Chronic osteomyelitis: what the surgeon needs to know

Abstract

Chronic osteomyelitis represents a progressive inflammatory process caused by pathogens, resulting in bone destruction and sequestrum formation.It may present with periods of quiescence of variable duration, whereas its occurrence, type, severity and prognosis is multifactorial.The 'gold standard' for the diagnosis of chronic osteomyelitis is the presence of positive bone cultures and histopathologic examination of the bone.Its management remains challenging to the treating physician, with a multidisciplinary approach involving radiologists, microbiologists with expertise in infectious diseases, orthopaedic surgeons and plastic surgeons.Treatment should be tailored to each patient according the severity and duration of symptoms, as well as to the clinical and radiological response to treatment.A combined antimicrobial and surgical treatment should be considered in all cases, including appropriate dead space management and subsequent reconstruction. Relapse can occur, even following an apparently successful treatment, which has a major impact on the quality of life of patients and is a substantial financial burden to any healthcare system. Cite this article EFORT Open Rev 2016;1:128-135. DOI: 10.1302/2058-5241.1.000017.

Keywords: antibiotics; chronic; complications; diagnosis; imaging; osteomyelitis; pathogenesis; surgical treatment.

Fig. 1

Patient presented with a discharging sinus and surrounding cellulitis over the distal tibia, 13 months following a closed distal tibia fracture that was surgically managed.

Fig. 2

Following the excision of the sinus tract and radical surgical debridement of the impaired bone, a bone defect of 5 cm was formed. This was managed with a two-staged procedure (Masquelet technique). During the first stage, an antibiotic-loaded cement spacer was inserted, and the bone was stabilised with an external fixator. Two months later, the second stage involved incision of the induced membrane and removal of the cement spacer. The bone defect was subsequently filled with graft obtained from the ipsilateral femur using the RIA technique, mixed with BMP-7. Finally, the membrane was closed and the long bone was internally fixed. a) Radical debridement of the devitalised tissue and resulting bone defect; b) Induced membrane around the cement spacer, two months after the first stage procedure; c) Containment of the graft within the membrane.

Fig. 3

Radiographs taken nine months post-revision surgery, showing good incorporation of the graft and continuity of the tibia. a) Anteroposterior (AP) radiograph; b) lateral (LAT) radiograph.