Brodie's Abscess: A Systematic Review of Reported Cases

Abstract

Introduction: Brodie's abscess is a form of osteomyelitis. Since its first appearance in the medical literature in 1832, numerous cases have been described. The aim of this article is to provide the first comprehensive overview of published cases of Brodie's abscess, and to describe diagnostic methods, therapeutic consequences and outcomes. Methods: According to PRISMA guidelines a systematic review of the literature was performed. All published data in English or Dutch were considered for inclusion with no limitations on publication date. Data was extracted on demography, duration of symptoms, signs of inflammation, diagnostic imaging, causative agent, treatment and follow-up. Results: A total of 70 articles were included, reporting on a total of 407 patients, mostly young (median age 17) males (male:female ratio 2.1:1). The median duration of symptoms before diagnosis was 12 weeks (SD 26). Mostly consisting of pain (98%) and/or swelling (53%). 84% of all patients were afebrile, and less than 50% had elevated serum inflammation markers. Diagnosis was made with a combination of imaging modalities: plain X-ray in 96%, MRI (16%) and CT-scan (8%). Treatment consisted of surgery in 94% of the cases, in conjunction with long term antibiotics in 77%. Staphylococcus aureus was the pathogen most often found in the culture (67,3%). Outcome was generally reported as favorable. Recurrence was reported in 15,6% of the cases requiring further intervention. Two cases developed permanent disability. Conclusion: Brodie's abscess has an insidious onset as systemic inflammatory signs and symptoms were often not found. Treatment consisted mostly of surgery followed by antibiotics (77%) or only surgery (17%) and outcomes were generally reported as favourable.

Keywords: Brodie's abscess; case report; osteomyelitis; systematic review.

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Search syntax

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PRISMA flow chart

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Anatomical distribution of Brodie's abscess in the included literature

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Reported microbiological results of cultures taken from Brodie's abscess in the included literature

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Case 1: A 14-year old girl with no prior medical or surgical history presented with a chronic wound. She strained her right ankle 6 months prior, with a non-revealing x-ray of the ankle taken at the local clinic. Previous treatment of the wound by other health care specialists included antibiotics and wound dressings. On presentation in our clinic a draining sinus tract is seen. Conventional x-ray showed a bone lesion that prompted further imaging with a MRI scan. In the metaphysis of the distal tibia a cystic lesion with rim enhancement is seen, suggestive of a Brodie's abscess. Surgical debridement was performed followed by insertion of gentamycin beads and primary closure. Ten days later these were removed and the defect was filled with autologous bone graft. Pus samples sent for microbiology examination revealed staphyloccus aureus. No further course of antibiotics were prescribed. During the 10 year follow-up she was free from complaints. (A) Draining sinus on the medial side of the right ankle in a 14-year old girl. (B) AP and Lateral x-ray of the right ankle of a 14-year old girl. Arrow pointing at a lytic lesion in de distal tibia. (C) MRI with coronal views of the right ankle with Gadolinium of a 14-year old girl. Bone lesion with rim enhancement suggestive of a Brodie's abscess in the metaphysis of the distal tibia.

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Case 2: A 68-year old man with a history of atherosclerotic disease presented at the clinic with recurrent pain below the right knee. During these pains he was unable to weight bear, but normally a short course of NSAID would quickly help him back on his feet. This time the pain persisted. Clinical examination showed a tender, non-fluctuating swelling over the right prox tibia. Serum inflammatory markers were within normal range but the x ray showed cortical widening of the proximal tibia and sclerotic changes in the medulla. A scintigraphy showed increase uptake in all three phases. A CT scan showed a radiolucent lesion in the proximal metaphysis of the tibia of 2.5 x 2.6 x 3.5 cm. There was sclerotic thickening of the cortex and a sinus to the anterior tibia with a small sequestrum seen centrally. Treatment followed with sequestrectomy and surgical debridement of the abscess and sinus tract. He received oral clindamycin for 1 week and was allowed to bear weight directly. Cultures taking peroperatively came back positive for staphylococci aureus. (A) AP and lateral x-ray of the right proximal tibia of a 68-year old man. Arrow pointing at lytic lesion. (B) Early and late phase bone scintigraphy of the lower extremities of a 68-year old man. Arrow pointing at heightened uptake located at the right proximal tibia. (C) Corronal CT image of right tibia of a 68-year old man. Arrow pointing at cystic lesion with sclerotic thickening of the cortex. (D) Pre-operative photo of a 68-year old man, showing progression of local inflammation around the right proximal tibia. Peri-operative photo of same patient showing bone window and debridement of Brodie's Abscess.