Treatment algorithms for chronic osteomyelitis

Abstract

Background: Osteomyelitis was described many years ago but is still incompletely understood. Its exogenously acquired form is likely to become more common as the population ages. We discuss biofilm formation as a clinically relevant pathophysiological model and present current recommendations for the treatment of osteomyelitis.

Methods: We selectively searched the PubMed and Cochrane databases for articles on the treatment of chronic osteomyelitis with local and systemic antibiotics and with surgery. The biofilm hypothesis is discussed in the light of the current literature.

Results: There is still no consensus on either the definition of osteomyelitis or the criteria for its diagnosis. Most of the published studies cannot be compared with one another, and there is a lack of scientific evidence to guide treatment. The therapeutic recommendations are, therefore, based on the findings of individual studies and on current textbooks. There are two approaches to treatment, with either curative or palliative intent; surgery is now the most important treatment modality in both. In addition to surgery, antibiotics must also be given, with the choice of agent determined by the sensitivity spectrum of the pathogen.

Conclusion: Surgery combined with anti-infective chemotherapy leads to long-lasting containment of infection in 70% to 90% of cases. Suitable drugs are not yet available for the eradication of biofilm-producing bacteria.

Figure 1

a, b) A 39-year-old woman with a 20-year history of chronic recurrent femoral osteitis, who had undergone five revisions. Deformation, sclerosis, iatrogenic defects after marrow revision, PMMA beads placed c) MRI (STIR sequence) shows deformation of the right distal femur and marked signal inhomogeneity of the bone, with increased signal in some parts and marked signal decrease where the beads were placed. Adjacent faint lamellar periosteal fluid collections

Figure 2

Treatment options for chronic osteomyelitis

Figure 3

a–d: A 75-year-old man with acute recurrence of chronic post-traumatic femoral osteitis which had been dormant for 17 years. Necrotizing soft tissue infections with evidence of methicillin-resistant staphylococci (MRSA) and hemolytic group G streptococci. On admission he had a 5-day history of progressive pain in the right distal thigh, leukocytes were 19 600/mm³, C-reactive protein 31 mg/dL (norm <0.5 mg/dL). Radical débridement with excision of skin, fascia, and parts of the left distal vastus lateralis, wide femoral resection, bone marrow revision and reaming, temporary wound closure with artificial skin. Staged revision after 48 hours with knee joint revision, subtotal synovectomy, implantation of gentamicin–Palacos spacers. Later, débridement with joint irrigation, placement of PMMA beads, and a total of six further revisions. Local flap graft using the biceps femoris and a myocutaneous lateral gastrocnemius flap. This was followed by long-lasting remission. Five months later the patient suffered a pathological fracture on twisting his knee. He was treated with an external fixator and cancellous bone graft. Full weight bearing possible after 6 months, follow-up after 12 months