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Deep Venous Thrombosis Associated with Osteomyelitis in Children
S. Tyler Hollmig, BA1; Lawson A.B. Copley, MD2; Richard H. Browne, PhD3; Linda M. Grande, RN, CPNP2; Philip L. Wilson, MD2
1 University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-9030. E-mail address: tyler.hollmig@utsouthwestern.edu
2 Children's Medical Center Dallas, 1935 Motor Street, Dallas, TX 75235
3 Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at Children's Medical Center Dallas, Dallas, Texas

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Jul 01;89(7):1517-1523. doi: 10.2106/JBJS.F.01102
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Abstract

Background: The association of deep venous thrombosis and deep musculoskeletal infection in children has been reported infrequently. The purpose of the present study was to evaluate the characteristics of children with osteomyelitis in whom deep venous thrombosis developed and to compare them with those of children with osteomyelitis in whom deep venous thrombosis did not develop.

Methods: A retrospective review of the records of children who were managed at our institution because of a deep musculoskeletal infection between January 2002 and December 2004 identified 212 children with osteomyelitis involving the spine, pelvis, or extremities. Children in whom deep venous thrombosis developed were compared with those in whom it did not develop with respect to age, diagnosis, causative organism, duration of symptoms prior to admission, laboratory values at the time of admission, surgical procedures, and required length of hospitalization.

Results: Eleven children with osteomyelitis and deep venous thrombosis were identified. The mean C-reactive protein level was 16.9 mg/dL for the group of eleven patients with osteomyelitis in whom deep venous thrombosis developed, compared with only 6.8 mg/dL for the group of 201 patients with osteomyelitis in whom deep venous thrombosis did not develop (p = 0.0044). Staphylococcus aureus was the causative organism of infection in all eleven children with deep venous thrombosis and in ninety-three (46%) of the 201 children without deep venous thrombosis. Methicillin-resistant strains of Staphylococcus aureus were identified in eight of the eleven children with deep venous thrombosis and in only forty-nine of the 201 children without deep venous thrombosis. The children with osteomyelitis and deep venous thrombosis were older, had a longer duration of hospitalization, had more admissions to the intensive care unit, and required more surgical procedures than those with osteomyelitis but without deep venous thrombosis.

Conclusions: Deep venous thrombosis in association with musculoskeletal infection is more common in children over the age of eight years who have osteomyelitis caused by methicillin-resistant Staphylococcus aureus and who present with a C-reactive protein level of >6 mg/dL. Diagnostic venous imaging studies should be performed to assess for the presence of deep venous thrombosis in children with osteomyelitis, especially those who have these risk factors.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    James D Heckman
    Posted on November 15, 2007
    From the Editor-in-Chief
    NULL

    It was recently brought to the attention of The Journal that an article by Copley et al published in the July 2007 issue of The Journal of Bone & Joint Surgery- American Volume 1 may have reported cases that had been previously reported in an article appearing in the October 2006 issue of The Journal of Pediatrics by Crary et al 2 . Both journals investigated the patient population by corresponding with the authors of the JBJS-A and The Journal of Pediatrics articles and the Institutional Review Board and Research Administration at the University of Texas Southwestern. Please see the following response from Lawson A. B. Copley, MD, corresponding author of the article published in JBJS-A.

    James D. Heckman, MD Editor-in-Chief The Journal of Bone and Joint Surgery

    1. Hollmig ST, Copley LAB, Browne RH, Grande LM, Wilson PL. Deep Venous Thrombosis Associated with Osteomyelitis in Children. J Bone Joint Surg [A] 2007; 89:1517-23. 2. Crary SE, Buchanan GR, Drake CE, Journeycake JM. Venous Thrombosis and Thromboembolism in Children with Osteomyelitis. J Pediatr 2006; 149: 537- 41.

    To the Editor:

    During our study period, from January 1, 2002 through December 31, 2004, we reported thirteen cases of DVT associated with musculoskeletal infection in children. Eleven of these cases occurred in children with osteomyelitis. After our publication, we became aware of the article of Crary et al. in the Journal of Pediatrics which reported ten cases of DVT associated with osteomyelitis from the same institution (University of Texas Southwestern—Children’s Medical Center of Dallas). After comparing both articles, it appears that there are eight children who are commonly described by the two articles. Our report, therefore, includes eight children who are previously reported in the literature by Crary et al, plus five additional children with DVT (three with Osteomyelitis, one with septic arthritis and one with pyomyositis) within a three year period.

    I apologize for any confusion that might have arisen as a result of reporting these eight cases twice.

    Lawson A. B. Copley, MD Assistant Professor of Orthopaedic Surgery University of Texas Southwestern

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