A multidisciplinary approach for the treatment of complication of hematogenous osteomyelitis in children

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Abstract


Background.

Severe orthopedic complications of osteomyelitis occurred in 22%–71.2% of children with osteomyelitis in previous studies. At the same time 26.5% of children with complications of osteomyelitis, according to data of The Turner Scientific and Research Institute for Children’s Orthopedics, have multiple bone lesions. The challenges involved in the orthopedic treatment of musculoskeletal system disorders are diverse and complex. In some cases, inadequate attention is paid to the need to treat the facial bones of the skull, temporomandibular joint (TMJ), and jaw bones.

Aim.

The aim of this paper is to demonstrate the need for a variety of options and to determine the best strategies for comprehensive medical rehabilitation, involving orthopedic and maxillofacial surgeons and other healthcare providers, for children with complications of osteomyelitis, who had destruction of the long tubular bones of the jaw.

Materials and methods.

Between 2011 and 2015 26 children (10 males and 16 females) aged 1.5–17 years with multiple localized lesions after osteomyelitis were treated in The Turner Scientific and Research Institute for Children’s Orthopedic. In addition to severe orthopedic disorders, there has been a loss of TMJ, which resulted in severe functional impairment and impaired development of the facial bones of the skull.

Results.

There was a individualized approach to the treatment of pediatric patients with complications of osteomyelitis. Early diagnosis and proper treatment prevented severe changes in the musculoskeletal system and maxillofacial area in pediatric patients.

Conclusion.

The modern concept of comprehensive medical rehabilitation of children with complications of osteomyelitis should include an interdisciplinary approach involving orthopedic and maxillofacial surgeons. Early diagnosis in children ensures the timely formation of individualized rehabilitation programs, designed to improve the anatomical and functional characteristics of the affected bones. Along with comprehensive orthopedic treatment, bone-reconstructive surgery of the facial bones of the skull should be focused on restoration of chewing function, external respiration, speech, and facial esthetics.

The orthopedic complications of hematogenous osteomyelitis are observed in 22%-71.2% affected children. The severe conditions are mainly caused by lesions in the limb long bones and require long-term treatment, which can sometimes be multi-staged. According to the data from the Turner Scientific and Research Institute for Children’s Orthopedics, 26.5% children with complications after hematogenous osteomyelitis exhibit multiple skeletal bone lesions [1].

Currently, the generally accepted standard in children’s orthopedics includes taking primary orthopedic measures to stabilize the large joints and eliminate defects and pseudarthrosis. The aim is the consequent restoration of the length and alignment of the affected joints and limbs.

As a result of the difficulties involved in solving the variety of orthopedic problems associated with musculoskeletal pathologies, pediatricians, surgeons, orthopedists, and parents may disregard the necessity of treating pathologies of the facial segments of the skull, which are primarily in the temporomandibular joint (TMJ) and jawbones. The process of bone destruction, and further ankylosis of the TMJ as a complication of hematogenous osteomyelitis due to neonatal sepsis is the main cause of acquired jawbone deformities in childhood, which occurs in up to 70% of cases [2].

As the child grows, complex, multiple symptoms occur that affect not only the maxillofacial region but also the total body. These are shown in the form of nutritional dysfunction due to an abnormal jaw opening and teeth malocclusion, respiratory disturbance due to a reduction in the volume of the oral cavity as a result of underdeveloped lower jaw and dislocation of tongue root toward the posterior pharyngeal wall, and also in the form of speech dysfunction. Finally, there may be asymmetry leading to the reduction of facial esthetics [3, 4, 5]. Any delay in the elimination of these symptoms may, therefore, eventually lead to the retardation of the child’ psychophysical development as well as to the life-long disability [6].

The aim of the current paper is to demonstrate the existence of different variants of complications of hematogenous osteomyelitis affecting the long tubular bones and jawbones in children. The strategy of the orthopedic and maxillofacial surgeons used for the complex medical rehabilitation of this group of patients will also be described.

Twenty-six children (10 boys and 16 girls) aged 1.5 to 17 years were treated at the Turner Scientific and Research Institute for Children’s Orthopedics during the period of 2011 to 2015. These children all had multiple skeletal lesions as complications of hematogenous osteomyelitis. And they experienced a combination of severe orthopedic musculoskeletal disorders with TMJ dysfunction which was demonstrated by pronounced functional insufficiency and developmental disorders of facial bones. Among these orthopedic complications, there was also a prevalence of the hip joint disorders with different severity (21 to 80.7%). In five (19.3%) patients the injury of proximal epiphyseal cartilage of the humeral bones was also observed.

It should be noted that the primary visit of the patients to the orthopedist or the pediatric maxillofacial surgeon was dependent upon the severity of primary symptoms, as well as the upon awareness of pediatrician, neurologists, surgeons, orthopedists, and child's dentists on the specific manifestations of this pathology. Majority of cases accounted for visits to orthopedists or surgeons who paid the most attention to tubular bone pathologies.

Nevertheless, it was possible to reveal signs of maxillofacial pathologies in the age of 1.5 to 2 years. The main symptoms that gained attention were difficulties in mouth opening and any asymmetry of the lower part of the face because of the retardation in lower jaw growth. In many children, complications of hematogenous osteomyelitis of the lower jaw developed much more slowly, with only a gradual increase in clinical symptoms by the age of 5 to 6 years and even by the age of 10 years. As a result, the surgical treatment by maxillofacial surgeon was not considered, or was delayed for a later period.

However, it is often necessary to perform surgical treatment in this group of patients from the age of 2 to 3 years with compulsory early orthodontic treatment and follow-up by the specialists. Timely and properly performed orthodontic treatment with removable dental devices should help to avoid severe dental malocclusion, significantly improve chewing function, and to delay any jawbone restorative surgery until adolescence.

Three clinical cases are discussed below

Case 1

Patient O, a 10-year-old female, was diagnosed with the complication of hematogenous osteomyelitis in the form of subtotal left femoral bone defect. She suffered from hematogenous osteomyelitis 5 years ago. At admission: she could not bear weight on her left lower limb and had a relative shortening of left lower limb by 17 cm. There is an abnormal mobility of the medium one-third of left hip.

The x-ray images showed a defect of the middle-third of the diaphysis of the left femoral bone; with an inter-fragment diastasis of approximately 3 cm. Thinning was observed at the distal end of the proximal fragment. The femoral head was reduced and deformed, and the femoral neck was shortened, and reduced. There was a high position of the greater trochanter. Osteoporosis, with the signs of osseous tissue dystrophy of II-III degree, was also observed.

On 23.10 2003, an extrenal fixation device using screws and wires was placed on the left hip, pelvis and shin. Distraction was performed for 75 days, and the distraction device was removed on the 13.01 2004. A free flap bone autoplasty with a microsurgical vessel suture was made using a fibular bone graft. Consolidation of the osseous fragments and the autograft was achieved. In 2009, the patient had a remedial intertrochanteric osteotomy on the left femoral bone, and in 2011, at age 17 years, the length of the left lower limb was restored using the method of monolocal distractive femoral osteosynthesis and polylocal distractive shin osteosynthesis (Fig. 1).

The patient was 17 years old when she was first examined for maxillofacial pathology. The surgeon identified a highly pronounced facial asymmetry, insufficient development of the lower jaw, dislocation to the right of the mental segment of the jaw, a limited mouth opening of only 15 mm, and teeth malocclusion. These problems were in addition to other clinical symptoms that caused disorders in chewing function, external respiration in the form of sleep apnea, as well as speech disorders. The diagnosis was ankylosis of the right TMJ and lower micrognathia, microgenia and cementoma tumors on the left half on the lower jaw.

On 08.01.2011, a single-stage surgery for elimination of right TMJ ankylosis was performed using a de-epithelialized dermis-fat graft. Elimination of lower micrognathia was achieved by means of compression-distraction osteosynthesis to the branch of the jaw on the right (1st stage). The distraction was started on the 9th day following the operation according to standard protocol. After the distraction was completed (on 09.05.11), an individual intermaxillary padding and devices placed on both jaws were inserted. External fixation devices were removed on the 11.21.2011. Contour correction of the mental area and removal of the lower jaw cementoma were also performed in the local outpatient clinic. As a result of the reconstructive surgery on the lower jaw, the patient had her chewing function restored and was able to open her mouth up to 30 mm. The symmetry of the lower third of her face was also restored (Fig. 2).

Case 2

Patient G., a 14-year-old female, was diagnosed with complications of hematogenous osteomyelitis of the proximal right femoral bone, a pathological dislocation of the right hip, neuropathy of right sciatic nerve, and history of total right hip replacement.

She experienced an acute hematogenous osteomyelitis during the neonatal period.

At 6 years of age, stretching of the right hip by 5 cm was achieved using an Ilizarov frame at her town of residence. At the age of 12 years, she underwent a total left hip replacement. While hospitalized in 2009, she was able to walk on her own but was lame in her right lower limb and leaned against the anterior segment of her foot. There was also hypotrophy of the soft tissue of the hip and shin. Equinus deformity of the right foot, flexion contractures, and a valgus deformity of 15° of the right knee joint was also observed. There was shortening of the right lower limb by 2 cm. In 2009, right achillotenoplasty was performed using right posterior arthrolysis of the ankle and the subtalar joints of the right lower limb. The flexor sinew in one toe on the right foot was stretched, and supracondylar remedial osteotomy of the right femoral bone was performed successively.

For correction of 6-cm progressive shortening of the right lower limb due to hip and shin problems, a needle device was set up on the right hip on the 09.14.2010. Osteotomy of the median third of the femoral bone was performed. An extrenal fixation device using wires was place on the right shin, and this was followed by a tibial bone osteotomy in the superior third and fibular bone osteotomy in the inferior third of the limb. Using the method of distractive osteosynthesis, the hip was stretched by 4 cm, the shin - by 3 cm and the length of the right lower limb length was restored. The devices were removed on the 06.02.2011 (Fig. 3).

In 2012, when Patient G was 16 years old, she consulted a maxillofacial surgeon due to the problems of a severely limited mouth opening (only up to 8 mm), malocclusion, a limited chewing function, and pronounced facial asymmetry. The diagnosis was ankylosis of the left TMJ and lower micrognathia. There was a secondary deformity of the upper jaw. She underwent a surgery for the elimination of lower jaw TMJ ankylosis at the age of 3 years (Fig. 4).

Because of the pronounced bite malocclusion, the limited chewing function, and the stage of growth of the patient, the decision was made to perform the complex surgical and orthodontic treatment continuously and successively in four stages. The first stage was a single operation to eliminate the left TMJ ankylosis and lower micrognathia using a dermal-fat graft taken from the gluteal region as biological padding for the end segment of the maxillary branch. The method of compression-distraction osteosynthesis (CDO) was applied on both sides of the jaw to remove the lower micrognathia. The orthodontic treatment was started using a bracket system to obtain the adequate positioning of the teeth after distraction period. The treatment necessary for the repair of the upper and lower jaw deformities was determined, and simultaneous reconstruction of the upper jaw and mental segment of the lower jaw was planned following the removal of the external fixation device. The second stage of treatment commenced on the 07.19.2012. Following the removal of the DCD, an upper jaw osteotomy by Le Fort I according to a previously made positioning template and osteotomy fragments were placed into the right position to complete a mentoplasty. A proper bite position was created and facial asymmetry was eliminated. The future orthodontic treatment was continued using fixed orthodontic devices. The combination of the surgical and orthodontic treatments resulted in a satisfactory functional and esthetic therapeutic result (Fig. 5).

Case 3

Patient Sh, a female aged 1 year 10 months, was diagnosed with the complications of the proximal metaphyseal cartilage of the right humeral bone, shortening of the left upper limb, ankylosis of the TMJ, microgenia, and lower micrognathia. She experienced a hematogenous osteomyelitis of the left humeral bone in the neonatal period, and was followed-up by neurologist and orthopedic surgeon. At the age of 6 months, her parents noticed facial asymmetry and the child was examined by a maxillofacial surgeon. Analyses of the results of multispiral computed tomography (MSCT) of the facial segment of the skull, revealed signs of ankylosis of the right TMJ, lower jaw asymmetry, a severe deformity of the mandibular ramus, abnormal dental occlusion, microgenia and lower micrognathia. These changes were combined with a severely limited mouth opening (Fig. 6).

During the discussions of the treatment plan, it was noticed that, despite obvious maxillofacial pathology, the affection of the left upper limb was associated with a satisfactory function with insignificant shortening of the shoulder. The decision was, therefore, taken to postpone orthopedic treatment until a later date.

Surgery was performed in the maxillofacial surgery department on the 10.07.14. Fat tissue extracted from the gluteal region was sent to the laboratory of the Pokrovsky hospital in St. Petersburg to prepare biological padding using a fibrin membrane coated with autologous prechondrocytes. The surgery to eliminate the TMJ ankylosis was done on 11.10.14 using this prepared biological padding. After an osteotomy of the right half of the lower jaw, a CDO was applied, and distraction was done according to the protocol. The size and shape of the lower jaw was completely restored and a full mouth opening was achieved. Thus, early surgical treatment enabled the complete restoration of the function of the maxillofacial region and prevented the development of any secondary deformities of the maxillofacial segment of the skull (Fig. 7).

These observations demonstrate the success of the individualized approach for the treatment of patients with complications of hematogenous osteomyelitis. Thanks to the use of early diagnostic techniques and the right therapeutic strategy, severe changes in the maxillofacial region of this child from young age group were averted.

Conclusions

The current conception on complete medical rehabilitation for children with complications of hematogenous osteomyelitis should reflect a multidisciplinary interaction and be based on co-operation of the doctors, orthopedists and maxillofacial surgeons.

The use of early diagnostics in children with complications of hematogenous osteomyelitis enables the timely development of an individual rehabilitation program aimed at improving the anatomic and functional characteristics of the specific affected skeletal segments.

Combined with adequate orthopedic treatment, the bone reconstructive surgeries on the facial segment of the skull in children and teenagers should aim at the complete restoration of the chewing function, external respiration, speech, as well as improving the face esthetics.

Funding information and conflict of interest

Conflict of interests: the authors state that there is no conflict of interests related to this paper. This work was performed in accordance to the ethical guidelines of the institution.

Yury Garkavenko Garkavenko

The Turner Scientific and Research Institute for Children’s Orthopedics; North-Western State Medical University n.a. I.I. Mechnikov

Author for correspondence.
Email: yurijgarkavenko@mail.ru

Russian Federation MD, PhD, professor of the chair of pediatric traumatology and orthopedics. North-Western State Medical University n. a. I.I.Mechnikov, leading research associate of the department of bone pathology of The Turner Scientific and Research Institute for Children’s Orthopedics.

Mikhail G Semyonov

The Turner Scientific and Research Institute for Children’s Orthopedics; North-Western State Medical University n.a. I.I. Mechnikov

Email: sem_mikhail@mail.ru

Russian Federation MD, PhD, рrofessor, head of the department of maxillofacial surgery and surgical dentistry named after A.A. Limberg of North-Western State Medical University n. a. I.I.Mechnikov. Leading research associate of the of the department of maxillofacial surgery. The Turner Scientific and Research Institute for Children’s Orthopedics.

Darya О Troschieva

North-Western State Medical University n.a. I.I. Mechnikov

Email: troschieva_dariya@mail.ru

Russian Federation MD, PhD student of the Department of Maxillofacial Surgery and Surgical Dentistry n. a. AA. Limberg. North-West State Medical University n.a. II. Mechnikov

  1. Гаркавенко Ю.Е. Ортопедические последствия гематогенного остеомиелита длинных трубчатых костей у детей (клиника, диагностика, лечение): Автореф. дис. … д-ра мед. наук. - СПб., 2011. - 55 с. [Garkavenko YE. Ortopedicheskie posledstviya gematogennogo osteomielita dlinnyih trubchatyih kostey u detey (klinika, diagnostika, lechenie) [dissеrtation]. Saint Peterburg; 2011. 55 p. (In Russ).]
  2. Рогинский В.В., Берлова М.М., Арсенина О.И., и др. Реабилитация детей с анкилозирующими поражениями височно-нижнечелюстного сустава. Московский центр детской челюстно-лицевой хирургии. 10 лет: Результаты, итоги, выводы / Под ред. В.В. Рогинского - М.: Детстомиздат, 2002. - С. 189-208. [Roginskii VV, Berlova MM, Arsenina OI, et al. Reabilitatsiya detei s ankiloziruyushchimi porazheniyami visochno-nizhnechelyustnogo sustava. Moskovskii tsentr detskoi chelyustno-litsevoi khirurgii. 10 let: Rezultaty. itogi. vyvody. Moscow: Detstomizdat; 2002. P. 189-208. (In Russ).]
  3. Водолацкий М.П. Родовая травма челюстно-лицевой области и ее последствия. - Ставрополь, 1994. - 98 с. [Vodolatskii MP. Rodovaya travma chelyustno-litsevoi oblasti i eye posledstviya. Stavropol; 1994. 98 p. (In Russ).]
  4. Семенов М.Г., Кудрявцева О.А. Выбор между ранним многоэтапным или поздним одномоментным костно-реконструктивным лечением у детей с приобретенными деформациями лицевого отдела черепа. Часть I // Стоматология. - 2014. - № 3. [Semyonov MG, Kudryavtseva OA. Vyibor mezhdu rannim mogoetapnyim ili pozdnim odnomomentnyim kostno-rekonstruktivnyim lecheniem u detey s priobretennyimi deformatsiyami litsevogo otdela cherepa. Chast I. Stomatologiya. 2014;(3) (In Russ).]
  5. Семенов М.Г., Кудрявцева О.А., Гаркавенко Ю.Е. Выбор между ранним многоэтапным или поздним одномоментным костно-реконструктивным лечением у детей с приобретенными деформациями лицевого отдела черепа. Часть II // Стоматология. - 2014. - № 4. - С. 38-41. [Semyonov MG., Kudryavtseva OA., Garkavenko YE. Vyibor mezhdu rannim mogoetapnyim ili pozdnim odnomomentnyim kostno-rekonstruktivnyim lecheniem u detey s priobretennyimi deformatsiyami litsevogo otdela cherepa. Chast II. Stomatologiya. 2014;(4):38-41. (In Russ).]
  6. Комелягин Д.Ю. Компрессионно-дистракционный остеосинтез у детей с недоразвитием и дефектами нижней челюсти врожденного и приобретенного характера: Автореф. дис.. канд. мед. наук. - М., 2002. - 12 с. [Komelyagin DYu. Kompressionno-distraktsionnyi osteosintez u detei s nedorazvitiyem i defektami nizhney chelyusti vrozhdennogo i priobretennogo kharaktera: [dissertation]. Moscow; 2002. P. 12 (In Russ).]

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Copyright (c) 2016 Garkavenko Y.G., Semyonov M.G., Troschieva D.О.

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