The management of chronic osteomyelitis: Part I – Diagnostic work-up and surgical principles (original) (raw)
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Advances in the treatment of chronic osteomyelitis
Current Orthopaedics, 2001
Chronic osteomyelitis presents complex diagnostic and therapeutic problems. It can be a prolonged illness having a profound e¡ect on the health of the sufferer.Like many chronic illnesses economic costs for healthcare providers is high. Chronic osteomyelitisis perhaps more common thanthought, being the major complication in the surgical management of fractures in multiply injured patients.In elective reconstructive surgery, it is the most dreaded complication of total joint replacement and other reconstructive procedures in the musculoskeletal system. Recent advancesin our understanding ofthe physiologyof bone healing, together with the availability of hybrid ring-thin wire ¢xation frames, have allowed resection of infected bone in any required amount, followed by the implementation of distraction osteogenesis after a rest period of 72 h. Bone gaps of up to 6 cm are managed by acute shortening followed by intermittent distraction in 6 hourly 0.25 mm increments. For longer defects, bone segmenttransport is used.The former method is more e⁄cient. Thus, a reliable avenue for surgical reconstruction in the treatment of chronic osteomyelitis has become available, which couples radical local resection of the infected focus with biological reconstitution of the surgically created bone defect.
Surgical management of chronic osteomyelitis
American journal of surgery, 2004
Chronic osteomyelitis is a surgical disease that can require significant dedication from both patients and surgeons to eradicate. Osteomyelitis can result from a variety of etiologies but most often is a consequence of trauma to a long bone, frequently the tibia. It is important to understand the etiology of the infection, as well as the pathophysiology of its chronicity. Additionally, the surgeon must individualize treatment for each patient, because host morbidities often play an important role in propagation of infection. Treatment requires isolation of the pathogens, significant debridement for removal of all infective and necrotic material, and then bony and soft tissue reconstruction. We review the literature of surgical treatment of chronic osteomyelitis and discuss the numerous techniques available to the treatment team, including debridement, dead space management, Ilizarov techniques, and vascularized reconstruction. These patients often require a multimodality approach th...
Optimal management of chronic osteomyelitis: current perspectives
Orthopedic Research and Reviews, 2015
Chronic osteomyelitis is a challenging condition to treat. It is seen mostly after open fractures or in implant-related infections following treatment of fractures and prosthetic joint replacements. Recurrence of infection is well known, and successful treatment requires a multidisciplinary team approach with surgical debridement and appropriate antimicrobial therapy as the cornerstone of treatment. Staging of the disease and identification of the causative microorganism is essential before initiation of treatment. Important surgical steps include radical debridement of necrotic and devitalized tissue, removal of implants, management of resultant dead space, soft-tissue coverage, and skeletal stabilization or management of skeletal defects. The route of administration and duration of antimicrobial therapy continues to be debated. The role of biofilm is now clearly established in the chronicity of bone infection, and newer modalities are being developed to address various issues related to biofilm formation. The present review addresses various aspects of chronic osteomyelitis of long bones seen in adults, with a review of recent developments.
Over the past few decades considerable progress has been made in terms of our ability to reconstruct postinfective soft tissue and bone defects. Soft tissue reconstruction is not always required and it is frequently possible to achieve a tension-free closure of well-perfused tissue following debridement. It is now generally accepted that primary closure of the wound, be it by direct suturing or tissue transfer, may be performed at the same sitting as the debridement. In cases were debridement has resulted in tissue loss, muscle or musculocutaneous flaps appear to be superior to random-pattern flaps in achieving resolution of infection. The management of bone defects is dependent on several factors including the host’s physiological status, the size of the defect, duration of the defect, quality of the surrounding soft tissue, the presence of deformity, joint contracture/instability or limb length discrepancy, as well as the experience of the surgeon. Surgery remains the mainstay of ...
Prophylactic external fixation and extensive bone debridement for chronic osteomyelitis
Acta orthopaedica Belgica, 2006
There is universal agreement that treatment of osteomyelitis should consist of debridement, obliteration of dead space, tissue coverage and antibiotic therapy, with debridement as the most important factor for therapeutic success. Four patients, 27 to 72 years old, with chronic osteomyelitis after a fracture of the femur (two), or of the tibia (two), were included in this study. The patients had already undergone 5 to 15 (mean: 9) surgical procedures. The same surgical technique was used in all of them: sinuses were carefully excised down to the bone, and necrotic bone was aggressively resected until normal bleeding was seen. A prophylactic circular external fixation frame, built on one proximal and one distal ring connected to the bone by thin wires and half pins, was used to protect and support the limbs, significantly weakened by radical debridement. Bone grafting or distraction osteogenesis was not necessary. All wounds healed without complications, and the infection did not rec...
Diagnosis and Treatment Modalities for Osteomyelitis
Cureus, 2022
Osteomyelitis is an infection-related inflammatory disease of the bones. Imaging and laboratory results are typically used to support a clinical diagnosis of osteomyelitis. Microbial cultures and bone biopsies provide conclusive diagnoses. The first imaging procedure that needs to be done is radiography, but its sensitivity is low in the early stages of the disease. The sensitivity of magnetic resonance imaging, both with and without contrast material, is higher for detecting areas of bone necrosis in advanced stages. Patients can be categorised for surgical treatment using a staging system based on major and minor risk factors. The main course of treatment should be antibiotics, which should be chosen depending on the findings of the culture and the characteristics of each patient. Bony debridement surgery is frequently required, and in high-risk patients or those with severe illness, additional surgical intervention can be necessary. Better outcomes are being attained in the treatment of this illness thanks to advancements in surgical treatment, antibiotic therapy, and the current resources for precise diagnosis and tailored responses to each kind of osteomyelitis. The classification systems that are most frequently employed, as well as the general epidemiological ideas, are presented together with the discussion of acute and chronic osteomyelitis. The key recommendations for diagnosing infections clinically, in the laboratory, and through imaging are covered, along with the recommendations for surgical and antibiotic procedures, and the function of hyperbaric oxygen as adjuvant therapy. We evaluate the osteomyelitis-related articles, summarise the most recent developments in diagnostic procedures and therapeutic regimens, evaluate the benefits and drawbacks of various diagnostic modalities and therapeutic approaches, and suggest areas of focus to help current diagnostic and therapeutic approaches.
Pathogenetic features of chronic osteomyelitis treatment
Genij Ortopedii, 2021
Over the past decades, there has been a steady increase in the incidence of osteomyelitis. It is associated with an increased use of implants in traumatology and orthopedics. The social aspects of osteomyelitis are, on the one hand, significant financial costs for the healthcare system, and on the other hand, high recurrence and re-infection in the treatment of joint pathology associated with long-term loss of work ability and a high risk of patient’s disability. Purpose To conduct a search and analysis of publications in Russian and English, devoted to the problem of osteomyelitis and periprosthetic infection, on the basis of which to summarize the main current notions about the etiology, pathogenesis, diagnosis and treatment of osteomyelitis. Materials and methods The search was carried out in the Pubmed and CyberLeninka databases of literature sources over the past 10 years. The data were analyzed and compared with the materials from earlier publications. Only publications from p...
The outcome of treatment of chronic osteomyelitis according to an integrated approach
Strategies in trauma and limb reconstruction (Online), 2016
Previous classification systems of chronic osteomyelitis have failed to provide objective and pragmatic guidelines for selection of the appropriate treatment strategy. In this study, we assessed the short-term treatment outcome in adult patients with long-bone chronic osteomyelitis prospectively where a modified host classification system was integrated with treatment strategy selection through a novel management algorithm. Twenty-six of the 28 enrolled patients were available for follow-up at a minimum of 12 months. The median patient age of was 36.5 years (range 18-72 years). Fourteen patients (54 %) were managed palliatively, and 11 patients (42 %) were managed through the implementation of a curative treatment strategy. One patient required alternative treatment in the form of an amputation. The overall success rate was 96.2 % (95 % CI 80.4-99.9 %) at a minimum of 12-months follow-up. Remission was achieved in all [11/11] patients treated curatively (one-sided 95 % CI 73.5-100.0...
The management of chronic osteomyelitis in adults: outcomes of an integrated approach
SA Orthopaedic Journal, 2021
Sixty patients (75%) presented with fracture-related infections, 17 patients (21%) developed chronic osteomyelitis following haematogenous spread and three (4%) from contiguous wounds. According to the Cierny and Mader classification, 21 patients presented with anatomical type I, 14 with type II, 24 with type III and 21 with type IV chronic osteomyelitis. Positive microbial cultures were obtained in 63 (79%) cases. Follow-up for the cohort ranged from 1 to 29 months, with a mean follow-up of 10.4 months. The overall complication rate for the cohort was 6% and included sterile drainage from the surgical site after management with bioactive glass (S53P4), refracture after hardware removal, and development of non-union. Five patients experienced recurrence after the initial procedure to eradicate infection, resulting in an overall resolution rate of 94%.
The management of osteomyelitis in the adult
Bone infection Clinical management a b s t r a c t Background and purpose: Osteomyelitis (OM) is considered one of the most challenging medical conditions an orthopaedic surgeon has to face. Much debate is present concerning diagnosis and treatment, especially about differences between acute and chronic forms of the condition. The main aim of the present work is to show the key points where research should be implemented. Methods: Online database were searched to find evidence about the clinical management of osteomyelitis. Clinical randomized trials, case series, prospective cohort studies reporting on diagnosis and treatment of acute and chronic osteomyelitis were taken into consideration. Cadaveric studies, laboratory studies, case reports, review articles and metaanalyses were excluded. Furthermore, studies concerning implant related OM were excluded. Studies in English, Spanish and French were considered in this process of inclusion. The cohorts of all the included studies were composed of adult patients.