Desbridamiento belfast
-
Upload
maripaz-lara -
Category
Education
-
view
11 -
download
0
Transcript of Desbridamiento belfast
©l993 British Editorial Society ofBone and Joint Surgery0301-620X/93/3557 $2.00
VOL. 75-B, No. 3. MAY 1993 375
TWO-STAGE MANAGEMENT OF CHRONIC
OSTEOMYELITIS OF THE LONG BONES
THE BELFAST TECHNIQUE
M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN
From Musgrave Park Hospital and the Ulster Hospital, Northern Ireland
We treated 37 patients with chronic osteomyelitis of the
tibia (25), femur (9), radius (2) and humerus (1) by a two-
stage technique, comprising radical debridement of all
infected bone and soft tissue with the provision of soft-
tissue cover, and delayed autogenous bone grafting when
necessary. All patients were reviewed at an average of 49
months (12 to 121). Infection-free bone union was achieved
in 34. No patient required amputation.
Wide excision of all compromised tissue and the
closure of bone within a healthy vascularised soft-tissue
envelope are essential if infection is to be eradicated. The
combined assessment and management of such patients by
an orthopaedic surgeon and a plastic surgeon are advocated.
J Bone Joint Surg [Br] 1993 ; 75-B : 375-80.
Received 29 May 1992; Accepted 24 September 1992
The development ofnew antimicrobial agents with wide-
spectrum activity and high bioavailability has greatly
improved the treatment of infection in many body tissues,
but this is not the case in infection of bones and joints.
Most patients with established bone infection are not
cured by prolonged antibiotic therapy and almost all
require surgical intervention (Waidvogel, Medoff and
Swartz 1970; Waidvogel and Vasey 1980; Fitzgerald et
M. A. McNally, FRCS, Orthopaedic Registrar, British OrthopaedicAssociation Wishbone Research FellowR. A. B. Mollan, MD, FRCS, FRCS I, Professor of OrthopaedicSurgeryDepartment of Orthopaedic Surgery, Musgrave Park Hospital, Stock-man’s Lane, Belfast BT9 7JB, UK.
J. 0. Small, FRCS I, Consultant Plastic SurgeonThe Ulster Hospital, Upper Newtownards Road, Dundonald, BelfastBT16ORH, UK.
H. 0. Tofighi, MD, Consultant Orthopaedic SurgeonDepartment ofOrthopaedic Surgery, University ofTabriz, Iran.
Correspondence should be sent to Mr M. A. McNally.
al 1985). “The hallmark of chronic osteomyelitis is
infected, dead bone within a compromised soft-tissue
envelope” (Cierny and Mader 1984). This is an important
summary of the disease process, as it highlights those
features which contribute to chronicity and which need
to be dealt with if eradication of infection is to be
achieved.
The need for surgery in the treatment of chronic
osteomyelitis is well recognised, but there is no consensus
on the best method. In 1946, Stark described the
treatment ofpost-traumatic chronic infection by debride-
ment and reconstruction with a pedicled muscle flap. He
stressed the importance of radical removal of dead bone
and the inadequacy of simple sequestrectomy. This has
been supported by more recent work by Cierny and
Mader (1984), Gordon and Chiu (1988) and Yoshimura
et al (1989). Papineau described his technique of excision
and bone grafting with delayed closure in 1973. This was
a significant advance with a good initial cure rate
(Papineau et al 1979). The technique, however, is time-
consuming, requires prolonged hospitalisation and has a
considerable associated morbidity. A 5% amputation
rate has been reported and secondary infection of the
open wound is a problem (Meyer, Weiland and Willeneg-
ger 1975).
In 1982, Mathes, Alpert and Chang showed that
muscle flaps (either local or free-transfer) were highly
resistant to infection and that they provided the “cellular,
non-cellular and oxygen environment” necessary for the
eradication of infection and wound ischaemia associated
with chronic osteomyelitis. Local muscle flaps (Ger 1977;
Fitzgerald et al 1985), delayed free flaps (Weiland, Moore
and Daniel 1984; Gordon and Chiu 1988) and myocuta-neous island flaps (Yoshimura et al 1989) have been used
extensively in the management ofchronic infection with
encouraging results, but problems remain with the long
duration and high cost of treatment, recurrence of
infection and requirement of theatre time. Several
workers have reported the need for amputation despite
extensive surgery (Ger 1977; Papineau et al 1979; Hall,
Fitzgerald and Rosenblatt 1983; Fitzgerald et al 1985;
Gordon and Chiu 1988).
We describe a series of patients managed by a
technique specifically designed to avoid the failings of
376 M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN
THE JOURNAL OF BONE AND JOINT SURGERY
the existing procedures and to reduce the time spent in
hospital, with its attendant morbidity and high cost.
PATIENTS
We treated 37 patients with chronic infection ofthe tibia
(25), the femur (9), the radius (2) and the humerus (1).
There were 28 men and 9 women with a mean age of 42
years (18 to 75), and a median duration of infection of 22
years (1 to 59). All patients had suffered recurring
symptoms with pain and sinus drainage, and had been
treated for prolonged periods with wide-spectrum anti-
biotics. Most had undergone multiple surgical procedures
including sinus curettage, drainage of abscesses and
sequestrectomy. Two had been treated by a modified
Papineau technique.
Chronic infection had followed a compound fracture
(25), plating of a closed tibial fracture (3), gunshot
wounds (3), acute haematogenous osteomyelitis (5) and
internal fixation of a pathological fracture after excision
of an osteoclastoma (1). In those cases in which culture
was positive, multiple organisms were invariably found,
including Staphylococcus aureus, Proteus mirabiis, group
D streptococci, Bacteroides fragiis and Pseudomonas
aeruginosa. Most cultures had a Gram-negative isolate.
All organisms were sensitive to combinations of fluclox-
acillin, Fucidin, Ciproxin, cephamandole, gentamicin
and metronidazole.
TREATMENT
We designed the staged ‘Belfast technique’ for use in any
long bone, based on the following principles : radical
debridement of all compromised tissues ; early provision
of healthy vascularised soft-tissue cover with elimination
of dead space ; delayed autogenous bone grafting when
necessary ; and reduction of inpatient time during
treatment.
The patients were assessed preoperatively by a
plastic surgeon and an orthopaedic surgeon to ascertain
the extent of infected and compromised bone and soft
tissue. Investigation included bacteriology, plain radio-
graphy, tomography, sinography, blood tests and bone
scanning when appropriate. The degree of debridement
required, the method of fixation to be used and the
requirement for soft-tissue reconstruction were then
determined for each patient. At least two antibiotics
were given before surgery.
Stage one. The limb was explored under tourniquet. Skin
incisions were placed along the lines of existing wounds
where possible to minimise further damage to the soft
tissues. Sinuses, when present, were excised elliptically
within the incision. If there was extensive soft-tissue
scarring, wide excision of the poor-quality skin was
undertaken.
Debridement of bone was guided in part by the
preoperative investigations but mainly by the operative
findings. In all cases the excision of bone was radical
with no attempt at a limited resection. All bone showing
an abnormal appearance was removed. Careful assess-
ment of the medullary canal was made by de-roofing
cortical bone. When the debridement was complete, the
defect was copiously irrigated with saline or noxythiolin
solution. The tourniquet was then deflated and the
pattern of bleeding from the bone surfaces was observed.
Any area which failed to bleed was excised back to
bleeding bone. This meticulous exploration and debride-
ment of all infected tissue usually took 30 to 60 minutes
to complete. All resected material was sent for anaerobic
and aerobic culture.
The management ofthe potential dead space created
by the debridement was thought to be important. In the
cases with a large bone cavity which were suitable for
direct closure of the skin, a few strings of gentamicin-
impregnated beads were used to fill the dead space.
Where a muscle flap was used for soft-tissue cover, this
was raised in such a way that it would fill the bone cavity
completely.
The treatment of soft tissues followed one of several
plans. In 23 patients the skin was closed directly. Ten
were managed by free microvascular transfer of a muscle
flap (five rectus abdominis, four latissimus dorsi and one
gracilis), two by local flaps (one soleus and one gastroc-
nemius flap), and two by free composite flaps from the
deep circumflex iliac artery (incorporating a large portion
of iliac crest bone). Muscle flaps were most often
transferred without overlying skin, and thus required
meshed split-skin grafting after anastomosis. Closed-
suction drainage was used in most cases.
The limb was usually protected in a plaster-of-Paris
back-slab or a split cast. External fixation was used only
when bone debridement had resulted in skeletal instabil-
ity.
Postoperatively, strict bed rest was imposed for five
days with elevation of the affected limb. Thereafter, non-
weight-bearing mobilisation was begun. A period for
wound healing was then allowed, averaging 33 days. The
antibiotic regime started before surgery was continued
with oral preparations of the chosen drugs. During this
time most patients were able to leave hospital.
Stage two. This was carried out between three and six
weeks after stage one, when the soft tissues had
adequately healed. Under tourniquet, the bone defect
was exposed through the same incision or along the
margin of the flap, avoiding the vascular pedicle. Any
antibiotic beads were removed and the cavity was
carefully inspected. Exuberant granulations were gently
curetted back to healthy vascularised tissue. A search
was made for areas not covered by fresh granulation
tissue, suggesting non-viability of bone, and any such
area was further debrided. A cancellous bone graft was
then harvested from the iliac crest, cut into small
segments and packed into the cavity. Care was taken to
ensure tension-free closure of the skin. No drainage was
Age
Case (yr)
I 41
2 42
3 29
4 31
Bone
Tibia
Tibia
Tibia
Tibia
Aetlology of infection
Acute haematogenous
Compound fracture
Compound fracture
Compound fracture
Skin cover
Direct closure
Direct closure
Direct closure
Direct closure
Complications
Follow-up
(mdi)
86
69
88
79
5 51 Tibia Compound fracture
6 51 Tibia Compound fracture
7 23 Tibia Excision of osteoclastoma
None
None
None
Split-skin graft to wound
2 weeks post-op
Direct closure 76 Gastrocnemius flap at 2weeks post-op
Duration of
infection �yr)
27
6
11
9
49
46
3
9
18
41
16
59
8 21 Tibia
9 58 Tibia
10 63 Tibia
II 49 Tibia
12 66 Tibia
Compound fracture
Compound fracture
Compound fracture
ORIF closed fracturet
Compound fracture
13 30 Tibia ORIF closed fracture
14 30 Tibia
15 24 Tibia
16 27 Tibia
17 64 Tibia
18 55 Tibia
19 30 Tibia
Gunshot wound
Compound fracture
Compound fracture
Compound fracture
Compound fracture
Compound fracture
Direct closure 84 None
Direct closure 40 Elective repeat. Infected
wound haematoma
Lat. dorsi free flap 33 None
Soleus local flap 41 None
Gracilis free flap 12 None
Lat. dorsi free flap 22 None
Rectus abdo. free 20 Noneflap
3 Direct closure 22 Rectus abdo. flap at 2weeks
7 Direct closure 33 None
2 Direct closure 3 1 None
9 Direct closure 22 Discharge at I 2 months
39 Direct closure 12 None
34 Rectus abdo. free 77 Noneflap
Unknown Rectus abdo. free 16 Noneflap
4 Composite DCIA 100 Noneflaps
1 Lat. dorsi free flap 49 Discharge at 24 months
1 Rectus abdo. free 57 Noneflap
I Composite DCIA 121 Minor scar revision at 2
flap years
Lat. dorsi free flap 67 None
Rectus abdo. free 27 Secondary infectionflap
Direct closure 65 None
Direct closure 90 None
Result
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Recurrences
Cured
Cured
Cured
Cured
Recurrence
Cured
Cured
Cured
Recurrence
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
Cured
20 47 Tibia Compound fracture
21 18 Tibia Compound fracture
22 29 Tibia Compound fracture
23 26 Tibia Compound fracture
24 21 Tibia Compound fracture
25 41 Tibia ORIF closed fracture
26 38 Radius Acute haematogenous
27 32 Radius Compound fracture
28 46 Humerus Gunshot wound
29 75 Femur Compound fracture
30 48 Femur Compound fracture
31 62 Femur Compound fracture
32 65 Femur Gunshot wound
33 46 Femur Brodie’s abscess
34 38 Femur Compound fracture
35 24 Femur Acute haematogenous
36 27 Femur Acute haematogenous
37 73 Femur Compound fracture
18
16
3
4
58
35
42
40
2
13
22
13
Unknown
Direct closure
Direct closure
Direct closure
Direct closure
Gastrocnemiuslocal flap
Direct closure
Direct closure
Direct closure
Direct closure
Direct closure
30 None
62 None
66 None
35 None
58 None
37 None
13 None
31 None
29 None
25 None
* infection-free bone union
t ORIF, open reduction and internal fixation� infection-free bone union at ten months after a repeat operation§ DCIA, deep circumflex iliac artery
TWO-STAGE MANAGEMENT OF CHRONIC OSTEOMYELITIS OF THE LONG BONES 377
VOL. 75-B, No. 3, MAY 1993
Table I. Details of 37 patients with chronic osteomyelitis treated by the two-stage Belfast technique
378 M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN
THE JOURNAL OF BONE AND JOINT SURGERY
used after stage two. Again a period of bed rest was
imposed with leg elevation. Mobilisation was started and
the patient was discharged when the wounds were healed.
Five patients did not have a second stage to their
treatment. In three the bone defect was small and did not
require grafting, and in two a large vascularised bone
graft was provided in a composite free flap at stage one.
Stabilisation and antibiotics were continued until
there was radiological and clinical evidence of union.
RESULTS
All 37 patients were followed up for a mean of49 months
(12 to 121). Eradication of infection with bone union was
achieved in 34 (92%). No case resulted in amputation.
Details of the patients are given in Table I.Three limbs had recurrence of deep infection, all in
patients with tibial disease. One of these (case 25)developed an abscess under a rectus abdominis free flap.
At the second stage the bone cavity was seen to be well
lined with granulation tissue and there was no evidence
of residual dead tissue or infection. The abscess was
thought to be due to secondary infection at the time of
the stage-two operation.
Two patients (cases 16 and 21) returned at 12 and 24
months respectively with symptoms and signs of recurrent
deep infection. Case 16 was a 27-year-old man who had
had chronic infection of his tibia for nine years after a
compound fracture. After stage one there was no difficulty
with direct skin closure and healing proceeded rapidly
with no evidence of underlying infection. Five weeks
after stage one, a bone graft was inserted. At this stage
the cavity was clean and infection-free. With the bone
chips in place, however, it was much more difficult to
effect direct skin closure although this was achieved.
Postoperatively, the wound remained inflamed and at 12
months it broke down and discharged infected material.
We repeated our technique using a gracilis free flap for
skin cover, but this flap failed. The resulting skin defect
was then treated by a local fasciocutaneous flap. This
patient has been followed for ten months since then and
is symptom-free with a healed wound and a united
fracture.
Case 21 returned with a swollen, painful leg and a
discharging sinus two years after his operations and
radiography confirmed the presence of a recurrence of
deep infection.
Four patients developed wound problems in the
three weeks after stage two. All had been managed
initially by direct skin closure, and all required revision
of their skin cover. One (case 4) required split-skin
grafting at three weeks, one (case 5) required a local
gastrocnemius muscle flap at two weeks, and one (case
I 3) was treated by a free rectus abdominis muscle flap at
two weeks. The fourth patient (case 7) developed an
infected haematoma at the margin of a rectus abdominis
free flap, applied during a previous attempt to eradicate
the infection. This was evacuated but it was decided to
repeat both stages of the technique rather than risk
extension to the underlying tibia. These four patients are
now an average of 54 months from surgery (minimum
22) and all have progressed to sound infection-free union.
Illustrative case report. A 66-year-old man (case 1 2) was
referred to the orthopaedic clinic with severe osteo-
arthritis of the right hip. He also had an extensive area
ofatrophic skin with discharging sinuses over the anterior
surface of his right tibia (Fig. 1). Radiography showed
widespread infection ofthe entire diaphysis and proximal
Fig. 1 Fig. 2
Case 12. Figure 1 - The appearance of the tibia at presentation. Chronicinfection had resulted from a compound fracture 59 years previously.Figure 2 - The radiograph shows extensive involvement of the proximalmetaphysis and almost all the diaphysis.
metaphysis (Fig. 2) which had followed a compound
fracture to his tibia 59 years previously. The tibia was
constantly painful and periodically discharged pus and
pieces ofdead bone. He had undergone several operations
including sinus curettage and sequestrectomy.
He was treated by the standard two-stage Belfast
technique. At stage one we performed a radical clearance
of all necrotic tissue and widely excised all atrophic or
infected skin (Fig. 3). The defect was closed by a free
rectus abdominis muscle-only flap covered with meshed
split-skin graft, and the limb was protected in a plaster
back-slab. The postoperative radiograph shows the extent
ofthe bone resection (Fig. 4). A period ofnine weeks was
allowed for full wound healing and during this time he
was allowed home, non-weight-bearing on crutches. At
Fig. 5
Fig. 6
TWO-STAGE MANAGEMENT OF CHRONIC OSTEOMYELITIS OF THE LONG BONES 379
VOL. 75-B, No. 3, MAY 1993
stage two, the flap was lifted along its lateral edge,
avoiding the vascular pedicle, and a thorough inspection
of the area undertaken. The large cavity was seen to be
fully lined with healthy granulation tissue and no further
debridement was necessary. Iliac crest bone graft was
inserted as bone chips and the wound was closed and a
back-slab provided.
Fig.3 Fig.4
Figure 3 - Stage one of the operation. Wide excision of all deadand compromised bone and soft tissue has been carried out. Theresulting defect was filled by a free rectus abdominis muscle flap.Figure 4 - The postoperative radiograph shows the extent of thebone resection.
Postoperatively, he made excellent progress with
rapid wound healing and mobilisation. At three months
there was no sign of infection and good consolidation of
the bone graft had occurred. At this time it was considered
that he should have treatment for his osteoarthritis and
we performed a Charnley cemented total arthroplasty
without complication. He regained a full range of hip,
knee and ankle movements (Fig. 5). When reviewed 20
months after his first operation he was symptom-free
with well-healed wounds (Fig. 6). He now feels well, has
an improved appetite and is gaining weight after many
years of ill health.
DISCUSSION
We have shown that the Belfast technique effectively
treated established bone sepsis, and achieved eradication
of infection and bone union in 34 out of 37 cases.
Recurrence can also be treated by repeating the two
stages ofthe procedure. The technique works by breaking
the cycle of bone death, sequestrum formation, spread of
infection and further bone death. Chronicity is encour-
aged by local ischaemia (Trueta 1953), and Gristina et al
Nine months after the stage-two operation, and sixmonths after a THR, the patient had a good range of hip,knee and ankle movements.
Two years later, the limbremains well healed witha tibia free of infectionfor the first time in 60years.
(1985) have shown that non-viable bone stimulates
adherence and colonisation by pathogenic bacteria. This
then leads to further ischaemia and further multiplication
of bacteria. Such areas of tissue are poorly accessible to
the host’s immune system. We believe that the success of
surgical treatment depends mainly on the total removal
380 M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN
THE JOURNAL OF BONE AND JOINT SURGERY
of the ischaemic tissues. In our patients the debridement
was always extensive with no attempt to preserve diseased
bone or soft tissue. This radical approach creates large
defects which must then be filled ; the skills of a plastic
surgeon are most valuable during the first stage of the
procedure.
The work of Ger (1977) and Chang and Mathes
(1982) suggests that the provision of healthy soft-tissue
cover to an adequately debrided area allows revascular-
isation to occur. We have shown that in some cases it is
sufficient to close the wound directly without the need to
import new vascularised tissue. Direct closure should
only be considered if, after debridement, the wound can
be closed without tension and if the overlying skin is
healthy and free from scarring. Care must be taken to
eliminate dead space, and to this end we have used
antibiotic-impregnated beads in a few cases.
Three of our patients treated by direct closure of the
skin required revision within three weeks of stage two,
but none had difficulty after stage one. When bone chips
had been inserted into the bone cavity, the less supple
skin proved more difficult to close. We consider that
these three patients represent failures ofthe preoperative
planning ; all were assessed initially without the advice
ofa plastic surgeon. We now recommend that all patients
should bejointly examined before any surgical procedure.
The Belfast technique reduces the length of time
spent, and thus the cost incurred, in treatment. No
patient spent more than six weeks as an inpatient.
Assessment at an average follow-up of 49 months can
only be regarded as an early review in this most
recalcitrant of conditions. The removal of all affected
tissue, however, and the provision ofhealthy vascularised
soft-tissue cover have been shown to give, at least, long
periods of remission.
M. A. McNally wishes to thank the British Orthopaedic AssociationWishbone Appeal for their financial support.
No benefits in any form have been received or will be receivedfrom a commercial party related directly or indirectly to the subject ofthis article.
REFERENCES
Chang N, Mathes SJ. Comparison of the effect of bacterial inoculationin musculocutaneous and random-pattern flaps. Plast ReconstrSurg 1982; 70:1-10.
Cierny G III, Mader JT. Adult chronic osteomyelitis. Orthopedics 1984;7: 1557-64.
Fitzgerald RH Jr, Ruttle PE, Arnold PG, Kelly PJ, Irons GB. Localmuscle flaps in the treatment of chronic osteomyelitis. J Bone JointSurgfAm] 1985; 67-A:175-85.
Ger R. Muscle transplantation for treatment and prevention of chronicpost-traumatic osteomyelitis of the tibia. J Bone Joint Surg [Am]1977; 59-A :784-91.
Gordon L, Chlu U. Treatment of infected non-unions and segmentaldefects ofthe tibia with staged microvascular muscle transplantingand bone grafting. J Bone Joint Surg [Am] 1988 ; 70-A :377-86.
Gristina AG, Oga M, Webb LX, Hobgood CD. Adherent bacterialcolonization in the pathogenesis of osteomyelitis. Science 1985;228:990-3.
Hall BB, Fitzgerald RH Jr, Rosenblatt JE. Anaerobic osteomyelitis.J Bone Joint Surg [Am] 1983 ; 65-A :30-5.
Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronicosteomyelitis : experimental and clinical correlation. P/ast ReconstrSurg 1982; 69 :815-28.
Meyer S, Weiland AJ, Willenegger H. The treatment of infected non-union of fractures of long bones : study of sixty-four cases with afive to twenty-one-year follow-up. J Bone Joint Surg [Am] 1975;57-A :836-42.
Papineau L-J. L’excision-greffe avec fermeture retard#{234}ed#{233}lib#{233}r#{233}edans
l’ost#{233}omy#{233}litechronique. Nour Press Med 1973; 2:2753-5.
Papineau U, Alfageme A, Dalcourt JP, Pilon L. Ost#{233}omy#{232}litechronique : excision et greffe de spongieux a l’air libre apr#{232}smisesa plat extensives. Int Orthop 1979 ; 3:165-76.
Stark WJ. The use of pedicled muscle flaps in the surgical treatment ofchronic osteomyelitis resulting from compound fractures. J BoneJointSurg 1946; 28 :343-50.
Trueta J. Acute haematogenous osteomyelitis : its pathology andtreatment. Bull Hosp Joint Dis 1953 ; 14:5-23.
Waldvogel FA, Vasey H. Osteomyelitis : the past decade. New EngI J
Med 1980; 303:360-70.
Waidvogel FA, Medoff G, Swartz MN. Osteomyelitis : a review ofclinical features, therapeutic considerations and unusual aspects.NEng/JMed 1970; 282:198-206, 260-6, 316-22.
Welland AJ, Moore JR, Daniel RK. The efficacy of free tissue transferin the treatment ofosteomyelitis. J Bone Joint Surg [Am] 1984 ; 66-A :181-93.
Yosbimura M, Shimada T, Matsuda M, Hosokawa M, Imura S.Treatment of chronic osteomyelitis of the leg by peronealmyocutaneous island flap transfer. J Bone Joint Surg [Br] 1989;71-B :593-6.