Adult posttraumatic osteomyelitis of the tibia

An alternative method for the treatment of nonunion of the tibia with bone loss

In this retrospective study we evaluated the method of acute shortening and distraction osteogenesis for the treatment of tibial nonunion with bone loss in 17 patients with a mean age of 36 years (10 to 58). The mean bone loss was 5.6 cm (3 to 10). In infected cases, we performed the treatment in two stages. The mean follow-up time was 43.5 months (24 to 96). The mean time in external fixation was 8.0 months (4 to 13) and the mean external fixator index was 1.4 months/cm (1.1 to 1.8). There was no recurrence of infection. The bone evaluation results were excellent in 16 patients and good in one, while functional results were excellent in 15 and good in two. The complication rate was 1.2 per patient.

We conclude that acute shortening and distraction osteogenesis is a safe, reliable and successful method for the treatment of tibial nonunion with bone loss, with a shorter period of treatment and lower rate of complication.

[Expert opinion problems in the evaluation of osteomyelitis]

Cases of osteomyelitis can be differentiated according to hematogenous (endogenous), and post-traumatic (exogenous) forms. Both types can lead to considerable permanent damage or recur even after a fairly long time. In the formulation of an expert opinion to assess cases of osteomyelitis, the foremost question concerns a possible error in treatment or clarification of a connection to a postulated trauma. The present article describes aspects of expert opinions on cases of osteomyelitis of the long bones, spinal column, and in children. In addition to potential claims for compensation for harm caused by permanent damage, other conceivable sequelae such as fistula carcinoma or amyloidosis are relevant for expert opinions. In contrast, substantiated clarification of the causality of a triggering traumatic event is essentially important for recognition of claims against accident insurance companies.

Surgical management of chronic osteomyelitis

Chronic osteomyelitis is a surgical disease that can require significant dedication from both patients and surgeons to eradicate. Osteomyelitis can result from a variety of etiologies but most often is a consequence of trauma to a long bone, frequently the tibia. It is important to understand the etiology of the infection, as well as the pathophysiology of its chronicity. Additionally, the surgeon must individualize treatment for each patient, because host morbidities often play an important role in propagation of infection. Treatment requires isolation of the pathogens, significant debridement for removal of all infective and necrotic material, and then bony and soft tissue reconstruction. We review the literature of surgical treatment of chronic osteomyelitis and discuss the numerous techniques available to the treatment team, including debridement, dead space management, Ilizarov techniques, and vascularized reconstruction. These patients often require a multimodality approach that incorporates a team approach involving orthopedic and plastic surgery, as well as infectious disease and general medicine.

Long-Term Results of Multiple-Stage Treatment for Posttraumatic Osteomyelitis of the Tibia

BACKGROUND

The treatment of posttraumatic osteomyelitis of the tibia requires meticulous debridement and adequate soft tissue coverage. At our institution, we perform a staged procedure consisting of surgical debridement followed by muscle coverage. If necessary, implantation of a cancellous iliac bone graft was always performed as a three-stage treatment.

METHODS

We performed a retrospective analysis of 47 patients treated for posttraumatic osteomyelitis of the tibia between 1987 and 1998.

RESULTS

Twenty-two patients originally had a Gustilo grade III fracture, 21 patients had a Gustilo grade I or II or closed fracture, the Gustilo grade was not known for 2 patients, and 2 patients had no fracture. Using the Cierny-Mader classification, most patients had a localized osteomyelitis. To cover the debrided area, 20 pedicled muscle transfers and 28 microvascular free flaps were used; one patient had two localizations of osteomyelitis (both proximal and distal) and received two muscle flaps. Flap failure was 8% and was successfully treated by additional flap coverage in two cases; one was closed by a split skin graft and one was closed by secundum. Twenty-six patients received a cancellous bone graft. During an average follow-up of 94 months, 9% had a recurrence of osteomyelitis for which additional surgical interventions were necessary. Finally, all the infections were eventually cured.

CONCLUSION

Our staged surgery proved to be an excellent method of treating osteomyelitis after open or closed fractures of the tibia.

One-stage treatment of chronic osteomyelitis of the proximal tibia using a pedicled vascularised double-barrel fibular flap together with a muscle flap

Although segmental bone loss together with a soft-tissue defect after debridement of a chronic osteomyelitic lesion of the tibia represents a challenging problem for the reconstructive surgeon, bone management has not usually been carried out at the time of soft-tissue coverage. In a one-stage procedure, we treated a patient who had suffered from chronic osteomyelitis of the tibia for 12 years, using a pedicled vascularised double-barrel fibular flap together with a pedicled medial gastrocnemius muscle flap, immediately after radical debridement of the osteomyelitic lesion. Bony union was obtained at 4 months. Full unprotected weight-bearing for normal walking was achieved 10 months after fibular transfer. Follow-up at 2 years showed no recurrence of the osteomyelitis.