Magister Chirurgiae Dentium (MChD) / Anecdotal and controversial discussion has.always been prompted by the bias of the clinician in relation to whether teeth in the line of fracture should be extracted or retained. In recent years, it became evident to clinicians serving the Maxi 11ofaci aland Oral Surgery Clinic at Groote Schuur Hospital, Cape Town, that a tendency towards reta ining teeth in the 1ine of fractu re did not seem to increase the possi bility of infecti on, providing that circumspection was used. A retrospective analysis of these cases was conducted in order to determine the outcome of our treatment. An independent sample of the 151 patients were investigated in relation to age, sex predilection, the effect timing has on the outcome of treatment and the incidence of infection when teeth in the line of mandibular fracture were extracted or retained. The results of this study has shown that most of our patients were young (aged 20-29yrs) and therefore a tendency to retain teeth was found. In older patients, (aged 30-49yrs), the tendency was to extract teeth. Males presented more than females in a 3:1 ratio. Patients treated early « 24hrs) had most of their teeth retained while others treated after 7 days had their teeth extracted. The infecti on rate was 2 percent if teeth were retained and 5 percent if teeth were extracted. A1though the difference was not statistically significant, it appeared that the retenti on of teeth in the 1ine of fracture presented more advantages to both patient and clinician.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第17859号 / 医博第3828号 / 新制||医||1000(附属図書館) / 30679 / 京都大学大学院医学研究科医学専攻 / (主査)教授 松田 秀一, 教授 佐藤 俊哉, 教授 戸口田 淳也 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DGAM

Syfte: Att systematiskt sammanfatta litteraturen inom området för medicinska behandlingsalternativ för icke-infektiös, kronisk osteomyelit i käkarna, utvärderat genom utläkning i ben och smärtlindring. Metod: En systematisk litteraturöversikt gjordes i fyra databaser; PubMed, Cochrane Library, Web of Science och Scopus. Översikten utfördes enligt instruktioner från ”PRISMA checklist” och ”CRD’s guidance”. En kvalitetsbedömning gjordes av samtliga inkluderade publikationer.Resultat: Sökningen resulterade i 2 100 artiklar. Efter urvalsprocessen återstod tre artiklar som inkluderades i denna systematiska litteraturöversikt. Samtliga studier utvärderade olika typer av bisfosfonatbehandlingar – ibandronat, pamidronat och disodium clodronat. Den smärtlindrande effekten utvärderades i alla tre studierna och utläkningen av benet utvärderades i två av artiklarna. Konklusion: Behandling av icke-infektiös osteomyelit med bisfosfonater visar en reduktion av smärta. Dock är den smärtlindrande effekten beroende på typen av bisfosfonat. Resultaten gällande utläkningen av ben är tvetydiga och därför kan ingen konklusion gällande detta göras. Endast en artikel ansågs i kvalitetsgranskningen ha hög kvalitet. För att kunna ta fram tydliga, evidensbaserade riktlinjer gällande behandling av icke-infektiös osteomyelit behövs fler kliniska studier som håller hög kvalitet. Bisfosfonater verkar vara ett bra behandlingsalternativ av icke-infektiös osteomyelit. Ett alternativ till bisfosfonater, skulle kunna vara behandling med denosumab, som har liknande verkningsmekanism men kortare halveringstid. Dock krävs fortsatta studier inom detta område. / Aim: To systematically review the literature of medical treatment alternatives of non-infectious chronic osteomyelitis in the jaws regarding bone healing and pain relief. Methods: A systematic literature search has been made in four databases; PubMed, Cochrane Library, Web of Science and Scopus. The review was performed with directions from the PRISMA checklist and CRD’s guidance. A quality assessment was made of the included studies.Results: The search resulted in 2 100 articles and after the selection process, only three articles were included in this review. The studies evaluated different types of bisphosphonates - ibandronate, pamidronate and disodium clodronate. The reduction of pain was evaluated in all three articles and the bone healing was assessed in two of the articles. Conclusion: Treatment of non-infectious osteomyelitis with bisphosphonates shows a reduction in pain. However, the pain-relieving effect is most probably dependent on the type of bisphosphonates. The results of bone healing assessed from Tc-scans are ambiguous and therefore no conclusion can be made. Only one article in this review was considered to have high quality in the quality assessment. To enable clear guidelines regarding treatment of non-infectious osteomyelitis, more clinical trials with high quality is desirable. In summary, bisphosphonates seem to be a good alternative in treatment of non-infectious osteomyelitis. An alternative to bisphosphonates might be treatment with denosumab, which have a similar mechanism of action but shorter half-life. However, further research is needed.

Introduktion: Osteomyelit är en infektion som omfattar samtliga lager i ben, och där en omfattande nekros kan förekomma. Det innebär ofta en smärtsam, lång och dyr behandling. Under behandlingsprocessen används vanligtvis en kombination av kirurgisk teknik och en antimikrobiell behandling. I den antimikrobiella behandlingen har lokal antibiotika presenterats som ett tillägg till systemiskt antibiotika som hypotetiskt kan innebära fördelar gällande benpenetration, kostnad, risk för systemiska bieffekter och antibiotika-resistans. Syftet med denna litteraturstudie är att bedöma effekten av lokal antibiotika i kombination med systemisk antibiotika, jämfört med enbart systemisk antibiotika, i behandlingen av osteomyelit. Metod: En systematisk litteratursökning gjordes i databaserna PubMed och Web of Science. En fri sökning gjordes och av de erhållna 2293 artiklarna, sammanställdes två relevanta artiklar. Dessa artiklar bedömdes avseende kvalité och relevans i enlighet med GRADE-systemet. Resultat: De två erhållna artiklarna bedömdes som relevanta och hade hög kvalité. Studierna angav avsaknaden av reinfektion som ett kriterium för utfall. Avsaknad av reinfektion efter behandling sträckte sig mellan 86,3%-95,6% för patienter behandlade med lokal antibiotika i kombination med systemisk antibiotika jämfört med 82,0%-92,6% för patienter som fick behandling med enbart systemiskt antibiotika. Detta bedömdes kliniskt, laborativt och radiografiskt. Konklusion: Fler jämförande studier behövs för att fastställa effekten av lokal antibiotika i kombination med systemisk antibiotika i behandlingen av osteomyelit. / Introduction: Osteomyelitis is an infection involving all layers of bone in which widespread necrosis may occur. It often requires a painful, prolonged and expensive treatment process usually including a surgical and an antimicrobial approach. In the antimicrobial approach, local antibiotics has been introduced as a treatment option that could implicate benefits regarding bone penetration, economical expenses, the risk of systemic side-effects and the risk for antibiotic resistance during the treatment process. The aim of this literature review is to evaluate the effect of local antibiotics and systemic antibiotics compared with only systemic antibiotics in the treatment of osteomyelitis.Method: A systematic literature search is performed using the databases of PubMed and Web of Science. Free searches was made and of the total 2293 articles found, two relevant articles were retrieved and evaluated with regard to the quality and relevance of the articles according to the GRADE system.Results: The two retrieved articles were evaluated with “high quality” and as “relevant”. The studies measured the treatment outcome as the absence of reinfection. The absence of reinfection was spread between 86,3%-95,6% in patients treated with local antibiotics in addition to systemic antibiotics compared with 82,0%-92,6% in the group with only systemic antibiotics. This was clinically, laboratory and radiographically measured. Conclusion: More comparative studies are required to determine the effect of local antibiotics in addition to systemic antibiotics in the treatment of osteomyelitis.

Syfte: Att systematiskt sammanfatta litteraturen inom området för medicinska behandlingsalternativ för icke-infektiös, kronisk osteomyelit i käkarna, utvärderat genom utläkning i ben och smärtlindring. Metod: En systematisk litteraturöversikt gjordes i fyra databaser; PubMed, Cochrane Library, Web of Science och Scopus. Översikten utfördes enligt instruktioner från ”PRISMA checklist” och ”CRD’s guidance”. En kvalitetsbedömning gjordes av samtliga inkluderade publikationer.Resultat: Sökningen resulterade i 2 100 artiklar. Efter urvalsprocessen återstod tre artiklar som inkluderades i denna systematiska litteraturöversikt. Samtliga studier utvärderade olika typer av bisfosfonatbehandlingar – ibandronat, pamidronat och disodium clodronat. Den smärtlindrande effekten utvärderades i alla tre studierna och utläkningen av benet utvärderades i två av artiklarna. Konklusion: Behandling av icke-infektiös osteomyelit med bisfosfonater visar en reduktion av smärta. Dock är den smärtlindrande effekten beroende på typen av bisfosfonat. Resultaten gällande utläkningen av ben är tvetydiga och därför kan ingen konklusion gällande detta göras. Endast en artikel ansågs i kvalitetsgranskningen ha hög kvalitet. För att kunna ta fram tydliga, evidensbaserade riktlinjer gällande behandling av icke-infektiös osteomyelit behövs fler kliniska studier som håller hög kvalitet. Bisfosfonater verkar vara ett bra behandlingsalternativ av icke-infektiös osteomyelit. Ett alternativ till bisfosfonater, skulle kunna vara behandling med denosumab, som har liknande verkningsmekanism men kortare halveringstid. Dock krävs fortsatta studier inom detta område. / Aim: To systematically review the literature of medical treatment alternatives of non-infectious chronic osteomyelitis in the jaws regarding bone healing and pain relief. Methods: A systematic literature search has been made in four databases; PubMed, Cochrane Library, Web of Science and Scopus. The review was performed with directions from the PRISMA checklist and CRD’s guidance. A quality assessment was made of the included studies.Results: The search resulted in 2 100 articles and after the selection process, only three articles were included in this review. The studies evaluated different types of bisphosphonates - ibandronate, pamidronate and disodium clodronate. The reduction of pain was evaluated in all three articles and the bone healing was assessed in two of the articles. Conclusion: Treatment of non-infectious osteomyelitis with bisphosphonates shows a reduction in pain. However, the pain-relieving effect is most probably dependent on the type of bisphosphonates. The results of bone healing assessed from Tc-scans are ambiguous and therefore no conclusion can be made. Only one article in this review was considered to have high quality in the quality assessment. To enable clear guidelines regarding treatment of non-infectious osteomyelitis, more clinical trials with high quality is desirable. In summary, bisphosphonates seem to be a good alternative in treatment of non-infectious osteomyelitis. An alternative to bisphosphonates might be treatment with denosumab, which have a similar mechanism of action but shorter half-life. However, further research is needed.

Staphylococcus aureus kann bei etwa 25% der gesunden Normalbevölkerung nachgewiesen werden, ohne Symptome zu verursachen. Dieser Keim ist jedoch auch einer der wichtigsten Erreger bei Osteomyelitis und Infektionen von orthopädischen Implantaten wie z. B. von künstlichen Knie- oder Hüftgelenken. Diese Infektionen führen meist zu aufwendigen und risikobehafteten operativen Eingriffen sowie zu einer langfristigen Antibiotikagabe. In der vorliegenden Arbeit sollten S. aureus-Isolate charakterisiert werden, die aus Osteomyelitisherden oder infizierten orthopädischen Implantaten gewonnen wurden. Ziel war es, die Isolate daraufhin zu untersuchen, ob bestimmte Stämme dominieren und ob das Vorhandensein bestimmter Virulenzfaktoren mit einem besonderen Risiko für solche Infektionen korreliert. Für diese Untersuchungen wurden DNA-Arrays eingesetzt, welche es ermöglichen, alle relevanten Virulenzfaktoren in einem Experiment nachzuweisen, einen „genetischen Fingerabdruck“ zu erheben und die Isolate so Verwandtschaftsgruppen (klonalen Komplexen, CC) zuzuordnen. Insgesamt wurden 119 klinische Isolate charakterisiert. Sie gehörten zu 20 verschiedenen klonalen Komplexen. CC8 (19,3%), CC45 (17,7%) und CC30 (12,6%) dominierten. MRSA waren selten nachweisbar. Die sieben MRSA-Isolate gehörten zu den lokal dominierenden Stämmen (Rhein-Hessen, Süddeutscher, Barnimer und Berliner Epidemiestamm sowie Europäischer caMRSA-Klon). Die Populationsstruktur der klinischen Isolate und die Häufigkeiten der untersuchten Virulenz- und Adhäsionsfaktoren entsprachen weitestgehend Isolaten von asymptomatischen Trägern, die in einer früheren Studie bestimmt wurden (Molecular epidemiology of Staphylococcus aureus in asymptomatic carriers; Monecke, Lüdicke, Slickers, Ehricht; Eur J Clin Microbiol Infect Dis. 2009). Es konnte kein molekularer Marker identifiziert werden, der allein für eine Risikostratifizierung eingesetzt werden kann. Das Gen für Staphylokinase (sak) war jedoch bei den klinischen Isolaten (90,8%) häufiger nachzuweisen als in Isolaten von asymptomatischen Trägern (71,6%). Einige andere Gene traten ebenfalls bei Patienten häufiger auf, aber waren insgesamt zu selten, um bei Osteomyelitis und Implantatinfektionen eine signifikante Rolle zu spielen. Ein Beispiel dafür war das Panton-Valentine Leukozidin, das in 0,7% der Isolate von asymptomatischen Trägern und in 3,4% der Patientenisolate gefunden wurde. CC15 war bei Isolaten von asymptomatischen Trägern häufiger vertreten (16.8%) als bei Patientenisolaten (5.9%). Da alle CC15-Isolate sak-negativ waren, könnte auch diese Beobachtung als Indiz für einen Zusammenhang zwischen dem Vorhandensein von Staphylokinase und Invasivität gewertet werden. CC45 war bei Patientenisolaten (17,7%) häufiger als bei den asymptomatischen Trägern (9,0%) vorhanden. Es konnte jedoch kein CC45-spezifischer Faktor identifiziert werden, der mit einer höheren Virulenz im Zusammenhang stehen könnte. Des Weiteren sollte untersucht werden, ob S. aureus in infizierten orthopädischen Implantaten endogenen Ursprungs ist. Bei 23 Patienten mit Infektionen von Knie- oder Hüfttotalendoprothesen konnten parallel Nasenabstriche genommen und untersucht werden. Fünfzehn von ihnen (65,2%) waren Träger von S. aureus und bei neun (39,1%) waren die Isolate aus Nasenabstrichen und den infizierten Endoprothesen identisch. Dies weist darauf hin, daß Träger von S. aureus ein erhöhtes Risiko haben, Infektionen von Knie- oder Hüfttotalendoprothesen zu erleiden und daß ein großer Teil dieser Infektionen endogenen Ursprungs ist. Deshalb sollten Patienten vor Implantation von Knie- oder Hüfttotalendoprothesen auf Trägerschaft von S. aureus untersucht werden. Falls S. aureus nachgewiesen wird, sollte dieser Keim generell präoperativ eradiziert werden, um das Risiko endogener Infektionen zu verringern. Eine prospektive Studie zu diesem Thema wird empfohlen. / Staphylococcus aureus is asymptomatically carried by approximately 25% of a normal population. It is also one of the most important causes of osteomyelitis and infections of orthopedic implants such as total hip or knee replacements. Such infections usually lead to complicated and risky surgical procedures as well as to long-term antibiotic treatment. In the present work, S. aureus isolates from osteomyelitis or implant infections were to be characterised. The aim of the study was to prove whether certain strains were overrepresented among patient isolates, and whether the presence of certain virulence factors might correlate with these infections. DNA arrays where used which facilitate to screen for all relevant virulence factors within a single experiment and which allow typing by obtaining a genetic fingerprint of the examined isolate. By this method, it was also possible to assign isolates to phylogenetic clusters, so-called clonal complexes. 119 clinical isolates were characterised in this way. They belonged to 20 different clonal complexes (CC). CC8 (19.3%), CC45 (17.7%) and CC30 (12.6%) dominated. MRSA were rarely detected. The seven MRSA isolates belonged to locally predominant epidemic strains (ST5-MRSA-II, ST228-MRSA-I, ST22-MRSA-IV, ST45-MRSA-IV and ST80-MRSA-IV). The population structure of the clinical isolates and the relative abundances of the examined virulence and adhesion factors corresponded largely to isolates from asymptomatic carriers, which has been examined in an earlier study (Molecular epidemiology of Staphylococcus aureus in asymptomatic carriers; Monecke, Lüdicke, Slickers, Ehricht; Eur J Clin Microbiol Infect Dis. 2009). No molecular maker was detected which could alone be used for risk assessment. The gene for staphylokinase (sak) was clearly more common among clinical isolates (90.8%) than in isolates from asymptomatic carriers (71.6%). Some other genes were also found to be more common in patient isolates, but were very rare so that a significant role in bone and implant infection appeared to be unlikely. An example is Panton-Valentine leukocidin, which was detected in 3.4% of patient isolates and 0.7% of carrier isolates. CC15 was more commonly detected among healthy carriers (16.8%), than among patients (5.9%). Since all CC15 isolates were negative for sak, this also might be related to a possible role of staphylokinase in pathogenesis of invasive disease. CC45 was more abundant in patient samples (17.7%) than in swabs of healthy carriers (9.0%). However, it was not possible to identify a CC45-specific factor which might have been related to a higher virulence. Another aim of the study was to investigate whether S. aureus from orthopaedic implant infections were of endogenous origin. For 23 patients with S. aureus infections of total knee or hip prosthetics, it was possible to obtain nasal swabs in order to detect and type possible S. aureus carriage strains. Fifteen of them (65.2%) carried S. aureus. In nine patients (39.1%), isolates from nasal swabs and foci of infection were identical. This indicates that carriers of S. aureus are at risk of developing infections of total knee or hip prosthetics, and that a considerable proportion of these infections are of endogenous origin. Therefore, patients should generally be screened for S. aureus carriage prior to joint replacement. In case of detection, S. aureus should be eradicated in order to decrease the risk of endogenous infection. A prospective study is recommended.

Staphylococcus aureus kann bei etwa 25% der gesunden Normalbevölkerung nachgewiesen werden, ohne Symptome zu verursachen. Dieser Keim ist jedoch auch einer der wichtigsten Erreger bei Osteomyelitis und Infektionen von orthopädischen Implantaten wie z. B. von künstlichen Knie- oder Hüftgelenken. Diese Infektionen führen meist zu aufwendigen und risikobehafteten operativen Eingriffen sowie zu einer langfristigen Antibiotikagabe. In der vorliegenden Arbeit sollten S. aureus-Isolate charakterisiert werden, die aus Osteomyelitisherden oder infizierten orthopädischen Implantaten gewonnen wurden. Ziel war es, die Isolate daraufhin zu untersuchen, ob bestimmte Stämme dominieren und ob das Vorhandensein bestimmter Virulenzfaktoren mit einem besonderen Risiko für solche Infektionen korreliert. Für diese Untersuchungen wurden DNA-Arrays eingesetzt, welche es ermöglichen, alle relevanten Virulenzfaktoren in einem Experiment nachzuweisen, einen „genetischen Fingerabdruck“ zu erheben und die Isolate so Verwandtschaftsgruppen (klonalen Komplexen, CC) zuzuordnen. Insgesamt wurden 119 klinische Isolate charakterisiert. Sie gehörten zu 20 verschiedenen klonalen Komplexen. CC8 (19,3%), CC45 (17,7%) und CC30 (12,6%) dominierten. MRSA waren selten nachweisbar. Die sieben MRSA-Isolate gehörten zu den lokal dominierenden Stämmen (Rhein-Hessen, Süddeutscher, Barnimer und Berliner Epidemiestamm sowie Europäischer caMRSA-Klon). Die Populationsstruktur der klinischen Isolate und die Häufigkeiten der untersuchten Virulenz- und Adhäsionsfaktoren entsprachen weitestgehend Isolaten von asymptomatischen Trägern, die in einer früheren Studie bestimmt wurden (Molecular epidemiology of Staphylococcus aureus in asymptomatic carriers; Monecke, Lüdicke, Slickers, Ehricht; Eur J Clin Microbiol Infect Dis. 2009). Es konnte kein molekularer Marker identifiziert werden, der allein für eine Risikostratifizierung eingesetzt werden kann. Das Gen für Staphylokinase (sak) war jedoch bei den klinischen Isolaten (90,8%) häufiger nachzuweisen als in Isolaten von asymptomatischen Trägern (71,6%). Einige andere Gene traten ebenfalls bei Patienten häufiger auf, aber waren insgesamt zu selten, um bei Osteomyelitis und Implantatinfektionen eine signifikante Rolle zu spielen. Ein Beispiel dafür war das Panton-Valentine Leukozidin, das in 0,7% der Isolate von asymptomatischen Trägern und in 3,4% der Patientenisolate gefunden wurde. CC15 war bei Isolaten von asymptomatischen Trägern häufiger vertreten (16.8%) als bei Patientenisolaten (5.9%). Da alle CC15-Isolate sak-negativ waren, könnte auch diese Beobachtung als Indiz für einen Zusammenhang zwischen dem Vorhandensein von Staphylokinase und Invasivität gewertet werden. CC45 war bei Patientenisolaten (17,7%) häufiger als bei den asymptomatischen Trägern (9,0%) vorhanden. Es konnte jedoch kein CC45-spezifischer Faktor identifiziert werden, der mit einer höheren Virulenz im Zusammenhang stehen könnte. Des Weiteren sollte untersucht werden, ob S. aureus in infizierten orthopädischen Implantaten endogenen Ursprungs ist. Bei 23 Patienten mit Infektionen von Knie- oder Hüfttotalendoprothesen konnten parallel Nasenabstriche genommen und untersucht werden. Fünfzehn von ihnen (65,2%) waren Träger von S. aureus und bei neun (39,1%) waren die Isolate aus Nasenabstrichen und den infizierten Endoprothesen identisch. Dies weist darauf hin, daß Träger von S. aureus ein erhöhtes Risiko haben, Infektionen von Knie- oder Hüfttotalendoprothesen zu erleiden und daß ein großer Teil dieser Infektionen endogenen Ursprungs ist. Deshalb sollten Patienten vor Implantation von Knie- oder Hüfttotalendoprothesen auf Trägerschaft von S. aureus untersucht werden. Falls S. aureus nachgewiesen wird, sollte dieser Keim generell präoperativ eradiziert werden, um das Risiko endogener Infektionen zu verringern. Eine prospektive Studie zu diesem Thema wird empfohlen. / Staphylococcus aureus is asymptomatically carried by approximately 25% of a normal population. It is also one of the most important causes of osteomyelitis and infections of orthopedic implants such as total hip or knee replacements. Such infections usually lead to complicated and risky surgical procedures as well as to long-term antibiotic treatment. In the present work, S. aureus isolates from osteomyelitis or implant infections were to be characterised. The aim of the study was to prove whether certain strains were overrepresented among patient isolates, and whether the presence of certain virulence factors might correlate with these infections. DNA arrays where used which facilitate to screen for all relevant virulence factors within a single experiment and which allow typing by obtaining a genetic fingerprint of the examined isolate. By this method, it was also possible to assign isolates to phylogenetic clusters, so-called clonal complexes. 119 clinical isolates were characterised in this way. They belonged to 20 different clonal complexes (CC). CC8 (19.3%), CC45 (17.7%) and CC30 (12.6%) dominated. MRSA were rarely detected. The seven MRSA isolates belonged to locally predominant epidemic strains (ST5-MRSA-II, ST228-MRSA-I, ST22-MRSA-IV, ST45-MRSA-IV and ST80-MRSA-IV). The population structure of the clinical isolates and the relative abundances of the examined virulence and adhesion factors corresponded largely to isolates from asymptomatic carriers, which has been examined in an earlier study (Molecular epidemiology of Staphylococcus aureus in asymptomatic carriers; Monecke, Lüdicke, Slickers, Ehricht; Eur J Clin Microbiol Infect Dis. 2009). No molecular maker was detected which could alone be used for risk assessment. The gene for staphylokinase (sak) was clearly more common among clinical isolates (90.8%) than in isolates from asymptomatic carriers (71.6%). Some other genes were also found to be more common in patient isolates, but were very rare so that a significant role in bone and implant infection appeared to be unlikely. An example is Panton-Valentine leukocidin, which was detected in 3.4% of patient isolates and 0.7% of carrier isolates. CC15 was more commonly detected among healthy carriers (16.8%), than among patients (5.9%). Since all CC15 isolates were negative for sak, this also might be related to a possible role of staphylokinase in pathogenesis of invasive disease. CC45 was more abundant in patient samples (17.7%) than in swabs of healthy carriers (9.0%). However, it was not possible to identify a CC45-specific factor which might have been related to a higher virulence. Another aim of the study was to investigate whether S. aureus from orthopaedic implant infections were of endogenous origin. For 23 patients with S. aureus infections of total knee or hip prosthetics, it was possible to obtain nasal swabs in order to detect and type possible S. aureus carriage strains. Fifteen of them (65.2%) carried S. aureus. In nine patients (39.1%), isolates from nasal swabs and foci of infection were identical. This indicates that carriers of S. aureus are at risk of developing infections of total knee or hip prosthetics, and that a considerable proportion of these infections are of endogenous origin. Therefore, patients should generally be screened for S. aureus carriage prior to joint replacement. In case of detection, S. aureus should be eradicated in order to decrease the risk of endogenous infection. A prospective study is recommended.

ENGLISH ABSTRACT: Background: The detection of bone infection can be very difficult especially in bone with altered structure due to prior trauma or surgical procedures. Complicated osteomyelitis (COM) is becoming a public health problem especially with the difficult choice between, high cost surgery and prolonged courses of intravenous or oral antibiotic therapy, as well as the social and psychological effect of longterm disease and disability of the patient. The correct localisation of especially bone infection is still a challenge for the clinician. The single photon emission computed tomography/low dose computed tomography (SPECT/CT), by fusing the functional information with the anatomical parts, is a wellestablished tool used in many nuclear medicine studies. This improves the overall quality of the study with more clear answers. The aim of the study was to determine the added value of SPECT/CT in the management of complicated osteomyelitis (COM) in patients with endo-prosthesis, post traumatic osteomyelitis with and without metal implants and diabetic foot. Methods: This was a prospective study, between February 2010 and February 2012. Patients with suspected COM who fulfilled the selection and inclusion criteria were included. All had abnormal three phase bone scan followed by infection imaging with 99mTc labelled white blood cells and 99mTc -colloid if the99mTc labelled white blood cell study was abnormal. 67Ga citrate was used in vertebral involvement. Planar and SPECT/CT images were reviewed for presence of abnormal uptake and for its localization in bone and soft tissue. Scan results were defined as positive or negative. Both planar and SPECT/CT images were compared regarding diagnosis and precise localization of infection. The final diagnosis was obtained from surgical specimen or microbiological culture as well as clinical follow-up of all patients. Results: There were 72 patients, 29 male and 43 female with mean age of 57 yrs [range 27-88].There were 24 patients with prosthesis, 16 with hip prosthesis (PH=16), and 8 with knee prosthesis (PK=8). There were 44 patients with post traumatic osteomyelitis, 26 with metal implants (TOM=26) and 18 without metal implants (TOWM= 18). Four patients had diabetic foot (DF= 4). Infection was diagnosed in 19/72 patients on planar images and in 21/72 on SPECT/CT. Infection was diagnosed in 4 patients with prosthesis, 16 patients with post traumatic injury and one diabetic foot patient. The four patients with prosthesis, SPECT /CT added diagnostic value by excluding osteomyelitis in 3 patients and by defining the exact extent and localizing soft tissue and bone infection (STI/OM) in one patient. In 16 patients with post traumatic OM on planar images, SPECT /CT added diagnostic value, by excluding OM in 4 patients and confirming only STI, better localisation of the uptake in bone and soft tissue in 5 patients, of them 2 patient was negative on planar, and in 7 patients, confirmed and defined the exact extent of both OM and STI. One diabetic foot was positive for STI on the planar, the SPECT/CT added diagnostic value by defining the extent of the infection. In summary the added value of SPECT/CT was: a. Overall infection: 1. Exclusion of osteomyelitis by confirming only soft tissue involvement: 7 patients (10%) 2. Better localization in bone and soft tissue: 6 patients (8%) 3. Better delineation of extent of infection: 9 patients (12%) 4. None: 50 patients (70%) b. In positive cases only: 1. Exclusion of osteomyelitis by confirming only soft tissue involvement: 7 patients (33%) 2. Better localization in bone and soft tissue: 5 patients (24%) 3. Better delineation of extent of infection: 9 patients (43%) 4. None: 0 patients The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy for infection, on planar was 90%, 100%, 100%, 97%, 97%, respectively and for SPECT/CT 100%, 100%, 100%, 100%, 100%. For OM on planar, the sensitivity, specificity , positive predictive value, negative predictive value and accuracy was 100%, 89%, 53%, 100%, 90%, respectively and for SPECT/CT 100%, 100%, 100%, 100%, 100%. Conclusion: In complicated osteomyelitis, SPECT/CT is useful in localizing, defining the exact extent of infection where the planar images are abnormal, with no added value if the planar images are negative. We recommend in clinical practice the routine use of hybrid SPECT/CT imaging in complicated osteomyelitis when planar images are abnormal. / AFRIKAANSE OPSOMMING: Agtergrond: Die opspoor van beeninfeksie is veral moeilik in been wat as gevolg van vorige trauma of chirurgiese prosedures misvorm is. Gekompliseerde osteomiëlitis word ‘n gesondheidsprobleem veral as gevolg van die moeilike keuse tussen hoë koste chirurgie en langdurige kursusse binneaarse of orale antibiotika, asook die sosiale en sielkundige gevolge van langstaande siekte en die gestremdheid van die pasiënt. Die korrekte lokalisering van veral beeninfeksie is steeds ‘n uitdaging vir die geneesheer. Enkel foton emissie rekenaartomografie / lae dosis rekenaartomografie (SPECT/CT), die kombinasie van funksionele en anatomiese inligting, is ‘n goed gevestigde metode in baie kerngeneeskunde ondersoeke. Dit verbeter die algemene kwaliteit van die studie met ‘n meer spesifieke antwoord. Die doel van hierdie studie was om die bykomende waarde van SPECT/CT in die hantering van gekompliseerde osteomiëlitis in pasiënte met endo-protese, post traumatise osteomiëlitis met en sonder metaal prosteses asook diabetiese voet te bepaal. Metode: ‘n Prospektiewe studie is tussen Februarie 2010 en Februarie 2012 gedoen. Pasiënte met vermoedelik gekompliseerde osteomiëlitis wat aan die keuse en insluitingskriteria voldoen het, is ingesluit. Almal het abnormale drie-fase beenflikkergramme gehad, gevolg deur infeksiebeelding met 99mTc gemerkte witselle en 99mTc kolloïed indien die 99mTc gemerkte witselstudie abnormaal was. 67Ga sitraat is gebruik wanneer daar werwelaantasting teenwoordig was. Die planare en SPECT/CT beelde is vergelyk ten opsigte van diagnose en presiese lokalisering van die infeksie. Die finale diagnose is met behulp van chirurgiese monsters en mikrobiologiese kweking asook die kliniese opvolg van alle pasiënte bepaal. Resultate: Die studie het 72 pasiënte, 29 mans en 43 vroue, met gemiddelde ouderdom van 57 jaar [27 – 88 ingesluit]. Daar was 24 pasiënte met prosteses, waarvan 16 met heupprosteses (PH= 16) en 8 met knieprosteses (PK= 8). Van die 44 pasiënte met post traumatiese osteomiëlitis, het 26 metaal prosteses (TOM= 26) en 18 geen metaalprosteses gehad nie (TOWM= 18). Vier pasiënte het diabetiese voet gehad (DF= 4). By 19/72 van die pasiënte is infeksie op die planare beelde gediagnoseer en in 21/72 op die SPECT/CT beelde. Die bykomende twee gevalle was 1 met TOM en 1 met TOWM. Infeksie is by 4 pasiënte met prosteses, 16 pasiënte met post traumatiese besering en 1 met diabetiese voet gediagnoseer. In die vier pasiënte met prosteses, het SPECT/CT ‘n diagnostiese bydrae gelewer om osteomiëlitis by 3 van die pasiënte uit te skakel en die presiese omvang en lokalisering van sagte weefsel en beeninfeksie (STI/OM) in een pasiënt te bepaal. In 16 pasiënte met post traumatise osteomiëlitis op die planare beelde, was SPECT/CT van diagnostiese waarde, waar osteomiëlitis in 4 pasiënte uitgesluit is, en slegs STI bevestig is. Beter lokalisering van die opname in been en sagte weefsel was in 5 pasiënte moontlik, van wie 2 op die planare beelde negatief was, en in 7 pasiënte bevestig en die presiese omvang met beide OM en STI gedefinieer is. Een diabetiese voet was positief vir STI op die planare beelde, maar die SPECT/CT het diagnostiese waarde verbeter deur die omvang van die infeksie beter te toon. Ter opsomming, was die waarde van die SPECT/CT: 1. Uitsluiting van osteomiëlitis deur slegs van sagte weefsel aantasting te bevestig: 7 pasiënte 10% 2. Beter lokalisering in been en sagte weefsel: 5 pasiënte 7% 3. Beter definisie van omvang van infeksie: 9 pasiënte 12% 4. Geen bykomende waarde: 51 pasiënte 71% Die algehele sensitiwiteit, spesifisiteit, positiewe voorspellingswaarde, negatiewe voorspellingswaarde en akkuraatheid vir die opspoor van infeksie vir die planare beelde was 90%, 100%, 100%, 97%, 97%, onderskeidelik en vir die SPECT/CT 100%, 100%, 100%, 100% en 100%. Vir osteomiëlitis was sensitiwiteit, spesifisiteit, positiewe voorspellingswaarde, negatiewe voorspellingswaarde en akkuraatheid van planare beelde 100%, 89%, 53%, 100%, 90%, onderskeidelik en die van SPECT/CT 100%, 100%, 100%, 100% , 100%. Gevolgtrekking: SPECT/CT is nuttig in die lokalisering en definiëring van die presiese omvang van die infeksie in gekompliseerde osteomiëlitis in gevalle waar die planare beelde abnormaal is, met geen bykomende waarde wanneer planare beelde negatief is nie. Ons beveel SPECT/CT beelding as roetine in kliniese praktyk aan wanneer planare beelde in gekompliseerde osteomiëlitis abnormaal is.

Ziel der vorliegenden Studie ist es, die Wertigkeit der 3-Phasen-Skelett¬szintigraphie in der Diagnostik und Therapieentscheidung bei der Unterkiefer¬osteomyelitis zu untersuchen. In die Auswertung gingen die Daten von 149 Pa-tienten (81 Frauen, 68 Männer; Durchschnittsalter: 48,3  15,2 Jahre) der Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie der Julius-Maximilians-Universität Würzburg aus den Jahren 1993 bis 2001 ein, bei denen die gesi-cherte oder Verdachtsdiagnose einer Unterkieferosteomyelitis vorlag und eine Abklärung mittels einer 3-Phasen-Skelettszintigraphie erfolgt war. / The aim of this study was to evaluate the importance of the bone scintigraphy in relation to the diagnosis and the choice of treatment of the osteomyelitis of the lower jaw. 149 patients were examined from the year 1993 until 2001, where a verified or suspected osteoyelitis was diagnosed via bone scintigraphy.

O objetivo deste estudo foi avaliar os fatores de risco, aspectos clínicos, imagenológicos e terapêuticos da osteonecrose dos maxilares associada ao uso dos bisfosfontos (ONMAB), bem como compará-los com o estado atual da doença, na busca de parâmetros que favoreceram o reparo tecidual. Foram avaliados retrospectivamente 40 casos de ONMAB de pacientes oncológicos encaminhados para avaliação estomatológica. Os dados demográficos, clínicos, imagenológicos, laboratoriais, histopatológicos e terapêuticos foram analisados. Foi realizada análise descritiva dos dados e para associar o estado atual da osteonecrose com as demais variáveis foi utilizado o teste exato de Fisher. O nível de significância estabelecido foi de 5% (p0,05). A ONMAB se mostrou mais comum em mulheres, com idade média de 59 anos e associadas mais freqüentemente ao de câncer de mama, seguido de câncer de próstata e do mieloma múltiplo. O principal bisfosfonato utilizado foi o ácido zoledrônico com média de uso de 23,54 meses. A exodontia, o tratamento quimioterápico e com corticóides foram associados com mais da metade dos casos. O aspecto clínico principal foi a exposição óssea com sintomatologia dolorosa associados ou não à drenagem de secreção, principalmente em mandíbula. Modificações no trabeculado ósseo, erosão da cortical e osteoesclerose foram os principais achados de imagem. Dentre todos os tratamentos realizados, a associação de cirurgia com plasma rico em plaquetas (PRP) e laser de diodo foi a mais utilizada (52,5%) e que mostrou alto índice de sucesso clínico (62,96%). A evolução dos casos tratados mostrou que 67,5% apresentaram reparo tecidual e mesmo aqueles que mantiveram a exposição óssea não mostraram sintomatologia dolorosa. A classificação clínica e o tipo de tratamento empregado influenciaram de forma significante a resolução da ONMAB. Conclui-se que medidas de controle local de infeccção, antibioticoterapia e pequenos debridamentos ósseos devem ser adotadas nos quadros de ONMAB, porém em conjunto com a utilização de bioestimuladores teciduais como o PRP e laser de diodo que promovem de forma mais eficiente o reparo tecidual. / The aim of this study was to evaluate the risk factors, clinical, radiological and treatment aspects of bisphosphonate-associated osteonecrosis of the jaws (BONJ) in cancer patients. Likewise, comparing the current state of the disease with the different variables in the search for parameters that favored the tissue repair. We evaluated retrospectively 40 cases of BONJ of cancer patients referred for stomatology evaluation. Demographic data, clinical, radiographic, laboratory, histopathological and treatment were analyzed. We performed descriptive analysis of data and to associate the current state of the osteonecrosis with the other variables we used Fisher\'s exact test. The level of significance established was 5% (p 0.05). The BONJ was more common in women, the mean age was 59 years and was more frequently associated to the breast cancer followed by prostate and multiple myeloma. Zoledronic acid was the main bisphosphonate used with average use of 23.54 months. The dental tooth, chemotherapy and corticosteroids history were associated with more than half of the cases. The clinical aspect was the main bone exposure associated with painful symptoms or drainage of secretions, especially in mandible. Structural alteration of trabecular bone, cortical bone erosion and osteosclerosis were the main radiological findings. Among all the treatments performed, the therapy combining bone resection, diode laser and platelet-rich plasma (PRP) was the most used (52.5%) which showed high rate of clinical success (62.96%). The evolution of treated cases showed that 67.5% had tissue repair and only 32.5% maintained the bone exposure, but all without painful symptoms. The clinical classification and type of treatment used significantly influence the outcome of BONJ . It is concluded that measures of infection local control, antibiotics and small bone debridement should be adopted in the BONJ but with the use of tissue stimulation using PRP and diode laser helps to promote more effective tissue repair.