Comparison of the Outcome of Treatment of Chronic Osteomyelitis by Surgical Debridement with and without Local Antibiotic Delivery System: Experience from a Nigerian Teaching Hospital
Affiliation(s)
Department of Orthopaedics and Traumatology, University of Calabar Teaching Hospital, Calabar, Nigeria;. Department of Com- munity Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria. Department of Anaesthesiology, University of Calabar Teaching Hospital, Calabar, Nigeria..
Department of Orthopaedics and Traumatology, University of Calabar Teaching Hospital, Calabar, Nigeria;. Department of Com- munity Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria. Department of Anaesthesiology, University of Calabar Teaching Hospital, Calabar, Nigeria..
ABSTRACT
Background: Chronic osteomyelitis is still common in the developing world and presents a continuing therapeutic challenge. Antibiotics cannot penetrate the dense fibrotic scar tissue that surrounds infected and avascular bone which perpetuates the infection. Surgical debridement/sequestrectomy is the cornerstone to treatment and aims to create a viable, vascularized base which promotes healing. Surgical debridement necessarily creates a dead space which must be dealt with to prevent re-infection. Local antibiotic delivery systems serve the dual purpose of obliterating dead space and creating a sterile local environment with high bactericidal concentrations. Aim: To determine the outcomes in patients with chronic osteomyelitis who received debridement/sequestrectomy alone, and those who received the procedure combined with a local antibiotic delivery system in the University of Calabar Teaching Hospital. Patients and Methods: A prospective descriptive analysis of patients managed surgically for chronic osteomyelitis from July 2007 to December, 2012. Patients’ biodata, aetiology, organisms, treatment options and outcomes were analysed. Results: Forty-four patients presented with the condition and accepted surgery. Male:Female ratio was 2.1:1, and mean age was 27.27 ± 17.48 years. The tibia was the most commonly affected bone (45.5%), Staphylococcus aureus was the commonest organism (56.8% of sinus cultures; 73% of marrow/sequestral cultures) and previous acute haematogenous osteomyelitis was the commonest mechanism. The use of a local antibiotic delivery system improved cure rates from 57.7% to 77.8%). Conclusion: Multiple surgical interventions increase the socioeconomic costs of treating this condition and have a direct impact on the economies of individuals especially in the developing world. Surgical interventions should aim at achieving maximum impact with minimum repetition of the processes. Adequate surgical debridement combined with a local antibiotic delivery system offer improved chances of obtaining cure in this therapeutically challenging disease.
Background: Chronic osteomyelitis is still common in the developing world and presents a continuing therapeutic challenge. Antibiotics cannot penetrate the dense fibrotic scar tissue that surrounds infected and avascular bone which perpetuates the infection. Surgical debridement/sequestrectomy is the cornerstone to treatment and aims to create a viable, vascularized base which promotes healing. Surgical debridement necessarily creates a dead space which must be dealt with to prevent re-infection. Local antibiotic delivery systems serve the dual purpose of obliterating dead space and creating a sterile local environment with high bactericidal concentrations. Aim: To determine the outcomes in patients with chronic osteomyelitis who received debridement/sequestrectomy alone, and those who received the procedure combined with a local antibiotic delivery system in the University of Calabar Teaching Hospital. Patients and Methods: A prospective descriptive analysis of patients managed surgically for chronic osteomyelitis from July 2007 to December, 2012. Patients’ biodata, aetiology, organisms, treatment options and outcomes were analysed. Results: Forty-four patients presented with the condition and accepted surgery. Male:Female ratio was 2.1:1, and mean age was 27.27 ± 17.48 years. The tibia was the most commonly affected bone (45.5%), Staphylococcus aureus was the commonest organism (56.8% of sinus cultures; 73% of marrow/sequestral cultures) and previous acute haematogenous osteomyelitis was the commonest mechanism. The use of a local antibiotic delivery system improved cure rates from 57.7% to 77.8%). Conclusion: Multiple surgical interventions increase the socioeconomic costs of treating this condition and have a direct impact on the economies of individuals especially in the developing world. Surgical interventions should aim at achieving maximum impact with minimum repetition of the processes. Adequate surgical debridement combined with a local antibiotic delivery system offer improved chances of obtaining cure in this therapeutically challenging disease.
Cite this paper
I. Ikpeme, E. Oku, N. Ngim, I. Ilori and I. Abang, "Comparison of the Outcome of Treatment of Chronic Osteomyelitis by Surgical Debridement with and without Local Antibiotic Delivery System: Experience from a Nigerian Teaching Hospital," International Journal of Clinical Medicine, Vol. 4 No. 7, 2013, pp. 313-318. doi: 10.4236/ijcm.2013.47055.
I. Ikpeme, E. Oku, N. Ngim, I. Ilori and I. Abang, "Comparison of the Outcome of Treatment of Chronic Osteomyelitis by Surgical Debridement with and without Local Antibiotic Delivery System: Experience from a Nigerian Teaching Hospital," International Journal of Clinical Medicine, Vol. 4 No. 7, 2013, pp. 313-318. doi: 10.4236/ijcm.2013.47055.
References
[1] P. Wirganowicz, “Aggressive Surgical Management of Chronic Osteomyelitis,” The University of Pennsylvania Orthopaedic Journal, Vol. 12, 1999, pp. 7-12. http://upoj.org/site/files/v12/v12_05.pdf [2] I. A. Ikpeme, N. E. Ngim and A. A. Ikpeme, “Diagnosis and Treatment of Pyogenic Bone Infections,” African Health Sciences, Vol. 10, No. 1, 2010, pp. 82-88. [3] G. Cierny III and D. DiPasquale, “Treatment of Chronic Infection,” Journal of the American Academy of Orthopaedic Surgeons, Vol. 14, No. 10, 2006, pp. S105-S110. [4] J. P. Anthony, S. J. Mathes and B. S. Alpert, “The Muscle Flap in the Treatment of Chronic Lower Extremity Osteomyelitis: Results in Patients over 5 Years after Treatment,” Plastic and Reconstructive Surgery, Vol. 88, No. 2, 1991, pp. 311-318. doi:10.1097/00006534-199108000-00023 [5] R. H. Fitzerald Jr., P. E. Ruttle, P. G. Arnold, J. P. Kelly and G. B. Irons, “Local Muscle Flaps in the Treatment of Chronic Osteomyelitis,” The Journal of Bone & Joint Surgery (American), Vol. 67, No. 2, 1986, pp. 175-185. [6] A. Ateschrang, B. G. Ochs, M. Lüdemann, K. Weise and D. Albrecht, “Fibula and Tibia Fusion with Cancellous Allograft Vitalized with Autologous Bone Marrow: First Results for Infected Tibial Non-Union,” Archives of Orthopaedic and Trauma Surgery, Vol. 129, No. 1, 2009, pp. 97-104. doi:10.1007/s00402-008-0699-2 [7] E. M. Evans and D. M. Davies, “The Treatment of Chronic Osteomyelitis by Saucerization and Secondary Skin Grafting,” The Journal of Bone & Joint Surgery (British), Vol. 51B, No. 3, 1969, pp. 454-457. [8] L. Lazzarini, J. T. Mader and J. H. Calhoun, “Osteomyelitis in Long Bones,” Journal of Bone and Joint Surgery (American), Vol. 86, No. 10, 2004, pp. 2305-2318. [9] L. Solomon, H. Srinivasan, S. Tuli and S. Govender, “Infection,” In: L. Solomon, D. Warwick and S. Nayagam, Eds., Apley’s System of Orthopaedics and Fractures, Hodder Arnold, London, 2010, pp. 29-59. [10] L. O. Conterno and C. R. da Silva Filho, “Antibiotics for Treating Chronic Osteomyelitis in Adults,” Cochrane Database of Systemic Reviews, Vol. 8, No. 3, 2009, Article ID: CD004439. [11] S. Gitelis and G. T. Brebach, “The Treatment of Chronic Osteomyelitis with a Biodegradable Antibiotic-Impregnated Implant,” Journal of Orthopaedic Surgery (Hong Kong), Vol. 10, No. 1, 2002, pp. 53-60. [12] M. A. Hashmi, P. Norman and M. Saleh, “The Management of Chronic Osteomyelitis Using the Lautenbach Method,” Journal of Bone and Joint Surgery (British), Vol. 86, No. 2, 2004, pp. 269-275. doi:10.1302/0301-620X.86B2.14011 [13] M. J. Patzakis, “Management of Acute and Chronic Osteomyelitis,” In: M. W. Chapman, Ed., Chapman’s Orthopaedic Surgery, Lippincott Williams & Wilkins, 2001, pp. 3534-3559. [14] B. Parsons and E. Straus, “Surgical Management of Chronic Osteomyelitis,” The American Journal of Surgery, Vol. 188, No. 1, 2004, pp. 57-66. doi:10.1016/S0002-9610(03)00292-7 [15] J. S. Gogia, J. P. Mechan, P. E. Di Cesare and A. A. Jamali, “Local Antibiotic Therapy in Osteomyelitis,” Seminars in Plastic Surgery, Vol. 23, No. 2, 2009, pp. 100107. doi:10.1055/s-0029-1214162 [16] M. S. Moon and J. L. Moon, “Management of Osteomyelitis Editorial,” Journal of Orthopaedic Surgery, Vol. 8, No. 2, 2000, pp. 8-10. [17] R. K. Beals and R. E. Bryant, “The Treatment of Chronic Open Osteomyelitis of the Tibia in Adults,” Clinical Orthopaedics and Related Research, Vol. 433, 2005, pp. 212-217. [18] M. A. McNally, J. O. Small, H. G. Tofighi and R. A. B. Mollan, “Two Stage Management of Chronic Osteomyelitis of the Long Bones. The Belfast Technique,” Journal of Bone and Joint Surgery (British), Vol. 75-B, No. 3, 1993, pp. 375-380. [19] S. G. Kim and H. S. Jang, “Treatment of Chronic Osteomyelitis in Korea,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, Vol. 92, No. 4, 2001, pp. 394-398. doi:10.1067/moe.2001.117810 [20] M. Kaya, G. Simsek-Kaya. N. Gürsan. E. Kirei, E. Dayi and B. Gündogdu, “Local Treatment of Chronic Osteomyelitis with Surgical Debridement and Tigecycline— Impregnated Calcium Hydroxyapatite: An Experimental Study,” Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, Vol. 113, No. 3, 2012, pp. 340-347. doi:10.1016/j.tripleo.2011.03.032 [21] V. Lok, E. Bal, A. Sebik and H. Aydinok, “Long-Term Results of Treatment Including Creation of a Gutter and Muscle Transposition for Chronic Sclerosing Osteomyelitis,” Acta Orthopaedica et Traumatologica, Vol. 43, No. 6, 2009, pp. 510-514. doi:10.3944/AOTT.2009.510 [22] I. M. Smith, O. M. Austine and A. G. Batchelor, “The Treatment of Chronic Osteomyelitis: A 10 Year Audit,” Journal of Plastic, Reconstructive & Aesthetic Surgery, Vol. 59, No. 1, 2006, pp. 1-15. [23] S. B. Agaja and R. O. Ayorinde, “Chronic Osteomyelitis in Ilorin, Nigeria,” South African Journal of Surgery, Vol. 46, No. 4, 2008, pp. 116-118. [24] W. L. Biruk and K. Wubshet, “Chronic Osteomyelitis at Tikur Anbessa Hospital, Addis Ababa University, Ethiopia,” East and Central African Journal of Surgery, Vol. 12, No. 1, 2007, pp. 33-41. [25] B. K. Shrestha, T. Rajbhandary, B. Bijukachhe and A. K. Banskota, “Surgical Interventions in Chronic Osteomyelitis,” Kathmandu University Medical Journal, Vol. 3, No. 1, 2005, pp. 50-54. [26] A. L. Akinyoola, O. O. Adegbehingbe and A. O. Aboderin, “Therapeutic Decision in Chronic Osteomyelitis: Sinus Track Culture versus Intraoperative Bone Culture,” Archives of Orthopaedic and Trauma Surgery, Vol. 129, No. 4, 2009, pp. 449-453. doi:10.1007/s00402-008-0621-y [27] T. O. Alonge, S. O. Ogunlade and A. N. Fashina, “Microbial Isolates in Chronic Osteomyelitis—A Guide to Management,” African Journal of Medicine and Medical Sciences, Vol. 31, No. 2, 2002, pp. 167-169. [28] A. A. Salman, E. Hussein, A. Yonis and R. A. Radwani, “Epidemiological and Bacteriological Study of Chronic Osteomyelitis,” Tikrit Medical Journal, Vol. 14, No. 1, 2008, pp. 59-62. [29] M. A. Haitham and A. A. Mahmood, “Bacterial Etiology of Chronic Osteomyelitis Involving Anaerobes,” Annals of the College of Medicine Mosul, Vol. 36, No. 1-2, 2010, pp. 106-113. [30] H. Wahlig, E. Dingeldein, R. Bergmann and K. Reuss, “The Release of Gentamicin from Polymethylmethacrylate Beads. An Experimental and Pharmacokinetic Study,” Journal of Bone and Joint Surgery (British), Vol. 60, No. 2, 1978, pp. 270-275. [31] S. F. Hoff, R. H. Fitzgerald Jr. and P. J. Kelly, “The Depot Administration of Penicillin G and Gentamicin in Acrylic Bone Cement,” Journal of Bone and Joint Surgery (American), Vol. 63, No. 5, 1981, pp. 798-804. [32] B. A. Cunha, “Osteomyelitis in Elderly Patients,” Clinical Infectious Diseases, Vol. 35, No. 3, 2002, pp. 287-293. doi:10.1086/341417
[1] P. Wirganowicz, “Aggressive Surgical Management of Chronic Osteomyelitis,” The University of Pennsylvania Orthopaedic Journal, Vol. 12, 1999, pp. 7-12. http://upoj.org/site/files/v12/v12_05.pdf [2] I. A. Ikpeme, N. E. Ngim and A. A. Ikpeme, “Diagnosis and Treatment of Pyogenic Bone Infections,” African Health Sciences, Vol. 10, No. 1, 2010, pp. 82-88. [3] G. Cierny III and D. DiPasquale, “Treatment of Chronic Infection,” Journal of the American Academy of Orthopaedic Surgeons, Vol. 14, No. 10, 2006, pp. S105-S110. [4] J. P. Anthony, S. J. Mathes and B. S. Alpert, “The Muscle Flap in the Treatment of Chronic Lower Extremity Osteomyelitis: Results in Patients over 5 Years after Treatment,” Plastic and Reconstructive Surgery, Vol. 88, No. 2, 1991, pp. 311-318. doi:10.1097/00006534-199108000-00023 [5] R. H. Fitzerald Jr., P. E. Ruttle, P. G. Arnold, J. P. Kelly and G. B. Irons, “Local Muscle Flaps in the Treatment of Chronic Osteomyelitis,” The Journal of Bone & Joint Surgery (American), Vol. 67, No. 2, 1986, pp. 175-185. [6] A. Ateschrang, B. G. Ochs, M. Lüdemann, K. Weise and D. Albrecht, “Fibula and Tibia Fusion with Cancellous Allograft Vitalized with Autologous Bone Marrow: First Results for Infected Tibial Non-Union,” Archives of Orthopaedic and Trauma Surgery, Vol. 129, No. 1, 2009, pp. 97-104. doi:10.1007/s00402-008-0699-2 [7] E. M. Evans and D. M. Davies, “The Treatment of Chronic Osteomyelitis by Saucerization and Secondary Skin Grafting,” The Journal of Bone & Joint Surgery (British), Vol. 51B, No. 3, 1969, pp. 454-457. [8] L. Lazzarini, J. T. Mader and J. H. Calhoun, “Osteomyelitis in Long Bones,” Journal of Bone and Joint Surgery (American), Vol. 86, No. 10, 2004, pp. 2305-2318. [9] L. Solomon, H. Srinivasan, S. Tuli and S. Govender, “Infection,” In: L. Solomon, D. Warwick and S. Nayagam, Eds., Apley’s System of Orthopaedics and Fractures, Hodder Arnold, London, 2010, pp. 29-59. [10] L. O. Conterno and C. R. da Silva Filho, “Antibiotics for Treating Chronic Osteomyelitis in Adults,” Cochrane Database of Systemic Reviews, Vol. 8, No. 3, 2009, Article ID: CD004439. [11] S. Gitelis and G. T. Brebach, “The Treatment of Chronic Osteomyelitis with a Biodegradable Antibiotic-Impregnated Implant,” Journal of Orthopaedic Surgery (Hong Kong), Vol. 10, No. 1, 2002, pp. 53-60. [12] M. A. Hashmi, P. Norman and M. Saleh, “The Management of Chronic Osteomyelitis Using the Lautenbach Method,” Journal of Bone and Joint Surgery (British), Vol. 86, No. 2, 2004, pp. 269-275. doi:10.1302/0301-620X.86B2.14011 [13] M. J. Patzakis, “Management of Acute and Chronic Osteomyelitis,” In: M. W. Chapman, Ed., Chapman’s Orthopaedic Surgery, Lippincott Williams & Wilkins, 2001, pp. 3534-3559. [14] B. Parsons and E. Straus, “Surgical Management of Chronic Osteomyelitis,” The American Journal of Surgery, Vol. 188, No. 1, 2004, pp. 57-66. doi:10.1016/S0002-9610(03)00292-7 [15] J. S. Gogia, J. P. Mechan, P. E. Di Cesare and A. A. Jamali, “Local Antibiotic Therapy in Osteomyelitis,” Seminars in Plastic Surgery, Vol. 23, No. 2, 2009, pp. 100107. doi:10.1055/s-0029-1214162 [16] M. S. Moon and J. L. Moon, “Management of Osteomyelitis Editorial,” Journal of Orthopaedic Surgery, Vol. 8, No. 2, 2000, pp. 8-10. [17] R. K. Beals and R. E. Bryant, “The Treatment of Chronic Open Osteomyelitis of the Tibia in Adults,” Clinical Orthopaedics and Related Research, Vol. 433, 2005, pp. 212-217. [18] M. A. McNally, J. O. Small, H. G. Tofighi and R. A. B. Mollan, “Two Stage Management of Chronic Osteomyelitis of the Long Bones. The Belfast Technique,” Journal of Bone and Joint Surgery (British), Vol. 75-B, No. 3, 1993, pp. 375-380. [19] S. G. Kim and H. S. Jang, “Treatment of Chronic Osteomyelitis in Korea,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, Vol. 92, No. 4, 2001, pp. 394-398. doi:10.1067/moe.2001.117810 [20] M. Kaya, G. Simsek-Kaya. N. Gürsan. E. Kirei, E. Dayi and B. Gündogdu, “Local Treatment of Chronic Osteomyelitis with Surgical Debridement and Tigecycline— Impregnated Calcium Hydroxyapatite: An Experimental Study,” Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, Vol. 113, No. 3, 2012, pp. 340-347. doi:10.1016/j.tripleo.2011.03.032 [21] V. Lok, E. Bal, A. Sebik and H. Aydinok, “Long-Term Results of Treatment Including Creation of a Gutter and Muscle Transposition for Chronic Sclerosing Osteomyelitis,” Acta Orthopaedica et Traumatologica, Vol. 43, No. 6, 2009, pp. 510-514. doi:10.3944/AOTT.2009.510 [22] I. M. Smith, O. M. Austine and A. G. Batchelor, “The Treatment of Chronic Osteomyelitis: A 10 Year Audit,” Journal of Plastic, Reconstructive & Aesthetic Surgery, Vol. 59, No. 1, 2006, pp. 1-15. [23] S. B. Agaja and R. O. Ayorinde, “Chronic Osteomyelitis in Ilorin, Nigeria,” South African Journal of Surgery, Vol. 46, No. 4, 2008, pp. 116-118. [24] W. L. Biruk and K. Wubshet, “Chronic Osteomyelitis at Tikur Anbessa Hospital, Addis Ababa University, Ethiopia,” East and Central African Journal of Surgery, Vol. 12, No. 1, 2007, pp. 33-41. [25] B. K. Shrestha, T. Rajbhandary, B. Bijukachhe and A. K. Banskota, “Surgical Interventions in Chronic Osteomyelitis,” Kathmandu University Medical Journal, Vol. 3, No. 1, 2005, pp. 50-54. [26] A. L. Akinyoola, O. O. Adegbehingbe and A. O. Aboderin, “Therapeutic Decision in Chronic Osteomyelitis: Sinus Track Culture versus Intraoperative Bone Culture,” Archives of Orthopaedic and Trauma Surgery, Vol. 129, No. 4, 2009, pp. 449-453. doi:10.1007/s00402-008-0621-y [27] T. O. Alonge, S. O. Ogunlade and A. N. Fashina, “Microbial Isolates in Chronic Osteomyelitis—A Guide to Management,” African Journal of Medicine and Medical Sciences, Vol. 31, No. 2, 2002, pp. 167-169. [28] A. A. Salman, E. Hussein, A. Yonis and R. A. Radwani, “Epidemiological and Bacteriological Study of Chronic Osteomyelitis,” Tikrit Medical Journal, Vol. 14, No. 1, 2008, pp. 59-62. [29] M. A. Haitham and A. A. Mahmood, “Bacterial Etiology of Chronic Osteomyelitis Involving Anaerobes,” Annals of the College of Medicine Mosul, Vol. 36, No. 1-2, 2010, pp. 106-113. [30] H. Wahlig, E. Dingeldein, R. Bergmann and K. Reuss, “The Release of Gentamicin from Polymethylmethacrylate Beads. An Experimental and Pharmacokinetic Study,” Journal of Bone and Joint Surgery (British), Vol. 60, No. 2, 1978, pp. 270-275. [31] S. F. Hoff, R. H. Fitzgerald Jr. and P. J. Kelly, “The Depot Administration of Penicillin G and Gentamicin in Acrylic Bone Cement,” Journal of Bone and Joint Surgery (American), Vol. 63, No. 5, 1981, pp. 798-804. [32] B. A. Cunha, “Osteomyelitis in Elderly Patients,” Clinical Infectious Diseases, Vol. 35, No. 3, 2002, pp. 287-293. doi:10.1086/341417