Principles of the therapy of bone infections in adult extremities : Are there any new developments?

Abstract

Septic diseases of the bone and immediately surrounding soft tissues can be differentiated into osteitis or osteomyelitis. Both are a most serious diagnosis in modern traumatology and orthopaedic surgery. The basis for treatment is a highly specific, problem-adapted therapy with a defined strategy, the paramount goal being to preserve the stable weightbearing bones, maintain a good mechanical axis with correctly working muscles and joints, and avoid permanent disability. "State-of-the-art" therapy of osteitis and osteomyelitis has two priorities: (a) Eradication of the infection; (b) Reconstruction of bone and soft tissue. Surgical treatment with resection of the affected bone segments and soft tissue, followed by reconstructive methods continues to be the main basic therapy, and is supported by local and systemic antibiotics and adjuvant methods such as hyperbaric oxygen. This article provides an overview of the diagnostic features and different surgical procedures as well as the current literature in order to reach the above named goals.

Fig. 1

Fifty-six-year-old male patient with chronic osteitis and fistula from a lower leg fracture. Osteosynthesis was performed in 1978. The preoperative X-ray shows the bone lesion under the osteosynthesis material and also a sequestrum (a, b)

Fig. 2

Clinical findings at the day of admission

Fig. 3

a Intraoperative situation. Exposure and removal of the osteosynthesis material. b Segmental resection of the tibia. The stabilising external fixator is already partially installed. c Resected bone material

Fig. 4

a Postoperative situation with completed external transport fixator. b, c Postoperative X-ray of the proximal lower leg. It shows the transport corticotomy. d, e Postoperative X-ray of the distal lower leg. It shows the bone defect after tibial segment resection

Fig. 5

a Critical soft tissue situation one week after the initial operation. Local treatment with repetitive debridement, lavage and vacuum sealing. Continuation of the transport as an open transport. b Advancing consolidation of the soft tissue. Continuation of the transport. c Consolidated soft tissue. Coverage with mesh graft. Transport completed

Fig. 6

a, b X-ray after 9 months. The transport is finished and the external fixator is removed. Good callus formation in the transport zone. c, d X-ray of the docking zone after 9 months. It shows almost complete consolidation. Owing to the soft tissue conditions, the docking manoeuvre was carried out as a compression docking without additional plating or cancellous bone graft

Fig. 7

Clinical examination after 9 months. The soft tissue is consolidated and full weight-bearing of the right leg. No further signs of bone or soft tissue infection