David Stubbs

The use of a biodegradable antibiotic-loaded calcium sulphate carrier containing tobramycin for the treatment of chronic osteomyelitis: a series of 195 cases

We report our experience using a biodegradable calcium sulphate antibiotic carrier containing tobramycin in the surgical management of patients with chronic osteomyelitis. The patients were reviewed to determine the rate of recurrent infection, the filling of bony defects, and any problems with wound healing. A total of 193 patients (195 cases) with a mean age of 46.1 years (16.1 to 82.0) underwent surgery. According to the Cierny-Mader classification of osteomyelitis there were 12 type I, 1 type II, 144 type III and 38 type IV cases. The mean follow-up was 3.7 years (1.3 to 7.1) with recurrent infection occurring in 18 cases (9.2%) at a mean of 10.3 months post-operatively (1 to 25.0). After further treatment the infection resolved in 191 cases (97.9%). Prolonged wound ooze (longer than two weeks post-operatively) occurred in 30 cases (15.4%) in which there were no recurrent infection. Radiographic assessment at final follow-up showed no filling of the defect with bone in 67 (36.6%), partial filling in 108 (59.0%) and complete filling in eight (4.4%). A fracture occurred in nine (4.6%) of the treated osteomyelitic segments at a mean of 1.9 years (0.4 to 4.9) after operation. We conclude that Osteoset T is helpful in the management of patients with chronic osteomyelitis, but the filling of the defect in bone is variable. Prolonged wound ooze is usually self-limiting and not associated with recurrent infection.

Chronic osteomyelitis of the pubic bones following radiotherapy for urological malignancy

We have observed osteomyelitis of the pubic bones in elderly comorbid patients with a significant urological history involving previous radiotherapy and subsequent radiation-induced osteonecrosis. The prevalence and incidence of pubic osteomyelitis in this setting is unknown. We distinguish our case series from other manifestations of pelvic osteomyelitis because radiation osteonecrosis limits the treatment options; by constraining surgery due to wound healing concerns, and by causing difficulty in defining the resection margins when excising diseased bone/tissue. Changes on imaging are often difficult to discern from post-radiotherapy changes,1,2 and recurrence of infection may occur. Our aim is to raise an awareness of this complex condition and discuss optimum management strategies.

Osteomyelitis of the Pelvic Bones: A Multidisciplinary Approach to Treatment

Background and Purpose: A case series review of chronic pelvic osteomyelitis treated with combined medical and surgical treatment by a multidisciplinary team. Methods: All patients treated with surgical excision of pelvic osteomyelitis at our tertiary referral centre between 2002 and 2014 were included. All received combined care from a clinical microbiologist, an orthopaedic surgeon and a plastic surgeon. The rate of recurrent infection, wound healing problems and post-operative mortality was determined in all. Treatment failure was defined as reoperation involving further bone debridement, a requirement for the use of long-term suppressive antibiotics or sinus recurrence. Results: Sixty-one adults (mean age 50.2 years, range 16.8-80.6) underwent surgery. According to the Cierny-Mader classification of osteomyelitis there were 19 type II, 35 type III and 7 type IV cases. The ischium was the most common site of infection. Osteomyelitis was usually the result of contiguous focus infection associated with decubitus ulcers, predominantly in patients with spinal or cerebral disorders. Most patients with positive microbiology had polymicrobial infection (52.5%). Thirty patients required soft tissue reconstruction with muscle or myocutaneous flaps. Twelve deaths occurred a mean of 2.8 years following surgery (range 7 days-7.4 years). Excluding these deaths the mean follow-up was 4.6 years (range 1.5-12.2 years). Recurrent infection occurred in seven (11.5%) a mean of 1.5 years post-operatively (92 days - 5.3 years). After further treatment 58 cases (95.1%) were infection free at final follow-up. Interpretation: Patients in this series have many comorbidities and risk factors for poor surgical outcome. Nevertheless, the multidisciplinary approach allows successful treatment in the majority of cases.

Ilizarov for radiologists

If you had a choice, you would probably not wish to undergo Ilizarov treatment; it is a long and stressful treatment and requires considerable effort. If you have a major deformity, massive bone loss or complex bone infection, however, the other options are even less appealing. Large allografts have high rates of infection, non-union and late fracture, and metal implants are at risk of loosening and fatigue particularly in younger patients. Sometimes the only other option is an amputation. The Ilizarov method offers the ability to correct deformity and grow new, normal bone which will continue to serve its purpose for the rest of your life.