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.     

Local muscle flaps in the treatment of chronic osteomyelitis

When large soft-tissue and osseous defects remain after débridement of a chronic osteomyelitic lesion, application of a local muscle flap can be an effective way to achieve wound closure. Utilizing this surgical technique and specific antimicrobial therapy for the causal microorganisms, the infectious process was eradicated in thirty-nine of forty-two patients with osteomyelitis who were followed for at least two years after treatment. The osteomyelitic process was post-traumatic in origin--that is, a complication of a fracture or its treatment--in twenty-eight patients, the result of soft-tissue trauma without a fracture in eight, a complication of elective surgery in three, and the result of hematogenous seeding in three patients. Nine of the forty-two patients had an infected non-union. The infectious process involved the tibia in 62 per cent of the patients. Pseudomonas aeruginosa was the most frequently isolated causal organism. A soleus or gastrocnemius muscle flap was most frequently utilized to achieve closure. In five patients, a combination of two muscle flaps was utilized. Although this technique successfully eradicated the infectious process in 93 per cent of the patients, twenty-two patients required additional surgical treatment. Six required such treatment for a persistent non-union and two, for weakened diaphyseal bone after eradication of the septic process. A cancellous bone-grafting procedure was performed in all eight patients after the muscle flap had healed, and union was achieved in six of them. One patient eventually requested an amputation for a persistent non-union, and the remaining patient had a fibular synostosis performed for a persistent tibial non-union. A local muscle flap can be used in patients with a large defect of soft tissue and bone after débridement of an osteomyelitic lesion if the flap can be elevated and transposed into the defect without compromising its vascular supply. Although they are not applicable to the treatment of all patients with osteomyelitis, local muscle flaps can be extremely useful in the treatment of this lesion. When combined with thorough débridement and specific antimicrobial therapy, it has become a successful technique in the management of chronic osteomyelitis.     

Transplantation of vascularized tissue flaps in the treatment of chronic osteomyelitis

Experience in transplantation of vascularized tissue grafts in 38 patients with chronic osteomyelitis showed the method to be highly effective and to possess some essential advantages over the other methods for surgical treatment of chronic osteomyelitis. Some types of skin and musculocutaneous grafts were used in cases with affection of the leg and foot bones with defects in the skin and soft tissues and "osteomyelitic ulcers". A vascularized graft of the greater omentum was used in the management of large osteomyelitic cavities in the tubular bones. The grafts took in 92.1% of patients.     

Dead space management strategies in the treatment of chronic osteomyelitis: a retrospective review

Purpose

Dead space management is critically important during the treatment of chronic osteomyelitis. Many dead space management strategies are available, each with their respective advantages and shortcomings. This study aims to present the outcomes and complications of dead space management strategies employed in the treatment of chronic osteomyelitis at a single tertiary level musculoskeletal unit.

Methods

A retrospective review of dead space management strategies employed at a tertiary-level musculoskeletal infection unit was conducted. Patients of any age treated for chronic osteomyelitis of the appendicular skeleton with a minimum follow-up of 6 months were included in the study. Data were collected regarding patient demographics, aetiology and site of infection, dead space management strategy employed, follow-up period and outcome in terms of resolution of infection.

Results

A final cohort of 132 patients underwent surgical treatment with a dedicated dead space management strategy for chronic osteomyelitis of the appendicular skeleton. Eleven patients (8%) experienced a recurrence of infection. Seven patients (63%) with recurrence were type B hosts, while four patients (37%) were type A hosts.

Conclusion

Dead space management is an integral part of treating chronic osteomyelitis; however, no guidelines currently exist regarding the most appropriate strategy. Favourable results are achievable in low to middle-income countries, and it is evident that no dead space management strategy is superior to another. The pursuit for the ideal void filler is ongoing.

Level of Evidence

III.

     

Intramedullary reaming in the treatment of chronic osteomyelitis of the femur and tibia

The authors comment on the experience acquired in the treatment of chronic osteomyelitis of the long bones with intramedullary reaming. The procedure is reserved for the femur and tibia with stage I chronic osteomedullary infection according to the Cierny-Mader classification. 2 A total of 36 patients were treated. Surgical treatment consists in reaming of the medullary canal and in its contra-opening with antiseptic solutions. Mean time for lavage is 6 days. Criteria for healing involves the absence of clinical, humoral, and radiologic signs of active medullary sites of infection. The percentage of healing was 83.2%, mean long-term follow-up was 2.9 years.     

Soft tissue coverage of the distal third of the tibia with fasciocutaneous propeller flaps

BACKGROUND: The distal third of the tibia is often only amenable to free tissue transfer to cover exposed bone, tendons and neurovascular structures. Using relatively constant perforators of the tibial and peroneal vessels, soft tissue coverage can be achieved with so-called propeller flaps. METHODS: 8 patients presenting with post-traumatic defects over the lateral malleolus and the Achilles tendon were included in this study. A propeller flap based on perforators from the peroneal or tibial artery was used to cover the defect. RESULTS: One case of partial flap necrosis was encountered in a diabetic patient. Transient venous congestion of the flap tip was witnessed in two instances, which resolved without further intervention. No other complications occurred. All patients were fully ambulatory within 8 weeks, except for 1 patient, who required a below-knee amputation. CONCLUSION: The propeller flap has proven to be a versatile and elegant method to obtain soft tissue coverage with local tissue. Contrary to conventional rotation flaps, direct closure of the donor site is possible. Patients are not impaired by bulky flaps and may wear normal shoes. Even in the elderly, this flap was successful.     

Comparative evaluation in the treatment of chronic post-traumatic osteomyelitis of the lower leg: free flaps compared with local flaps

Forty-nine out of 101 patients treated for post-traumatic chronic osteomyelitis of the lower leg at the Innsbruck University Hospital for Plastic and Reconstructive Surgery in Austria between 1979 and 1996 were included in this retrospective study. The following parameters were covered in the statistic evaluation: postoperative complications, rates of flap survival, recurrence and revision, nosocomial infections, duration of hospitalisation, chronic oedema of the lower leg, and patient satisfaction. Postoperative complications, recurrence, and flap loss rates were significantly lower in the free-flap group. These low rates are most likely responsible for the significantly shorter hospitalisation of patients treated with free flaps. For these reasons, their use may be considered first-choice therapy in the treatment of chronic post-traumatic osteomyelitis of the lower leg.     

Hemi-corticotomy in the management of chronic osteomyelitis of the tibia

We reviewed 20 cases of chronic osteomyelitis of the tibial diaphysis without shortening or deformity resulting from different causes. Debridement included removal of the anterior half of the tibial cortex with any sequestrum, leaving the posterior cortex intact with its vascular muscle attachments. This was then followed by hemi-corticotomy (hemi-circumferential corticotomy and partial bone fragment transfer) in order to reconstruct the resulting defect. This technique proved effective in 19 out of the 20 patients. Follow-up was by plain radiography and sedimentation rate estimations, with an average follow-up of 34 months after operation. In nine patients, early removal of the fixation frame immediately after segment transfer followed by cast application produced the same outcome as achieved with patients in whom the frame remained in position until the end of the procedure.     

骨搬运治疗胫骨慢性骨髓炎,是否需要加用抗生素骨水泥?

[目的]探讨加用抗生素骨水泥能否减少骨搬运技术治疗胫骨慢性骨髓炎的复发率。[方法]将18例胫骨慢性骨髓炎的患者随机分为两组,一组为对照组,10例,不使用抗生素骨水泥,用油纱填塞骨缺损处;骨水泥组8例,在骨缺损处填充万古霉素骨水泥(20 g骨水泥加入3 g万古霉素)。骨段搬运的过程中,骨缺损处的空间越来越小,逐渐拉出骨水泥链珠或油纱。根据Paley等感染性骨缺损评分标准评定疗效。[结果]10例对照组中的1例出院后失访,其余17例术后获12~47个月(平均31个月)随访,所有的患者感染治愈。骨水泥组平均创口闭合时间为63 d,对照组平均创口闭合时间为69 d;骨缺损端愈合时间骨水泥组平均4.4个月,对照组平均4.3个月。并发症包括钉道感染:骨水泥组7例,对照组9例;>10°的力线偏移:骨水泥组5例,对照组3例,均在随访过程中纠正;关节僵硬:骨水泥组1例,对照组2例;根据Paley感染性骨缺损的评分标准:骨水泥组优7例,良1例,对照组优7例,良2例。两组间比较差异无统计学意义。[结论]即使在骨缺损处不填充抗生素骨水泥,通过彻底清创,骨搬运技术可以很好的治疗胫骨慢性骨髓炎。     

Free fasciocutaneous flaps for reconstruction of complete circumferential degloving injury of digits

Complete circumferential degloving injury of the digits usually results in a large cutaneous defect with tendinous structure and bone and joint exposure. When revascularization is not possible, a thin and adequately sized flap is required to resurface the defect, restore finger function, and prevent amputation. In this report, we present our experience with reconstruction of the entire circumferential degloving injury of the digits using free fasciocutaneous flaps. Between February 2006 and January 2011, 9 male patients with circumferential degloving injury of 9 digits underwent reconstruction using free fasciocutaneous flap transfer with the posterior interosseous artery flap, medial sural artery flap, anteromedial thigh flap, or radial forearm flap. The average flap size was 14.2 × 6.9 cm. Donor sites were closed primarily or covered with split‐thickness skin graft. All flaps survived completely and the donor sites healed without complications. The mean follow‐up period was 34.8 months. A maximum Kapandji score (10/10) was seen in 2 cases with crushed thumbs. All patients could achieve good key pinch and grasping functions. All skin flaps showed acceptable static 2‐point discrimination and adequate protective sensation. Patient satisfaction for resurfaced digits averaged 9 on a 10‐points visual analogic scale. In conclusion, the free fasciocutaneous flaps used were thin and did not interfere with finger movements. The patient's finger formed a smooth contour and acceptable functional results were obtained after reconstruction. This method may be a valuable alternative for reconstruction of entire circumferential avulsion injury of the digits. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.