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A review of necrotising external otitis, a relatively unknown and dangerous disease, brings out that, initially, it has three characteristics: a granulating necrotising ostitis of the external meatus, extreme pain and a yellowish green secretion. It is always caused by a pseudomonas infection and in almost all cases the patients suffer from diabetes mellitus. If the condition is not recognized in good time and an extensive debridement of the bone involved not performed promptly, ostomyelitis of the base of the skull may follow with involvement of cranial nerves. Severe chronic osteomyelitis of cervical vertebrae occurred in one of our cases. The neurologist must bear this disease in mind in the differential diagnosis when cranial nerves are affected because the nerve disturbances may become evident only after the local condition has subsided or the nerve deficits may be more prominent than and obscure the local ear condition. The most commonly involved nerve is the facial although there may be multiple cranial nerves involved including the third through the twelfth. If the cervical vertebrae become affected there may be nerve root lesions. A torpid meningoencephalitis may also occur. Close cooperation between otologists and neurologists is necessary to recognize and treat these conditions properly.
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PMID:[To the differential diagnosis of cranial nerve lesions: the progressive necrotising external otitis (author's transl)]. 5 Oct 78

Foot lesions constitute an important cause of morbidity and mortality in Nigerian diabetics, yet remain poorly characterised. We, therefore, prospectively studied 50 diabetics with 84 major foot lesions over a three-year period at Ibadan, Nigeria. Sixty eight percent of the patients were illiterate and 80% ignorant regarding the importance of footcare. Duration of diabetes was significantly longer in these patients (p less than 0.05) than in age- and sex-matched diabetics without foot lesions. The prevalence rates of neuropathy (68%), foot ischaemia (54%), hypertension (42%) and nephropathy (20%) in diabetics with foot lesions were higher than in previous reported groups of Nigerian diabetics. The initiating factors were predominantly trivial trauma and "spontaneous" blisters. Sixty percent were anaemic at presentation, while short-term glycaemic control was generally poor. Mixed bacterial organisms were cultured in 70% of the cases, with anaerobes presumed present in 33%. Chronic osteomyelitis (38%) and soft tissue changes (35%) were the commonest foot x-ray findings. Some aspects of prevention of foot lesions were discussed.
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PMID:The pattern of presentation of foot lesions in Nigerian diabetic patients. 227 17

The pathophysiology and pathologic appearances of adult osteomyelitis are discussed, without reference to childhood hematogenous (metaphyseal) osteomyelitis or chronic osteomyelitis secondary to vascular phenomena such as diabetes or arteriosclerosis. Osteomyelitis as a feature of generalized sepsis in the immunocompromised patient is also excluded. The focus is on infection of the adult skeleton that occasionally arises spontaneously but more commonly presents as a complication of an open fracture or an operative procedure. The special features of adult osteomyelitis that are the result of the infection developing within the confined and rigid structure of the skeleton are highlighted. Lastly, the histopathology of osteomyelitis is examined in an effort to demonstrate the host bone's response to this injury.
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PMID:The pathogenesis of adult osteomyelitis. 265 95

Two cases of pathologic fracture of the mandible resulting from chronic osteomyelitis are described. The first case was treated successfully by antibiotic therapy followed by resection of the affected bone and iliac bone grafting after six months of follow-up care. In the second case, a patient with a history of diabetes mellitus, a fracture of the condyloid process occurred because of extension of the Actinomyces infection after extraction of the third molar. Because antibiotics failed to prevent exacerbation of the disease, the patient was given human gamma globulin. Then, all the signs of inflammation disappeared gradually with no evidence of recurrence for more than a year. There was no spontaneous bony healing of the fractured site.
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PMID:Pathologic fracture of the mandible resulting from osteomyelitis: report of cases. 692 6

Fourteen patients with 15 open tibial fractures were examined retrospectively to compare postoperative infection rates of asymptomatic patients who tested positive or negative for the human immunodeficiency virus antibody (HIVab). All patients were treated with a standard open-fracture protocol. All of the HIVab-positive patients developed postoperative infections. There were five postoperative infections in 4 patients; 3 of the 4 patients were HIVab-positive and 2 of these patients developed chronic osteomyelitis. The only other infection, in an HIVab-negative patient with insulin-dependent diabetes, resolved without complication. All other HIVab-negative patients had no complications. The infection rate for asymptomatic HIVab-positive patients with open tibial fractures was higher than that for HIVab-negative patients in our study. These data suggest that the HIV status of patients with open tibial fractures is relevant to treatment outcome.
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PMID:Open tibial fracture infections in asymptomatic HIV antibody-positive patients. 799 49

Thirty-eight lesions found by physical and/or radiological examination in 25 patients with long-term diabetes mellitus were studied in order to evaluate the clinical utility of immunoscintigraphy using 99Tcm-labelled anti-granulocyte monoclonal antibodies (MAb BW 250/183) for the diagnosis of infectious pathology in diabetic foot. All the patients underwent three-phase bone scintigraphy with 740 MBq 99Tcm-methylene disphosphonate. Immunoscintigraphy was performed 4 and 24 h after administration of 500 MBq of the labelled antibody by planar selective views. Uptake intensity was scored 0 to 4 (0 = normal, 1 = mildly increased, 2 = moderately increased, 3 = intense, 4 = very intense) when compared with adjacent or contralateral uninvolved bone marrow and soft tissue. Several projections were performed and anatomical references of bone scan were used to determine whether the lesion involved the bone or soft tissue. Definitive diagnoses were 15 osteomyelitis, 14 soft tissue lesions (nine cellulitis and five noninfected ischaemic or trophic wounds), and nine degenerative bone disease. 99Tcm-granulocyte scintigraphy showed increased uptake in seven soft tissue lesions, in four of which exclusively soft tissue involvement was demonstrated by scintigraphy. Only one false negative scintigraphic finding was observed (chronic osteomyelitis). No abnormal anti-granulocyte antibody uptake was observed in degenerative lesions. Based on our observations, immunoscintigraphy with 99Tcm-MAb BW250/183 has a sensitivity of 93% in the diagnosis of osteomyelitis involving diabetic patients' feet. Although it is feasible to distinguish exclusive soft tissue involvement, this is still the main cause of misdiagnosis in current clinical practice.
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PMID:Diabetic foot infections: scintigraphic evaluation with 99Tcm-labelled anti-granulocyte antibodies. 845 12

The factors of immune defense were studied in 83 patients. Chronic osteomyelitis of foot and shin was in 48 patients (hematogenic osteomyelitis in 36 patients, posttraumatic osteomyelitis-in 12 patients). Trophic ulcers were in 25 patients: in 36% in the presence of diabetes mellitus; diabetic angiopathy complicated with diabetic gangrene was in 10 patients. The complex of immune and morphological changes, developing chronic inflammation underlying chronic course of disease, have been detected by clinical trials. The development of immune insufficiency makes it necessary to use various methods of immunocorrection (pharmacological, biological, physical) in treatment of such patients that will decrease rate of postoperative morbidity and improve results of treatment.
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PMID:[Immune system defence and its correction in patients with chronic inflammatory disorders of lower extremities]. 901 56

The purpose of this study is to present the surgical and functional results of a total calcanectomy procedure as a foot salvage alternative in patients with extensive chronic osteomyelitis of the calcaneus. A retrospective review identified eight patients treated with a total calcanectomy for a chronic nonhealing plantar ulcer of the heel and osteomyelitis of the calcaneus. The primary diagnosis was insulin-dependent diabetes mellitus (six patients), pneumococcal septicemia (one patient), and an open calcaneal fracture (one patient). The average age of the patients was 52 years. Prior procedures included irrigation and debridement of the heel ulcer (seven patients), partial calcanectomy (three patients), and split thickness skin grafting (two patients). The vascular status of each limb was assessed preoperatively. Distal extremity bypass surgery was performed on two patients before calcanectomy. Osteomyelitis of the calcaneus was diagnosed by magnetic resonance imaging alone in three patients, and by technetium/indium scans and magnetic resonance imaging in five patients. The average follow-up duration was 27.3 months (range, 6-57 months). Infection at the plantar heel was controlled in all patients. In all eight cases the incisions were closed primarily. During a prolonged time of total contact casting to facilitate wound healing, one patient developed an anterior tibial ulcer that progressed to osteomyelitis and underwent below-knee amputation. Talonavicular subluxation occurred as a late complication in one patient. This was treated with a talonavicular arthrodesis and subsequent bracing for a nonunion. An assessment of functional ambulation was performed on all eight patients. Four patients maintained the same ambulation level postoperatively in a modified heel-containment orthosis. Two patients decreased one functional ambulation level, and one patient decreased two levels. One patient underwent below-knee amputation and is currently ambulatory with a prothesis. Assessment of ankle strength and range of motion of the surgical limb demonstrated decreased dorsiflexion and plantarflexion strength and a variable range of motion compared to the contralateral limb. Total calcanectomy is an alternative procedure to transtibial amputation in patients with chronic osteomyelitis of the calcaneus. Eradication of infection and preservation of the functional ambulation is achieved.
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PMID:Total calcanectomy for the treatment of chronic calcaneal osteomyelitis. 987 73

The extraction of a tooth led to the acute exacerbation of existing chronic osteomyelitis then phlegmon, and sepsis as a result. Persisting coma developed after three reanimations of the patient, on account of septic shock. Finally, in more than two weeks following the extraction the patient died due to multiorgan failure. This case description wishes to call attention to the risks of complications of diabetes, to summarize the relevant documents of diagnosis and treatment of osteomyelitis and phlegmon and the data of mortality. Hopefully we offer some useful advice to the general dentist about patients with immunosuppressive diseases.
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PMID:[Lethal complication of an odontogenic infection developing after tooth extraction in a patient with untreated diabetes. Case report]. 1126 99

Seventeen patients who underwent soft-tissue reconstruction of various anatomic regions of the foot and ankle, using the radial forearm fasciocutaneous free flap, are reported. The procedures were performed between January, 1992 and December, 1998. Indications for reconstruction included diabetes and/or vascular insufficiency (four patients), soft-tissue defects (six patients), and chronic osteomyelitis (seven patients). The weight-bearing surface of the foot was involved in 16 patients. Defects ranged in size from 35 to 206 cm2 (mean: 86.2 cm2). At a mean follow-up of 3.8 years, the radial forearm flap was successful in all cases (100 percent). Flap complications included superficial infection (three patients), and minor wound dehiscence at the flap-leg-skin interface (two patients). Recurrent ulceration occurred in two patients; both were diabetics with weight-bearing flaps. Donor-site complications included partial skin graft loss with tendon exposure in one patient, which healed with conservative management. Recurrent or persistent osteomyelitis was not demonstrated in any of the patients. Of the 16 patients with weight-bearing flaps, 12 were ambulatory, three had limited ambulation, and one was non-ambulatory. Three patients required modified shoes. No debulking of the transferred flaps was necessary. The radial forearm flap is one of the preferred flaps for reconstruction of moderate-sized ankle and foot defects, for weight-bearing surfaces, and in the treatment of osteomyelitic and diabetic wounds. It meets most of the anatomic prerequisites for an ideal foot coverage; it also facilitates the restoration of normal foot contour, allowing patients to wear ordinary shoes. The flap provides a durable and stable weight-bearing plantar surface during ambulation, and achieves excellent aesthetic results; when used as a neurosensory flap, it permits adequate reinnervation.
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PMID:Radial forearm fasciocutaneous free-tissue transfer in ankle and foot reconstruction: review of 17 cases. 1133 44


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