Pre-operative planning together with orthopaedic colleagues is paramount. Chronic osteomyelitis is defined as having symptoms for at least six months with clinical and radiological signs in addition to minimum one of the following: the presence of an abscess, a sinus or intra-operative pus, two or more microbiological cultures with the same organisms, or supportive histology[1].
Chronic osteomyelitis has the presence of infected dead bone and biofilm. Antibiotics alone can suppress the infection but not eradicate it. Osteomyelitis may recur if dead bone is not resected, or the soft tissue is not closed over the wound allowing reinfection of bone. The use of local antibiotics is increasingly being advocated as it delivers very high antibiotic doses in the surgical field and nearby tissues [2]. Staged surgical treatment with repeated debridement, and delayed skin closure is common[3]. Also, negative pressure wound therapy has been used, resulting in an increased number of revision surgeries without improving the rate of resolution of osteomyelitis[4]. Single-stage treatment with efficient removal of dead bone and biofilm, sampling of the tissue to elucidate the infecting organism, application of local antibiotics, immediate surgical reconstruction of the bone and soft tissues, followed by systemic antibiotic therapy is the standard treatment, and the procedure planned for, in the presented case[3,5]. Surgical plan for single-stage protocol of osteomyelitis.
– 1 Exposure of bone to allow uncontaminated sampling.
– 2 Multiple deep intra-operative microbiological and histopathological samples following strict protocol.
– 3 Debridement and excision of sinus tracts, scar and dead bone continuing until healthy, bleeding bone and soft tissues are reached.
– 4 Washout with 0.05% aqueous chlorhexidine solution.
– 5 Obturate dead space with local antibiotics biocomposite material.
– 6 Immediate reconstruction of the soft tissues with a free gracilis flap and split-skin graft.
- – Patient information: Risk of flap failure, risk of post-operative fracture, infection recurrence, post-operative infection, wound dehiscence
1
