Osteomyelitis of the Pelvic Bones: A Multidisciplinary Approach to Treatment

Abstract

Background and Purpose: A case series review of chronic pelvic osteomyelitis treated with combined medical and surgical treatment by a multidisciplinary team. Methods: All patients treated with surgical excision of pelvic osteomyelitis at our tertiary referral centre between 2002 and 2014 were included. All received combined care from a clinical microbiologist, an orthopaedic surgeon and a plastic surgeon. The rate of recurrent infection, wound healing problems and post-operative mortality was determined in all. Treatment failure was defined as reoperation involving further bone debridement, a requirement for the use of long-term suppressive antibiotics or sinus recurrence. Results: Sixty-one adults (mean age 50.2 years, range 16.8-80.6) underwent surgery. According to the Cierny-Mader classification of osteomyelitis there were 19 type II, 35 type III and 7 type IV cases. The ischium was the most common site of infection. Osteomyelitis was usually the result of contiguous focus infection associated with decubitus ulcers, predominantly in patients with spinal or cerebral disorders. Most patients with positive microbiology had polymicrobial infection (52.5%). Thirty patients required soft tissue reconstruction with muscle or myocutaneous flaps. Twelve deaths occurred a mean of 2.8 years following surgery (range 7 days-7.4 years). Excluding these deaths the mean follow-up was 4.6 years (range 1.5-12.2 years). Recurrent infection occurred in seven (11.5%) a mean of 1.5 years post-operatively (92 days - 5.3 years). After further treatment 58 cases (95.1%) were infection free at final follow-up. Interpretation: Patients in this series have many comorbidities and risk factors for poor surgical outcome. Nevertheless, the multidisciplinary approach allows successful treatment in the majority of cases.

Keywords: Chronic osteomyelitis; infection; pelvis; pressure ulcer; surgical debridement..

Figure 1

Extensive osteomyelitis in a paraplegic patient with sinus drainage from the ischium, trochanteric region and sacrum.

Figure 2

A. This patient had Crohn's Disease with multiple fistulae extending from the bowel to the pelvis and right hip joint. The right sacro-iliac joint was exposed. B. The pelvic osteomyelitis was treated by radical excision including the right hemipelvis, the right hip and lower limb. The anterior thigh muscles were preserved on the healthy femoral vessels. C. The defect was directly closed using the thigh musculocutaneous flap.

Figure 2

A. This patient had Crohn's Disease with multiple fistulae extending from the bowel to the pelvis and right hip joint. The right sacro-iliac joint was exposed. B. The pelvic osteomyelitis was treated by radical excision including the right hemipelvis, the right hip and lower limb. The anterior thigh muscles were preserved on the healthy femoral vessels. C. The defect was directly closed using the thigh musculocutaneous flap.

Figure 3

A. Osteomyelitis of the right posterior ilium after a bone graft harvest for a spinal fusion. There is a central cavity with surrounding increased bone density (involucrum). B. MRI showing the bone destruction in the ilium, with a central area of dead bone. C. MRI demonstrating the bone involvement and sinus formation to the skin of the lateral buttock. D. Postoperative radiograph showing the area of resection. The bone defect has been filled with a bioabsorbable antibiotic carrier with Gentamicin (Cerament G, Bonesupport AB, Sweden).

Figure 3

A. Osteomyelitis of the right posterior ilium after a bone graft harvest for a spinal fusion. There is a central cavity with surrounding increased bone density (involucrum). B. MRI showing the bone destruction in the ilium, with a central area of dead bone. C. MRI demonstrating the bone involvement and sinus formation to the skin of the lateral buttock. D. Postoperative radiograph showing the area of resection. The bone defect has been filled with a bioabsorbable antibiotic carrier with Gentamicin (Cerament G, Bonesupport AB, Sweden).

Figure 4

Patient with a longstanding pressure ulcer over the left ischium. At operation, this was found to have developed a squamous carcinoma.