Prinzipien der operativchirurgischen Therapie der Osteitis

Osteomyelitis threatens the affected patients'social and professional existence.The total treatment costs that health insurances are faced with can easily amount to 500,000.00 EURO.Therefore, from the first onset of infection every effort must be made to minimize the problems for both patients and insurance companies by preventing the condition from becoming chronic.Once this happens there is absolutely no guarantee of success.Treatment must start with the removal of all necrotic tissue - soft tissue and bone - and all implants should be removed. As in tumor surgery, en-bloc resection is best.There is still no possible way of determining precisely where the infection ends intraoperatively.The surgeon's personal experience of treating osteomyelitis is most important in these cases.Bone reconstruction is mostly performed as a secondary procedure with bone grafting (defect <3 cm) or segment transfer (defect >3 cm).With the techniques of modern reconstructive surgery the results can be quite good if the management is meticulous and technically perfect.Patients with osteomyelitis should therefore be treated in specialized hospitals.     

Infektionen am Unterarm

Osteomyelitis patients feel a threat to their social and professional existence. Health insurances have to pay high amounts of money up to 500.000,00 € for total treatment costs. Therefore we need strategies from the first onset of infection to minimize the problems for patients and insurance companies. But once it is a chronic osteomyelitis there is absolutely no guarantee for success. In the beginning of the treatment all necrotic tissue—soft tissue and bone—and all implants should be removed. Favorable is, like in tumor surgery, the “en-bloc-resection”. There is up to now no possibility to demonstrate the exact border, where infection ends. The personal experience of the surgeon with the osteomyelitis is most important in these cases. Reconstruction of bone is performed secondary with shortening of the extremity, bone graft or by segment transfer. With the modern possibilities of reconstructive surgery the results are quite good, if the management of the problem is perfect. Patients with osteomyelitis therefore should be treated in specialized hospitals.     

Omental free flap for surgical treatment of chronic osteomyelitis of lower limb: A technical note

Soft tissue reconstruction of chronic lower extremity wounds with bone infection entails an important challenge in reconstructive surgery. We report our experience using the omentum free flap to provide coverage in two patients suffering chronic osteomyelitis of the lower limbs. After extensive soft tissue and bone debridement, an omentum free flap was performed in both cases, providing dead space obliteration and soft tissue coverage in behalf of its large size and pliability. As a result, the chronic illness was eradicated in both patients, with satisfactory outcomes and infection resolution.     

Management of chronic calcaneal osteomyelitis with pull-through abductor hallucis muscle flap -a report of three cases

Three patients who had chronic osteomyelitis of the calcaneus were treated with radical debridement of all involved soft tissue and bone and obliteration of dead space with a pull-through abductor hallucis brevis muscle flap. Two patients had calcaneal osteomyelitis without soft tissue loss resulting from previous comminuted calcaneal fractures while a third patient had a large soft tissue defect and calcaneal osteomyelitis resulting from a destructive infection. All of the patients had undergone several surgical procedures for treatment of the osteomyelitis with histories ranging 18 months to 30 months. Following treatment with the pull-through muscle flap there has been no recurrence over the longterm (>two years). We believe that radical removal of all contaminated tissue and immediately coverage with a muscle flap provides an effective single stage treatment of chronic calcaneal osteomyelitis.     

Therapy of osteomyelitis

Exogenic post-traumatic bone infection has come strongly into focus of attention, as compared to haematogenic cases. Complex prophylaxis against such infection, therefore, is of great importance. The initial phase of bacterial osteomyelitis must be identified and must be followed by immediate action, as early treatment is absolutely essential. That is why the routes of infection, which depend on the extent of injury and on the mode of primary treatment, as well as all areas affected must be fully detected. Substantial therapeutic steps should include radical sanitation, stabilisation (especially fixateur externe), different variants of drainage, and autogenic spongiosa transplantation. New results have become available also in the context of supplementary specialised antibiotic therapy and coverage of soft tissue.     

Die Saug-Spül-Behandlung bei der Behandlung der chronischen Osteomyelitis

The instillation drainage is a very important part in the treatment of chronic osteomyelitis (the débridement of necrotic bone and soft tissue cellulitis, the need of stability, the local antiinfectious treatment, and the plastic reconstruction of soft tissue and bone defects). In acute osteomyelitis under stabile conditions the instillation drainage helps spontaneous reossification, in most of these cases bone grafting is not necessary. For the local treatment of an intramedullary infection the closed technique of the instillation drainage is recommended. There must be an exact balance of Ringer's solution in the instillation and drainage system. In the open technique no retention of solution is possible.—Antibiotics can be added to Ringer's solution for the first few days, the more important effect of the instillation drainage is the mechanical cleansing of all infected spaces.     

Chronic calcaneal osteomyelitis associated with soft‐tissue defect could be successfully treated with platelet‐rich plasma: a case report

Chronic osteomyelitis associated with soft‐tissue defect following surgical management is a severe complication for orthopaedic surgeons. Traditionally, the treatment protocol for the notorious complication involved thorough debridement, bone grafting, long‐term antibiotic use and flap surgery. Alternatively, platelet‐rich plasma (PRP), a high concentration of platelets collected via centrifugation, has been successfully used as an adjuvant treatment for bone and soft‐tissue infection in medical practices. PRP has numerous significant advantages, including stypsis, inflammation remission and reducing the amount of infected fluid. It increases bone and soft‐tissue healing and allows fewer opportunities for transplant rejection. Through many years of studies showing the advantages of PRP, it has become preferred organic product for the clinical treatment of infections, especially for chronic osteomyelitis associated with soft‐tissue defect. To promote the clinical use of this simple and efficacious technique in trauma, we report the case of a patient with chronic calcaneal osteomyelitis associated with soft‐tissue defect that healed uneventfully with PRP.     

Akute posttraumatische Osteitis

Acute osteomyelitis, a bacterial infection of the bone and the surrounding soft tissue after an open fracture or surgical treatment, is a severe complication in orthopaedic and trauma surgery. If not treated correctly, it is catastrophic for the patient. The diagnosis is a clinical one. Radical surgery must be performed as early as possible. In most cases it is possible to save the osteosynthesis, but not if a nail is infected or if the infection is combined with instability.     

Pseudarthrosen und Infektionen proximaler Oberschenkel

Nonunion and osteomyelitis in the proximal femur are severe complications that often result in immobilisation of the patient.Both require surgical therapy.The treatment depends on the type of nonunion (hypertrophic, atrophic, defect, infect) or osteomyelitis (acute, chronic).Importance also attaches to the quality of the bone and soft tissues, the age of the patient,any malunions,previously inserted implants and general risks.During the treatment of nonunions, it is most important to provide stability.Malunions must be corrected if necessary.The aim of the treatment for osteomyelitis is to cure the infection. This requires radical debridement of infected or avital bone and soft tissues, restabilisation and insertion of antibiotic carriers.After treatment of the infection, reconstruction of defects by means of cancellous bone grafting or segmental transport is performed if necessary. In addition, intensive physiotherapy, sports therapy, occupational therapy, retraining in walking and help with employment matters are important.     

Two stage management of Cierny-Mader type IV chronic osteomyelitis of the long bones

IntroductionCierny-Mader (C-M) type IV chronic osteomyelitis represents a complex clinical challenge with permeation of extensive bone and soft tissue involvement. Aggressive debridement through viable tissue margin includes en bloc resection improves the odds of eradication of infection, which creates large bone and soft tissue loss in treating this type of osteomyelitis. The potentially large defects increase reconstruction problems with traditional reconstruction technique. The newly staged induced membrane technique presents length-independent, potential as an alternative reconstruction method for segmental bone defects due to type IV chronic osteomyelitis. The purpose of this study was to assess the result and related factors of C-M type IV chronic osteomyelitis treated with staged methods of aggressive debridement and induced membrane technique.MethodsFrom January 2012 to January 2014, 36 consecutive adult patients of C-M type IV chronic osteomyelitis were treated by this staged method in our clinical center with a minimum of 2-years follow-up. The clinical and imaging results were retrospectively analyzed.ResultsFive patients had a second debridement and eight needed a local flap transfer to cover the wound in the first stage. Patients formed a mean of 5.5 cm (range: 2–10.9) segmental bone defect; Sixteen patients had autograft and twenty had autograft mixed allograft in the second stage. The mean follow-up time was 29.5 months (range: 24–45). No patients required amputation. Bone union was achieved in all patients. Clinical eradication of osteomyelitis was achieved in 35 (97%) patients, 35 (97%) patients were able to walk independently, and 31patients (86%) returned to work. Patients returned to a mean of 82% (46.3%–100%) lower extremity function. Bone union time was not dependent on the length of bone defect, but associated with the infection site (p = 0.005) and age (p = 0.005).ConclusionsStaged methods of aggressive debridement and induced membrane technique seems to be a simple, reliable and effective for the treatment of C-M type IV chronic osteomyelitis. Advanced age and poor soft tissue envelope may have adverse affects and are relative contraindications. The combined assessment and management of such patients with a plastic surgeon are advocated.     

Surgical management of the acute severely infected diabetic foot – The ‘infected diabetic foot attack’. An instructional review

Diabetic Foot Infection (DFI), in its severest form the acute infected ‘diabetic foot attack’, is a limb and life threatening condition if untreated. Acute infection may lead to tissue necrosis and rapid spread through tissue planes, in the patient with poorly controlled diabetes facilitated by the host status. A combination of soft tissue infection and osteomyelitis may co-exist, in particular if chronic osteomyelitis serves as a persistent source for recurrence of soft tissue infection. This “diabetic foot attack” is characterised by acutely spreading infection and substantial soft tissue necrosis.In the presence of ulceration, the condition is classified by the Infectious Diseases Society of America/International Working Group on the Diabetic Foot (IDSA/IWGDF Class 3 or 4) presentation requiring an urgent surgical intervention by radical debridement of the infection. Thus, ‘time is tissue’, referring to tissue salvage and maximal limb preservation. Emergent treatment is important for limb salvage and may be life-saving. We provide a narrative current treatment practices in managing severe DFI with severe soft tissue and osseous infection. We address the role of surgery and its adjuvants, the long term outcomes, potential complications and possible future treatment strategies.     

清创一期植骨及腓肠神经皮瓣治疗跟骨慢性骨髓炎伴软组织缺损

【摘要】 目的 探讨清创、一期植骨联合腓肠神经皮瓣移植治疗跟骨慢性骨髓炎伴软组织缺损的疗效。方法 2008年11月~2011年11月,对 12例合并软组织缺损的跟骨慢性骨髓炎患者采用清创、一期植骨联合腓肠神经皮瓣移植修复创面,观察术后皮瓣成活、骨髓炎治愈及踝关节功能情况。结果 术后随访9~24个月,平均 17个月。9例皮瓣Ⅰ期愈合,3例窦道形成或边缘坏死经处理后愈合;随访期间无骨髓炎复发;根据美国足踝外科协会(AOFAS ) 踝后足功能评分术后(89.4±7.8)较术前(42.8±15.3)明显提高,差异有统计学意义(P<0.05)。结论 跟骨慢性髓炎合并软组织缺损通过彻底清创、一期植骨及腓肠神皮瓣移植取得良好的效果,该方法具有疗效确切、疗程短、简单易行等特点。     

Radical excision and reconstruction of chronic tibial osteomyelitis with microvascular muscle flaps

We report a series of 21 patients with chronic osteomyelitis of the tibia treated with microvascular muscle flap reconstruction. All patients underwent a radical bone and soft-tissue excision until healthy, well-bleeding tissue was exposed. Six patients required cancellous bone grafting. Latissimus dorsi was used in 14 patients, gracilis in 4, and rectus abdominis in 4. One gracilis flap was lost due to vessel thrombosis and was replaced with a rectus abdominis free flap. Average follow-up was 2.5 years. There was no evidence of clinical infection in 20 patients at follow-up; the bone had healed, the soft-tissue cover was stable, and the laboratory parameters were normal. Bone infection recurred in 1 patient, resulting in a below-knee amputation. The radical excision of infected bone and affected soft tissue and reconstruction with a well-vascularized large free-muscle flap is an excellent solution in most difficult chronically infected cases.     

Kontinuitätserhalt oder Segmentresektion

Septic diseases of the bone and immediately surrounding soft tissue (i.e., osteitis) are among the most alarming findings in traumatology and orthopedic practice. The paramount goal is to preserve the stable weight-bearing bones, maintaining a correct axis and proper working muscles and joints, in order to avoid permanent disability in the patient. State-of-the-art therapy for osteitis/osteomyelitis has two priorities: eradication of the infection and reconstruction of the bone and soft tissue. Surgical treatment with resection of the affected bone segments and soft tissue, followed by reconstruction, continues to be the main basic therapy. Deciding whether the affected bone segment must be resected or if bone continuity can be preserved is sometimes very difficult. This article provides strategies and decision-making guidance for this problem.     

Utility of the sural fasciocutaneous flap for the treatment of chronic osteomyelitis of the distal tibia

Treatment of chronic osteomyelitis of distal tibia is complex. It often requires the association of antibiotic therapy and a surgical procedure. This consists of exhaustive debridement of infected bone and soft tissue which must have adequate cutaneous coverage and vascular supply which enables creating a barrier to microorganisms and greater resistance to infection. Free or pedicled muscular flaps have been the techniques most often used for this type of lesions. Free flaps require a precise microsurgical technique and prolonged surgery. Pedicled muscular flaps do not provide sufficient coverage and vascularisation of the distal tibia for large size defects. The fasciocutaneous flap has been used for the treatment of coverage defects in the perimalleolar area and the heel. We report the utility of this flap as management of chronic osteomyelitis of the distal third of the tibia with complete healing of the infection and correct cutaneous coverage without complications.     

Correlational aspects of hematogenous osteomyelitis in children and adults

Osteomyelitis is an inflammation of the bone caused by an infecting organism. The infection may be limited to a single portion of the bone or may involve a number of regions such as the marrow, cortex, periostium and even the surrounding soft tissue. Material and method: This retrospective study included a number of 256 cases made by 152 children (56%) and 115 adults (44%). RESULTS: Hematogenous osteomyelitis appears at any age, most frequently in growth period, 85% cases until 16 years. This study relieve a high frequency of subacute (40.1%) and acute (31.1%) hematogenous osteomyelitis compare with chronic form (28.8%). Regarding the distribution of cases by sex, there are no differences between man and woman in chronic osteomyelitis, but subacute form is most frequently at men. The analysis of the cases distribution by location and sex relieve that at womans metaphysis and diaphysis are most interested (70.09%) but only 53.7% at men. Regarding the treatment, the distribution of cases relieve that chronic osteomyelitis generally cannot be eradicated without surgical treatment (sequestrectomy and resection followed by reconstruction with material. Those others forms, acute and subacute hematogenous osteomyelitis, were resolved with medical and surgical treatment, equally. CONCLUSION: Prompt diagnosis and early treatment are required to prevent further destruction and growth disturbance. Generally, a multidisciplinary approach is required, involving an orthopaedic surgeon, an infectious disease specialist and a plastic surgeon in complex cases with soft tissue loss.     

Treatment of chronic post-traumatic infections of the bone and soft tissue with gentamycin PMMA beads (PMMA = polymethylmethacrylate) (author's transl)

Temporary implantation of Gentamycin PMMA beads and chains provides a most effective local antibiotic therapy as supplementary and consecutive treatment after surgical procedures executed in bone and soft tissue infections. Gentamycin beads and chains are used as an alternative to irrigation-suction drainage. From 1977 to 1979 70 patients were treated for chronic post-traumatic osteomyelitis and infection of the soft tissue. The chronic bone infections subsided completely in 90% of the patients, but 8.3% re-infections were observed within 3 to 24 months after termination of treatment. In 18 patients with gunshot wounds 66.6% of the patients got primary healing and 33.4% secondary healing.     

Strategies for the analysis of osteitic bone defects at the diaphysis of long bones

Septic diseases of the bone and the immediate surrounding soft tissue, i.e., osteitis, belong to the most alarming findings in recent traumatology and orthopedic surgery. The paramount goal of this therapy is to preserve the stable weight-bearing bones while maintaining a correct axis and proper working muscles and joints, in order to avoid permanent disability in the patient. “State-of-the-art” therapy of osteitis/osteomyelitis therapy has two priorities: eradication of the infection and reconstruction of bone and soft tissue. Surgical treatment of the affected bone segments and soft tissue, followed by reconstructive methods, continues to be the main basic therapy. It is often extremely difficult to decide whether the affected bone segment has to be resected, or whether bone continuity can be preserved. The following paper provides strategies and guidance to help guide decisions in this complex and challenging area.     

慢性骨髓炎保肢治疗现状及进展

慢性骨髓炎治疗周期长,效果差,截肢率高,是创伤骨科临床中的难题之一。近年来保肢治疗成为慢性骨髓炎研究的热点,该文综述慢性骨髓炎保肢治疗涉及的病灶清除、骨缺损治疗、软组织覆盖、患肢骨稳定、抗生素治疗以及辅助治疗的现状及进展。     

Lower extremity salvage and reconstruction by free-tissue transfer. Analysis of results

The application of soft tissue or bone free-tissue transfers to lower extremity salvage or reconstruction was assessed in a review of 86 consecutive procedures done during a 36-month period. This group included 65 cases of free skin or muscle flap transfer and 21 cases of free vascularized bone transfer. In terms of tissue viability, the success rate was 80.2% (78.5% for the soft tissue group and 85.7% for the bone group). With due consideration of indications, the incidence of secondary sepsis in patients with chronic osteomyelitis, and other potential complications, free-tissue transfers are valuable for salvage and reconstructive surgery of the lower extremity.