Divisions of Pediatric Orthopaedics (W.J.Y., I.H.C., T-J.C., and M.H.S.), Radiology (J.-E.C.), and Pediatrics (E.C. and H.J.L.), Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, 110-744 Seoul, South Korea. E-mail address for I.H. Choi:
Department of Orthopedic Surgery, Ewha Womans University Mok-Dong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, 158-710 Seoul, South Korea.
J Bone Joint Surg Am. 2014 Sep 3;96(17):e145. doi: 10.2106/JBJS.M.01186.
Mycobacterial osteomyelitis involving only the epiphysis of a long bone is extremely rare, and its clinical and radiographic features remain unclear. The purpose of this study was to characterize mycobacterial epiphyseal osteomyelitis and to identify differences between its features and those reported for epiphyseal osteomyelitis caused by bacteria or unidentified pathogens.
We retrospectively reviewed the cases of eight children (five males and three females) who presented at a median age of nineteen months (range, twelve to twenty-five months). Clinical findings were compiled. Radiographs and magnetic resonance imaging (MRI) were used to determine local spread of the abscess outside the epiphysis during the disease course. At the time of the latest follow-up evaluation, the presence of limited joint mobility or growth disturbance was determined. Physeal damage was evaluated with use of MRI.
Pathogens were identified through multiplex polymerase chain reaction. Mycobacterium bovis bacille Calmette-Guérin (BCG, Tokyo-172 strain) was identified in four patients; Mycobacterium tuberculosis, in three patients; and nontuberculous mycobacterium, in one patient. The lesion was located at the distal femoral epiphysis in six patients, at the proximal tibial epiphysis in one patient, and at the proximal humeral epiphysis in one patient. The abscess was confined to the epiphysis at the time of initial presentation but, over time, extended outside the epiphysis in seven cases. The lesion was initially located in the cartilaginous epiphysis in two patients, which could be diagnosed only on MRI. Seven patients worsened despite surgical drainage and medication, and five required additional surgery. At follow-up at a mean of 4.1 years (range, 1.3 to 7.8 years), focal physeal damage was evident in five patients, and clinical growth disturbance was evident in one patient.
In contrast to the reported benign features of epiphyseal osteomyelitis caused by bacteria or unidentified pathogens, mycobacterial epiphyseal osteomyelitis seems to have an unfavorable clinical course that tends to lead to physeal damage. MRI is useful for early diagnosis of a cartilaginous lesion and evaluation of abscess spread and physeal damage.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
仅累及长骨骨骺的分枝杆菌骨髓炎极为罕见，其临床和影像学特征仍不清楚。本研究的目的是描述分枝杆菌骨骺骨髓炎，并确定其特征与细菌或未明病原体引起的骨骺骨髓炎特征之间的差异。
我们回顾性分析了 8 名儿童（男 5 例，女 3 例）的病例，这些儿童的中位年龄为 19 个月（12-25 个月）。收集了临床表现。使用 X 线平片和磁共振成像（MRI）来确定脓肿在疾病过程中在骨骺外的局部扩散。在最新的随访评估时，确定了关节活动度受限或生长障碍的存在。使用 MRI 评估骺板损伤。
通过多重聚合酶链反应确定了病原体。4 例患者中培养出牛分枝杆菌卡介苗（Tokyo-172 株），3 例患者中培养出结核分枝杆菌，1 例患者中培养出非结核分枝杆菌。病变位于 6 例患者的股骨远端骨骺、1 例患者的胫骨近端骨骺和 1 例患者的肱骨近端骨骺。在初始表现时，脓肿局限于骨骺，但在 7 例中随时间推移而扩展至骨骺外。在 2 例患者中，病变最初位于软骨骨骺，仅可通过 MRI 诊断。7 例患者尽管进行了手术引流和药物治疗仍病情恶化，5 例需要进一步手术。在平均 4.1 年（1.3-7.8 年）的随访中，5 例患者出现局灶性骺板损伤，1 例患者出现临床生长障碍。
与细菌或未明病原体引起的骨骺骨髓炎的良性特征相比，分枝杆菌骨骺骨髓炎似乎具有不良的临床病程，容易导致骺板损伤。MRI 有助于早期诊断软骨病变，并评估脓肿扩散和骺板损伤。
预后 IV 级。欲了解完整的证据水平描述，请参见作者须知。
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