Magnitude of chronic osteomyelitis and its associated factors in children as diagnosed on X-ray visiting at Felege Hiwot Comprehensive Specialized Hospital,Northwest Ethiopia: A cross-sectional study

Abstract

Objectives:

To assess the magnitude of chronic osteomyelitis and its associated factors in children at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Ethiopia, in 2022.

Methods:

A hospital-based cross-sectional study was done between April 15, 2022 and August 15, 2022, in children with an age of 18 years or below, who visited Felege Hiwot Comprehensive Specialized Hospital. A total sample size of 168 participants was involved in the study. The random sampling technique was applied to select the study participants. The data were collected from the patients, their charts, and X-ray requests. The data were cleaned, stored, checked for completeness, and entered into EpiData Version 3.1, which were then exported to SPSS Version 23 for analysis. Descriptive analysis was done, and bivariable and multivariable logistic regression were used for analysis.

Results:

The prevalence of chronic osteomyelitis was found to be 86.3%. The tibia and femur were the most commonly involved bones, and metaphyseal involvement was very common. The most common radiological findings were sequestrum (56%) and involucrum (53%). Of the total patients with radiological evidence of chronic osteomyelitis, 16.6% had complications, the most common of which was a pathologic fracture (12.4%). Being male (adjusted odds ratio = 6.162, 95% confidence interval: 1.12–34.147), being over 10 years old (adjusted odds ratio = 4.048, 95% confidence interval: 1.032–15.886), living in a rural area (adjusted odds ratio = 4.046, 95% confidence interval: 1.236–13.364), having a discharging sinus (adjusted odds ratio = 5.237, 95% confidence interval: 1.393–19.693), having a clinical complaint lasting more than 1 year (adjusted odds ratio = 5.189, 95% confidence interval: 1.247–21.588), and a preceding event of trauma (adjusted odds ratio = =10.363, 95% confidence interval: 1.101–97.509) were the factors associated with chronic osteomyelitis.

Conclusion:

The prevalence of chronic osteomyelitis is high. In this study, being male, being in the age group above 10 years, having rural residency, having a discharging sinus, having a clinical complaint duration of more than 1 year, and having a preceding event of trauma were the factors associated with chronic osteomyelitis. Therefore, healthcare providers should have a high index of suspicion of chronic osteomyelitis in older male children from rural areas with a chronic discharging sinus following trauma.

Keywords

Children chronic osteomyelitis Ethiopia magnitude radiographic findings

Introduction

Osteomyelitis (OM) is an inflammation of the bone medullary cavity and adjacent bone structures with soft tissue components. A bone infection lasting at least 6 weeks and accompanied by radiological evidence is referred to as chronic OM (COM).^1,2 The long bones, particularly the tibia and femur, are the most frequently affected areas by infection. Although most infections are monostotic, infants and neonates have been observed to have polyostotic involvement up to 6.8% and 21%, respectively.^3,4

Long-lasting (chronic) nasal drainage and/or persistent bone pain are the predominant symptoms. Acute OM (AOM), trauma, or surgery to treat a fracture was frequently present in the past. There may occasionally be a flare phenomenon that is marked by sharp increases in the area’s discomfort, swelling, and redness. Muscle wasting and joint contractures are additionally related symptoms in cases that have been present for a while.⁵

The initial modality of preference for evaluating osseous alterations is conventional radiography. Although the data are sparse (levels II–III), conventional imaging has a stated sensitivity of 20–75% and a specificity of 75–83%.³ When examining COM in anatomically complex regions, computed tomography is helpful since it can reveal whether sequestra, cloaca, cortical destruction, and involucrum thickness are present. Even in the very beginning stages of bone infections, magnetic resonance imaging is quite sensitive. OM can be found with good sensitivity but low specificity using bone scintigraphy. There is very little use of ultrasound in treating bone infections.^3,5

One of the most common musculoskeletal infections in children is OM. Around the world, there are only 3–14 cases of childhood OM per 100,000 children.² The incidence is lower in high-income countries, which is 1.94–13/100,000, compared to low-income countries, which is 43–200/100,000.¹

In developed countries, the prevalence of COM is decreasing due to improvements in both healthcare delivery and socioeconomic status, whereas in developing countries, the prevalence is still high, owing to an increase in traumatic incidents, primarily from road traffic accident (RTA), and a high incidence of AOM, which is either misdiagnosed or undertreated.⁶ Furthermore, late presentation of patients for treatment, poor nutritional and immune status of patients, and limited access to antibiotics are the factors that contribute to the higher prevalence of COM in developing countries.⁷

Previously, the mortality rate from OM was higher, but with the advent of antibiotics and complex surgical interventions, the risk of death is almost negligible and the complication rate has dropped to 5%. Despite the drop in mortality rate, patients from developing nations still suffer from chronic complications.⁷

Children with COM mostly experience economical, psychological, and physical morbidity. In terms of physical morbidity, general poor health and mobility issues are included. A child disabled by COM may not be able to do movement properly, which can make them dependent on their family members, and this may also add to the family’s economic problems.The presence of malodorous discharge from their sinuses and their disability will predispose them to social isolation and stigma. Because of the similar problems described, these children may have poor school attendance.⁸ In addition to its disabling complications, COM can have a serious, life-threatening malignant transformation, which is squamous cell cancer (Marjolin’s ulcer).⁹

The treatment of COM requires specialized orthopedic reconstructive surgery and long-term, expensive antibiotic courses, which are difficult to meet in resource-poor settings.¹⁰ Although the recurrence rate in contexts with scarce resources is unknown, it is widely believed to be approximately 30% in richer nations.^10–12 COM is also a problem and a challenge to the orthopedic surgeons and the health facilities, as it is never truly cured.¹³

In Ethiopia, COM accounted for 30% of admissions to Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia.⁹ Despite the significant burden imposed by COM, little research has been conducted in Ethiopia. A study was conducted in Jimma on the treatment and clinical outcome of osteoarticular infections that include both OM and septic arthritis. That study tried to address the management and outcomes of these infections, but it lacked specific treatment outcomes for COM.¹⁴ There is only one documented study done in Ethiopia focusing on the patterns of COM at TASH, which was a 2-year prospective study from 2005 to 2007 that included all ages. But this study was done 15 years ago, which does not give us updated information.⁹ There is only one documented study done on COM patients at Felege Hiwot Referral Comprehensive Specialized Hospital, Bahir Dar, Ethiopia. But this research was done on the nutritional status and associated factors in adult patients with COM.¹⁵ The aim of this study was to assess the magnitude of COM and its associated factors in children to address the aforementioned gap in the area.

Methods and materials

Study setting and period

The study was conducted at the Felege Hiwot Comprehensive Specialized Hospital (FHCSH) in Bahir Dar, Ethiopia. Bahir Dar, the capital city of the Amhara region, is 565 km from Addis Ababa, the capital city of Ethiopia. FHCSH serves a total of 12 million people. The radiology department, one of the several departments at FHCSH, has three qualified radiologists. It provides radiological medical service, and residents are deployed to the department from Tibebe Ghion Specialized Hospital to cover duty-time emergency imaging-related activities. This study was conducted from April 15, 2022 to August 15, 2022.

Study design: An institution-based cross-sectional study was conducted.

Sample size determination

✓ The sample size is determined using the single population proportion formula:

n = \frac{((Z 1 - α / 2) 2 P (1 - P))}{d 2}

where α = level of significance, (Z1 − α/2) = standard normal variate (1.96 at 5%), P = the proportion of the target population estimated to have particular characteristics, and d = margin of error.

Using p < 0.05 (Z1 − α/2 = 1.96), according to a study done at Makerere University Medical School, Uganda, the prevalence of children with COM was 10%.¹⁰

d = 3%

Then n = 384, and after accounting for a 10% nonresponse rate, our final sample size was 422. A total estimate of 50 X-ray requests with a clinical impression of COM per month is sent to the radiology department. So, a total of 250 cases were sent. Since this is <10,000 per study period, we used the population correction formula so that the final sample size was 168.

Inclusion criteria: All patients at the age of 18 years or below, who presented to the orthopedic clinic and were sent for an X-ray to the radiology department in the period between April 15, 2022 and August 15, 2022, were included in the study.

Exclusion criteria: All patients with poor-quality X-ray films were excluded.

Operational definitions

COM is a bone infection lasting 6 weeks or more with radiological evidence. For this study, we defined COM as having 6 weeks of clinical signs and evidence of one or more of the following radiological findings: sequestrum, involucrum, soft tissue swelling that obliterates the fat planes, periosteal reaction, lytic destructions, and cloaca. Other findings that were used to diagnose a case as COM in our study were either extensive sclerosis or Brodie’s abscess.^9,16

Sequestrum is a necrotic bone that appears denser than the surrounding bones on radiography.^5,17

Involucrum is a new bone that surrounds the sequestrum, and it is less dense on radiography than the sequestrum. It may appear thicker and more extensive, involving the entire shaft of the bone, or have a normal density or be inadequate.¹⁸

Cloacae are perforations in the involucrum that appear as a defect in the involucrum in radiography to allow the continued discharge (decompression) of inflammatory products from the bone.⁵

Brodie’s abscess is a geographic lytic lesion, as metaphysis displays, with a distinct, often broad sclerotic margin. It normally borders the growth plate and is oval in shape with the long axis running parallel to the long axis of the bone.¹⁷

Extensive sclerosis is a form of COM that lacks the traditional sequestrum, involucrum, and cloacae on radiography and is characterized by sclerosis.⁵

Periosteal reaction is a nonspecific radiographic finding that indicates periosteal irritation. It has different types. The solid type appears as a homogeneous, continuous single layer of new bone attached to the outer layer of the cortex. The laminated type of periosteal reaction appears as alternating layers of lucent and opaque densities on the cortex. The spiculated type of periosteal reaction is seen as radiating spicules arising from the cortex. Codman’s triangle appears as a triangle of periosteal new bone at the peripheral lesion–cortex junction.¹⁸

Sampling technique and procedures

A simple random sampling (SRS) technique was used to select the study participants from the daily X-rayed children below the age of 18 years at FHCSH who present with a clinical complaint of discharging sinuses, pain, swelling, or limitation of movement with a complaint duration of above 6 weeks. Monthly, on an average, 50 children below the age of 18 years had an X-ray for this complaint, giving a total of 250 cases in the study period. So, using the SRS technique, 167 patients were selected from these 250 cases. X-ray requests for these patients were selected, and demographic data, clinical complaints, and preceding events were documented. Subsequently, the patients’ charts were followed to look for other preceding events and comorbidities. Data were also collected from the patients directly. X-rays of the patients were collected to describe the radiographic findings.

Statistical analysis

EpiData Version 3.1 was used to enter the data, which were subsequently exported to SPSS Version 23 for analysis. Binary logistic regression and descriptive statistics were calculated. To select the variables associated with COM, binary logistic regression was used. In binary logistic regression, both bivariate and multivariable logistic regression were computed.

Bivariate analysis was used to choose independent variables with p < 0.25 as candidates for multiple logistic regressions. Statistical significance in multivariable logistic regression was set at p = 0.05. The adjusted odds ratio (AOR) and their respective 95% confidence intervals (CI) were used to measure the association’s strength. Backward stepwise logistic regression was applied. Finally, the data were presented with tables, charts, and figures.

Data quality assurance

The data collection tool was pretested on 5% of the study participants at FHCSH before data were collected to ensure that the questionnaires are simple, clear, and easy to understand. The principal investigator trained four data collectors and one supervisor on interview technique procedures. At the conclusion of data collection, the consistency, completeness, clarity, and accuracy of the collection tool were randomly evaluated. The accuracy of the information was also verified throughout data processing.

Results

Sociodemographic characteristics of the respondents

A total of 168 patients were included in this study. The respondents’ mean age (standard deviation (SD)) was 13.68 (SD: ±4.046). The majority of patients, 104 (61.9%), came from rural areas. Males accounted for 122 (72.6%) of the cases.

Clinical presentation of the respondents

The most frequent clinical manifestation seen in 114 (67.9%) patients was a discharging sinus followed by swelling in 113 (66.3%), pain in 59 (35.1%), limitation of movement in 13 (7.7%), and limping in 4 (2.4%).

The majority of patients, 96 (57.1%), present with a clinical complaint that has lasted more than a year, followed by 44 (26.2%) with 6 weeks–6 months and 28 (16.7%) with 6 months–1 year.

Preceding events of the respondents

The disease started spontaneously in 55.4% and was followed by trauma in 40 (23.8%), soft tissue infections, which include abscesses and cellulitis, in 24 (14.3%), AOM treatment or diagnosis (5.3%), and surgery (3.18%).

Falling down was the most frequent mechanism of injury seen in 28 (16.7%) of the cases from the trauma-preceding cases, followed by prick injuries 6 (3.6%), RTA injuries 2 (1.2%), bullet injuries 2 (1.2%), stick injuries 1 (0.6%), and other types of mechanisms of injury 1 (0.6%) (Table 1).

Table 1.

Mechanism of injury in study participants who had a preceding event of trauma at FHCSH, Bahir Dar, Ethiopia, in 2022.

Mechanisms of injury	Frequency	Percent
Falling down	28	16.7
Prick injury	6	3.6
Bullet injury	2	1.2
RTA	2	1.2
Stick injury	1	0.6
Others	1	0.6
Total	40	23.8

FHCSH: Felege Hiwot Comprehensive Specialized Hospital; RTA: road traffic accident.

Associated comorbid diseases were found in nine of the participants, six of whom had anemia, one had malnutrition, and the other two were known epileptic and psychotic patients.

Characteristics of COM cases

From the total of 145 patients with radiological evidence of COM, the mean age at presentation was 13.4 (SD: ±3.940). About 101 (66.9%) of the cases were men, while 97 (66.9%) of the patients were from rural areas. The most frequent clinical occurrence (74.5%) was a discharge from a sinus followed by swelling (95.5%), pain (37.3%), limitation of movement (7.6%), and limping (2.1%).

Most patients present with a clinical complaint duration of more than 1 year (62.4%), followed by 6 weeks to 6 months (21.4%).

The disease started spontaneously in 55.2% of the cases, and 44.8% had preceding events, the most common of which was trauma 39 (26.9%), followed by soft tissue infections 24 (16.1%), AOM 5 (3.3%), and surgery 3 (2.1%). The most common mechanism of injury in trauma cases was a falling accident (28; 71.8%), followed by prick injuries (6; 15.4%), RTAs (2; 5.1%), bullet injuries (2; 5.1%), and stick injuries (1; 2.6%). Five patients with COM had anemia, one had malnutrition, and the rest were known epileptic and psychotic patients.

Only 6.9% (10) of the patients with radiological evidence of COM had multiple bone involvement. The lower extremity was involved in 86.9% (126) of the cases. The right side was involved in 51% (74) of the total cases. The tibia and the femur were the most common bones involved, accounting for 46.2% and 38.6%, respectively. The humerus, calcaneus, and fibula bones accounted for 6.9%, 2.8%, and 1.4%, respectively (Table 2).

Table 2.

Frequency of involved bones in participants with radiological evidence of COM at FHCSH, Bahir Dar, Ethiopia in 2022.

Involved bone	Frequency	Percent
Tibia	67	46.2
Femur	56	38.6
Humerus	10	6.9
Calcaneus	4	2.8
Fibula	2	1.4
Other foot bones	2	1.4
Radius	2	1.4
Ulna	1	0.7
Hand bones	1	0.7
Total	145	100

COM: chronic osteomyelitis; FHCSH: Felege Hiwot Comprehensive Specialized Hospital.

In terms of location within the bone, metaphyseal and metadiaphyseal locations each accounted for 37.3% (53) of the cases, diaphyseal location accounted for 21.1% (30), metaepiphyseal accounted for 1.4% (2), and metadiaphyseal location accounted for 2.8% (4) of the cases. There was no isolated involvement of the epiphysis.

Sequestrum 94 (56%) and involucrum 89 (53%) were the most common radiological findings (Table 3). Periosteal reaction was seen in 34 (20.2%) of the patients, and the most common type of periosteal reaction was solid 20 (58.8%), followed by laminated type 9 (26.5%), Codman’s triangle 1 (2.9%), and combined form 4 (11.8%) (Table 3).

Table 3.

Radiological findings of COM patients at FHCSH, Bahir Dar, Ethiopia in 2022.

Radiological findings	Frequency	Percent
Sequestrum	94	56
Involucrum	89	53
Soft tissue swelling	53	31.5
Lytic destruction	49	29.2
Periosteal reaction	34	20.2
Extensive sclerosis	25	14.9
Cloaca	22	13.1
Brodie’s abscess	10	6

COM: chronic osteomyelitis; FHCSH: Felege Hiwot Comprehensive Specialized Hospital.

Of the study participants with radiological evidence of COM 24 (16.6%), there were complications that included fracture 18 (12.4%), angular deformity 5 (3.4%), and joint involvement 4 (2.8%). From the joint involvement, two patients had joint space narrowing, and the rest had ankylosis and effusion. Two of the angular deformities were valgus, and one was varus.

Magnitude of COM

The magnitude of COM diagnosed with radiological evidence was found to be 86.3% with 95% CI (80.2–91.1).

Factors associated with the magnitude of COM

On bivariate logistic regression analysis, respondents’ age group, sex, residency, duration of clinical presentation, discharging sinus, pain, swelling, and trauma showed a statistically significant association at p < 0.25.

On multivariable logistic regression analysis, the respondent’s age group, sex, residency, duration of clinical presentation, discharging sinus, pain, swelling, and trauma were significant factors that made an association at p < 0.05.

In our study, children with ages above 10 years were 4.0481 times more likely to develop COM than those with ages below 5 years (AOR = 4.0481 (1.032–15.886)).

In this study, male children were 6.162 times more likely to develop COM than female children (AOR = 6.162, 95% CI (1.12–334.147)).

This study showed that children from rural areas were 4.046 times more likely to develop COM than those from urban areas (AOR = 4.046, 95% CI (1.236–13.364)).

The study also showed that children who presented with a clinical complaint duration of more than 1 year were 5.189 times more likely to have COM than those who presented with a complaint duration of 6 weeks to 6 months (AOR = 5.189, 95% CI (1.247–21.588)).

This study showed that children who had discharging sinuses were 5.237 times more likely to have COM than those who did not (AOR = 5.189, 95% CI (1.247–21.588)).

This study showed that children who had discharging sinus were 5.237 times more likely to have COM than those who did not (AOR = 5.237, 95% CI (1.393–19.693)).

In this study, children who had trauma as a preceding event were 10.363 times more likely to have COM than those who did not (AOR = 10.363, 95% (1.101–97.509)) (Table 4).

Table 4.

Bivariable and multivariable logistic regression analysis results for factors associated with the magnitude of COM in FHCSH, Bahir Dar, Ethiopia in 2022.

Variable	Categories	COM		COR (95%)	AOR (95%)	p Value
Variable	Categories	Yes	No	COR (95%)	AOR (95%)	p Value
Sex	Male	101	21	4.574 (1.028–20.357)	6.162 (1.12–34.147)	0.037**
Sex	Female	44	2	1	1
Age range (years)	>10	118	14	3.0650 (1.150–8.172)	4.048 (1.032–15.886)	0.045**
	5–10	22	8	1.686 (0.184–15.480)	0.928 (0.067–12.881)	0.956
	<5	5	1	1	1
Residency	Rural	97	7	4.619 (1.781–11.981)	4.046 (1.236–13.364)	0.021**
Residency	Urban	48	16	1	1
Discharging sinus	Yes	108	6	8.270 (3.034–22.544)	5.237 (1.393–19.693)	0.014**
Discharging sinus	No	37	17	1	1
Swelling	Yes	95	18	1.895 (0.664–5.405)	0.366 (0.081–1.657)	0.192
Swelling	No	50	5	1	1
Pain	Yes	47	12	2.275 (0.935–5.533)	1.088 (0.337–3.507)	0.888
Pain	No	98	11	1	1
Duration of clinical presentation	>1 year	90	6	6.290 (2.201–17.974)	5.189 (1.247–21.588)	0.024**
	6 months–1 year	24	4	2.500 (0.653–9.575)	2.951 (0.491–17.750)	0.237
	6 weeks–6 months	31	13	1	1
Trauma	Yes	39	1	8.094 (1.055–62.086)	10.363 (1.101–97.509)	0.041**
Trauma	No	106	22	1	1

Indicates that variables are statistically significant at p < 0.05.

AOR: adjusted odds ratio; COM, chronic osteomyelitis; COR: crude odds ratio; FHCSH: Felege Hiwot Comprehensive Specialized Hospital.

Discussion

The results of the study revealed that the proportion of children with radiological evidence of COM was about 86.3% with 95% CI (80.2–91.1). This was higher than the finding in studies done in Mbarara (9.7%),² Makerere University Medical School, Uganda (10%),¹⁰ Malawi (6.7%),¹⁹ and the Gambia (5.7%).²⁰ This difference is because the data in our study were collected from selected patients who presented with discharging sinuses, pain, swelling, limitation of movement, and limping of more than 6 weeks of duration, which are the main presenting clinical features of COM. The studies carried out in the aforementioned countries determine the proportion of COM in total orthopedic visits. In addition, the discrepancy can be a result of their usage of a high sample size.

This study’s most common radiological findings were sequestrum, involucrum, soft tissue swelling, and lytic destruction, consistent with the studies done in Uganda,² the Philippines, southeast Nigeria,²¹ Malawi,¹⁶ and TASH, Ethiopia.⁹ Multiple bone involvement was seen in only 6.9% of the COM cases, which is consistent with the studies done in Nigeria,⁷ the Philippines,²² and TASH, Ethiopia.⁹ The right side was involved in 51% of the cases and the left side was involved in 46.2% of the cases, while 2.8% of patients had the involvement of both sides, which can be explained by the right-side dominance of the extremities in the population²³ and so more activities on the right-side predisposing to traumatic incidents that can precede COM.²

The tibia and the femur were the most common bones involved, accounting for 46.2% and 38.6%, respectively. This was consistent with the studies done in Uganda,² the Philippines,²² and Malawi.¹⁶ This can be explained by the fact that the tibia has poor soft tissue coverage with no muscle layer on it, which makes it vulnerable to traumatic incidents preceding COM and the contiguous spread of soft tissue infections to it.¹ Since the femur is contiguously located with the tibia, infections could spread locally or be hematogenous to it.² This finding was inconsistent with a study done in rural Uganda,²⁴ which showed that the most common site of involvement was the phalangeal bones. This difference is explained by the fact that the study was conducted in a peasant community and 46.6% of the cases had prick injuries associated with agricultural activities and pastoralism. As a result, the phalangeal bones were heavily involved. The other reason was that the study included people of all ages, unlike our study, which included only pediatric patients.

Most of the infectious process involved the metaphysis and metadiaphyseal areas of the bone, which could be explained by the blood supply pattern to the long bones, where blood flow in the metaphysis is slow and turbulent, and in children aged >18 years, the metaphyseal blood vessels will not cross the physis to involve the epiphysis, which can explain the noninvolvement of the epiphysis in our study as well.^24,25

In this study, 16.6% of patients had complications, which include pathologic fracture, angular deformity (varus and valgus types), and joint involvement as joint space narrowing, effusion, and ankylosis. This is similar to the study done in southeast Nigeria, where anemia, pathologic fractures, and septic arthritis were the most common complications.²¹

The factors associated with the magnitude of COM in this study were being male, being over the age of 10 years, having a rural residency, having a discharging sinus, having a clinical complaint duration of more than 1 year, and having a previous trauma event.

This study indicated that age groups above 10 years were significantly associated with the development of COM. This finding was consistent with the study done in Uganda.¹⁰ Children whose age was above 10 years had 4.0481 times higher odds of developing COM than those whose age was below 5 years (AOR = 4.0481 (1.032–15-886)). This might be because at this age most children will attend school, they are highly active, and they will be predisposed to traumatic incidents that could precede COM.^2,24

Being male was significantly associated with the development of COM. The predominant male distribution of COM in studies conducted in Nigeria,⁷ TASH, Ethiopia,⁹ Uganda,² Malawi,¹⁹ and the Philippines²² supported our findings. The odds of COM were 6.169 times higher among male children compared to female children (AOR = 6.162, 95% CI (1.12–34.147)). This finding might be because males engage in more activities than females that put them at risk for trauma, which can precede COM.^2,26

This study also showed a significant association between rural residency and COM. The odds of COM were 4.046 times higher among children from rural areas as compared to those from urban areas (AOR = 4.046, 95% CI (1.236–13.364)). This finding is supported by the predominance of COM in those patients from rural areas, according to the studies done at TASH⁹ and Nigeria.²¹ Children from rural areas face malnutrition and poverty due to a lack of health facilities, which can predispose them to COM.¹ Increasing the number of health facilities in the rural areas, improving the already built facilities with qualified health professionals and medical equipment will improve the detection rate of COM and the treatment of its risk factors, which will decrease its magnitude. Giving awareness to the community in rural areas about the predisposing factors, clinical presentation, and complications of COM will decrease its magnitude and the physical, psychological, and socioeconomic morbidity associated with it.

In this study, sinus discharge was found to be significantly associated with COM. The odds of COM were 5.237 times higher among children who had discharging sinuses as compared to those who did not (AOR = 5.237, 95 CI (1.393–19.693)). This is supported by the studies done in the Philippines,²² Nigeria,²¹ Kenya,²⁷ Rwanda,¹ and TASH, Ethiopia,⁹ where discharging sinus was the most common clinical presentation. The most common clinical manifestation of COM is a discharged sinus. Most patients may not visit health facilities until pus starts to ooze out of the sinus tract.²⁸

This study also found that having a clinical complaint for more than a year was significantly associated with COM. The odds of COM were 5.189 times higher among patients with a clinical complaint duration of more than 1 year compared to those patients who present with a complaint duration of 6 weeks to 6 months (AOR = 5.189, 95% CI (1.247–21.588)). This finding is supported by the studies done in Nigeria²¹ and TASH, Ethiopia,⁹ where most patients presented more than 1 year after clinical onset. This could be because patients may seek alternative traditional and religious medicines before visiting health facilities.² The other reason might be that patients may prefer to take medications by themselves, which may delay their presentation to the hospital.^2,9 The other reason could also include a misdiagnosis.²⁹ A high index of suspicion and accurate diagnosis by primary healthcare providers may lead to patients being referred early to areas with orthopedicians, potentially reducing late presentation.

In this study, trauma showed a significant association with the development of COM. Children who had prior incidents of trauma were 10.363 times more likely to develop COM than those who did not have trauma (AOR = 10.363, 95% CI (1.101–97.509)). This finding is supported by the studies done in Kenya,²⁷ the Philippines,²² and TASH, Ethiopia,⁹ where COM followed trauma in 19.8%, 35%, and 27% of the cases, respectively. This calls for giving attention to those children with a history of trauma and a clinical presentation suggesting bone infections and intervening with them early.

Strengths and limitations of the study

The study’s strengths were taking data directly from the patients, their charts, and X-ray requests. Since the study is cross-sectional, it is possible that it will not show a clear relationship between the dependent and independent variables. In addition, this study was done at the hospital level, and it may not be generalized to the general population. The diagnosis of COM relies on X-ray findings, which may not be applicable at all times.

Conclusions

The magnitude of COM is high. COM is common among older male children, and the most common clinical presentations are chronic discharge from the sinuses, swelling, and pain. Trauma was the most common cause of 48% of the cases. The tibia and femur were the most commonly involved bones, and metaphyseal involvement was very common. The most common radiological findings were sequestrum and involucrum. Being male, having an age group above 10 years, rural residency, having a discharging sinus, a clinical complaint duration of more than 1 year, and a preceding event of trauma were positively associated with COM. Healthcare providers should have a high index of suspicion about the possibility of COM in those older male children from rural areas with a chronic discarding sinus following traumatic events.

Supplemental Material

sj-docx-1-smo-10.1177_20503121231161191 – Supplemental material for Magnitude of chronic osteomyelitis and its associated factors in children as diagnosed on X-ray visiting at Felege Hiwot Comprehensive Specialized Hospital, Northwest Ethiopia: A cross-sectional study

Supplemental material, sj-docx-1-smo-10.1177_20503121231161191 for Magnitude of chronic osteomyelitis and its associated factors in children as diagnosed on X-ray visiting at Felege Hiwot Comprehensive Specialized Hospital, Northwest Ethiopia: A cross-sectional study by Biruk Mulualem, Genetu Belay and Eyob Ketema Bogale in SAGE Open Medicine

Footnotes

Acknowledgements

We would like to give our special thanks to the study participants, data collectors, and supervisors for their willingness and cooperation during the time of data collection.

Availability of data and materials

All data relevant to the study are included in the article or uploaded as supplementary.

Authors’ contribution

BM, GB, and EK participated in the conception and design of the study. BM carried out data collection; BM, GB, and EK participated in the data analysis and interpretation. BM drafted the article, GB and EK reviewed and edited the article. All authors read and approved the final article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics approval and consent to participate

The Bahir Dar University College of Medicine and Health Sciences’ Institutional Review Board (IRB), with reference number CHMS 008/04/2022, granted ethical approval. The College of Medicine and Health Sciences at Bahir Dar University’s Institutional Review Board determined and authorized that obtaining verbal informed consent from each study participant would be sufficient to ensure the ethical conduct of research process. This was done since there would not be any ethical concerns raised until the names and medical registration numbers of the participants were used during data collection. Caretakers of participants under the age of 18 years were requested for their agreement and consent for their child’s participation. Permission was obtained at all levels to conduct the investigation. During the permission process, caregivers received thorough explanations of the study’s objectives, data gathering methods, potential risks, discomforts, and advantages of participating. All parents whose kids took part in the study verbally consented to participate. The families in this instance were portrayed as guardians. Only when the guardians agreed with the youngsters were they allowed to participate in the study. A child’s decision not to participate in the study was respected despite the caretakers’ consent.

Informed consent

The Institutional Review Board of College of Medicine and Health Sciences, Bahir Dar University decided and approved that verbal informed consent obtained from each study participant could be enough to be ethically assured of the research process. This was because unless the name and the participants’ medical registration numbers were used during data collection, no ethical issue will be raised. For participants <18 years, caretakers were asked to provide consent for their child’s participation, approval, and consent to participate. Permission to undertake the study was performed at all levels. Caretakers were given detailed information about the purpose of the study, data collection procedures, and possible risks/discomforts and benefits of participating in the study through the consent process. Verbal informed consent was obtained from all caretakers whose children participated in the study. In this case, the families were presented as caretakers. A child was included in the study only if the caretakers agreed with the child. Despite the caretakers’ consent, a child’s decision not to participate in the study was respected.

Consent for publication

The authors declare that they have agreed to publish this journal.

Author’s information

BM: School of Medicine and Health Sciences, Department of Clinical Radiology, Bahir Dar University, Bahir Dar, Ethiopia

GB: School of Medicine and Health Sciences, Department of Clinical Radiology, Bahir Dar University, Bahir Dar, Ethiopia

EK: School of Medicine and Health Sciences, Health Promotion and Behavioral Sciences, Bahir Dar University, Bahir Dar, Ethiopia

BM: Credential was specialty in clinical Radiology

GB: Credential was specialty in clinical Radiology (Assistant Professor)

EK: Credential was Mph in Health Promotion

All researchers are men.

ORCID iD

Eyob Ketema Bogale

Supplemental material

Supplemental material for this article is available online.

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