatment, duration of antibioticotherapy are controversial. Investigation of different surgical techniques can help finding the ways to treat the patients more effectively.
2 GOAL AND OBJECTIVES
2.1 The Goal
The goal is to evaluate incidence, clinical course and treatment of acute hematogenous osteomyelitis in children.
2.2 The Objectives
1. To investigate possible changes in AHO incidence and clinical course between 1982–2008.
2. To evaluate and to compare diagnostic accuracy of plain x-ray, ultrasonography, bone scintigraphy, CT and MRI in diagnosis of pediatric AHO.
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3. To compare the symptoms, laboratory tests, and clinical course of disease between patients with AHO that were treated conservatively and had a surgery.
4. To compare the symptoms, laboratory tests, and clinical course between patients with uncomplicated AHO and complicated AHO, with subperiostal and soft tissue abscess.
5. To compare the open (usual) and percutaneal (minimally invasive) surgery methods.
3 NOVELTY AND ORIGINALITY OF THE STUDY
The incidence and the clinical course of AHO have not been studied in Kaunas and Lithuania before. The conservative treatment of AHO is a new method in our department and there have not been done any studies to justify this method of treatment. The diagnosis of AHO is essential, but finding subperiostal and soft tissues abscess is also very important. This aspect of AHO has not been studied either. Analyzing the surgical treatment methods is a novelty in our department and Lithuania.
4 PATIENTS AND METHODS
The diagnostic criteria of AHO were local pain and fever plus one or more of the following: positive blood culture, positive culture from the bone or inflammatory signs in the smear from the bone, pus in the bone discovered during the operation, a lesion in the bone confirmed radiologically.
Newborns and infants younger than one year old were excluded from the study because of different features and manifestations of AHO in this age group.
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According to the objectives, the study consists of five parts. The scheme of the entire study is presented in the Fig. 4.1.
Fig. 4.1. The scheme of the whole study
We compared the following data in the different groups: demographic data (age, gender, city-country residency), anamnesis (duration of symptoms before hospitalization, use of antibiotics for the treatment before hospitalization, injury before the onset of the symptoms, presence of source of infection), clinical symptoms (inspection, palpation, laboratory blood tests), clinical course (time until operation, duration of pain, febrile fever, maximal pain score, maximal temperature, duration of antibioticotherapy, hospital stay, results of bone x-ray examination). Duration of pain was the number of days when maximal pain score according to VAS (visual analogue scale) was 2 or more. Duration of fever was the number of days when body temperature was 38ºC and more.
The incidence of AHO in Kaunas area between 1982 and 2008 was analyzed by obtaining the demographic data from the Lithuanian Statistics Department, considering that our unit is the only pediatric surgery center
Incidence study, Study of clinical changes Study of accuracy of imaging methods Study of treatment methods and diagnosis of complications Study of surgical methods Treated conservatively, n=47 Operated on, n=106 Complicated AHO, n=59 Uncomplicated AHO, n=47 Open surgery, n=44 Min. invasive surgery, n=12 Retrospective part, 1982‐2001, n=702 Prospective part 2002‐2008, n=183 Other, n=30 AHO, n=153
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in the area, where all patients with AHO are treated. The ratio of operated patients, frequency of sepsis, arthritis, time until operation, duration of antibiotic therapy and length of hospital stay – all criteria evaluated during the period of 1982–2008. Three patient groups were compared: patients treated between 1982 and 1983, patients treated between 2002 and 2003, and patients treated between 2007 and 2008. The number of patients, patient age, gender proportions, duration of symptoms until admission, stage of the process presenting with periosteal or soft tissue abscess, duration of antibiotic therapy, positive blood culture ratio, and length of hospital stay were compared.
One hundred eighty six patients with suspected AHO were prospectively included in the study of accuracy of imaging methods. The diagnosis of 156 patients was AHO. Plain x-ray, ultrasound examination, bone scintigraphy with Tc99, CT and MRI were performed according to the clinical indications to the patients with suspected AHO of this study. We performed plain x-rays two times – the early x-ray just after hospitalization and the late x-ray – not earlier than two weeks after the onset of the disease. According to the final diagnosis, the results were classified as true positive and negative, and false positive and negative. Sensitivity, specificity, overall accuracy, positive and negative predictive values, positive and negative likelihood ratio, and diagnostic odds ratio and its 95% confidence intervals were counted.
Both patients that had surgery and patients treated conservatively were compared after the matching of the groups. The pair matching method was used for the groups; the “unnecessary surgery” group was sampled. Patients with subperiosteal and soft tissue abscess and patients with redness and infiltration in the area of affected site were excluded.
Patients operated openly by usual method were compared with patients operated by minimally invasive method. None of these patients had subperiosteal and soft tissue abscesses. The treating doctor chased the surgery method. There were usual indications to do the surgery – unsuccessful conservative treatment (continuation of fever and pain) or suspicion of abscess. The control of groups matching was performed before comparison.
The Kolmogorov-Smirnov test was applied to distribution analysis. When the distribution of the samples was considered “normal”, the statistical analysis methods for parametric data had to be used. When the distribution of all the samples could not be considered “normal”, the analysis methods for non-parametric data had to be used. The Student’s
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test and ANOVA analysis were applied for parametric data. The Mann– Whitney U and Kruskal-Wallis tests were applied for comparison of non-parametric data. The proportional difference was evaluated by chi-square criterion. The incidence of AHO was calculated for 100,000 children of 16 years of age or younger per year. 95% confidence interval was calculated using the formula. Linear and logistic regression analysis o was carried out. Values of p<0.05 were considered as significant.
5 RESULTS
From 1982 to 2008, 848 patients with AHO were treated at the Department of Paediatric Surgery of Kaunas University of Medicine. Five of them (0.59%) died. The general characteristic and etiological agents of entire group are presented in Table 5.1 and Table 5.2.
Table 5.1. General characteristics AHO patients (1982–2008)
Total number of the patients 848
Male/female 2,6/1
Mean age 9.6 years (SD 4.0)
Median duration of symptoms before hospitalization (range)
4 days (0,5–30)
Frequency of sepsis 38.0%
Frequency of arthritis 31.8%
Operated patients 82.2%
Table 5.2. Etiological agents
n %
S.aureus 561 90.78
Streptococcus spp. 22 3.56
Coagulase negative Staphylococcus* 21 3.40
E.coli 5 0.81 Salmonella spp. 3 0.49 Haemophilus spp. 3 0.49 Enterobacter spp. 1 0.16 Proteus spp. 1 0.16 Pseudomona spp. 1 0.16 Total 618 100
* Coagulase negative Staphylococcus was not considered as etiological agent from
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The population of Kaunas area is 1,031,965 people; among them, 195,265 are children from 0 to 16 years of age (as of January, 2008). The incidence of AHO for 100,000 children varied from 22.6 in 2000 to 6.1 in 2008, per year (Table 5.3, Fig. 5.1).
Table 5.3. Number of children and incidence of AHO per year, 1982–2008
Year Number of AHO cases Number of children (0–16) in the beginning of the year Average number of children (0–16) Incidence for 100,000 children per year –95% CI +95% CI 1982 31 269751 270365 11,5 7,4 15,5 1983 18 270978 272071 6,6 3,6 9,7 1984 29 273163 273824 10,6 6,8 14,5 1985 29 274485 275222 10,5 6,7 14,4 1986 44 275959 276718 15,9 11,2 20,7 1987 24 277477 276366 8,7 5,2 12,1 1988 35 275255 275407 12,7 8,5 16,9 1989 36 275558 276144 13,0 8,8 17,3 1990 34 276729 277315 12,3 8,2 16,4 1991 23 277901 276934 8,3 4,9 11,7 1992 39 275967 274083 14,2 9,7 18,6 1993 31 272198 274804 11,3 7,4 15,4 1994 43 277409 271437 15,8 10,9 20,1 1995 39 265465 263468 14,8 10,1 19,3 1996 46 261470 258352 17,8 12,5 22,7 1997 45 255234 252923 17,8 12,5 22,8 1998 18 250611 247953 7,3 3,9 10,5 1999 37 245295 237349 15,6 10,2 19,9 2000 51 229402 225733 22,6 21,4 35,2 2001 36 222063 212506 16,9 10,9 21,5 2002 38 202949 206301 18,4 12,8 24,7 2003 30 209650 211318 14,2 9,2 19,4 2004 21 212986 217827 9,6 5,6 14,1 2005 25 222668 215791 11,6 6,8 15,6 2006 19 208913 205618 9,2 5,0 13,2 2007 15 202323 198794 7,5 3,7 11,2 2008 12 195265 195265 6,1 2,7 9,6
14 r = 0,061 r2=0,0037 p=0,76 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Year 4 6 8 10 12 14 16 18 20 22 24 In ci dence ( for 1 00000 chi ld ren per ye ar ) 95% CI
Fig. 5.1. AHO incidence and trend for 100,000 children (0–16 years)
per year in Kaunas area, 1982–2008
There was a positive, but not statistically significant trend of the incidence during the entire period of 1982–2008 (r=0.06; p=0.76). In the course of study the variation of the incidence, we found that during the last eight years the trend has been negative and it was statistically significant (r=–0.94, p=0.0001) (Fig. 5.2). r = -0,9437 r2=0,89 p=0,0001 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Y ear 4 6 8 10 12 14 16 18 20 22 24 In ci de n ce ( fo r 1 00 0 00 ch ild re n pe r ye ar ) 95% PI
Fig. 5.2. AHO incidence and trend for 100,000 children (0–16 years)
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The hospital stay statistically significantly decreased during entire period of 1982–2008 (Figure 5.3). r =-0,8682 r2=0,75 p=0,0000 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Year 20 25 30 35 40 45 50 55 60 65 H os pi tal s tay in day s 95% CI
Fig. 5.3. Hospital stay for AHO patients in 1982–2008
The duration of antibioticotherapy also statistically significantly decreased (Fig. 5.4). r = -0,7942 r2=0,63 p=0,000002 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Year 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 D ur at ion of an tib io tic ot he ra py 95% CI
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The ratio of operated patients during the period of 1982–2008 decreased statistically significantly (Fig. 5.5).
r = -0,7703 r2=0,61 p=0,000004 1980 19821984198619881990 199219941996199820002002 2004200620082010 Year 30 40 50 60 70 80 90 100 % of o per at ed pat ie nt s 95% CI
Fig. 5.5. The ratio of operated patients in 1982–2008
If we compare three periods – 1982–1983, 2002–2003 and 2007–2008,
we can see that the time until hospitalization did not differ statistically significantly in those periods (Fig. 5.6).
Kruskal-Wallis: H=5,721 p =0,057 Median 25%-75% Min-Max 4 3 3 4 3 3 1982-1983 2002-2003 2007-2008 Time period -5 0 5 10 15 20 25 30 35 D ur a tio n of t he di se as e (d a ys ) 4 3 3
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The frequency of subperiosteal or soft tissue abscess was statistically significantly different in years 1982–1983 and 2002–2003 (p=0.0146), but there was no difference in years 2002–2003 and 2007–2008 (p>0.05)
(Fig. 5.7). 0% 20% 40% 60% 80% 100% 1982‐1983 2002‐2003 2007‐2008 40.8% 19.3% 19.2% 59.2% 80.7% 80.8% Abscess + Abscess ‐
Fig. 5.7. The ratio of subperiosteal and soft tissue abscess in periods
1982–1983, 2002–2003 and 2007–2008
According those results, we can conclude that AHO is becoming both less common and less severe. In recent years, various authors have observed a decline in the incidence of AHO as well as a shift from severe forms to subacute or primary chronic forms. An improvement in treatment results has also occurred in the last years. Our results show the same tendencies only in the last decade.
All 183 prospectively studied patients were enrolled into the study of evaluation of imaging methods. There were 127 boys and 56 girls with mean age of 10.3 (SD 3.8). AHO was diagnosed in 156 (85.2%) cases, of which 19 (10.4%) had arthritis, other purulent diseases were present in five cases (2.7%), and three patients (1.6%) had other diseases. Most of the patients (68.3%) had 2 or 3 different radiologic investigations done. One radiologic examination was performed in 4.9% of patients and 5 or more investigations were done in 10.9% of cases.
There were performed 169 early x-rays (median test day – 1st day of hospital stay) and 142 late x-rays (median on 15th day of hospital stay). The frequency (prevalence) of AHO in those groups was 0.86 and 0.92. There were performed 82 ultrasonographies (median on 2nd day). The
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frequency of AHO to those patients was 0.79 and pathologic changes were in 66.1% of the patients. Of all the patients, 91.2% had pathologic changes in 76 bone scintigraphies with Tc99 (median on 3rd day, AHO frequency 0.76); 83.9% of the patients had pathologic changes in 38 MRI (median 7th day, frequency of AHO 0.83). There were performed 17 CT in median 10th day, with frequency of AHO 0.88. The pathologic changes were in 73.3% of the patients.
Sensitivity, specificity, overall accuracy, positive and negative predictive values, positive and negative likelihood ratio and diagnostic odds ratio and its 95% confidence intervals are in the Table 5.4.
Table 5.4. Diagnostic accuracy of radiologic imaging methods in AHO
US US for compli– cations
CT Early x-ray MRI x-ray Late graphy Scinti–
Sensitivity (95% CI) 0.55 (0.43– 0.67) 0.74 (0.51– 0.88) 0.67 (0.38– 0.88) 0.16 (0.1– 0.23) 0.81 (0.64– 0.93) 0.82 (0.75– 0.88) 0.81 (0.68– 0.90) Specificity (95% CI) 0.47 (0.24– 0.7) 0.95 (0.86– 0.98) 0.5 (0.01– 0.98) 0.96 (0.78– 1.0) 0.67 (0.22– 0.96) 0.92 (0.62– 1.0) 0.84 (0.60– 0.97) Overall accuracy (95% CI) 0.54 (0.43– 0.64) 0.9 (0.84– 0.97) 0.65 (0.42– 0.87) 0.27 (0.21– 0.34) 0.79 (0.66– 0.92) 0.83 (0.77– 0.89) 0.82 0.73– 0.9) PPV (95% CI) 0.82 (0.71– 0.93) 0.82 (0.64– 1.0) 0.91 (0.74– 1.0) 0.96 (0.88– 1.0) 0.93 (0.83– 1.0) 0.99 (0.97– 1.0) 0.94 (0.87– 1.0) NPV (95% CI) 0.19 (0.06– 0.32) 0.92 (0.86– 0.99) 0.17 (0–0.46) 0.16 (0.1– 0.22) 0.4 (0.1–0.7) 0.32 (0.17– 0.48) 0.59 (0.41– 0.78) Positive likelihood ratio (95% CI) 1.04 (0.62– 1.74) 15.23 (4.89– 47.43) 1.33 (0.32– 5.58) 3.81 (0.54– 26.9) 2.44 (0.78– 7.65) 9.88 (1.56– 20.1) 5.11 (1.79– 14.44) Negative likelihood ratio (95% CI) 0.96 (0.53– 1.75) 0.28 (0.13– 0.59) 0.67 (0.14– 3.17) 0.88 (0.79– 0.98) 0.28 (0.11– 0.7) 0.19 (0.13– 0.29) 0.23 (0.13– 0.4) Diagnostic odds ratio (95% CI) 1.08 (0.30– 3.84) 55.07 (11.74– 258.3) 2.0 (0.02– 172.4) 4.34 (0.63– 186.3) 8.67 (0.91– 108.5) 51.17 (6.61– 2222.0) 22.3 (4.90– 132.7)
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The sensitivity of early x-ray was statistically significantly lower (p<0.05) than sensitivity of all other radiologic tests. Sensitivity and specificity of MRI, CT and scintigraphy had no statistically significant difference. The sensitivity of ultrasonography was statistically significantly lower (p<0.05) than sensitivity of MRI and scintigraphy, but specificity was statistically significantly lower only from scintigraphy. Ultrasonography for AHO complications had high sensitivity and specificity.
The diagnostic odds ratio of all imaging methods with the time of its performing is presented in Fig. 5.8.
Fig. 5.8. Diagnostic odds ratio of imaging methods in AHO
A decade ago, AHO diagnosis was indication for operation. In recent years, only about a half of all AHO patients undergo the operation (Table 5.5).
Table 5.5. Treatment methods
Method N %
Conservative treatment 47 30.7
Surgery
Open surgery Percutaneal (miniinvasive) surgery
106 69.3 93 87.7 13 12.3 US (2nd day)
0,01 0,1 0,2 0,5 1 2 5 10 100 1000
Diagnostic odds ratio
Rö (15th day) 51,17 (CI 6,61-2221,97)
CT (10th day)
2,00 (CI 0,02-172,43)
MRI (7th day) 8,67 (CI 0,91-108,55)
Tc99 (3rd day) 22,30 (CI 4,90-132,66)
1,08 (CI 0,30-3,85)
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The surgery findings are presented in Table 5.6.
Table 5.6. Surgery findings
Findings N %
Pus just in the bone 19 17.9
Pus under the periosteum 19 17.9
Soft tissue abscess 28 26.4
No pus 37 34.9
Fluid in the joint 3 2.8
Total 106 100
The location of AHO and general characteristics of the conservatively treated patients are in Fig. 5.9 and Table 5.7.
1 0 1 0 1 0 0 3 0 1 1 1 3 1 9 7 18 0 1 1 2 1 2 3 1 5 5 6 8 9 15 14 17 16 Scapula Costae Radius Talium Patella Clavicula Ulna Vertebra Multifocalis Humerus Collum femoris Metatarsalis Calcaneus Fibula Femur Tibia Pelvis Surgery Antibiotics
Fig.5.9. Location of AHO of conservatively treated and surgery patients
In majority of patients, AHO was in pelvic location (pubic, iliac and ischial). There was statistically significant difference in frequency of surgery in different AHO locations.
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Table 5.7. General features of conservatively treated AHO
Number of patients 47
Male/female ratio 1.76/1
Mean age (SD) 10.6 years (3.3)
Median duration of symptoms until hospitalization (range) 4 days (0.5–14)
Mean duration of antibioticotherapy in days (SD) 21.9 (6.9)
Mean hospital stay in days (SD) 22.2 (6.9)
Median duration of pain (range) 3 days (1–10)
Median duration of fever (range) 3 days (1–14)
Median highest fever (range) 38.4ºC (37.3–41.0)
Median highest pain score (range) 5 (2–8)
No bone destruction in x-ray 32.4%
Minor bone destruction in x-ray 32.4%
Bone destruction in x-ray 35.4%
Major bone destruction in x-ray 0%
The clinical course of AHO is different. Because of that, we cannot compare all AHO patients that had surgery with patients treated conservatively. Pair matching method was used to form the groups. The patients with subperiosteal and soft tissue abscesses and with the redness and infiltration in the area of affected site were excluded and “unnecessary surgery” group was sampled.
The comparison of demographic and anamnestic data of matched groups is presented in Table 5.8; the comparison of clinical symptoms and course – in Table 5.9 and table 5.10, x-ray – in Table 5.11.
Table 5.8. Demographic and anamnestic data of conservatively treated
and operated patients
Data Treated conservatively (N=40) “Unnecessary surgery” (N=10) Statistical test p
Mean age (SD) 10.9 years 10.2 years t=0.55 0.59
Median duration of symptoms until hospitalization (range) 4 (1–14) days 3 (1–4) days z=1.26 0.2 Male/female ratio % 62.5/37.5 70/30 χ2=0.2 0.65 City/country % 67.5/32.5 60/40 χ2=0.2 0.65
22 Continuation of Table 5.8. Data Treated conservatively (N=40) “Unnecessary surgery” (N=10) Statistical test p Use of antibiotics % 15.0 20.0 χ2=0.15 0.7
Trauma in disease history % 30.0 14.3 χ2=1.7 0.43
Presence of infection source % 27.8 33.3 χ2=0.11 0.74
Table 5.9. Clinical symptoms of conservatively treated and operated
patients Symptom Treated conservatively (N=40) “Unnecessary surgery” (N=10) χ2 p Swelling % 42.5 50.0 0.18 0.67 Local warmness % 55.0 50.0 0.08 0.78 Position % 17.5 30.0 0.78 0.38 Painful movements % 50.0 50.0 3.5 1.0
There was no statistically significant difference comparing demographic, anamnesis data and clinical symptoms of conservatively treated and operated patients.
Table 5.10. Clinical course of conservatively treated and operated
patients Clinical course Treated conservatively (N=40) “Unnecessary surgery” (N=10) z (t) p
Median highest fever
(range) 38.4 (1.9) 38.5 (0.56) 0.12 0.9
Median duration of fever
(range) 3 (1–14) 6.5 (4–13) 3.0 0.003
Median duration of pain 3 (1–10) 5.5 (3–9) 1.5 0.14
Mean highest pain score
(SD) 4.6 (1.8) 6.5 (2.4) 1.8 0.09
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Table 5.11. X-ray changes of conservatively treated and operated
patients X-ray Treated conservatively (N=40) “Unnecessary surgery” (N=10) χ2 p No bone destruction % 30.0 8.4 7.11 0.07
Minor bone destruction % 33.0 22.2
Bone destruction % 36.7 33.3
Major bone destruction % 0 0
Osteoperforations % 0 22.0
Median duration of fever was statistically significantly longer in operated patients. Those patients had higher pain score and longer duration of pain, but these differences were not statistically significant. There was higher frequency with no x-ray changes of patients treated conservatively.
When AHO is complicated with subperiostal and soft tissue abscess, the surgery is indicated. When AHO diagnosis is indication for surgery, the presence of subperiostal and soft tissue abscess before the surgery is not important. When part of AHO patients can be treated conservatively, diagnosis of those AHO complications is very important. To find differences in symptoms and laboratory tests, we compared the patients with complications, those with subperiostal and soft tissue abscess (47 pts), and patients with uncomplicated AHO (57 pts). All patients had surgery. The comparison of the groups is presented in Tables 5.12 and 5.13.
Table 5.12. Demografic and anamnestic data of uncomplicated and
complicated AHO patients
Data Uncomplicated AHO (N=59) Complicated AHO (N=47) Statistical test p value
Mean age. years. (SD) 10.2 (3.9) 10.7 (3.7) t=0.67 0.50
Male/female ratio % 72.9/27.1 78.7/2.3 χ2=0.48 0.49
City/country % 59.3/40.7 55.3/44.7 χ2=0.17 0.68
Use of antibiotics % 27.6 29.8 χ2=0.02 0.80
Injury in the anamnesis % 26.1 28.3 χ2=0.53 0.77
Source of infection % 37.5 45.2 χ2=0.55 0.46 Median duration of symptoms until hospitalisation in days. (range) 3 (0.5–9) 4 (0.5–12) z=2.5 0.01
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Table 5.13. Clinical symptoms of uncomplicated and complicated AHO
patients.
Symptom Uncomplicated AHO (N=59) AHO (N=47) Complicated χ2 p value
Swelling % 71.2 74.5 0.14 0.71 Redness % 45.8 58.6 2.0 0.16 Local warmness % 25.4 48.9 6.3 0.01 Local infiltration % 27.1 51.1 6.4 0.01 Compulsory position % 23.7 25.5 0.05 0.83 Painful movements % 61.1 66.7 1.2 0.53
Local warmness and infiltration in the projection of affected site was statistically significantly more frequent in complicated AHO patients. The duration of the disease was longer for complicated AHO patients.
Blood laboratory tests can also help to diagnose AHO complications. The accuracy and cut-off values of laboratory tests for diagnosis of AHO complications were compared by ROC curve analysis (Table 5.14.)
Table 5.14. The accuracy of blood laboratory tests in diagnosis of AHO
complications. Analysis of ROC curves
ROC curve Area under ROC curve 95 % CI p value Cut-off value
CRP 0.618 0.514–0.715 0.04 70.7 mg/l
Leucocytes 0.559 0.456–0.659 0.32 16.9x109 /l
Granulocytes 0.593 0.450–0.726 0.23 67.7
ESR 0.651 0.482–0.796 0.12 18 mm/h
Platelets count 0.722 0.603–0.822 0.0004 304x109 /l
The biggest area is for platelets count. CRP and platelets count area under ROC curve was statistically significantly different from area under referral line.
Using logistic regression method we have analyzed the relationship between all clinical symptoms and laboratory tests, and AHO compli-cations (Table 5.15). Laboratory test was considered as positive, when it was higher than cut-off value.
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Table 5.15. The relationship between clinical symptoms and blood
laboratory tests for AHO complications. Logistic regression analysis
Test and symptom Regression coefficient Standart error p value Odds ratio 95% CI CRP 0.43 0.87 0.62 1.54 0.28–8.39 Leucocytes 0.34 1.10 0.76 1.40 0.16–12.10 Granulocytes 1.47 1.34 0.27 4.37 0.31–60.92 Platelets count 2.56 0.98 0.009 12.93 1.88–88.45 Local infiltration 0.29 1.07 0.78 1.34 0.17–10.88 Local warmness 0.42 1.09 0.70 1.53 0.18–12.97 Redness 0.36 0.85 0.67 1.43 0.27–7.53
Only plateles count was considerred statistically signifficant factor for AHO complications.
There were performed 19 ultrasonographies for 59 uncomplicated AHO, 16 times of which the test was true negative, and only three times the test was false positive. There were performed 18 ultrasonographies for 47 complicated AHO patients, 12 of which were true positive tests, and five were false negative. The accuracy of ultrasonography in AHO complications diagnosis is high: the sensitivity was 0.74, the specificity – 0.95 and diagnostic odds ratio – 55.1.
There is statistically significant difference in x-ray – for complicated AHO cases severe changes were more frequent (Table 5.16).
Table 5.16. X-ray results of uncomplicated and complicated AHO
X-ray Uncomplicated AHO (N=59) AHO (N=47) Complicated χ2 p
No bone destruction % 13.5 2.3
15.2 0.01
Minor bone destruction % 30.8 23.3
Bone destruction % 46.2 55.8
Major bone destruction % 0 11.6
Linear periostitis % 1.9 7.0
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The goal of the surgery is to open, decompress and drain the bone marrow. Usually we perform this operation doing skin incision, layer by layer through subskin fat, fascias, muscles, periosteum reaching the bone and performing drilling of the bone. The damage of the tissues is significant just reaching the bone. It is possible to use miniinvasive or close or percutaneal technique for drilling. The procedure consists of puncturing of soft tissues in the area of focus until the bone is reached. The procedure is performed using 4 mm trocar. Then, inner part, stylet is removed and drilling of the bone through the trocar is performed; after, it is possible to make the aspiration and irrigation of bone marrow. Then, it is possible to leave the drain in the bone hole through the same trocar. The scheme of this type of operation – in the Fig. 5.10.
Fig. 5.10. The scheme of percutaneal osteoperforation
We compared two methods of surgery: usual – open surgery method and percutaneal osteoperforations method. None of the patients without subperiostal and soft tissue abscess had complications. There were twelve patients operated percutanealy. This group was compared with the group that had open surgery. There were 44 patients in this group.
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The demographics, anamnestic and clinical data of for both open surgery and percutaneal osteoperforations groups is in Table 5.17.
Table 5.17. Demographic, anamnestic and clinical data of the open and
percutaneal groups Data Open osteoperforations (N=44) Percutaneal osteoperforations (N=12) Statistical test p value
Mean age 10.2 years 10.4 years t=0.1 0.9
Duration of symptoms before hospitalisation (range)
3 days (0.5–9) 3 days (1–6) z=0.02 0.98
Male/female ratio % 78.3/21.7 66.8/33.3 χ2=0.7 0.40
Use of antibiotics before
hospitalisation % 31.1 16.8 χ2=1.0 0.32 Local swelling % 71.1 75.0 χ2=0.05 0.82 Local redness % 43.5 66.7 χ2=2.1 0.15 Local warmness % 19.6 50.0 χ2=4.6 0.03 Local infiltration % 26.1 41.7 χ2=1.1 0.29 Compulsory position % 21.7 41.7 χ2=1.9 0.16 Painful movements % 73.0 45.6 χ2=7.9 0.02 Leucocytes count (×109 /l) 11.8 11.4 t=0.3 0.76 CRP (mg/l) 103.5 78.8 t=0.9 0.38 ENG (mm/h) 55.5 35.7 t=1.6 0.13 Granulocytes count % 71.8 71.0 t=0.1 0.91 Plateletes count (×109 /l) 232.2 259.0 t=0.9 0.34
Time until operation h 34.7 40.3 t=0.7 0.46
Artritis % 47.8 25.0 χ2=2.0 0.15
Sepsis % 76.1 54.6 χ2=2.0 0.15
There was no statistically significant difference in any of demographic, anamnestic and clinical data in both groups.
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We expect that the duration of the operation, pain, fever and hospital stay can differ in groups (Table 5.18).
Table 5.18. Comparison of open and percutaneal osteoperforations
Open osteoperforations (N=44) Percutaneal osteoperforations (N=12) t (z) p Mean duration of
operation (SD) 65.4 (23.4) min. 35.8 (15.8) min. 4.1 0.0001
Median duration of
pain (range) 5 (3–15) days 4 (2–5) days 2.8 0.007
Median duration of
febrile fever 6 (3–30) days 4 (3–7) days 2.4 0.02
Mean hospital stay
(SD) 27.2 (7.4) days 24.8 (5.2) days 1.1 0.30
Duration of the operation, duration of pain and fever was statistically significantly shorter for patients, who were operated percutanealy.
If we compare x-ray of both groups, there is no statistically significant difference in frequency of changes (Table 5.19).
Table 5.19. Late x-ray of open and percutaneal osteoperforations
groups Open osteoperforations (N=44) Percutaneal osteoperforations (N=12) χ 2 p No bone destruction % 15.0 11.1 4.6 0.33
Minor bone destruction % 35.0 11.1
Bone destruction % 40.0 77.8
Major bone destruction % – –
Linear periostitis % 2.5 –
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6. CONCLUSIONS
1. The AHO incidence did not change during the 27-year period studied, but the incidence decreased statistically significantly during period of 2000–2008. Nowadays, the clinical course is less complicated and is marked by less frequent occurrence of periosteal abscess, shorter hospital stays, and shorter duration of antibiotic therapy.
2. The late x-ray is the most accurate radiologic imaging method of AHO diagnosis. Bone scintigraphy and MRI are the most accurate diagnostic methods in the beginning of the disease. Ultrasonography is accurate method for AHO complications diagnosis.
3. The treatment results of operated uncomplicated patients and treated conservatively patients are the same. The hospital stay for treated conservatively patients is shorter. Conservative treatment of AHO is possible.
4. There are differences in clinical symptoms and laboratory tests in uncomplicated and complicated with subperiostal and soft tissue abscess patients. Local tissue infiltration and platelets count higher than 304×109 /l are the main symptoms of complicated AHO.
5. The duration of surgery, the duration of pain and fever is shorter for patients operated using minimally invasive operation method with the same treatment results.
PRACTICAL SIGNIFICANCE OF THE STUDY
According to the results of this study, the new AHO management principals are justified. The presence of those complications is an indication for surgery. If there are no complications, conservative treatment can be initiated. Mini-invasive surgery method can be applied for uncomplicated AHO patients with some advantages against usual open surgery.
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LIST OF THE AUTHOR‘S PUBLICATIONS
Articles
1. Two decades of acute hematogenous osteomyelitis in children: are there any changes? Malcius D., Trumpulyte G., Barauskas V., Kilda A. Pediatr Surg Int. 2005 May;21(5):356-9.
2. Vaikų ūminio hematogeninio osteomielito ir sepsinio artrito diag-nostikos ypatumai. Trumpulytė G., Eiva E., Kilda A., Malcius D., Palep-šaitis A., Rinkevičius S., Žeromskienė D. Pediatrija 2005, Nr. 3(16), p. 77-80.
3. Kai kurie ūminio hematogeninio osteomielito vėlyvųjų gydymo rezul-tatų aspektai. Malcius D., Barauskas V., Užkuraitė R. Medicina (Kaunas), 2007, 43(6), 472 - 477.
Articles in press
1. The accuracy of different imaging techniques in diagnosis of acute hematogenous osteomyelitis. Malcius D., Jonkus M., Kuprionis G., Malec-kas A., Monastyreckienė E., Uktveris R., Rinkevičius S., Barauskas V. Medicina (Kaunas).
Theses and presentations
1. Vaikų ūminio hematogeninio osteomielito du dešimtmečiai: ar kas nors pasikeitė? Malcius D., Trumpulytė G., Barauskas V., Kilda A. Lietuvos vaikų chirurgų draugijos konferencija, 2005. Pranešimas
2. Vaikų ūminio hematogeninio osteomielito ir sepsinio artrito diagnos-tikos ypatumai. Trumpulytė G., Eiva E., Kilda A., Malcius D., Palepšai-tis A., Rinkevičius S., Žeromskienė D. Lietuvos pediatrų draugijos konfe-rencija, 2004. Pranešimas.
3. Klubinės venos trombozė ir plaučių arterijos mikroembolizacija – reta ūminio hematogeninio osteomielito komplikacija. Trumpulytė G., Mal-cius D. Pranešimas. Lietuvos vaikų chirurgų draugijos konferencija, 2006. Pranešimas.
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4. Long term results of the treatment of acute hematogenous osteomyelitis. Malcius D., Barauskas V., Užkuraitė R. 7th European Congress of Paediatric Surgery, Maastricht, The Netherlands, 2006. Pranešimas, tezės.
5. Iliac vein thrombosis and pulmonary microembolism as the complication of acute osteomyelitis of femur. Case report. Trumpulytė G., Malcius D. 9th Conference of the Baltic Association of Paediatric Surgeons, Riga, Latvia, 2006. Pranešimas, tezės.
6. Long term results of the treatment of acute haematogenous osteomyelitis. Malcius D., Barauskas V., Užkuraitė R. 9th Conference of the Baltic Association of Paediatric Surgeons, Riga, Latvia, 2006. Pranešimas, tezės.
7. Radiologinių tyrimų palyginimas ūminio hematogeninio osteomielito diagnostikoje. Malcius D., Monastyreckienė E., Kuprionis G., Uktveris R., Barauskas V. Lietuvos vaikų chirurgų draugijos suvažiavimo „Lietuvos vaikų chirurgija 2008“. Pranešimas, tezės.
8. The value of radiological imaging in diagnosis of acute hematogenic osteomyelitis. Malcius D., Monastyreckienė E., Kuprionis G., Uktveris R., Barauskas V. 10th Conference of the Baltic Association of Paediatric Surgeons, Kaunas, Lithuania, 2008. Pranešimas, tezės.
9. Vaikų ūminis hematogeninis osteomielitas. Malcius D. Lietuvos pediatrų draugijos metinė konferencija “Lietuvos vaikų sveikata 2009”. Pranešimas.
10. The accuracy of different imaging techniques in diagnosis of acute hematogenous osteomyelitis. Malcius D., Maleckas A., Monastyreckienė E., Kuprionis G., Uktveris R., Rinkevičius S., Barauskas V. 10th Congress of European Paediatric Surgeons’ Association /56th Congress of British Association of Paediatric Surgeons. Graz, Austria, 2009. Pranešimas, tezės.
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SANTRAUKA
Sergamumas, klinikinė eiga ir kitos ūminio hematogeninio osteomielito (ŪHO) ypatybės gali skirtis priklausomai nuo šalies geografinės, ekonominės ir socialinės padėties. Išsivysčiusiose šalyse ŪHO užre-gistruojama vis rečiau. ŪHO sergamumo mažėjimas per pastaruosius 30 metų gali būti susijęs su pragyvenimo lygio augimu, geresniais higienos įpročiais, platesniu antibiotikų vartojimu. Medicinos pažanga ir kintančios aplinkos sąlygos keičia būdingus vaikų osteomielito simptomus ir ligos eigą. Vis dažniau ūminis hematogeninis osteomielitas sėkmingai išgydo-mas konservatyviai, antibiotikais. Lietuvoje sergamuišgydo-mas ūminiu hemato-geniniu osteomielitu ir osteomielito klinikinės eigos pokyčiai nebuvo tyrinėti. Ligos sukėlėjo išskyrimas iš osteomielito židinio yra reikšmin-giausias tyrimas, patvirtinantis diagnozę. Konservatyviai gydomiems ligoniams to atlikti negalima, todėl šiuolaikiniai neinvaziniai radiologiniai tyrimai tampa vis svarbesni ŪHO diagnostikai. Svarbu žinoti kiekvieno radiologinio tyrimo privalumus, jų diagnostinę vertę. Žinios apie osteomielito gydymą daugeliu atvejų empirinės ir dažniausiai pagrįstos retrospektyviaisiais tyrimais, todėl nėra aišku, koks gydymo būdas yra veiksmingiausias. Mokslinėje literatūroje tebediskutuojama, ar būtina operacija, kokie laboratoriniai ir radiologiniai tyrimai nulemia diagnozę ir antibakterinio gydymo trukmę, kokiu būdu skirti antibiotikus, ar būtina operacija, kokios indikacijos chirurginiam gydymui, koks chirurginis metodas geresnis. Prieš 10 metų mūsų klinikoje visi ūminiu osteomielitu sergantys vaikai buvo operuojami. Šiuo metu osteomielito klinikinė eiga lengvėja, didelė dalis pacientų išgydomi be operacijos. Operuoti būtina tais atvejais, kai pūlinis procesas išplitęs – yra poantkaulinis ir minkštųjų audinių pūlinys. Todėl svarbu ne tik diagnozuoti osteomielitą, bet ir komplikacijas. Operacijos tikslas – osteoperforacijos. Įprastiniu būdu jos atliekamos per audinius pasluoksniui pasiekiant kaulą. Tačiau galima operuoti ir uždaru, minimaliai invaziniu būdu, tausojant audinius.
Šio darbo tikslas – įvertinti vaikų ūminio hematogeninio osteomielito sergamumo, klinikinės eigos ir gydymo ypatybes. Darbo uždaviniai: 1) nustatyti vaikų ŪHO sergamumą, klinikinę eigą ir gydymą ir jo pokyčius Kauno krašte 1982–2008 m.; 2) įvertinti radiologinių tyrimų tikslumą, diagnozuojant ŪHO; 3) palyginti konservatyviai ir chirurginiu būdu gydyto ŪHO simptomus, tyrimus, klinikinę eigą; 4) palyginti nekomplikuoto ir komplikuoto poantkauline ar minkštųjų audinių
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flegmona ŪHO simptomus, tyrimus, klinikinę eigą; 5) palyginti įprastą ir minimaliai invazinį chirurginį vaikų ŪHO gydymą.
Retrospektyviai analizuoti 1982–2001 metais dėl ŪHO gydytų pacientų medicininių dokumentų duomenys. Atlikta perspektyvioji 2002–2008 metais Kauno medicinos universiteto vaikų chirurgijos klinikoje dėl įtariamo ūminio hematogeninio osteomielito gydytų vaikų ligos eigos duomenų analizė.
Tyrimas pagal uždavinius suskirstytas į dalis: 1) sergamumo tyrimas ir klinikinės eigos pokyčių tyrimas; 2) radiologinių tyrimų tikslumo ŪHO diagnostikai tyrimas; 3) gydymo metodų tyrimas; 4) ŪHO pūlinio proceso išplitimo tyrimas; 5) operacijų būdų tyrimas.
Visu analizuojamuoju 1982–2008 m. laikotarpiu sergamumas ūminiu hematogeniniu osteomielitu nepasikeitė, tačiau iki 2000 m. sergamumas didėjo, o 2000–2008 m. – mažėjo. Ūminio osteomielito klinikinė eiga lengvėjo, pastaraisiais metais buvo mažiau išplitusio osteomielito atvejų – minkštųjų audinių ir poantkaulinių pūlinių, trumpėjo priešbakterinio gydymo ir gydymo stacionare trukmė. Laikas nuo ligos pradžios iki patekimo į ligoninę nepasikeitė. Operuotų ligonių dalis (chirurginis aktyvumas) sumažėjo.
Radiologinių tyrimų diagnostinė vertė pateikiama 1 lentelėje.
1 lentelė. Radiologinių tyrimų diagnostinė vertė
Rodiklis Echo– skopija KT Ankstyvoji rentgeno– grafija MRT Vėlyvoji rentgeno– grafija Scinti– grafija Jautrumas 0,55 0,67 0,16 0,81 0,82 0,81 Specifiškumas 0,47 0,5 0,96 0,67 0,92 0,84 Diagnostinis šansų santykis 1,08 2,0 4,34 8,67 51,17 22,3
Dalis pacientų sirgo lengvesne ŪHO forma. Jie išgydyti konservatyviai. Norint pagrįsti konservatyvaus ŪHO gydymo galimybę, buvo palyginti konservatyvaus ir chirurginio gydymo rezultatai. Po duomenų suvieno-dinimo porinimo metodu, analizuota neoperuotųjų ligonių grupė – 40 pacientų ir „be reikalo“ operuotų ligonių grupė – 10 pacientų. Statistiškai reikšmingai ilgiau karščiavo operuotieji ligoniai. Jiems 12–ąją gydymo parą buvo didesnis leukocitų skaičius. Neoperuotiesiems ligoniams buvo mažesnis skausmas ir skausmo trukmė, nors šie skirtumai ir nebuvo
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statistiškai reikšmingi. Reikšmingo skirtumo operuotųjų ir neoperuotųjų pacientų rentgenogramose nebuvo.
Dalis pacientų, sergančių ūminiu osteomielitu gydomi konservatyviai, todėl poantkaulinio ir minkštųjų audinių pūlinio diagnostika tapo svarbi. Atlikto tyrimo duomenimis, komplikuoto ir nekomplikuoto ŪHO grupėse skyrėsi įvairių klinikinių simptomų dažnis. Židinio srities infiltracija, vietinis paraudimas ir aukštesnė temperatūra yra svarbiausi išplitusio proceso simptomai. Pacientai, kuriems ŪHO buvo išplitęs, sirgo viena diena ilgiau. CRB ir trombocitų kiekis yra vertingiausi laboratorinių kraujo tyrimų rodikliai, diagnozuojant poantkaulinį ar minkštųjų audinių pūlinį. Echoskopija – tikslus būdas surasti ŪHO išplitimą, Echoskopijos jautru-mas, diagnozuojant ŪHO išplitimą – 0,74, specifiškumas – 0,95, diagnos-tinis šansų santykis – 55,1.
Pacientams, kuriems pūlinis procesas neišplitęs po antkauliu ar į minkštuosius audinius, reikalinga tik osteoperforacija. Odos, poodžio, fascijų, raumenų perpjovimas tik sužaloja sveikus audinius. Didelio audinių sužalojimo padeda išvengti minimaliai invazinis būdas – perkuta-ninė osteoperforacija. Gydymo metodų palyginimas pateikiamas 2 lente-lėje.
2 lentelė. Gydymo metodų palyginimas
Lyginami rodikliai Atviros osteoperforacijos, n=44 Perkutaninės osteoperforacijos, n=12 t (z) p Operacijos trukmė minutėmis vidurkis (SN) 65,4 (23,4) 35,8 (15,8) 4,1 0,0001 Skausmo trukmė dienomis mediana (nuo, iki) 5 (3–15) 4 (2–5) 2,8 0,007 Karščiavimo trukmė dienomis mediana (nuo, iki) 6 (3–30) 4 (3–7) 2,4 0,02 Stacionarinio gydymo trukmė dienomis vidurkis (SN) 27,2 (7,4) 24,8 (5,2) 1,1 0,30
Statistiškai reikšmingai minimaliai invazinė operacija (perkutaninės osteoperforacijos) užtruko trumpiau, pacientų pooperacinio skausmo ir karščiavimo trukmė buvo mažesnė.
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Remiantis atlikto tyrimo duomenimis, pateikiamos šios išvados:
1. Sergamumas ŪHO per 27 metus nekito, bet per pastaruosius aštuo-nerius metus žymiai sumažėjo. ŪHO eiga tapo lengvesnė: mažiau poant-kaulinių ir minkštųjų audinių pūlinių, trumpesnis gydymas antibiotikais ir trumpesnis gydymas ligoninėje, nekintant ligos trukmei iki gydymo pra-džios.
2. Diagnozuojant ŪHO, diagnostikoje tiksliausias yra vėlyvasis rent-genologinis tyrimas, o ligos pradžioje – kaulų scintigrafija ir MRT. Echo-skopija – tikslus tyrimas diagnozuojant ŪHO komplikacijas.
3. Operuotų nekomplikuotų ir gydytų konservatyviai pacientų grupėse gydymo rezultatai vienodi, neoperuoti ŪHO pacientai gydomi stacionare trumpiau. Galimas sėkmingas konservatyvus ŪHO gydymas.
4. Komplikuoto ir nekomplikuoto ŪHO grupėse yra klinikinių simpto-mų ir laboratorinių tyrisimpto-mų rodmenų skirtusimpto-mų. Apčiuopiant jaučiama infiltracija ir didesnis nei 304×109 litre trombocitų skaičius yra svarbiausi komplikuoto ŪHO požymiai.
5. Minimaliai invazinė operacija trumpesnė, mažesnė pacientų poope-racinio skausmo ir karščiavimo trukmė, vienodi gydymo rezultatai.
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CURRICULUM VITAE
Name and surname Dalius Malcius
Date and place of birth 18 01 1967, Kaunas, Lithuania E-mail dalius.malcius@gmail.com
Education 1973–1984 Secondary school in Kaunas 1984–1990 Kaunas Medical University
Postgradute education 1990–1993 residency of surgery
Postgraduate training 1996 – Department of Paediatric Surgery,
Ependorf University Hospital, Hamburg, Germany
1998 – Department of Paediatric Surgery, Astrid Lindgren Children‘s Hospital, Karolinska
Universitety, Stokholm, Sweden
Work experience since 1993– Department of Paediatric Surgery, Kaunas University of Medicine Hospital
Membership in societies Lithuanian Society of Paediatric Surgeons
Baltic Assotiation of Pediatric Surgeons European Paediatric Surgeons‘ Association
