Management of medullary osteomyelitis of the humerus

Chronic humeral osteomyelitis in an adult with sickle-cell disease

INTRODUCTION AND IMPORTANCE

The rising incidence of sickle-cell disease in European countries has led to an increase in associated complications. Osteomyelitis, a rare complication in non-traumatic adult cases, poses diagnostic challenges and presents treatment difficulties due to limited cases and studies.

CASE PRESENTATION

A 23-year-old woman diagnosed with sickle-cell disease presented with a six-day fever and painful swelling in the left upper extremity persisting for a fortnight. She had no history of trauma but had experienced a previous episode of bacteremia due to Salmonella, four years prior. Magnetic resonance imaging revealed an intramedullary bone injury with cortical rupture extending into soft tissues, forming a collection that raised clinical suspicion of osteomyelitis, despite negative blood and aspirate cultures. Empiric antibiotic therapy was initiated, followed by surgical debridement of infected tissues. The resulting dead space was filled with antibiotic-coated calcium phosphate beads and tissue grafting. Anatomopathological studies confirmed findings consistent with chronic osteomyelitis. Stabilization of the arm was achieved with an orthopedic brace, and antibiotic administration continued for 6 weeks post-surgery. The injury consolidated 4 months after treatment, and nearly two years later she has not suffered a recurrence.

CLINICAL DISCUSSION

The scarcity of literature implies the absence of clinical guidelines for treating osteomyelitis in these patients. Empirical antibiotic therapy combined with surgery when there are abscesses that need debridement can be an effective approach.

CONCLUSION

Humeral osteomyelitis in sickle-cell disease patients can be effectively managed using a pharmaco-surgical strategy, but it should be tailored to the patient's needs.

Investigating clinical characteristics and prognostic factors in patients with chronic osteomyelitis of humerus

Background

Chronic osteomyelitis in the humerus, which has complex neuroanatomy and a good soft tissue envelope, represents a unique clinical challenge. However, there are relatively few related studies in the literature. This article retrospectively reviewed a large case series with the aims of sharing our management experiences and further determining factors associated with the outcomes.

Methods

Twenty-eight consecutive adult patients with a mean age of 36 years were identified by reviewing the osteomyelitis database of our clinic centre. The database was used to prospectively identify all osteomyelitis cases between 2013 and 2017, and all data then was retrospectively analysed.

Results

The mean follow-up period was 35 months (range 24–60). The aetiology was trauma in 43% (12) of the patients and haematogenous in 57% (16) of the patients, and Staphylococcus aureus was a solitary agent in 50% (14) of the patients. Host-type (Cierny’s classification) was IA in 8, IIIB in 11 and IVB in 9 patients. All patients required debridement followed by the placement of a temporary antibiotic-impregnated cement spacer (rod). Seventeen patients received a cement-coated plate for internal fixation after debridement, and 13 patients needed bone grafts when the spacer was staged removed. All patients attained an infection-free bone healing state at the final follow-up. The final average DASH (disabilities of the arm, shoulder and hand) score was 18.14 ± 5.39, while 6 patients (two developed traumatic olecranarthritis, four developed radial nerve injuries) showed the lowest levels of limb function (p = 0.000) and were unemployed. Three patients (type I; significant difference between type I versus type III and type IV patients, p < 0.05) experienced recurrence after debridement and underwent a second revision, which was not related to the bone graft (p = 0.226) or plate fixation (p = 0.050).

Conclusions

Humeral chronic osteomyelitis can be treated with general surgery and anti-infective therapy; medullary (type I) infection presents a challenge, and the antibiotic-coated cement plate provides favourable fixation without increasing recurrence of infections. Clinicians should be aware of potential iatrogenic nerve injuries when treating these patients with complicated cases, and an experienced surgeon may improve the outcome.

Sequestrectomy in primary osteomyelitis of the humerus: a new indication for posterior approach

Surgical treatment for primary osteomyelitis of the humerus is not well standardized; guidelines come from the scientific literature on osteomyelitis of the femur and tibia. Commonly deltopectoral approach is used for the proximal humerus and posterior approach for the distal humerus. Sequestrectomy alone or the use of antibiotic cement (bead pouch technique) is advised in case of chronic osteomyelitis. Berger and Buckwalter described a posterior approach to the proximal part of the humerus for an excisional biopsy of an osteoid-osteoma. We found that this approach is also useful for sequestrectomy in primary osteomyelitis of the humerus. We describe the technique and make a review of the literature.