[Chronic osteitis of the lower extremities. An interdisciplinary treatment concept]

Osteomyelitis

INTRODUCTION

Osteomyelitis is a challenging diagnosis for every patient because of its protracted treatment process. Very experienced orthopaedic surgeons are needed to diagnose and treat this bacteria-related severe disorder in a right and proper way.

MATERIALS AND METHODS

Different treatment options are possible for osteomyelitis at any stage: antibiotics in the acute and chronic stage for conservative treatment or radical debridement, bone fenestration, reaming, bone troughing, the Masquelet-technique, segmental resection with callus distraction, bone grafting and even amputation as surgical therapy.

RESULTS

Depending on different stages of the disease, there are good results with every technique available-on condition that radical debridement was performed. The complication rate is remarkable so that soft tissue defects should be assessed by using flaps to close the wounds in early stages.

CONCLUSIONS

The treatment of osteomyelitis should be done in centres with expertise in the treatment of this challenging disease. Different methods should be offered by surgeons and individual treatment concepts acquired together with the patient. The treatment of complications like soft tissue defects should be provided in the same centre and performed in short time lag to the prior surgery. The cooperation of the patient and surgeons of different specialities is mandatory in these cases.

[Free latissimus dorsi flap transfer for reconstruction of soft tissue defects of the lower extremity]

OBJECTIVE

Sustainable and durable soft tissue coverage at the lower extremity following trauma, tumor resections, sequelae of radiation therapy or osteomyelitis using free latissimus dorsi muscle transfer is provided by a free latissimus dorsi muscle flap.

INDICATIONS

Soft tissue defects at the lower extremity following trauma, tumor resections, and sequelae of radiation therapy or osteomyelitis.

CONTRAINDICATIONS

Thoracotomy with incision of the latissimus dorsi muscle; a relative contraindication in wheelchair drivers as well as in overhead athletes due to potential diminished strength and shoulder proprioception following latissimus dorsi muscle transplantation.

SURGICAL TECHNIQUE

Under general anesthesia the patient is positioned laterally, and a substantial and meticulous debridement of the defect is performed, as is the identification and preparation of the target vessel, which is preferentially the posterior tibial artery at the calf, or more proximally the popliteal or femoral artery from the medial side as well as concomitant veins/the great saphenous vein. A tailored latissimus dorsi musculocutaneous flap is harvested with subsequent microsurgical anastomosis to the target vessel with preferential end-to-side anastomosis of the artery and end-to-end anastomosis of one or two veins.

POSTOPERATIVE MANAGEMENT

A 24-h intermediate care unit, clinical flap monitoring for at least 5-7 days, dangling of the flap using an elastic bandage for an initial 3  times  5 min starting on POD 7, compression stockings for at least 6 months subsequently.

RESULTS

From 2001-2007 75 free latissimus dorsi flaps were performed (53 ± 17 years) for soft tissue coverage at the lower extremity. In 58% the target vessel was the posterior tibial artery, in 11% the femoral artery, in 8% the anterior tibial artery and in 8% the popliteal artery. In 15% an arteriovenous (AV) loop was applied. Overall free flap survival was 95%. We encountered four total flap losses, exclusively in complex reconstructions with AV-loop situations.

Treatment algorithms for chronic osteomyelitis

BACKGROUND

Osteomyelitis was described many years ago but is still incompletely understood. Its exogenously acquired form is likely to become more common as the population ages. We discuss biofilm formation as a clinically relevant pathophysiological model and present current recommendations for the treatment of osteomyelitis.

METHODS

We selectively searched the PubMed and Cochrane databases for articles on the treatment of chronic osteomyelitis with local and systemic antibiotics and with surgery. The biofilm hypothesis is discussed in the light of the current literature.

RESULTS

There is still no consensus on either the definition of osteomyelitis or the criteria for its diagnosis. Most of the published studies cannot be compared with one another, and there is a lack of scientific evidence to guide treatment. The therapeutic recommendations are, therefore, based on the findings of individual studies and on current textbooks. There are two approaches to treatment, with either curative or palliative intent; surgery is now the most important treatment modality in both. In addition to surgery, antibiotics must also be given, with the choice of agent determined by the sensitivity spectrum of the pathogen.

CONCLUSION

Surgery combined with anti-infective chemotherapy leads to long-lasting containment of infection in 70% to 90% of cases. Suitable drugs are not yet available for the eradication of biofilm-producing bacteria.

Medium-term results after total clavicle resection in cases of osteitis: a consecutive case series of five patients

PURPOSE

Claviculectomy is a rare and poorly described event in the surgical therapy of diseases of the clavicle. We present a case series and functional results of patients who underwent total claviculectomy.

METHODS

From 1995 to 2006 a total of 26 patients diagnosed with osteitis of the clavicle underwent surgery in our unit. Of these, five patients (all female) needed a total resection of the clavicle in order to ensure permanent healing from infection. The data collection was prospective. The data gathered preoperatively and at follow-up included clinical examinations, laboratory findings, radiographs and the Constant shoulder scores. The mean follow-up period was 7.5 months.

RESULTS

The surgical concept described was able to eliminate infection in all cases studied within an average hospital stay of 13.4 days (8-18 days). Only one patient showed complications; suffering from chronic pain syndrome requiring surgical revision. After total resection of the clavicle four of five patients showed very good functional results. The average Constant score showed a significant increase from 82 before surgery to 95 at follow-up.

CONCLUSIONS

The surgical technique described for total claviculectomy, along with the insertion of local antibiotic beads, was able to eliminate infection in every case. Good functional results and a low complication rates were observed. For good functional results and the permanent elimination of infection, adjacent joints have to be addressed, the periosteal tube should be preserved and early functional treatment is essential.

[Medium-term results of surgical treatment for osteitis of the clavicle]

AIM

Osteitis of the clavicle is rare and not well described in the international literature. We describe a concept of surgical treatment with medium-term observations.

METHOD

A total of 22 patients (12 women, 10 men; BMI Ø 24.6 kg/m(2), age Ø 48 years) with osteitis of the clavicle were included in the series. The treatment regime consisted of a surgical approach. Data collection was prospective. Data gathered preoperatively and at follow-up included clinical examination, laboratory findings, radiographs and the Constant scoring system. The mean follow-up period was 13.3 (3-53) months.

RESULTS

The described surgical concept was able to permanently eliminate infection in all cases studied. Surgical revisions were required in six patients. The average Constant score showed a significant increase from 66 to 84 at follow-up. Patients also showed good functional results after total resection of the clavicle.

CONCLUSION

The reported treatment regime provides reliable results in terms of eliminating infection with good clinical results. Neighboring joints were frequently also involved in the infection and needed to be surgically addressed.