Case 16 (2023): Single-stage treatment of chronic osteomyelitis reconstructed with a free muscle flap

Josefine Slater; Birgitte Kiil; Alex Ramsden

Journal of Plastic, Breast & Reconstructive Surgery·Casi chirurgici peer-reviewed e open-accessPeer-reviewed · Accesso aperto

Case 16 (2023): Single-stage treatment of chronic osteomyelitis reconstructed with a free muscle flap · JPBRS

Case report

Case 16 (2023): Single-stage treatment of chronic osteomyelitis reconstructed with a free muscle flap

Josefine Slater, Birgitte Kiil, Alex Ramsden

Pubblicato 29 aprile 2023130 visualizzazioni6 min di lettura

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Abstract

A 53-year-old female was referred to the Nuffield Orthopaedic Centre, Bone Infection Unit, Oxford University Hospital, for treatment of a chronic osteomyelitis defect on the left tibia. The patient had a limb laceration leading to a contiguous osteomyelitis of her left tibia that developed at the age of 3 years.

Punti chiave di apprendimento

Consigli pratici

Single-stage surgery is an effective, patient centric and time efficient treatment.
Two team operating reduces time in the operating theatre.
Meticulous tissue sampling with multiple samples
Compress bandaging for optimal contouring of muscle flaps, reducing the need for corrective surgery later on.

Insidie

Failure to sample correctly.
Failure to excise bone fully
Recipient vessels are often scarred and spastic.
The gracillis flap has a short pedicle (approx. 5 cm)

Patient history

She had previously been treated with a debridement as a child that was left to heal by secondary intention. The chronic wound broke down 2-3 times a year and discharged malodorous pus, but since 2021 it has remained unhealed. The patient is hypothyroid, has a BMI of 35, complete heart block and has a pacemaker since 2014. Antibiotics had been stopped two weeks prior to surgery according to protocol.

Examination

The patient has a 15x5cm area of scaring on the mid shaft of the left tibia with areas of discharging sinuses from bone. There were palpable tibialis posterior and dorsalis pedis arteries.

Pre-operative considerations

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

Riferimenti bibliografici

Cierny, G., 3rd; DiPasquale, D. Treatment of chronic infection. J Am Acad Orthop Surg 2006, 14, S105-110, doi:10.5435/00124635-2006
McNally, M.A.; Ferguson, J.Y.; Lau, A.C.; Diefenbeck, M.; Scarborough, M.; Ramsden, A.J.; Atkins, B.L. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J 2016, 98-B, 1289-1296, doi:10.1302/0301-620X.98B9.38057.
Chan, J.K.K.; Ferguson, J.Y.; Scarborough, M.; McNally, M.A.; Ramsden, A.J. Management of Post-Traumatic Osteomyelitis in the Lower Limb: Current State of the Art. Indian J Plast Surg 2019, 52, 62-72, doi:10.1055/s-0039-1687920.
Diefenbeck, M.; Mennenga, U.; Guckel, P.; Tiemann, A.H.; Muckley, T.; Hofmann, G.O. [Vacuum-assisted closure therapy for the treatment of acute postoperative osteomyelitis]. Z Orthop Unfall 2011, 149, 336-341, doi:10.1055/s-0030-1270952.
Lorentzen, A.K.; Engel, L.; Gottlieb, H.; Obinah, M.P.B. One-stage treatment of chronic osteomyelitis with an antibiotic-loaded biocomposite and a local or free flap. Eur J Plast Surg 2021, 44, 367-374, doi:10.1007/s00238-020-01754-5.