Management of Post-Traumatic Osteomyelitis in the Lower Limb: Current State of the Art

 

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Abstract

Osteomyelitis (OM) of the lower limb represents a large unmet global healthcare burden. It often arises from a contiguous focus of infection and is a recognized complication of open fractures or their surgical treatment, arthroplasty, and diabetic foot ulcers. Historically, this debilitating condition is associated with high rates of recurrence and secondary amputation. However, excellent long-term outcomes are now achieved by adopting a multidisciplinary approach with meticulous surgical debridement, skeletal and soft tissue reconstruction, and tailored antimicrobial treatment. This review focuses on the modern evidence-based management of post-traumatic OM in the lower limb from a reconstructive plastic surgery perspective, highlighting the latest developments and areas of controversy.

• References

• 1 Huang CC, Tsai KT, Weng SF. et al. Chronic osteomyelitis increases long-term mortality risk in the elderly: a nationwide population-based cohort study. BMC Geriatr 2016; 16: 72
  CrossrefPubMedGoogle Scholar
• 2 Olesen UK, Pedersen NJ, Eckardt H. et al. The cost of infection in severe open tibial fractures treated with a free flap. Int Orthop 2017; 41 (05) 1049-1055
  CrossrefPubMedGoogle Scholar
• 3 Shirley R, Fazekas J, McNally M, Ramsden A. Costs and renumeration of osteomyelitis treatment involving free flaps: implications of return to theatre. J Bone Jt Infect 2018; 3 (01) 15-19
  CrossrefPubMedGoogle Scholar
• 4 Hackett DJ, Rothenberg AC, Chen AF. et al. The economic significance of orthopaedic infections. J Am Acad Orthop Surg 2015; 23 (Suppl) S1-S7
  CrossrefPubMedGoogle Scholar
• 5 Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton III LJ, Huddleston III PM. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. J Bone Joint Surg Am 2015; 97 (10) 837-845
  CrossrefPubMedGoogle Scholar
• 6 Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004; 364 (9431) 369-379
  CrossrefPubMedGoogle Scholar
• 7 McNally M, Nagarajah K. Osteomyelitis. Orthop Trauma 2010; 24 (06) 416-429
  CrossrefGoogle Scholar
• 8 Barker JC, Khansa I, Gordillo GM. A formidable foe is sabotaging your results: what you should know about biofilms and wound healing. Plast Reconstr Surg 2017; 139 (05) 1184e-1194e
  CrossrefPubMedGoogle Scholar
• 9 Libraty DH, Patkar C, Torres B. Staphylococcus aureus reactivation osteomyelitis after 75 years. N Engl J Med 2012; 366 (05) 481-482
  CrossrefPubMedGoogle Scholar
• 10 Sendi P, Meier R, Sonderegger B, Bonel HM, Schäfer SC, Vögelin E. Reactivated Moraxella osteitis presenting as granulomatous disease. Neth J Med 2014; 72 (09) 491-493
  PubMedGoogle Scholar
• 11 Ziran BH, Rao N, Hall RA. A dedicated team approach enhances outcomes of osteomyelitis treatment. Clin Orthop Relat Res 2003; (414) 31-36
  PubMedGoogle Scholar
• 12 Sheehy SH, Atkins BA, Bejon P. et al. The microbiology of chronic osteomyelitis: prevalence of resistance to common empirical anti-microbial regimens. J Infect 2010; 60 (05) 338-343
  CrossrefPubMedGoogle Scholar
• 13 Street TL, Sanderson ND, Atkins BL. et al. Molecular diagnosis of orthopedic-device-related infection directly from sonication fluid by metagenomic sequencing. J Clin Microbiol 2017; 55 (08) 2334-2347
  CrossrefPubMedGoogle Scholar
• 14 Ferguson J, Diefenbeck M, McNally M. Ceramic biocomposites as biodegradable antibiotic carriers in the treatment of bone infections. J Bone Jt Infect 2017; 2 (01) 38-51
  CrossrefPubMedGoogle Scholar
• 15 Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects. N Engl J Med 1970; 282 (04) 198-206
  CrossrefPubMedGoogle Scholar
• 16 Senneville E, Coelho A. Eds. AVAPOM: Complete Oral Versus Intravenous Antibiotic Documented Treatment in Prosthetic Joint Infections. Orthopaedic Proceedings. 2017. Nantes, France: Orthopaedic Proceedings; 2018
  Google Scholar
• 17 Li HK, Rombach I, Zambellas R. et al; OVIVA Trial Collaborators. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med 2019; 380 (05) 425-436
  CrossrefPubMedGoogle Scholar
• 18 Bernard L, Dinh A, Ghout I. et al; Duration of Treatment for Spondylodiscitis (DTS) study group. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet 2015; 385 (9971) 875-882
  CrossrefPubMedGoogle Scholar
• 19 Lora-Tamayo J, Euba G, Cobo J. et al; Prosthetic Joint Infection Group of the Spanish Network for Research in Infectious Diseases—REIPI. Short- versus long-duration levofloxacin plus rifampicin for acute staphylococcal prosthetic joint infection managed with implant retention: a randomised clinical trial. Int J Antimicrob Agents 2016; 48 (03) 310-316
  CrossrefPubMedGoogle Scholar
• 20 Hogan A, Heppert VG, Suda AJ. Osteomyelitis. Arch Orthop Trauma Surg 2013; 133 (09) 1183-1196
  CrossrefPubMedGoogle Scholar
• 21 Høiby N, Bjarnsholt T, Moser C. et al; ESCMID Study Group for Biofilms and Consulting External Expert Werner Zimmerli. ESCMID guideline for the diagnosis and treatment of biofilm infections 2014. Clin Microbiol Infect 2015; 21 (Suppl. 01) S1-S25
  CrossrefPubMedGoogle Scholar
• 22 Govaert GA, IJpma FF, McNally M, McNally E, Reininga IH, Glaudemans AW. Accuracy of diagnostic imaging modalities for peripheral post-traumatic osteomyelitis - a systematic review of the recent literature. Eur J Nucl Med Mol Imaging 2017; 44 (08) 1393-1407
  CrossrefPubMedGoogle Scholar
• 23 Hong JPJ, Goh TLH, Choi DH, Kim JJ, Suh HS. The efficacy of perforator flaps in the treatment of chronic osteomyelitis. Plast Reconstr Surg 2017; 140 (01) 179-188
  CrossrefPubMedGoogle Scholar
• 24 Cierny III G, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res 2003; (414) 7-24
  PubMedGoogle Scholar
• 25 Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome?. Br J Anaesth 2011; 107 (Suppl. 01) i90-i95
  CrossrefPubMedGoogle Scholar
• 26 Hahn HM, Jeong YS, Hong YS. et al. Use of revascularized artery as a recipient in microvascular reconstruction of the lower leg: an analysis of 62 consecutive free flap transfers. J Plast Reconstr Aesthet Surg 2017; 70 (05) 606-617
  CrossrefPubMedGoogle Scholar
• 27 Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 2011; 124 (02) 144-54 e8
  CrossrefPubMedGoogle Scholar
• 28 Bode LG, Kluytmans JA, Wertheim HF. et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010; 362 (01) 9-17
  CrossrefPubMedGoogle Scholar
• 29 Atkins BL, Athanasou N, Deeks JJ. et al; The OSIRIS Collaborative Study Group. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. J Clin Microbiol 1998; 36 (10) 2932-2939
  CrossrefPubMedGoogle Scholar
• 30 McNally M. Infection after fracture. In: Kates SL, Borens O. eds. Principles of Orthopaedic Infection Management. 1st ed.. AO Trauma. Stuttgart, Germany: Thieme; 2017: 139-165
  Google Scholar
• 31 Morgenstern M, Athanasou NA, Ferguson JY, Metsemakers WJ, Atkins BL, McNally MA. The value of quantitative histology in the diagnosis of fracture-related infection. Bone Joint J 2018; 100-B (07) 966-972
  CrossrefPubMedGoogle Scholar
• 32 McNally M, Ferguson J, Kugan R, Stubbs D. Ilizarov treatment protocols in the management of infected nonunion of the tibia. J Orthop Trauma 2017; 31 (Suppl. 05) S47-S54
  PubMedGoogle Scholar
• 33 Mifsud M, Ferguson J, Stubbs D, Ramsden A, McNally M. Eds. Outcomes of Simultaneous Ilizarov Frame Reconstruction and Free Muscle Flaps in the Management of Complex Limb Infection. British Limb Reconstruction Society (BLRS) Annual Conference. 2018. Southampton, UK: Orthopaedic Proceedings; 2018
  Google Scholar
• 34 McNally M, Ferguson J, Mifsud M, Stubbs D. Eds. Internal Fixation and Local Antibiotics for Infected Nonunions: Technique and Outcome at over one year. British Limb Reconstruction Society (BLRS) Annual Conference. 2018. Southampton, UK: Orthopaedic Proceedings; 2018
  Google Scholar
• 35 Mayberry-Carson KJ, Tober-Meyer B, Smith JK, Lambe Jr DW, Costerton JW. Bacterial adherence and glycocalyx formation in osteomyelitis experimentally induced with Staphylococcus aureus. Infect Immun 1984; 43 (03) 825-833
  CrossrefPubMedGoogle Scholar
• 36 Stravinskas M, Horstmann P, Ferguson J. et al. Pharmacokinetics of gentamicin eluted from a regenerating bone graft substitute: in vitro and clinical release studies. Bone Joint Res 2016; 5 (09) 427-435
  CrossrefPubMedGoogle Scholar
• 37 Walenkamp GH, Vree TB, van Rens TJ. Gentamicin-PMMA beads. Pharmacokinetic and nephrotoxicological study. Clin Orthop Relat Res 1986; (205) 171-183
  PubMedGoogle Scholar
• 38 McGrory JE, Pritchard DJ, Unni KK, Ilstrup D, Rowland CM. Malignant lesions arising in chronic osteomyelitis. Clin Orthop Relat Res 1999; (362) 181-189
  PubMedGoogle Scholar
• 39 May Jr JW, Jupiter JB, Gallico III GG, Rothkopf DM, Zingarelli P. Treatment of chronic traumatic bone wounds. Microvascular free tissue transfer: a 13-year experience in 96 patients. Ann Surg 1991; 214 (03) 241-250 discussion 250–252
  CrossrefPubMedGoogle Scholar
• 40 McNally MA, Small JO, Tofighi HG, Mollan RA. Two-stage management of chronic osteomyelitis of the long bones. The Belfast technique. J Bone Joint Surg Br 1993; 75 (03) 375-380
  PubMedGoogle Scholar
• 41 McNally MA, Ferguson JY, Lau AC. et al. 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 (09) 1289-1296
  CrossrefPubMedGoogle Scholar
• 42 Chan JK, Harry L, Williams G, Nanchahal J. Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps. Plast Reconstr Surg 2012; 130 (02) 284e-295e
  CrossrefPubMedGoogle Scholar
• 43 Cierny III G, Byrd HS, Jones RE. Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results. Clin Orthop Relat Res 1983; (178) 54-63
  PubMedGoogle Scholar
• 44 Mouës CM, Vos MC, van den Bemd GJ, Stijnen T, Hovius SE. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial. Wound Repair Regen 2004; 12 (01) 11-17
  CrossrefPubMedGoogle Scholar
• 45 Olesen UK, Juul R, Bonde CT. et al. A review of forty five open tibial fractures covered with free flaps. Analysis of complications, microbiology and prognostic factors. Int Orthop 2015; 39 (06) 1159-1166
  CrossrefPubMedGoogle Scholar
• 46 Diefenbeck M, Mennenga U, Gückel P, Tiemann AH, Mückley T, Hofmann GO. [Vacuum-assisted closure therapy for the treatment of acute postoperative osteomyelitis]. Z Orthop Unfall 2011; 149 (03) 336-341
  Article in Thieme ConnectPubMedGoogle Scholar
• 47 Chan JK, Miller R, Ramsden A. Microvascular reconstruction in the management of chronic osteomyelitis of the lower limb. 9th Congress of World Society for Reconstructive Microsurgery. Seoul, Korea: 2017
  Google Scholar
• 48 Sendi P, McNally MA. Wound irrigation in initial management of open fractures. N Engl J Med 2016; 374 (18) 1788
  CrossrefPubMedGoogle Scholar
• 49 Costa ML, Achten J, Bruce J. et al; UK WOLLF Collaboration. Effect of negative pressure wound therapy vs standard wound management on 12-month disability among adults with severe open fracture of the lower limb: the WOLLF randomized clinical trial. JAMA 2018; 319 (22) 2280-2288
  CrossrefPubMedGoogle Scholar
• 50 Iheozor-Ejiofor Z, Newton K, Dumville JC, Costa ML, Norman G, Bruce J. Negative pressure wound therapy for open traumatic wounds. Cochrane Database Syst Rev 2018; 7: CD012522
  Google Scholar
• 51 NICE. NICE Guidance: Fractures (complex). 2016 [Available from: https://www.nice.org.uk/guidance/ng37/evidence
  Google Scholar
• 52 Schaverien MV, Hamilton SA, Fairburn N, Rao P, Quaba AA. Lower limb reconstruction using the islanded posterior tibial artery perforator flap. Plast Reconstr Surg 2010; 125 (06) 1735-1743
  CrossrefPubMedGoogle Scholar
• 53 de Blacam C, Colakoglu S, Ogunleye AA. et al. Risk factors associated with complications in lower-extremity reconstruction with the distally based sural flap: a systematic review and pooled analysis. J Plast Reconstr Aesthet Surg 2014; 67 (05) 607-616
  CrossrefPubMedGoogle Scholar
• 54 Erdmann MW, Court-Brown CM, Quaba AA. A five year review of islanded distally based fasciocutaneous flaps on the lower limb. Br J Plast Surg 1997; 50 (06) 421-427
  CrossrefPubMedGoogle Scholar
• 55 Artiaco S, Battiston B, Colzani G. et al. Perforator based propeller flaps in limb reconstructive surgery: clinical application and literature review. BioMed Res Int 2014; 2014: 690649
  CrossrefPubMedGoogle Scholar
• 56 Bekara F, Herlin C, Mojallal A. et al. A systematic review and meta-analysis of perforator-pedicled propeller flaps in lower extremity defects: identification of risk factors for complications. Plast Reconstr Surg 2016; 137 (01) 314-331
  CrossrefPubMedGoogle Scholar
• 57 Sabino J, Polfer E, Tintle S. et al. A decade of conflict: flap coverage options and outcomes in traumatic war-related extremity reconstruction. Plast Reconstr Surg 2015; 135 (03) 895-902
  CrossrefPubMedGoogle Scholar
• 58 Sofiadellis F, Liu DS, Webb A, Macgill K, Rozen WM, Ashton MW. Fasciocutaneous free flaps are more reliable than muscle free flaps in lower limb trauma reconstruction: experience in a single trauma center. J Reconstr Microsurg 2012; 28 (05) 333-340
  Article in Thieme ConnectPubMedGoogle Scholar
• 59 Paro J, Chiou G, Sen SK. Comparing muscle and fasciocutaneous free flaps in lower extremity reconstruction--does it matter?. Ann Plast Surg 2016; 76 (Suppl. 03) S213-S215
  CrossrefPubMedGoogle Scholar
• 60 Cho EH, Shammas RL, Carney MJ. et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
  CrossrefPubMedGoogle Scholar
• 61 Askouni EP, Topping A, Ball S, Hettiaratchy S, Nanchahal J, Jain A. Outcomes of anterolateral thigh free flap thinning using liposuction following lower limb trauma. J Plast Reconstr Aesthet Surg 2012; 65 (04) 474-481
  CrossrefPubMedGoogle Scholar
• 62 Hui-Chou HG, Sulek J, Bluebond-Langner R, Rodriguez ED. Secondary refinements of free perforator flaps for lower extremity reconstruction. Plast Reconstr Surg 2011; 127 (01) 248-257
  CrossrefPubMedGoogle Scholar
• 63 Ooi A, Wong CH, Ong YS. Combined use of liposuction and arthroscopic shaver in lower-limb fasciocutaneous flap contouring. J Plast Reconstr Aesthet Surg 2013; 66 (04) 538-542
  CrossrefPubMedGoogle Scholar
• 64 Kotsougiani D, Platte J, Bigdeli AK. et al. Evaluation of 389 patients following free-flap lower extremity reconstruction with respect to secondary refinement procedures. Microsurgery 2018; 38 (03) 242-250
  CrossrefPubMedGoogle Scholar
• 65 Nelson JA, Fischer JP, Haddock NT. et al. Striving for normalcy after lower extremity reconstruction with free tissue: the role of secondary esthetic refinements. J Reconstr Microsurg 2016; 32 (02) 101-108
  Article in Thieme ConnectPubMedGoogle Scholar
• 66 Chen HC, Chuang CC, Chen S, Hsu WM, Wei FC. Selection of recipient vessels for free flaps to the distal leg and foot following trauma. Microsurgery 1994; 15 (05) 358-363
  CrossrefPubMedGoogle Scholar
• 67 Haddock NT, Weichman KE, Reformat DD, Kligman BE, Levine JP, Saadeh PB. Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: a 26-year review. J Am Coll Surg 2010; 210 (01) 66-72
  CrossrefPubMedGoogle Scholar
• 68 Heidekrueger PI, Ehrl D, Heine-Geldern A, Ninkovic M, Broer PN. One versus two venous anastomoses in microvascular lower extremity reconstruction using gracilis muscle or anterolateral thigh flaps. Injury 2016; 47 (12) 2828-2832
  CrossrefPubMedGoogle Scholar
• 69 Lorenzo AR, Lin CH, Lin CH. et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 2011; 64 (05) 649-655
  CrossrefPubMedGoogle Scholar
• 70 Fujiwara RJT, Dibble JM, Larson SV, Pierce ML, Mehra S. Outcomes and reliability of the flow coupler in postoperative monitoring of head and neck free flaps. Laryngoscope 2018; 128 (04) 812-817
  CrossrefPubMedGoogle Scholar
• 71 Kempton SJ, Poore SO, Chen JT, Afifi AM. Free flap monitoring using an implantable anastomotic venous flow coupler: analysis of 119 consecutive abdominal-based free flaps for breast reconstruction. Microsurgery 2015; 35 (05) 337-344
  CrossrefPubMedGoogle Scholar
• 72 Hotchen AJ, McNally MA, Sendi P. The classification of long bone osteomyelitis: a systemic review of the literature. J Bone Jt Infect 2017; 2 (04) 167-174
  CrossrefPubMedGoogle Scholar
• 73 Egeler SA, de Jong T, Luijsterburg AJM, Mureau MAM. Long-term patient-reported outcomes following free flap lower extremity reconstruction for traumatic injuries. Plast Reconstr Surg 2018; 141 (03) 773-783
  CrossrefPubMedGoogle Scholar