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treatment of
chronic osteomyelitis
6. Are there other suitable
Jack
Carruthers
1. Chronic osteomyelitis overview
4. What are the options?
Aetiology
Haematogenous seeding (rare in West); post-traumatic (especially in compound
fractures); infected foreign body.
Pathology
Bacterial entry into bone triggers an acute inflammatory response. Bacterial
virulence factors disrupt the blood supply, leading to the formation of a necrotic
sequestrum. The infection progresses to chronicity due to damaged skin,
abundant scarring, and impaired vascularity. Patient factors including
malnutrition, diabetes mellitus and smoking contribute to infection persistence.
Infection can spread to the soft tissues causing a discharging sinus.
Clinical features
Localised bone pain accompanied by erythema, and swelling. Sometimes there
are symptoms of systemic infection. A raised ESR and CRP can be present.
Diagnosis
Radiological features include: loss of trabecular architecture, osteopaenia,
scalloping of the inner surface of the bone cortex, periosteal involucrum
formation seen next to a radio-dense sequestrum. (1)
bioceramics?
PMMA beads
These were developed by Klemm in the 1970s (4). The delivery of antibiotics by
PMMA bead chains to the osteomyelitic cavity was demonstrated to be
in the order of 200 times that of systemic antibiotics (5). In rabbit
experimental models, treatment of osteomyelitis with PMMA beads
showed a 100% success rate at preventing infection recurrence (6).
Human studies by Nelson et al. demonstrated a reduction in the risk of
infection recurrence of 18% in patients treated with PMMA beads versus
conventional therapy (7). PMMA seemed to be the way forward; but a
major concern is that they require a second operation to remove.
Therefore, the focus is now on resorbable antibiotic carriers.
Collagen fleece
Although widely used and biodegradable, collagen fleece has numerous drawbacks. It is associated with seroma formation, and a recent study
demonstrated that it eluted 95% of its gentamicin in the first day (8).
5. Calcium sulphate
3. Antibiotic-loaded carriers
What? Usually of an inert substance, they are loaded with broad-spectrum
antibiotics and placed into the excision cavity.
Why? They deliver high concentrations of antibiotics locally without the sideeffects of high-dose systemic antibiotics. In addition, they are important
in dead-space management, preventing haematoma formation. The
osteoconductive carriers act as bone graft substitutes, helping new bone
grow to fill the cavity (3).
9. References
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
Berendt, A., Chapter 41: Acute and chronic osteomyelitis, In Cohen, J. et al., Infectious Diseases, volume one, Mosby Elsevier, p.p. 445-456.
Parsons, B. and E. Strauss, Surgical management of chronic osteomyelitis, The American Journal of Surgery, 188, 57S-66S (2004).
El-husseiny, M. et al., Biodegradable antibiotic delivery systems, The Journal of Bone and Joint Surgery, 93-B, 151-157 (2011).
Klemm, K. W., Gentamicin-PMMA chains (Septopal chains) for the local antibiotic treatment of chronic osteomyelitis, Reconstructive Surgery and Traumatology, 20, 11-35 (1988).
Wahlig, H. et al., The release of gentamicin from PMMA beads: an experimental and pharmacokinetic study, The Journal of Bone and Joint Surgery, 60-B, 270 (1978).
Evans, R. P. and C. L. Nelson, Gentamicin-impregnated PMMA beads compared with systemic antibiotic therapy in the treatment of chronic osteomyelitis, Clinical Orthopaedics and Related Research, 295,
37-42 (1993).
Nelson, C. L. et al., A comparison of gentamicin-impregnated polymethylmethacrylate bead implantation to conventional parenteral antibiotic therapy in infected total hip and knee arthroplasty, Clinical
Orthopaedics and Related Research, 295, 96-101 (1993).
Srensen, T. S., et al., Rapid release of gentamicin from collagen sponge: in vitro comparison with plastic beads, Acta Orthopaedica Scandinavica, 61, 353-361 (1990).
Wichelhaus, T. A. et al., Elution characteristics of vancomycin, teicoplanin, gentamicin and clindamycin from calcium sulphate beads, Journal of Antimicrobial Chemotherapy, 48, 117-119 (2001).
McKee, L. et al., The use of an antibiotic-impregnated, osteoconductive, bioabsorbable bone substitute in the treatment of infected long bone defects: early results of a prospective trial, Journal of Orthopaedic
Trauma, 16, 622-627 (2002).
Sidqui, M. et al., Osteoblast adherence and resorption activity of isolated osteoclasts on calcium sulphate hemihydrate, Biomaterials, 16, 1327-1332 (1995).
Chang, W. et al., Adult osteomyelitis: debridement versus debridement plus Osteoset T pellets, Acta Orthopaedica Belgica, 73, 238-243 (2007).
Franceschini, M. et al., Treatment of a chronic recurrent fistulised tibial osteomyelitis: administration of a novel antibiotic-loaded bone substitute combined with a pedicular muscle flap sealing, European
Journal of Orthopaedic Surgery and Traumatology, Published online (2012).
Thomas, D. B. et al., Tobramycin-impregnated calcium sulphate prevents infection in contaminated wounds, Clinical Orthopaedics and Related Research, 441, 366-371 (2005).
Nelson, C. L. et al., The treatment of experimental osteomyelitis by surgical debridement and the implantation of calcium sulfate tobramycin pellets, Journal of Orthopaedic Research, 20, 643-647 (2002).
Bouillet, R. et al., Traitement de losteomylite chronique en milieu africain par implants de pltre impregne dantibiotiques, Acta Orthopaedica Belgica, 55, 2-11 (1989).
Hing, K. A. et al., Comparative performance of three ceramic bone graft substitutes, The Spine Journal, 7, 475-490 (2007).
Stubbs, D. et al., In vivo evaluation of resorbable bone graft substitutes in a rabbit tibial defect model, Biomaterials, 25, 5037-5044 (2004).
Lu, J. et al., Relationship between bioceramics sintering and micro-particles-induced cellular damages, Journal of Materials Science: Materials in Medicine, 15, 361-365 (2004).
Rauschmann, M. A. et al., Nanocrystalline hydroxyapatite and calcium sulphate as biodegradable composite carrier material for local delivery of antibiotics in bone infections, Biomaterials, 26, 2677-2684
(2005).
Ueng, S. W. et al., Biodegradable alginate antibiotic beads, Clinical Orthopaedics and Related Research, 380, 250-259 (2000).