Factors Associated with Corticotomy in Children with Osteomyelitis

Factors Associated with Corticotomy in Children with Osteomyelitis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factors Associated with Corticotomy in Children with Osteomyelitis Danika Baskar, Brianna Vey, Andrew Jergel, Kiery Braithwaite, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6037397/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Rapid non-contrast MRI is accurate in diagnosing osteomyelitis. However, prior studies demonstrate that contrast may improve osseous abscess/necrosis assessment to better guide surgical decision-making regarding sampling bone marrow. Our study aims to identify critical associations between clinical, laboratory, and imaging findings with corticotomy status to determine the ideal population for a rapid osteomyelitis MRI. Methods: A retrospective review of patients under 18 years old with osteomyelitis was conducted from two children’s hospitals. Demographic data, lab values, operative reports, the presence of intraosseous abscess/necrosis on pre-procedure contrast-enhanced MRI, and corticotomy status were reviewed. Analyses were performed using Wilcoxon rank sum test, Pearson’s Chi-squared test, and Fisher’s exact test where appropriate with a p-value < 0.05 for statistical significance. Results: 124 patients with osteomyelitis were analyzed – 81% of patients underwent a corticotomy, and 55% had osseous abscess/necrosis identified on MRI. Of those who underwent a corticotomy, 63% had MRI confirmed osseous abscess/necrosis compared to 21% who did not (p < 0.001). Further, these patients had a statistically significant higher median age and lower WBC counts than those who did not undergo corticotomy. There was no association between corticotomy status and inflammatory lab markers (ESR/CRP), anatomical location, BMI, sex, race, or ethnicity. Conclusions: Although patients with osseous abscess/necrosis on MRI were more likely to undergo bone marrow sampling, most patients analyzed still underwent corticotomy – with 81% receiving marrow sampling. Preoperative imaging plays a crucial role, but these findings highlight the importance of the clinical intraoperative assessment in surgical management of pediatric patients with osteomyelitis. pediatric osteomyelitis corticotomy MRI pediatric radiology pediatric orthopedics Figures Figure 1 Figure 2 Introduction When a patient is suspected to have osteomyelitis, accurate and early diagnosis is necessary to prevent progression to chronic infectious sequelae and complications such as osseous necrosis. 1 Direct inoculation from contaminated wounds can contribute to the pathogenesis of osteomyelitis. 1 – 5 In children, hematogenous seeding of the highly vascular physis within growing bone is the most common cause of disease. 1 – 7 Treatment of bacterial osteomyelitis in children involves a multimodal approach including careful clinical examination, advanced imaging, prolonged antibiotic therapy, surgical debridement, and appropriate follow-up until the infection is resolved. 1 The role of imaging in the diagnosis of osteomyelitis is one that is crucial to visualize the extent of disease burden and anatomical location. Modalities such as radiography, radionuclide studies, computed tomography (CT), and magnetic resonance imaging (MRI) have been previously described to be used in the evaluation of osteomyelitis. 1 Radiography is typically ordered as the initial imaging study for workup, although it should be noted that osseous changes related to infection may not be visible on plain films for 7–15 days following onset. 1 The most accurate modality to quantify osteomyelitis disease burden and offer superior resolution of the soft tissues is MRI – with a sensitivity of 90% and specificity of 79%. 1,2,8,9 Within the emergency setting, limitations to scanner access and high cost pose several challenges to MRI utilization. 1 For children specifically, lengthy MRI exams often require sedation to obtain diagnostic quality imaging for accurate interpretation. 2 Despite these challenges, MRI is still the preferred modality for osteomyelitis diagnosis and assessment. There has been much discussion regarding MRI protocols for osteomyelitis, especially in reference to the use of contrast agents in enhancing detection of disease. Intravenous (IV) gadolinium-based contrast agents are typically used to improve detection of soft tissue and osseous complications, including intraosseous necrosis/abscess formation, which may guide surgical decision-making regarding whether a corticotomy is necessary to sample bone marrow intraoperatively. 2 , 8 Some studies have noted that the use of IV contrast agents are not necessary for imaging patients with concern for osteomyelitis and further describe that this does not significantly increase sensitivity or specificity in confirming disease. 8 , 10 Another study similarly challenges the utility of contrast-enhanced MRI exams for musculoskeletal infections outside of the spine when no abnormalities are identified on pre-contrast imaging. 11 Recent work by Singer et al. and Parikh et al. demonstrate how an abbreviated non-contrast MRI protocol can be comparable to contrast-enhanced MRI exams in diagnosing osteomyelitis, and holds great potential in decreasing sedation use in pediatric patients. 2 , 12 Our study aims to extend these perspectives beyond imaging visualization to identify whether critical associations exist between clinical, laboratory, and imaging findings with surgical corticotomy status. These findings will help us better understand if pre-imaging attributes can help predict if patients may benefit from contrast-enhanced MRI examinations for the detection of osteomyelitis-related complications. Methods This study was reviewed and approved by the Institutional Review Board (IRB) prior to beginning study activities. No protected health information or patient identifiers were analyzed and all patient imaging studies were de-identified when reviewed as part of the study efforts. Study activities comply with the health insurance portability and accountability act (HIPAA). Patient cases analyzed for this study were sourced from two large quaternary care children’s hospitals under a single institution serving a diverse population across a wide metropolitan region. These two children’s hospitals are part of a clinically integrated network, forming the only freestanding pediatric healthcare system serving the state. Both hospitals included in our analysis have a wide range of subspecialty services available and as a result are closely integrated with one other to meet the care needs of pediatric patients and their families. A retrospective review of patients less than 18 years old with a MRI imaging confirmed diagnosis of osteomyelitis was conducted in collaboration with the Informatics Division of our pediatric healthcare network. Patient cases were sourced from two distinct quaternary care children’s hospitals under the same integrated health system during a 6-year period (August 2015-August 2021). All patients included in our analysis had a prior contrast MRI performed for diagnostic purposes and underwent subsequent intraoperative management for osteomyelitis. Patients were excluded from the study if they had non-contrast MRI exams performed, studies performed at outside institutions, were missing significant information in their radiology or operative reports, or if the following conditions were identified in their clinical history that may further complicate their diagnosis, treatment, or care needs: sickle cell disease, hardware placement, head/neck/spine disease, chronic infection, or were deceased. Patient charts were reviewed for demographic data including age, sex, race, and ethnicity. BMI and inflammatory lab markers upon admission such as WBC count, ESR, and CRP were also recorded. Radiology reports were reviewed for confirmed visualization of osseous abscess or necrosis, which were additionally noted for each patient case. Operative reports were individually evaluated by a single reviewer (pediatric radiology fellow) to determine whether a corticotomy or bone marrow sampling was performed during the patient’s procedure. Terms such as ‘corticotomy’, ‘curettage’, ‘drilled through marrow’ were defined as having bone marrow sampling. If these terms were not included in the report, the entire operative report was reviewed again in conjunction with a second reviewer (pediatric radiologist, 8 years of experience) to assess whether the bone cortex was sampled during the operative procedure. The cases were categorized into upper vs lower extremities. Continuous and categorical variables were summarized using medians and interquartile ranges (IQR) and counts with percentages respectively. Medians were chosen over means because BMI was not normally distributed – for consistency all continuous variables used medians. Comparisons for continuous variables were analyzed using Wilcoxon rank sum test while categorical variables used Pearson’s Chi-squared test (Fisher’s exact test was used when appropriate). For all statistical comparisons a p-value of < 0.05 considered statistically significant. All data cleaning and analysis was performed using R Statistical Software (v4.2.1; R Core Team 2022). Results 194 patients were initially identified to have had a pre-operative contrast enhanced MRI and subsequent operative management for osteomyelitis. 70 were excluded due to factors mentioned previously yielding a total of 124 cases for inclusion in our analysis. The overall mean/median age of our pediatric patient cohort was 7 years (range 2 to 10 years). Children with osteomyelitis who underwent corticotomy during surgical debridement were found to be significantly older, having a median age of 8.0 years compared to those who did not undergo corticotomy with a median age of 2.0 years (p = 0.001). In our sample 63% of patients were male while 37% were female. The majority of patients identified their primary race as White (54%), while 40% identified as black or African American and 77% reported their ethnicity as Non-Hispanic. The average BMI of patients analyzed in our study was 17.29 (Table I). 81% of our studied cohort underwent corticotomy (100/124) as part of their surgical debridement. Between those who underwent a corticotomy and those who did not, there were no significant statistical differences detected in race, ethnicity, sex, and BMI (Table I). Table I: Summary of Demographic Variables Analyzed (n = 124) Corticotomy Overall, N = 124 1 Yes, N = 100 1 No, N = 24 1 p-value 2 Patient Age 7.0 8.0 2.0 0.001 < 2 23 (19%) 14 (14%) 9 (38%) 2–5 32 (26%) 26 (26%) 6 (25%) 6–9 26 (21%) 21 (21%) 5 (21%) 10–13 36 (29%) 32 (32%) 4 (17%) 14–18 7 (6%) 7 (7%) 0 (0%) Sex 0.145 Male 78 (63%) 66 (66%) 12 (50%) Female 46 (37%) 34 (34%) 12 (50%) Race 0.640 White 64 (54%) 54 (56%) 10 (45%) Black or African American 47 (40%) 36 (38%) 11 (50%) Other 7 (6%) 6 (6%) 1 (5%) (Missing) 6 4 2 Ethnicity 0.820 Hispanic or Latino 28 (23%) 23 (23%) 5 (21%) Non-Hispanic or Latino 96 (77%) 77 (77%) 19 (79%) BMI 17.29 (15.33, 19.76) 17.63 (15.38, 20.40) 17.22 (14.77, 18.46) 0.196 1 Median (IQR); n (%) 2 Wilcoxon rank sum test; Fisher's exact test; Pearson's Chi-squared test This table shows a summary of the overall demographic features analyzed for the studied patient cohort and additionally stratified by corticotomy status. Three infectious/inflammatory lab values were noted for each patient including CRP, ESR, and WBC counts (Table II). The mean value for these labs among our pediatric osteomyelitis patient cohort was CRP – 7.5 (normal < 1.0mg/dL), ESR – 59.00 (normal 0-15mm/hr), and WBC – 9.43 (normal 4.5–13.5 THOU cells/uL). There were no statistical differences detected in CRP values between patients who underwent corticotomy during surgery (7.54) compared to those who did not have a corticotomy performed (7.52) (p = 0.796). ESR was slightly higher among patients who underwent a corticotomy at 59.67 compared to 53.83 in patients who did not have a corticotomy, however, there was no statistically significant difference detected between the two groups (p = 0.352). Patients who underwent corticotomy were found to have significantly lower average WBC counts at the time of initial admission of 9.12 cells/µL, compared to those who did not with 11.10 cells/µL (p = 0.007). Table II: Inflammatory Markers Reviewed for Analyzed Cohorts (n = 124) Corticotomy Lab Values Overall, N = 124 1 Yes, N = 100 1 No, N = 24 1 p-value 2 CRP 7.54 (4.06, 11.66) 7.54 (4.03, 11.66) 7.52 (4.16, 12.34) 0.796 ESR 59.00 (38.00, 81.83) 59.67 (40.58, 81.67) 53.83 (31.75, 82.42) 0.352 WBC 9.43 (7.78, 12.10) 9.12 (7.57, 11.69) 11.10 (9.40, 16.85) 0.007 1 Median (IQR); n (%) 2 Wilcoxon rank sum test; Fisher's exact test; Pearson's Chi-squared test This table displays WBC, ESR, and CRP values for the studied patient cohort and additionally stratified by corticotomy status. Figure I provides an overall summary of our analyzed sample of pediatric patients diagnosed with osteomyelitis with further detail based on corticotomy status and MRI findings in Figure II. Regarding key findings on contrast-enhanced MRI performed prior to the patient’s procedure, we found that 55% (68/124) of the total sample mentioned findings concerning for bone abscess and/or necrosis in their imaging reports (Table III). Among the 68 patients with identified bone abscess or necrosis on imaging, 93% (63/68) underwent corticotomy during their operative procedure. Of those who underwent a corticotomy, 63% (63/100) had confirmed osseous abscess/necrosis on MRI compared to only 21% (5/24) of those who did not undergo a corticotomy (p < 0.001). There was no significant difference detected in anatomical location of upper extremity versus lower extremity in whether a corticotomy was performed during surgery (p = 0.373). Figure I: Summary of Osteomyelitis Patients with MRI Findings and Corticotomy Status This graphic shows a breakdown of the patients analyzed in our study cohort based on whether intraosseous abscess/necrosis was identified on pre-procedure MRI and corticotomy status during surgical debridement. Figure II: Corticotomy Status versus Intraosseous Abscess Identification on MRI Shown here is the corticotomy status of patients in our study cohort stratified by whether intraosseous abscess was identified on pre-procedure MRI. Table III: MRI Findings and Anatomical Location Differences Corticotomy Overall, N = 124 1 Yes, N = 100 1 No, N = 24 1 p-value 2 Bone Abscess/Necrosis 68 (55%) 63 (63%) 5 (21%) < 0.001 Location 0.373 Lower Extremities Only 101 (82%) 83 (84%) 18 (75%) Upper Extremities Only 22 (18%) 16 (16%) 6 (25%) (Missing) 1 1 0 1 Median (IQR); n (%) 2 Wilcoxon rank sum test; Fisher's exact test; Pearson's Chi-squared test This table demonstrates findings of whether intraosseous abscess/necrosis was identified on pre-procedure MRI and anatomical location of disease involvement further stratified by corticotomy status. Discussion MRI stands as the best imaging exam for the diagnosis of osteomyelitis given its superior soft tissue resolution. 1 , 2 , 8 , 9 Considering the frequent need for sedation in obtaining pediatric MRI exams, resource coordination, and the financial costs associated with these additional measures, exploring options that provide expedited and safe imaging with high-quality diagnostic ability may be worthwhile. 13 , 14 The identification of osseous abscess or necrosis on imaging has traditionally been an important factor in surgical decision-making to perform a corticotomy for sampling bone marrow at the time of debridement, and is usually a reason for which IV contrast is favored for MRI exams in these patients. 2 , 8 Although IV contrast has been used to identify osseous necrosis or abscess formation in patients with concern for osteomyelitis, studies have also challenged this practice by demonstrating equivocal evaluation using non-contrast MRI studies. 2 , 8 , 10 To further extend the clinical utility of identifying these imaging characteristics on MRI exams, our study investigated whether a correlation exists between corticotomy status and clinical, laboratory, or imaging findings to determine whether certain factors may help dictate patient selection for MRI exams with IV contrast. From an analysis of pediatric patients who underwent contrast-enhanced MRI exams prior to surgical intervention for osteomyelitis, we found a significant correlation between patients with identified osseous necrosis and/or abscess on MRI and undergoing corticotomy during the time of surgery. Although patients with identified osseous abscess or necrosis on pre-operative MRI were more likely to undergo bone marrow sampling, the majority of patients analyzed still underwent corticotomy – with 81% receiving marrow sampling. Review of intraoperative reports during data collection for this study revealed how surgeons would inspect the bone marrow visually for signs of infection or purulence after drilling through the cortex to determine whether sampling would be indicated. This underscores the importance that both imaging-based guidance and intraoperative clinical assessment have in decision-making for children with osteomyelitis undergoing surgical debridement. Regarding potential predictors of corticotomy status among children with osteomyelitis, only age and WBC count were found to be significantly different between children who underwent corticotomy during surgical debridement versus those who did not among the analyzed demographic, clinical, or laboratory markers. It was found that patients who underwent corticotomy had a significantly higher median age than patients who did not undergo corticotomy. A potential explanation for this may be related to the ability of an older child to communicate the extent and severity of their symptoms compared to a younger child or infant, prompting potential further bone marrow sampling at the time of surgery. Additionally, contrary to what we initially expected, we found that our patient cohort who underwent corticotomy had significantly lower WBC counts than patients who did not undergo a corticotomy during surgery. Although patients with a higher concern for severe osteomyelitis infection as indicated by a more elevated WBC count would be expected to undergo a corticotomy, increased WBC count has been reported to be a nonspecific marker of inflammation in children with osteomyelitis which may decrease its ability to serve as a reliable predictor. 15 In our analyzed pediatric patient cohort, there were twice as many males as females affected with osteomyelitis, which is consistent with estimates in existing literature. 2 , 3 , 6 Considering the clinical significance of using contrast agents for MRI, IV gadolinium-based contrast has been found to identify smaller associated abscesses that are difficult to visualize on non-contrast imaging. 11 However, Kan and team reported that only a minority of them undergo debridement during surgery, making the ultimate clinical impact of this finding identified on contrast-enhanced MRI minimal. 11 The discussion surrounding an abbreviated non-contrast MRI protocol is being further explored through recent investigation. 2 , 8 , 11 , 12 A study by Parikh et al. found an accuracy of 89% and 95% between 2 reviewers, as well as a high inter-observer agreement (k = 0.79) in using an abbreviated non-contrast MRI protocol to diagnose osteomyelitis compared to a standard pre and post contrast-enhanced MRI exam. 2 This study also reported accuracy of 91% and 100% between reviewers in identifying osseous abscesses using an abbreviated non-contrast MRI exam. 2 Alternative considerations described in the literature include how incorporating diffusion weighted imaging as part of a non-contrast MRI exam can provide equivocal diagnostic ability in recognizing soft tissue abscesses as contrast-enhanced MRI imaging. 16 Overall, the takeaways from our study in addition to recent evidence from related work support further research into the implementation of non-contrast MRI protocols for osteomyelitis detection, especially within our pediatric patient population where rapid scan acquisition, constraints with sedation, and early accurate diagnosis factor into providing timely care. While this study provides initial insight into correlations between imaging and clinical diagnosis that may affect the decision to perform bone marrow sampling in guiding management and treatment of osteomyelitis, there are some limitations that must be noted from our efforts. As our study involved a retrospective review of patient records, our analysis was limited to the information available and were therefore unable to control for potential unreported confounding factors. The analyzed sample size for patients who did not undergo corticotomy was also fairly low, affecting our ability to detect potential significant differences in the analyzed factors within the study. By assessing patients who underwent contrast-MRI examinations and those who had confirmed surgical management for osteomyelitis, we may have been selecting patients with more extensive infection. The specific organism causing infection and underlying disease burden were factors that were not specifically evaluated in this study, which may impact the severity of the ongoing infectious process and decisions pertaining to management. Additionally, a side-by-side comparison of pediatric patients with osteomyelitis diagnosed using non-contrast or contrast-enhanced MRI may reveal more about how the diagnostic ability of these exams impact surgical corticotomy rates. Another potential area to consider investigating would be the perspectives of the orthopedic surgeon to better understand whether certain characteristics guide preference for the use of contrast agents in MRI visualization of osseous abscess/necrosis and the spectrum of factors that impact their decision to perform a surgical corticotomy. These limitations may inform areas of future research to promote interdisciplinary collaboration between pediatric radiologists and orthopaedic surgeons in improving existing diagnostic imaging protocols and patient care outcomes for children affected with osteomyelitis. Conclusion There is a significant association between the presence of osseous abscess/necrosis on contrast-enhanced MRI in children with osteomyelitis and surgical corticotomies performed during intraoperative debridement. However, a high percentage of patients without abscess or necrosis on imaging still receive corticotomies at the time of surgical debridement. Patients who underwent corticotomy were significantly older and had lower WBC counts than patients who did not undergo corticotomy. Otherwise, no other demographic, clinical, or inflammatory markers were found to be associated with corticotomy status in our study. These factors highlight the importance that both imaging-guided diagnosis and clinical intraoperative assessment provides in treating pediatric osteomyelitis. Further investigation designed with an interdisciplinary approach directly comparing non-contrast versus contrast-enhanced MRI examinations for osteomyelitis diagnosis may be helpful to determine whether circumventing the challenges of IV contrast MRI examination in children translates to equitable clinical treatment outcomes. This may not only improve our ability to rapidly assess children with concern for osteomyelitis while improving resource allocation, but also further direct targeted contrast use in pediatric patients with a concern for osteomyelitis and better assist surgical colleagues in their clinical decision-making process. Declarations The authors have no relevant financial or non-financial interests to disclose relevant to the content of this article. The authors did not receive support from any organization for the submitted work. Author Contribution All authors listed contributed to the study conception and design. Material preparation and data collection were performed by D.B., B.V., K.B., and A.P. Data analysis was performed by A.J., B.V., and D.B. The first draft of the manuscript was written by D.B. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Kotecha HM, Lo HS, Vedantham S, Shin H, Cerniglia CA. Abbreviated MRI of the foot in patients with suspected osteomyelitis. Emerg Radiol . 2020;27(1):9-16. doi:10.1007/s10140-019-01722-y Parikh AK, Richer EJ, Shen A, Zhang C, Braithwaite KA, Rostad BS. An Abbreviated Non-Contrast MRI Protocol for Osteomyelitis May Reduce the Need for Sedation in Young Children. Current Problems in Diagnostic Radiology . 2023;52(6):485-492. doi:10.1067/j.cpradiol.2023.05.011 Peltola H, Pääkkönen M. Acute osteomyelitis in children. N Engl J Med . 2014;370(4):352-360. doi:10.1056/NEJMra1213956 Pugmire BS, Shailam R, Gee MS. Role of MRI in the diagnosis and treatment of osteomyelitis in pediatric patients. World J Radiol . 2014;6(8):530-537. doi:10.4329/wjr.v6.i8.530 Lee YJ, Sadigh S, Mankad K, Kapse N, Rajeswaran G. The imaging of osteomyelitis. Quant Imaging Med Surg . 2016;6(2):184-198. doi:10.21037/qims.2016.04.01 Moore-Lotridge SN, Gibson BH, Duvernay MT, Martus JE, Thomsen IP, Schoenecker JG. Pediatric Musculoskeletal Infection : An Update Through the Four Pillars of Clinical Care and Immunothrombotic Similarities With COVID-19. JPOSNA . 2020;2(2). doi:10.55275/JPOSNA-2020-124 Lew DP, Waldvogel FA. Osteomyelitis. Lancet . 2004;364(9431):369-379. doi:10.1016/S0140-6736(04)16727-5 Averill LW, Hernandez A, Gonzalez L, Peña AH, Jaramillo D. Diagnosis of osteomyelitis in children: utility of fat-suppressed contrast-enhanced MRI. AJR Am J Roentgenol . 2009;192(5):1232-1238. doi:10.2214/AJR.07.3400 Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis . 2008;47(4):519-527. doi:10.1086/590011 Markhardt BK, Woo K, Nguyen JC. Evaluation of suspected musculoskeletal infection in children over 2 years of age using only fluid-sensitive sequences at MRI. Eur Radiol . 2019;29(10):5682-5690. doi:10.1007/s00330-019-06143-6 Kan JH, Young RS, Yu C, Hernanz-Schulman M. Clinical impact of gadolinium in the MRI diagnosis of musculoskeletal infection in children. Pediatr Radiol . 2010;40(7):1197-1205. doi:10.1007/s00247-010-1557-2 Singer AD, Umpierrez M, Kakarala A, et al. Performance of a rapid two-sequence screening protocol for osteomyelitis of the foot. Skeletal Radiol . 2020;49(6):977-984. doi:10.1007/s00256-019-03367-x Vanderby SA, Babyn PS, Carter MW, Jewell SM, McKeever PD. Effect of anesthesia and sedation on pediatric MR imaging patient flow. Radiology . 2010;256(1):229-237. doi:10.1148/radiol.10091124 Edwards AD, Arthurs OJ. Paediatric MRI under sedation: is it necessary? What is the evidence for the alternatives? Pediatr Radiol . 2011;41(11):1353-1364. doi:10.1007/s00247-011-2147-7 Ferguson LP, Beattie TF. Osteomyelitis in the well looking afebrile child. BMJ . 2002;324(7350):1380-1381. Chun CW, Jung JY, Baik JS, Jee WH, Kim SK, Shin SH. Detection of soft-tissue abscess: Comparison of diffusion-weighted imaging to contrast-enhanced MRI. J Magn Reson Imaging . 2018;47(1):60-68. doi:10.1002/jmri.25743 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Parikh","email":"data:image/png;base64,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","orcid":"","institution":"Emory University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Ashishkumar","middleName":"","lastName":"Parikh","suffix":""}],"badges":[],"createdAt":"2025-02-15 15:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6037397/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6037397/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":77310059,"identity":"5d845ce7-120f-4349-9e64-234a521fa4d6","added_by":"auto","created_at":"2025-02-27 09:43:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63866,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSummary of Osteomyelitis Patients with MRI Findings and Corticotomy Status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis graphic shows a breakdown of the patients analyzed in our study cohort based on whether intraosseous abscess/necrosis was identified on pre-procedure MRI and corticotomy status during surgical debridement.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6037397/v1/9741cbc720f088e6aa05345b.png"},{"id":77311463,"identity":"ffd7da96-f3d6-4799-a0f0-2e284eae1d3e","added_by":"auto","created_at":"2025-02-27 09:59:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":88847,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorticotomy Status versus Intraosseous Abscess Identification on MRI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShown here is the corticotomy status of patients in our study cohort stratified by whether intraosseous abscess was identified on pre-procedure MRI.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6037397/v1/24a60c6d56af40a1d00cc834.png"},{"id":80899558,"identity":"b3f3447f-83b6-4751-998e-e8563c18834e","added_by":"auto","created_at":"2025-04-18 13:01:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1021509,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6037397/v1/d1cc4c75-5712-4de4-9751-57fa1b72a775.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors Associated with Corticotomy in Children with Osteomyelitis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWhen a patient is suspected to have osteomyelitis, accurate and early diagnosis is necessary to prevent progression to chronic infectious sequelae and complications such as osseous necrosis.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Direct inoculation from contaminated wounds can contribute to the pathogenesis of osteomyelitis.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e In children, hematogenous seeding of the highly vascular physis within growing bone is the most common cause of disease.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Treatment of bacterial osteomyelitis in children involves a multimodal approach including careful clinical examination, advanced imaging, prolonged antibiotic therapy, surgical debridement, and appropriate follow-up until the infection is resolved.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The role of imaging in the diagnosis of osteomyelitis is one that is crucial to visualize the extent of disease burden and anatomical location.\u003c/p\u003e \u003cp\u003eModalities such as radiography, radionuclide studies, computed tomography (CT), and magnetic resonance imaging (MRI) have been previously described to be used in the evaluation of osteomyelitis.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Radiography is typically ordered as the initial imaging study for workup, although it should be noted that osseous changes related to infection may not be visible on plain films for 7\u0026ndash;15 days following onset.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The most accurate modality to quantify osteomyelitis disease burden and offer superior resolution of the soft tissues is MRI \u0026ndash; with a sensitivity of 90% and specificity of 79%.\u003csup\u003e1,2,8,9\u003c/sup\u003e Within the emergency setting, limitations to scanner access and high cost pose several challenges to MRI utilization.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e For children specifically, lengthy MRI exams often require sedation to obtain diagnostic quality imaging for accurate interpretation.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Despite these challenges, MRI is still the preferred modality for osteomyelitis diagnosis and assessment.\u003c/p\u003e \u003cp\u003eThere has been much discussion regarding MRI protocols for osteomyelitis, especially in reference to the use of contrast agents in enhancing detection of disease. Intravenous (IV) gadolinium-based contrast agents are typically used to improve detection of soft tissue and osseous complications, including intraosseous necrosis/abscess formation, which may guide surgical decision-making regarding whether a corticotomy is necessary to sample bone marrow intraoperatively.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Some studies have noted that the use of IV contrast agents are not necessary for imaging patients with concern for osteomyelitis and further describe that this does not significantly increase sensitivity or specificity in confirming disease.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Another study similarly challenges the utility of contrast-enhanced MRI exams for musculoskeletal infections outside of the spine when no abnormalities are identified on pre-contrast imaging.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Recent work by Singer et al. and Parikh et al. demonstrate how an abbreviated non-contrast MRI protocol can be comparable to contrast-enhanced MRI exams in diagnosing osteomyelitis, and holds great potential in decreasing sedation use in pediatric patients.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Our study aims to extend these perspectives beyond imaging visualization to identify whether critical associations exist between clinical, laboratory, and imaging findings with surgical corticotomy status. These findings will help us better understand if pre-imaging attributes can help predict if patients may benefit from contrast-enhanced MRI examinations for the detection of osteomyelitis-related complications.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study was reviewed and approved by the Institutional Review Board (IRB) prior to beginning study activities. No protected health information or patient identifiers were analyzed and all patient imaging studies were de-identified when reviewed as part of the study efforts. Study activities comply with the health insurance portability and accountability act (HIPAA).\u003c/p\u003e \u003cp\u003e Patient cases analyzed for this study were sourced from two large quaternary care children\u0026rsquo;s hospitals under a single institution serving a diverse population across a wide metropolitan region. These two children\u0026rsquo;s hospitals are part of a clinically integrated network, forming the only freestanding pediatric healthcare system serving the state. Both hospitals included in our analysis have a wide range of subspecialty services available and as a result are closely integrated with one other to meet the care needs of pediatric patients and their families.\u003c/p\u003e \u003cp\u003e A retrospective review of patients less than 18 years old with a MRI imaging confirmed diagnosis of osteomyelitis was conducted in collaboration with the Informatics Division of our pediatric healthcare network. Patient cases were sourced from two distinct quaternary care children\u0026rsquo;s hospitals under the same integrated health system during a 6-year period (August 2015-August 2021). All patients included in our analysis had a prior contrast MRI performed for diagnostic purposes and underwent subsequent intraoperative management for osteomyelitis. Patients were excluded from the study if they had non-contrast MRI exams performed, studies performed at outside institutions, were missing significant information in their radiology or operative reports, or if the following conditions were identified in their clinical history that may further complicate their diagnosis, treatment, or care needs: sickle cell disease, hardware placement, head/neck/spine disease, chronic infection, or were deceased.\u003c/p\u003e \u003cp\u003ePatient charts were reviewed for demographic data including age, sex, race, and ethnicity. BMI and inflammatory lab markers upon admission such as WBC count, ESR, and CRP were also recorded. Radiology reports were reviewed for confirmed visualization of osseous abscess or necrosis, which were additionally noted for each patient case. Operative reports were individually evaluated by a single reviewer (pediatric radiology fellow) to determine whether a corticotomy or bone marrow sampling was performed during the patient\u0026rsquo;s procedure. Terms such as \u0026lsquo;corticotomy\u0026rsquo;, \u0026lsquo;curettage\u0026rsquo;, \u0026lsquo;drilled through marrow\u0026rsquo; were defined as having bone marrow sampling. If these terms were not included in the report, the entire operative report was reviewed again in conjunction with a second reviewer (pediatric radiologist, 8 years of experience) to assess whether the bone cortex was sampled during the operative procedure. The cases were categorized into upper vs lower extremities.\u003c/p\u003e \u003cp\u003eContinuous and categorical variables were summarized using medians and interquartile ranges (IQR) and counts with percentages respectively. Medians were chosen over means because BMI was not normally distributed \u0026ndash; for consistency all continuous variables used medians. Comparisons for continuous variables were analyzed using Wilcoxon rank sum test while categorical variables used Pearson\u0026rsquo;s Chi-squared test (Fisher\u0026rsquo;s exact test was used when appropriate). For all statistical comparisons a p-value of \u0026lt;\u0026thinsp;0.05 considered statistically significant. All data cleaning and analysis was performed using R Statistical Software (v4.2.1; R Core Team 2022).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e194 patients were initially identified to have had a pre-operative contrast enhanced MRI and subsequent operative management for osteomyelitis. 70 were excluded due to factors mentioned previously yielding a total of 124 cases for inclusion in our analysis.\u003c/p\u003e \u003cp\u003eThe overall mean/median age of our pediatric patient cohort was 7 years (range 2 to 10 years). Children with osteomyelitis who underwent corticotomy during surgical debridement were found to be significantly older, having a median age of 8.0 years compared to those who did not undergo corticotomy with a median age of 2.0 years (p\u0026thinsp;=\u0026thinsp;0.001). In our sample 63% of patients were male while 37% were female. The majority of patients identified their primary race as White (54%), while 40% identified as black or African American and 77% reported their ethnicity as Non-Hispanic. The average BMI of patients analyzed in our study was 17.29 (Table I). 81% of our studied cohort underwent corticotomy (100/124) as part of their surgical debridement. Between those who underwent a corticotomy and those who did not, there were no significant statistical differences detected in race, ethnicity, sex, and BMI (Table I).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable I: Summary of Demographic Variables Analyzed (n\u0026thinsp;=\u0026thinsp;124)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCorticotomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall, N\u0026thinsp;=\u0026thinsp;124\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes, N\u0026thinsp;=\u0026thinsp;100\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo, N\u0026thinsp;=\u0026thinsp;24\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u0026ndash;5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u0026ndash;9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10\u0026ndash;13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e14\u0026ndash;18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.640\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhite\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlack or African American\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e(Missing)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.820\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHispanic or Latino\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon-Hispanic or Latino\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.29 (15.33, 19.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.63 (15.38, 20.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.22 (14.77, 18.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.196\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003cb\u003eMedian (IQR); n (%)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003eWilcoxon rank sum test; Fisher's exact test; Pearson's Chi-squared test\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThis table shows a summary of the overall demographic features analyzed for the studied patient cohort and additionally stratified by corticotomy status.\u003c/p\u003e \u003cp\u003eThree infectious/inflammatory lab values were noted for each patient including CRP, ESR, and WBC counts (Table II). The mean value for these labs among our pediatric osteomyelitis patient cohort was CRP \u0026ndash; 7.5 (normal\u0026thinsp;\u0026lt;\u0026thinsp;1.0mg/dL), ESR \u0026ndash; 59.00 (normal 0-15mm/hr), and WBC \u0026ndash; 9.43 (normal 4.5\u0026ndash;13.5 THOU cells/uL). There were no statistical differences detected in CRP values between patients who underwent corticotomy during surgery (7.54) compared to those who did not have a corticotomy performed (7.52) (p\u0026thinsp;=\u0026thinsp;0.796). ESR was slightly higher among patients who underwent a corticotomy at 59.67 compared to 53.83 in patients who did not have a corticotomy, however, there was no statistically significant difference detected between the two groups (p\u0026thinsp;=\u0026thinsp;0.352). Patients who underwent corticotomy were found to have significantly lower average WBC counts at the time of initial admission of 9.12 cells/\u0026micro;L, compared to those who did not with 11.10 cells/\u0026micro;L (p\u0026thinsp;=\u0026thinsp;0.007).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable II: Inflammatory Markers Reviewed for Analyzed Cohorts (n\u0026thinsp;=\u0026thinsp;124)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCorticotomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLab Values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall, N\u0026thinsp;=\u0026thinsp;124\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes, N\u0026thinsp;=\u0026thinsp;100\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo, N\u0026thinsp;=\u0026thinsp;24\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCRP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.54 (4.06, 11.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.54 (4.03, 11.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.52 (4.16, 12.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.796\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eESR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.00 (38.00, 81.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.67 (40.58, 81.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.83 (31.75, 82.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.43 (7.78, 12.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.12 (7.57, 11.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.10 (9.40, 16.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003eMedian (IQR); n (%)\u003c/p\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003eWilcoxon rank sum test; Fisher's exact test; Pearson's Chi-squared test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThis table displays WBC, ESR, and CRP values for the studied patient cohort and additionally stratified by corticotomy status.\u003c/p\u003e \u003cp\u003eFigure I provides an overall summary of our analyzed sample of pediatric patients diagnosed with osteomyelitis with further detail based on corticotomy status and MRI findings in Figure II. Regarding key findings on contrast-enhanced MRI performed prior to the patient\u0026rsquo;s procedure, we found that 55% (68/124) of the total sample mentioned findings concerning for bone abscess and/or necrosis in their imaging reports (Table III). Among the 68 patients with identified bone abscess or necrosis on imaging, 93% (63/68) underwent corticotomy during their operative procedure. Of those who underwent a corticotomy, 63% (63/100) had confirmed osseous abscess/necrosis on MRI compared to only 21% (5/24) of those who did not undergo a corticotomy (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no significant difference detected in anatomical location of upper extremity versus lower extremity in whether a corticotomy was performed during surgery (p\u0026thinsp;=\u0026thinsp;0.373).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure I: Summary of Osteomyelitis Patients with MRI Findings and Corticotomy Status\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis graphic shows a breakdown of the patients analyzed in our study cohort based on whether intraosseous abscess/necrosis was identified on pre-procedure MRI and corticotomy status during surgical debridement.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure II: Corticotomy Status versus Intraosseous Abscess Identification on MRI\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eShown here is the corticotomy status of patients in our study cohort stratified by whether intraosseous abscess was identified on pre-procedure MRI.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable III: MRI Findings and Anatomical Location Differences\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCorticotomy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall, N\u0026thinsp;=\u0026thinsp;124\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes, N\u0026thinsp;=\u0026thinsp;100\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo, N\u0026thinsp;=\u0026thinsp;24\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBone Abscess/Necrosis\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (55%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (63%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (21%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.373\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLower Extremities Only\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e101 (82%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e83 (84%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e18 (75%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUpper Extremities Only\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e22 (18%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e16 (16%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e6 (25%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e(Missing)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003cb\u003eMedian (IQR); n (%)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003eWilcoxon rank sum test; Fisher's exact test; Pearson's Chi-squared test\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThis table demonstrates findings of whether intraosseous abscess/necrosis was identified on pre-procedure MRI and anatomical location of disease involvement further stratified by corticotomy status.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMRI stands as the best imaging exam for the diagnosis of osteomyelitis given its superior soft tissue resolution.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Considering the frequent need for sedation in obtaining pediatric MRI exams, resource coordination, and the financial costs associated with these additional measures, exploring options that provide expedited and safe imaging with high-quality diagnostic ability may be worthwhile.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The identification of osseous abscess or necrosis on imaging has traditionally been an important factor in surgical decision-making to perform a corticotomy for sampling bone marrow at the time of debridement, and is usually a reason for which IV contrast is favored for MRI exams in these patients.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Although IV contrast has been used to identify osseous necrosis or abscess formation in patients with concern for osteomyelitis, studies have also challenged this practice by demonstrating equivocal evaluation using non-contrast MRI studies.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo further extend the clinical utility of identifying these imaging characteristics on MRI exams, our study investigated whether a correlation exists between corticotomy status and clinical, laboratory, or imaging findings to determine whether certain factors may help dictate patient selection for MRI exams with IV contrast. From an analysis of pediatric patients who underwent contrast-enhanced MRI exams prior to surgical intervention for osteomyelitis, we found a significant correlation between patients with identified osseous necrosis and/or abscess on MRI and undergoing corticotomy during the time of surgery. Although patients with identified osseous abscess or necrosis on pre-operative MRI were more likely to undergo bone marrow sampling, the majority of patients analyzed still underwent corticotomy \u0026ndash; with 81% receiving marrow sampling. Review of intraoperative reports during data collection for this study revealed how surgeons would inspect the bone marrow visually for signs of infection or purulence after drilling through the cortex to determine whether sampling would be indicated. This underscores the importance that both imaging-based guidance and intraoperative clinical assessment have in decision-making for children with osteomyelitis undergoing surgical debridement.\u003c/p\u003e \u003cp\u003eRegarding potential predictors of corticotomy status among children with osteomyelitis, only age and WBC count were found to be significantly different between children who underwent corticotomy during surgical debridement versus those who did not among the analyzed demographic, clinical, or laboratory markers. It was found that patients who underwent corticotomy had a significantly higher median age than patients who did not undergo corticotomy. A potential explanation for this may be related to the ability of an older child to communicate the extent and severity of their symptoms compared to a younger child or infant, prompting potential further bone marrow sampling at the time of surgery. Additionally, contrary to what we initially expected, we found that our patient cohort who underwent corticotomy had significantly lower WBC counts than patients who did not undergo a corticotomy during surgery. Although patients with a higher concern for severe osteomyelitis infection as indicated by a more elevated WBC count would be expected to undergo a corticotomy, increased WBC count has been reported to be a nonspecific marker of inflammation in children with osteomyelitis which may decrease its ability to serve as a reliable predictor.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e In our analyzed pediatric patient cohort, there were twice as many males as females affected with osteomyelitis, which is consistent with estimates in existing literature.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Considering the clinical significance of using contrast agents for MRI, IV gadolinium-based contrast has been found to identify smaller associated abscesses that are difficult to visualize on non-contrast imaging.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e However, Kan and team reported that only a minority of them undergo debridement during surgery, making the ultimate clinical impact of this finding identified on contrast-enhanced MRI minimal.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe discussion surrounding an abbreviated non-contrast MRI protocol is being further explored through recent investigation.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e A study by Parikh et al. found an accuracy of 89% and 95% between 2 reviewers, as well as a high inter-observer agreement (k\u0026thinsp;=\u0026thinsp;0.79) in using an abbreviated non-contrast MRI protocol to diagnose osteomyelitis compared to a standard pre and post contrast-enhanced MRI exam.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e This study also reported accuracy of 91% and 100% between reviewers in identifying osseous abscesses using an abbreviated non-contrast MRI exam.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Alternative considerations described in the literature include how incorporating diffusion weighted imaging as part of a non-contrast MRI exam can provide equivocal diagnostic ability in recognizing soft tissue abscesses as contrast-enhanced MRI imaging.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Overall, the takeaways from our study in addition to recent evidence from related work support further research into the implementation of non-contrast MRI protocols for osteomyelitis detection, especially within our pediatric patient population where rapid scan acquisition, constraints with sedation, and early accurate diagnosis factor into providing timely care.\u003c/p\u003e \u003cp\u003eWhile this study provides initial insight into correlations between imaging and clinical diagnosis that may affect the decision to perform bone marrow sampling in guiding management and treatment of osteomyelitis, there are some limitations that must be noted from our efforts. As our study involved a retrospective review of patient records, our analysis was limited to the information available and were therefore unable to control for potential unreported confounding factors. The analyzed sample size for patients who did not undergo corticotomy was also fairly low, affecting our ability to detect potential significant differences in the analyzed factors within the study. By assessing patients who underwent contrast-MRI examinations and those who had confirmed surgical management for osteomyelitis, we may have been selecting patients with more extensive infection. The specific organism causing infection and underlying disease burden were factors that were not specifically evaluated in this study, which may impact the severity of the ongoing infectious process and decisions pertaining to management. Additionally, a side-by-side comparison of pediatric patients with osteomyelitis diagnosed using non-contrast or contrast-enhanced MRI may reveal more about how the diagnostic ability of these exams impact surgical corticotomy rates. Another potential area to consider investigating would be the perspectives of the orthopedic surgeon to better understand whether certain characteristics guide preference for the use of contrast agents in MRI visualization of osseous abscess/necrosis and the spectrum of factors that impact their decision to perform a surgical corticotomy. These limitations may inform areas of future research to promote interdisciplinary collaboration between pediatric radiologists and orthopaedic surgeons in improving existing diagnostic imaging protocols and patient care outcomes for children affected with osteomyelitis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThere is a significant association between the presence of osseous abscess/necrosis on contrast-enhanced MRI in children with osteomyelitis and surgical corticotomies performed during intraoperative debridement. However, a high percentage of patients without abscess or necrosis on imaging still receive corticotomies at the time of surgical debridement. Patients who underwent corticotomy were significantly older and had lower WBC counts than patients who did not undergo corticotomy. Otherwise, no other demographic, clinical, or inflammatory markers were found to be associated with corticotomy status in our study. These factors highlight the importance that both imaging-guided diagnosis and clinical intraoperative assessment provides in treating pediatric osteomyelitis. Further investigation designed with an interdisciplinary approach directly comparing non-contrast versus contrast-enhanced MRI examinations for osteomyelitis diagnosis may be helpful to determine whether circumventing the challenges of IV contrast MRI examination in children translates to equitable clinical treatment outcomes. This may not only improve our ability to rapidly assess children with concern for osteomyelitis while improving resource allocation, but also further direct targeted contrast use in pediatric patients with a concern for osteomyelitis and better assist surgical colleagues in their clinical decision-making process.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors listed contributed to the study conception and design. Material preparation and data collection were performed by D.B., B.V., K.B., and A.P. Data analysis was performed by A.J., B.V., and D.B. The first draft of the manuscript was written by D.B. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKotecha HM, Lo HS, Vedantham S, Shin H, Cerniglia CA. Abbreviated MRI of the foot in patients with suspected osteomyelitis. \u003cem\u003eEmerg Radiol\u003c/em\u003e. 2020;27(1):9-16. doi:10.1007/s10140-019-01722-y\u003c/li\u003e\n\u003cli\u003eParikh AK, Richer EJ, Shen A, Zhang C, Braithwaite KA, Rostad BS. An Abbreviated Non-Contrast MRI Protocol for Osteomyelitis May Reduce the Need for Sedation in Young Children. \u003cem\u003eCurrent Problems in Diagnostic Radiology\u003c/em\u003e. 2023;52(6):485-492. doi:10.1067/j.cpradiol.2023.05.011\u003c/li\u003e\n\u003cli\u003ePeltola H, P\u0026auml;\u0026auml;kk\u0026ouml;nen M. Acute osteomyelitis in children. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2014;370(4):352-360. doi:10.1056/NEJMra1213956\u003c/li\u003e\n\u003cli\u003ePugmire BS, Shailam R, Gee MS. Role of MRI in the diagnosis and treatment of osteomyelitis in pediatric patients. \u003cem\u003eWorld J Radiol\u003c/em\u003e. 2014;6(8):530-537. doi:10.4329/wjr.v6.i8.530\u003c/li\u003e\n\u003cli\u003eLee YJ, Sadigh S, Mankad K, Kapse N, Rajeswaran G. The imaging of osteomyelitis. \u003cem\u003eQuant Imaging Med Surg\u003c/em\u003e. 2016;6(2):184-198. doi:10.21037/qims.2016.04.01\u003c/li\u003e\n\u003cli\u003eMoore-Lotridge SN, Gibson BH, Duvernay MT, Martus JE, Thomsen IP, Schoenecker JG. Pediatric Musculoskeletal Infection : An Update Through the Four Pillars of Clinical Care and Immunothrombotic Similarities With COVID-19. \u003cem\u003eJPOSNA\u003c/em\u003e. 2020;2(2). doi:10.55275/JPOSNA-2020-124\u003c/li\u003e\n\u003cli\u003eLew DP, Waldvogel FA. Osteomyelitis. \u003cem\u003eLancet\u003c/em\u003e. 2004;364(9431):369-379. doi:10.1016/S0140-6736(04)16727-5\u003c/li\u003e\n\u003cli\u003eAverill LW, Hernandez A, Gonzalez L, Pe\u0026ntilde;a AH, Jaramillo D. Diagnosis of osteomyelitis in children: utility of fat-suppressed contrast-enhanced MRI. \u003cem\u003eAJR Am J Roentgenol\u003c/em\u003e. 2009;192(5):1232-1238. doi:10.2214/AJR.07.3400\u003c/li\u003e\n\u003cli\u003eDinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. \u003cem\u003eClin Infect Dis\u003c/em\u003e. 2008;47(4):519-527. doi:10.1086/590011\u003c/li\u003e\n\u003cli\u003eMarkhardt BK, Woo K, Nguyen JC. Evaluation of suspected musculoskeletal infection in children over 2 years of age using only fluid-sensitive sequences at MRI. \u003cem\u003eEur Radiol\u003c/em\u003e. 2019;29(10):5682-5690. doi:10.1007/s00330-019-06143-6\u003c/li\u003e\n\u003cli\u003eKan JH, Young RS, Yu C, Hernanz-Schulman M. Clinical impact of gadolinium in the MRI diagnosis of musculoskeletal infection in children. \u003cem\u003ePediatr Radiol\u003c/em\u003e. 2010;40(7):1197-1205. doi:10.1007/s00247-010-1557-2\u003c/li\u003e\n\u003cli\u003eSinger AD, Umpierrez M, Kakarala A, et al. Performance of a rapid two-sequence screening protocol for osteomyelitis of the foot. \u003cem\u003eSkeletal Radiol\u003c/em\u003e. 2020;49(6):977-984. doi:10.1007/s00256-019-03367-x\u003c/li\u003e\n\u003cli\u003eVanderby SA, Babyn PS, Carter MW, Jewell SM, McKeever PD. Effect of anesthesia and sedation on pediatric MR imaging patient flow. \u003cem\u003eRadiology\u003c/em\u003e. 2010;256(1):229-237. doi:10.1148/radiol.10091124\u003c/li\u003e\n\u003cli\u003eEdwards AD, Arthurs OJ. Paediatric MRI under sedation: is it necessary? What is the evidence for the alternatives? \u003cem\u003ePediatr Radiol\u003c/em\u003e. 2011;41(11):1353-1364. doi:10.1007/s00247-011-2147-7\u003c/li\u003e\n\u003cli\u003eFerguson LP, Beattie TF. Osteomyelitis in the well looking afebrile child. \u003cem\u003eBMJ\u003c/em\u003e. 2002;324(7350):1380-1381.\u003c/li\u003e\n\u003cli\u003eChun CW, Jung JY, Baik JS, Jee WH, Kim SK, Shin SH. Detection of soft-tissue abscess: Comparison of diffusion-weighted imaging to contrast-enhanced MRI. \u003cem\u003eJ Magn Reson Imaging\u003c/em\u003e. 2018;47(1):60-68. doi:10.1002/jmri.25743\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pediatric, osteomyelitis, corticotomy, MRI, pediatric radiology, pediatric orthopedics","lastPublishedDoi":"10.21203/rs.3.rs-6037397/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6037397/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eRapid non-contrast MRI is accurate in diagnosing osteomyelitis. However, prior studies demonstrate that contrast may improve osseous abscess/necrosis assessment to better guide surgical decision-making regarding sampling bone marrow. Our study aims to identify critical associations between clinical, laboratory, and imaging findings with corticotomy status to determine the ideal population for a rapid osteomyelitis MRI.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA retrospective review of patients under 18 years old with osteomyelitis was conducted from two children\u0026rsquo;s hospitals. Demographic data, lab values, operative reports, the presence of intraosseous abscess/necrosis on pre-procedure contrast-enhanced MRI, and corticotomy status were reviewed. Analyses were performed using Wilcoxon rank sum test, Pearson\u0026rsquo;s Chi-squared test, and Fisher\u0026rsquo;s exact test where appropriate with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for statistical significance.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003e124 patients with osteomyelitis were analyzed \u0026ndash; 81% of patients underwent a corticotomy, and 55% had osseous abscess/necrosis identified on MRI. Of those who underwent a corticotomy, 63% had MRI confirmed osseous abscess/necrosis compared to 21% who did not (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Further, these patients had a statistically significant higher median age and lower WBC counts than those who did not undergo corticotomy. There was no association between corticotomy status and inflammatory lab markers (ESR/CRP), anatomical location, BMI, sex, race, or ethnicity.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eAlthough patients with osseous abscess/necrosis on MRI were more likely to undergo bone marrow sampling, most patients analyzed still underwent corticotomy \u0026ndash; with 81% receiving marrow sampling. Preoperative imaging plays a crucial role, but these findings highlight the importance of the clinical intraoperative assessment in surgical management of pediatric patients with osteomyelitis.\u003c/p\u003e","manuscriptTitle":"Factors Associated with Corticotomy in Children with Osteomyelitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-27 09:43:36","doi":"10.21203/rs.3.rs-6037397/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c923f29d-b22f-44bc-bad1-98075473eca4","owner":[],"postedDate":"February 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-18T12:53:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-27 09:43:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6037397","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6037397","identity":"rs-6037397","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}