- See: tibial infection and debridement of tibial fractures
- Discussion:
- see cierny classifcation
- a sequestrum is infected dead bone resulting from osteomyelitis;
- it is secluded from host immune system and is secluded from antibiotics;
- result is a chronic and persistent of infection;
- if large sequestra form, continued suppuration may result in formation of sinus tracts that burrow through the soft tissues, exit through skin, and result in the drainage of pus;
- this chronic form of osteomyelitis is difficult to eradicate and can persist for many years;
- when chronic osteomyelitis is controlled, disease may become quiescent for long periods;
- reactivation of quiescent osteomyelitis can occur many years after the original infection;
- Marjolin’s ulcer:
- malignant transformation (squamous cell carcinoma) which occurs in response to a chronic draining sinus;
- may occur in upto 1% of those with draining sinus tract;
- references:
- Malignant lesions arising in chronic osteomyelitis.
- Marjolin's ulcer on frostbite.
- Images in clinical medicine. Marjolin's ulcer.
- Thirty-one cases of Marjolin's ulcer.
- Squamous-cell carcinoma complicating chronic osteomyelitis.
- Radiographic Studies:
- see radiographic findings in hematogenous om
- look for bone resorption, periosteal or endosteal new bone formation, cortical irregularities, and sequestration;
- plain radiographs or tomograms may show a sequestrum, and sinograms may delineate extent of infected area;
- CT or MRI may help plan the debridement in some cases (if internal hardware is not present);
- bone labeling techniques:
- tetracycline bone labeling w/ a Wood's Lamp illumination in the OR may aid in the debridement of devascularized bone, since well vasculared bone incorporates the tetratcycline, which fluoresces under the Wood's lamp;
- Non Operative Treatment:
- generally, the presence of a sequestra will not allow successful treatment with antibiotics alone, because antibiotics cannot penetrate avascular tissue;
- this is analogous to the management of a soft tissue abscess which requires incision and drainage in addition to ATB;
- antibiotics for OM
- Operative Treatment:
- debridement of tibial osteomyelitis
- tetracycline bone labeling w/ a Wood's Lamp illumination in the OR may aid in the debridement of devascularized bone, since well vasculared bone incorporates the tetratcycline, which fluoresces under the Wood's lamp;
- intramedullary reaming for debridement: (see reaming of tibia fractures)
- consider reaming the tibial medullary canal to assist with debridement (including decompression of the sequestrum);
- debridement should consist of drainage of infected area including any sequestrum;
- often the draining sinus will exit thru the anteromedial skin (which typically is of poor quality and will not allow primary or secondary closure if included in the debridement);
- if the anteromedial skin surrounding the sinus is debrided, then flap coverage is often necessary;
- as an alterantive, consider making a small longitudinal incision over the anterior compartment, in order to gain access to the sequestrum;
- w/ this technique, wound closure is not a problem, and following debridement and appropriate antibiotics, drainage from the sinus will cease (and soft tissue coverage is not required);
- hardware removal:
- for infections after internal fixation in which fixation is stable, implant may be left in place until union occurs, and then internal hardware is removed along w/ any necrotic or devascularized tissue;
- i.e., a stable infected union is better than an unstable infected non union;
- if implant failure has occurred, however, implant usually should be removed & external fixator applied for stability;
- outcomes:
- in the report by Simpson, et al (2001), prospectively studied a consecutive series of 50 patients with chronic osteomyelitis.
- patients were allocated to the following treatment groups:
- wide resection, with a clearance margin of 5 mm or more;
- marginal resection, with a clearance margin of less than 5 mm;
- intralesional biopsy, with debulking of the infected area;
- all patients had a course of antibiotics, intravenously for six weeks followed by orally for a further six weeks;
- no patients in group 1 had recurrence;
- in patients treated by marginal resection (group 2) 8 of 29 (28%) had recurrence;
- all patients who had debulking had a recurrence within one year of surgery
- Chronic Osteomyelitis. The Effect of the Extent of Surgical Resection on Infection-Free Survival.
Osteomyelitis of the calcaneus in children.
Osteomyelitis of the calcaneum.
Gram-negative osteomyelitis following puncture wounds of the foot.
An aggressive surgical approach to the management of chronic osteomyelitis.
Intracellular Staphylococcus aureus. A mechanism for the indolence of osteomyelitis.
In vivo internalization of Staphylococcus aureus by embryonic chick osteoblasts.