Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Introduction

Wide, tumor-like resection for chronic osteomyelitis (COM), a standard practice previously, has been challenged recently with adequate, local debridement. This paper reviews the evolution of surgical debridement for long bone osteomyelitis, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Introduction

Osteomyelitis (OM) is a challenging condition to diagnose and treat. The multidisciplinary team (MDT) approach is used in managing complex diseases such as cancer and diabetes. The Hull Regional Bone Infection MDT team was established to provide coordinated care for patients suspected to have OM. This study reviews the orthoplastic treatment and outcomes of patients with non-periprosthetic OM.

Aim

This study aimed to evaluate the impact on length of hospital stay from dedicated infectious diseases input for orthopaedic infection patients compared to sporadic infection specialist input.

Open fractures of the long bones of the limbs are associated with an increased risk of osteomyelitis and few studies investigate this complication in circular frames. We reviewed the incidence of and contributory factors toward infection-related outcomes in Grade 3 open fractures, managed with a circular frame, at a single centre.

We performed a retrospective study of consecutive adult patients presenting with a Grade 3 open fracture, who required a circular frame for definitive skeletal fixation from 2005 to 2014. Patient case notes, microbiology results and radiological studies were reviewed for demographic details and surgical management. Infection-related outcomes were classified as ‘possible’ and ‘definitive’, based on clinical findings, microbiology and imaging features at follow-up at 6 and 12 months.

74 patients were identified with an average age of 43 years. There were 70 unilateral and 4 bilateral limb injuries. Most treated limbs had a tibial fracture (97%). There were 24 Gustillo-Anderson grade 3A, 37 grade 3B, 4 grade 3C and 9 not sub-classified. 33% of patients were debrided on the day of injury. Average time to circular frame installation was 14 days. 27 Ilizarov, 44 Taylor spatial and 3 other circular frames were used. A variety of plastic surgery reconstruction was used to provide wound coverage: skin grafts, local and free flaps. Circular frames were in place for 259 days on average. 10 patients (1 bilateral limb fracture) still have their frames in-situ. Additional bone grafting to the fracture site was carried out in 13 patients and 15 limbs (1 patient had 2 episodes of bone grafting to the same limb). 8 limbs in 8 patients were excluded from infection-related outcome analysis: 4 patients lost to follow-up, 2 patients who went on to below knee amputation and 2 patients had <6 months’ follow-up. 13 patients (14 limbs) had only 6 months’ follow-up and 53 patients (56 limbs) had 12 months’ follow-up. There were 5 patients (5 limbs) with ‘possible’ infection (7%): 1 screw infection and 4 soft tissue infections. 1 patient (1 limb) had a tissue-confirmed ‘definitive’ infected non-union (1.4%).

Patients managed with circular frames typically have complex fracture configurations less amenable to other methods of definitive fixation. Our patient cohort has a limb salvage rate (97%) and a soft tissue infection rate (‘possible’ infection) comparable to other reported series. We report a low rate of osteomyelitis (‘definitive’ infection) in consecutive patients managed using our protocol.

We report a prospective single-blind controlled study of the incidence of early wound infection after internal fixation for trauma in 609 patients, of whom 132 were HIV-positive. Wounds were assessed for healing using the ASEPSIS score. There was no significant difference in the rate of infection between HIV-positive and HIV-negative patients undergoing clean surgery (4.2% vs 6%, respectively; p = 0.65). HIV-positive patients did not receive additional antibiotic prophylaxis or antiretroviral therapy as part of their management. The difference in the rate of infection between HIV-positive and HIV-negative patients with an open fracture or other contamination was not significant (33% vs 15%, respectively; p = 0.064). There was no relationship between CD4 count and infection rate. HIV status did not significantly influence the number of secondary surgical procedures (p = 0.183) or the likelihood of developing chronic osteomyelitis (p = 0.131). Although previous contamination from the time of injury was a risk factor for infection in mal- and nonunions, it was not significantly increased in HIV-positive patients (p = 0.144).

We conclude that clean implant surgery in HIV-positive patients is safe, with no need for additional prophylaxis.

A number of series report limb length discrepancy in long bone chronic osteomyelitis, however in most cases, it is shortening of the affected bone. This is thought to be due to damage in the affected growth plate leading to early growth arrest. However, it is known that the inflammatory state of chronic osteomyelitis results in an increased blood supply and, as in other conditions such as rheumatoid arthritis, the increased blood supply results in overgrowth of the affected bone.

In order to study the effect of long bone chronic osteomyelitis on limb length, we designed a prospective trial of 42 consecutive patients presenting to our unit with chronic osteomyelitis of a long bone. The inclusion criteria were all patients presenting with a long bone osteomyelitis. There were no exclusion criteria. The mean age at presentation was 10.3 years. The mean duration of symptoms of 18.2 months prior to presentation. For 37 (88%) of patients the cause of osteomyelitis was haematogenous. On examination, 3 (7%) patients had shortening of the long bone compared to the unaffected side (of an average of 2.5cm), whilst 13 (31%) patients had overgrowth of the affected bone (average overgrowth 2.2cm). The most common bone affected was the tibia (20/42, 48%), followed by the femur (8/42, 19%) and the humerus (6/42, 14%).

All patients underwent radiographic analysis, and the average percentage of long bone affected was 59%. 8/42 (12%) of patients had at least one physis affected (2 of these patients had undergrowth and 1 had overgrowth).

This large prospective series of patients is the first in the world literature to show the effect of osteomyelitis on the growth of long bones, in particular an overgrowth rate of 31%. We suggest that the mechanism for this is related to the duration of symptoms. In areas of the world where there is poor access to health care, there is consequently a prolonged period of increased blood supply as a result of inflammation. This increased blood supply may make limb length discrepancy is more likely to be due to overgrowth rather than undergrowth.