Journal of Pediatric Orthopaedics Issue: Volume 16(2), M arch/April 1996, pp 220-223 Copyright: Lippincott-Raven Publishers.

. Publication Type: [Trauma] ISSN: 0271-6798 Accession: 01241398-199603000-00017 Keywords: Conservative and surgical treatment, Subacute osteomyelitis [Trauma]

Subacute Hematogenous Osteomyelitis: Are Biopsy and Surgery Always Indicated?

Hamdy, Reggie C. M .B., F.R.C.S.(C.); Lawton, Louis M .D., F.R.C.S.(C.); Carey, Timothy M .D., F.R.C.S.(C.); Wiley, James M .D., F.R.C.S.(C.); M arton, Dominique M .D., F.R.C.P. (C.)

Author Information
Department of Orthopaedics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada Address correspondence and reprint requests to Dr. R. Hamdy, Shriners Hospital for Crippled Children, 1529 Cedar Avenue, M ontreal, Quebec, Canada H3G 1A6.

Abstract
Summary: Forty-four consecutive cases of subacute osteomyelitis admitted at our institution over a 12-year period were retrospectively reviewed to assess the effectiveness of conservative versus surgical treatment of this condition and to determine the indications for open biopsy and surgical debridement. Twenty-four cases were treated with antibiotics only, and 20 had surgical debridement followed by antibiotics. Except for one case that received inadequate antibiotic therapy, all patients responded well to this treatment, whether conservative or surgical. At an average follow-up of 18 months, there were no recurrences. Our results also showed that with a careful radiologic assessment of these cases, most lesions showed characteristic benign radiologic features. We can therefore conclude that conservative management of cases of subacute osteomyelitis is as effective as surgical treatment. We believe that conservative treatment with antibiotics should be the first line of management in most of these cases and that open biopsy or surgical debridement or both should be reserved for cases that do not respond to antibiotics or show aggressive radiologic features.

Subacute hematogenous osteomyelitis is an infectious process in bone, characterized by mild localized bony pain and tenderness usually of >2 weeks' duration, mild or no systemic manifestations, noncontributory laboratory data, negative blood cultures, and positive radiologic findings (11-13,15,18,21,31,33,35).

The pathogenesis of this condition is believed to be the result of an altered host-pathogen relation in which there is an increased host resistance and decreased bacterial virulence (11,13,31). Some reports have shown an increasing incidence of this form of osteomyelitis (18) and a higher prevalence in certain countries (15).

This entity was first described by Brodie in 1836 (9). However, it was only in 1881 that Billroth first coined the term subacute (5). Today, >100 years after the condition was first described in the literature, its management still remains controversial.

M ost authors (1,3,4,7,12-17,19-21,24,25,28,29,32,35,36,38-40) have expressed a preference toward surgical management of these lesions, both for diagnostic and therapeutic purposes: for diagnostic purposes, because of the apparent difficulties in differentiating some of these lesions from tumors and tumor-like conditions and thus the need to obtain a tissue diagnosis; for therapeutic purposes, because of the teaching that a cavity that may contain pus should be curetted and evacuated.

However, these same authors also showed evidence that the results of conservative treatment of some of these patients is as effective as the operative regimen.

In view of this controversy in the literature regarding the management of this condition, conservative versus surgical, the aim of this work was to review our own experience with the management of cases of subacute osteomyelitis and specifically to answer the following questions:

1. What are the results of conservative versus surgical treatment of these lesions? 2. When is biopsy of the lesion necessary? 3. What are the indications for surgical debridement?

MATERIAL AND METHODS

The charts and radiologic files were reviewed of 44 consecutive patients admitted to the Children's Hospital of Eastern Ontario, Ottawa, Ontario, between 1976 and 1989 with a diagnosis of subacute hematogenous osteomyelitis. All cases met the criteria mentioned (symptoms >2 weeks, no systemic manifestations, negative blood cultures, positive plain radiographs). There were 32 boys and 12 girls. The average age of the patients was 7 years (range, 1-16). Age and sex distribution are shown in Fig. 1. The tibia was the most commonly afected bone (27% of cases) followed by the pelvis (18% of cases). The anatomic locations of the different lesions are shown in Fig. 2.

FIG. 1. Age and sex distribution.

FIG. 2. Anatomic locations of the lesions.

BACTERIOLOGIC FINDINGS

BACTERIOLOGIC FINDINGS
An organism was isolated in 20 (45%) cases. Staphylococcus aureus was the most common organism isolated (in 17 of the 20 cases). Blood cultures were taken in 32 cases and were always negative. Seventy-five percent of intraoperative swabs (of the 20 surgical cases), and 56% of bony aspirates were positive. Bacteriologic diagnosis is shown in Table 1.

TABLE 1. Bacteriologic diagnosis

RADIOLOGIC FINDINGS
All patients had positive radiologic findings on admission. The classification described by Roberts et al. (31) was used in this study. As shown in Table 2, all types were represented except type III. Type I was the most common lesion: 10 cases were type Ia and 10 type Ib.

TABLE 2. Radiologic types based on the classification described by Roberts et al. (31)

TREATMENT
Twenty-four cases were treated conservatively and 20 surgically. The choice of treatment was not determined by the radiologic appearance of the lesion (as shown in Table 2) or by the duration of symptoms, but rather by the preference of the admitting orthopaedic surgeon. The 24 cases that were treated conservatively received antistaphylococcal antibiotics (intravenous followed by oral) for an average of 6 weeks. The 20 surgically treated cases had debridement and curettage of the lesion followed by antibiotics for an average of 6 weeks. All cases were followed-up for an average of 18 months.

RESULTS
Except for one case, all 24 patients treated with antibiotics only responded well to this conservative regimen with no failures or recurrences. The one exception was a patient who received inadequate antibiotic therapy for only 2 days and subsequently required surgical debridement. All 20 patients treated surgically and with antibiotics also did well with no failures or recurrences. None of the 44 cases showed damage to the physis. The clinical response was within a few days of initiation of treatment. However, the radiologic response was much slower healing radiologically was evident within 3-12 months.

DISCUSSION
Our results indicated that conservative treatment of cases of subacute osteomyelitis is as effective as surgical management. However, in a review of the literature, we were able to find only five studies in which conservative therapy was recommended. None of these studies was from the United States, the five being from England, Canada, Israel, Belgium, and Australia, respectively (2,6,11,33,34). The majority of published reports (3,7,1217,19,21,24,25,29,32,35,36) and all (1,4,20,28,29,38-40) except two (26,30) of the English written standard textbooks in paediatric orthopaedics and infections preferred and recommended surgical debridement over conservative therapy.

However, the reasons for this preference and the rationale behind surgical treatment are not clear to us.

However, the reasons for this preference and the rationale behind surgical treatment are not clear to us. These authors who recommended surgical debridement as a primary line of management for cases of subacute osteomyelitis did not give convincing evidence that surgical debridement is better than antibiotics only. On the contrary, these same authors who recommended surgical treatment showed that in their series, the patients who were treated conservatively did as well as those treated surgically.

Why then recommend surgical treatment? Based on our results, on the fact that most of these lesions, when explored surgically, do not contain frank pus, and because of the lack of evidence in the English and French literature that surgical debridement gives results superior to those of conservative therapy, we strongly believe that, from a therapeutic point of view, cases of subacute osteomyelitis can be treated effectively with antibiotics only and that surgical debridement should be reserved only for those cases that do not respond to a conservative trial.

As regards the need for an open biopsy to obtain a tissue diagnosis, a review of the literature revealed that most authorsthe same who recommended surgical debridementdid indeed prefer and recommend such an approach. The primary and most important reason that these authors recommended such management is because they believe that it is very difficult to differentiate many of these lesions from tumors and other tumor-like conditions, and that only a histologic specimen could provide the final diagnosis (7,10,12-14,16-18,24,25,29,35,40). Some authors have even recommended a biopsy all lesions approach (10,25). We believe that such an approach is unjustified and that not all lesions need to have a biopsy.

The clue to a correct diagnosis in cases of subacute osteomyelitisshort of an open biopsyis the radiologic appearance of these lesions, as the clinical picture and laboratory data are usually noncontributory. We agree with other authors that many of these lesions resemble radiologically tumors and other tumor-like conditions (8,10,22,23,25,27,37).

However, based on our data and those of several other authors (6,11,12,22-24,27,33,34,37), we believe that with a very careful radiologic assessment of these lesions (including plain radiographs, computed and conventional tomography) most cases of subacute osteomyelitis (90% in our series) show a benign character with very specific and characteristic radiologic findings.

These benign characteristic radiologic features include (a) lesions surrounded by sclerosis, (b) lesions crossing the growth plate, (c) lesions with serpentine shape or multiple cavities, (d) lesions in the epiphysis, and (e) a hole in bone with no surrounding destruction.

We believe that such cases of subacute osteomyelitis, having any of these benign radiologic findings, can be safely managed with antibiotics as a first line of treatment. If, however, there is no response to antibiotics, or if the lesion progresses radiologically (which occurred in none of our cases), then an open biopsy is indicated.

On the other hand, our results showed that <10% of cases of subacute osteomyelitis (in our series) have an aggressive radiologic appearance, which includes lesions with subperiosteal new bone formation and lesions with destruction of cortex or surrounding matrix. In such instances, in which a differential diagnosis from a malignant tumor becomes difficult, we completely agree with other authors (10,25) that an open biopsy is warranted without any delay and without any trial of conservative treatment.

Lesions in which the differential diagnosis is from benign tumors can justifiably have a trial of conservative treatment. Even if the lesion is a benign tumor, it is very unlikely that a short trial of conservative therapy will alter the prognosis. However, in cases in which the differential diagnosis is from malignant tumors of if there is any concern about the diagnosis, then there is no place for a conservative trial, and open biopsy is warranted.

We can therefore conclude that

1. A careful radiologic assessmentoften with different techniquesis necessary in cases of subacute osteomyelitis, to differentiate benign-looking from malignant-looking lesions. 2. Lesions with benign radiologic features (the vast majority) do not need an open biopsy and can be safely treated with antibiotics as a first line of management. If the lesions progress, then open biopsy becomes mandatory. 3. Lesions with aggressive radiologic findings (<10% in our series) need an immediate open biopsy for diagnostic purposes. 4. Conservative management of cases of subacute osteomyelitis is as effective as surgical treatment.

5. Surgical debridement is indicated only in the rare cases that fail to respond to conservative therapy.

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Key Words: Conservative and surgical treatment; Subacute osteomyelitis

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