■ trauma update

Section Editors: David J. Hak, MD, MBA & Philip F. Stahel, MD

infection
S P OT L I G H T O N
ERRATUM

This article has been amended to include a factual correction. An error was identified subsequent to its original
printing (2013; 36[5]:368-375), which was acknowledged in an erratum printed in 2014; 37(1):16. The online
article and its erratum are considered the version of record.

Long Bone Osteomyelitis in Adults:

Fundamental Concepts and Current
Techniques
Julia Sanders, MD; Cyril Mauffrey, MD, FRCS

to retained humor.2 Warfare behind the disease process are

Abstract: Osteomyelitis is challenging for orthopedic sur- in the 20th century spurred
geons. The fundamental basis of osteomyelitis treatment is
advances in plastic and ortho-
wide surgical debridement. A variety of operative techniques
pedic surgery and, along with
exist for soft tissue coverage and segmental bony stabilization;
the introduction of penicillin
however, extensive resection remains the crucial starting point
in the 1940s, pointed the treat-
in a comprehensive treatment plan. Antibiotic therapy con-
ment of osteomyelitis in the
tinues to be a cornerstone of adjuvant therapy; nevertheless,
the length of treatment is still debated. With ever-increasing direction that has taken today.3
antimicrobial resistance rates, targeted therapy based on ac- Unfortunately, the man-
curate cultures has become imperative. Osteomyelitis requires agement of osteomyelitis has
a multidisciplinary team prepared to formulate an individual- been given too little attention
ized surgical and medical plan for each patient. The aim of to date, and quality clinical
the current article is to highlight and summarize the current trials to support treatment
concepts in the management of long bone osteomyelitis. practice are scarce. The vari-
ability in practice and lack of
standardization highlights the
reviewed and the current tech-
niques for the management of
osteomyelitis are discussed.
An algorithm for treatment
based on these concepts and
techniques is presented and
illustrated using clinical ex-
amples.
EPIDEMIOLOGY
Although many break-
throughs have been made in
the field of infectious disease
over the past decades, osteo-
myelitis remains a difficult

O steomyelitis is a chal-
lenge for orthopedic sur-
geons. Bone provides a unique
ated by both pathophysiol-
ogy and treatment algorithms.
Hippocrates first described the
latter statement. A treatment
algorithm that is based on a
classification scheme with a
problem for the orthopedic
community, particularly in
busy trauma centers that care
harbor for microorganisms disease, recommending splint- poor interobserver variability for open and complex frac-
that produce biofilms, allow- ing and clean dressings for can contribute to this difficul- tures. Infection rates in open
ing them to attach resiliently open fractures and highlight- ty. Furthermore, few centers long bone fractures range from
to biologic and implanted ing the risk of bone infection.1 treat a high volume of patients 4% to 64%.4 A recent study
surfaces while remaining in- Ambroise Paré, a French sur- that would be sufficient to showed that even in patients
susceptible to host defenses. geon, described his own open develop evidence-based algo- receiving state-of-the-art or-
Acute and chronic phases of tibia fracture that developed an rithms. Finally, surgical meth- thopedic and plastic surgical
osteomyelitis are differenti- infection, and attributed this ods aimed at local excision of care, 23% of patients devel-
the lesion are bound to failure; oped infections after an aver-
The authors are from the Department of Orthopaedics, Denver Health the infected tissue within bone age of 3 procedures per limb.5
Medical Center, Denver, Colorado. has the potential to spread, Chronic infections are both
The authors have no relevant financial relationships to disclose.
and wide excision with clear expensive and challenging to
Correspondence should be addressed to: Cyril Mauffrey, MD, FRCS,
Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, margins is the most valid treat- treat and cure rates are still
Denver, CO 80204 (cyril.mauffrey@dhha.org) ment philosophy. In this arti- not optimal. Ideally, treatment
doi: 10.3928/01477447-20130426-07 cle, the fundamental concepts methods should offer complete

368 ORTHOPEDICS | Healio.com/Orthopedics


resolution of infection and op-
timized function and mobil-
ity of the affected extremity.
Currently, despite advances
in both surgical and chemical
treatment, recurrence rates fol-
lowing bony infection are be-
tween 20% and 30%.6
CLASSIFICATION
Several classification sys-
tems have been devised for
osteomyelitis, but the Cierny-
Mader system remains the most
clinically relevant. This system
stratifies hosts into 3 categories
(A-C) based on physiologic
comorbidities and designates 4
anatomic stages of infection (1-
4), which are combined to pro-
duce 12 classifications.7 This
system assists in clinical deci-
sion making for the extent of
surgical debridement, as well
as antibiotic therapy.
Host factors are impor-
tant in determining treat-
ment algorithms. According
to the Cierny-Mader system,
a type A host is a healthy pa-
tient without comorbidities
that might affect their ability
to heal. Type B hosts have 1
or more comorbidities that
increase their risk of treat-
ment failure, including local
(eg, vascular disease, chronic
edema, fibrosis from radiation
or scarring, and obesity) and
systemic factors (eg, drug use,
age, diabetes mellitus, malig-
nancy, immune deficiencies,
and malnutrition).8 Type C
hosts are compromised to the
point that the benefits of treat-
ment are outweighed by the
possible risks. These patients
are offered palliation or treated
expectantly while their comor-
bidities are addressed.
MAY 2013
The Cierny-Mader system
identifies 4 anatomic types of
osteomyelitis (Figure 1): med-
ullary (type I), superficial (type
II), localized (type III), and
diffuse (type IV). Medullary
disease involves the internal
surface of the bone only, often
associated with intramedul-
lary hardware. Superficial os-
teomyelitis is often associated
with soft tissue infections that
spread down to bone, such as
the base of an open pressure
ulcer. Localized disease in-
volves the full thickness of the
cortex and is essentially a deep
extension of a superficial pro-
cess. These lesions are limited
enough that surgical resec-
tion of involved bone leaves
a stable segment. In contrast,
diffuse osteomyelitis is a full-
thickness infection extensive
enough to require fixation
following debridement due
to instability.7 This classifica-
tion system still guides treat-
ment despite having a poor
interobserver variability. It is
often difficult to differentiate
between a medullary and a su-
perficial or localized infection.
Magnetic resonance imaging
often shows a diffuse appear-
ance, which is a more accurate
and realistic representation of
the infectious process.
ETIOLOGY
Osteomyelitis can arise sec-
ondary to hematogenous spread
or from a contiguous source of
infection. Hematogenous infec-
tion is more common in those
younger than 20 years and older
than 60 years and is the least
common form of the disease.
It rarely causes osteomyelitis
of the long bones in adults.9
1A
1C
Figure 1: Cierny and Mader classification showing the 4 anatomic types
of osteomyelitis known as medullary (A), superficial (B), localized (C), and
diffuse (D).
Contiguous spread of infection
can be caused by surgery, partic-
ularly the placement of prosthe-
ses or hardware, and trauma or
other foreign body introduction.
Osteomyelitis can also arise sec-
ondary to vascular insufficiency,
commonly from a soft tissue in-
fection in patients with diabetes
mellitus.
In the hematogenous form,
a single pathogen is usu-
ally isolated, with the most
common organism being
Staphylococcus aureus.10 In
contrast, osteomyelitis sec-
ondary to contiguous spread
or direct inoculation is usu-
ally caused by multiple organ-
isms. Polymicrobial infection
was responsible for approxi-
mately 30% of infections in
one series.11 Staphylococcus
aureus is the most common
isolate in polymicrobial infec-
tions, but anaerobes and gram-
■ trauma update
1B
1D
negative bacilli are also iso-
lated. Antimicrobial-resistant
organisms have become more
common, and a recent study
of approximately 200 patients
noted that no single antibiotic
regimen would adequately
treat the infections.11 Rarely,
tuberculosis, other atypical
mycobacterium, and fungi
may also cause osteomyelitis.
PATHOGENESIS
At the onset of infection
in osteomyelitis, immediate
vascular changes occur that
compromise blood flow to the
bone. If the infection is not
eradicated before the bone
dies, a sequestrum develops
and provides a base for the
formation of a microbial bio-
film. Biofilms are comprised
of exopolysaccharide poly-
mers forming a protective
fibrous matrix around host
369
■ trauma update
2A
Figure 2: Anteroposterior (A) and lateral (B) radiographs of a distal femur
highlighting the features of diffuse osteomyelitis, which include regional os-
teopenia, periosteal reaction with aggressive features (including Codman’s
triangle), peripheral sclerosis, sequestrum, and involucrum.
cells, as well as bacteria.12
Necrotic bone is resorbed,
with cancellous bone requir-
ing a few weeks to disappear.
Cortical bone may take longer,
even up to months, to erode.
Inflammatory cells in granu-
lation tissue are responsible
for the destruction of infected
bone. Microorganisms freely
propagate, and the biofilm ex-
pands within the cavity formed
by this resorption. As osteo-
myelitis progresses, new bone
forms around the sequestrum
from the neighboring pieces
of intact periosteum and end-
osteum. As it begins to sur-
round the area of infection, it
is known as the involucrum.
The involucrum is often ir-
regular with perforating sinus
tracts and may increase in den-
sity and thickness with time.13
DIAGNOSIS
Diagnosis is based on clini-
cal examination, tissue cul-
tures, laboratory studies, and
imaging. Symptoms of chron-
ic osteomyelitis are not always
obvious and may include low-
grade fever and chronic pain.
370
2B
Swelling, skin changes, and
drainage over the site may be
present. Acute infection in
adults and particularly chil-
dren may present with more
systemic signs, such as chills,
night sweats, erythema, and
severe pain.13 Sinus tracts are
often present over the area of
chronically infected bone. If
these become obstructed, they
may form abscesses.
LABORATORY
Initial workup should in-
clude basic complete blood
count, inflammatory markers,
cultures, and gram stain. Gram
stain is a reflexive addition to
any workup but may not lend
any diagnostic value except
to potentially guide early tai-
loring of antibiotic therapy.
Cultures are necessary to iden-
tify the microbial offender
responsible for the infection.
Bone biopsies should be taken
at the time of surgical debride-
ment and should be carefully
evaluated for sensitivities.
Cultures taken from sinus tract
drainage are not reliable for
determining the microorgan-
ism responsible for deep infec-
tion.14 Cierny8 recommended
using polymerase chain reac-
tion DNA pyrosequencing to
detect and characterize micro-
organisms. Prolonged culture
(up to 14 days) has also been
recommended to increased
sensitivity for low-virulence
organisms because 7-day cul-
tures only provided evidence
of infection in 64% of patients
in a recent series.11
Surprisingly, leukocyte
count may be normal; how-
ever, elevated erythrocyte
sedimentation rate and noncar-
diac C-reactive protein are key
signs of infection. The eryth-
rocyte sedimentation rate and
C-reactive protein will both
decrease with successful treat-
ment; therefore, their values
should be followed closely dur-
ing the pre- and postoperative
phases. C-reactive protein is
known to increase and decrease
faster in response to physio-
logic changes than erythrocyte
sedimentation rate. In addition
to inflammatory markers, labo-
ratory studies, including albu-
min, prealbumin, creatinine,
and blood glucose should be
followed to ensure optimiza-
tion of host factors.10 Blood
cultures are positive only in
the acute hematogenous form
of osteomyelitis and generally
do not assist with the diagno-
sis of chronic infection in long
bones.1
IMAGING
Common imaging tech-
niques for detecting osteomy-
elitis include plain radiography
(Figure 2), computed tomogra-
phy, magnetic resonance imag-
ing, and radionuclide labeled
ORTHOPEDICS | Healio.com/Orthopedics
scans (Figure 3). Often, more
than 1 type of imaging is needed
for adequate diagnosis and sur-
gical planning. Radiographic
changes are visible approxi-
mately 2 weeks after the physi-
ologic process of infection be-
gins. The classic signs on plain
radiographs include periosteal
reaction and osteopenia.10 As
the infection progresses, radio-
graphic signs (in order of ap-
pearance) are soft tissue swell-
ing, solid periostitis, lysis and
lucencies, surrounding sclero-
sis, and sinus tracts.15
Computed tomography scan
can assist in visualizing soft tis-
sue changes surrounding a bony
infection but is impractical to
use for infections with local
hardware due to resultant arti-
fact. It is best used for detailed
surgical planning because it
clearly identifies sequestra and
devascularized bone. Magnetic
resonance imaging offers high-
er resolution and easily dif-
ferentiates between bone and
soft tissue involvement. It has
high sensitivity and specificity
for diagnosing osteomyelitis,
which typically appears as a
decreased local marrow signal
on T1 and an increased local
marrow signal on T2.16 Sinus
tracts are also well visualized
on magnetic resonance imag-
ing but often require gadolini-
um enhancement.15
Radionuclide labeled scans
are useful, especially in clini-
cal situations where a clear
diagnosis has not been made
and in acute settings when
radiographs are not helpful.
However, they do not offer
high-resolution delineation of
anatomical involvement. Bone
scans with methylene diphos-

phonate are highly sensitive
and specific for osteomyelitis
when increased activity is seen
on initial and delayed images
but becomes less accurate in
the setting of recent surgery
or trauma. White blood cell la-
beled scans may be performed
with several different labels
and require longer testing time
but offer improved specific-
ity.15 Gallium citrate and in-
dium may also be used as la-
beling compounds to identify
areas of inflammation but are
less popular due to cost and
technical requirements.10
TREATMENT
Definitive management of
long bone osteomyelitis re-
quires a multidisciplinary ap-
proach involving aggressive
surgical debridement and re-
construction followed by an-
tibiotic therapy.10 Antibiotic
therapy alone leads to high
failure rates. The current au-
thors believe that osteomyelitis
should be surgically treated as
a malignancy, with wide clear
margins ensuring adequate soft
tissue coverage. High recur-
rence rates are seen with con-
servative debridement.1 Soft
tissue coverage and dead space
management after extensive
debridement is paramount be-
cause spaces left unmanaged
may contribute to ongoing in-
fection. All efforts should be
made to optimize the host prior
to treatment, such as smoking
cessation and close control of
blood glucose in patients with
diabetes mellitus.9
Antibiotics
Tradition has dictated that
antibiotic therapy should last
MAY 2013
3A
4 to 6 weeks, based largely
on animal studies and the
knowledge that it takes ap-
proximately 4 weeks for bone
to revascularize after surgical
debridement.10 Haidar et al17
proposed that a shorter duration
of antibiotic treatment could be
feasible following aggressive
surgical debridement and well-
vascularized flap placement.
Antibiotic therapy alone fails
because the infection site has a
poor vascular supply. Without
adequate blood flow to the area,
adequate concentrations of an-
timicrobials cannot be attained.
Levels of antibiotics in bone
are less than 20% of serum lev-
els, even in healthy bone,1 and
are theoretically even lower in
diseased tissue. The biofilms
formed in osteomyelitis may
further decrease the penetration
of antimicrobials.
■ trauma update
3C
3D
Figure 3: Features of diffuse tibial
osteomyelitis as shown on coronal
T1- (A) and T2-weighted (B) magnetic
resonance images. Axial computed to-
mography scan revealing diffuse proxi-
mal femoral osteomyelitis (C) and axial
magnetic resonance image showing
type II osteomyelitis of the tibia (D).
3B
Once adequate surgical de- Antibiotics can also be
bridement has occurred, both delivered locally rather than
the offending biofilm and the systemically. Alternate routes
vascular deficiency should of antibiotic delivery include
have been addressed, and in- antibiotic-impregnated cement
travenous antibiotics should beads, which provide both high
be effective. Shorter courses local antibiotic concentrations
of intravenous antibiotics and dead space management.
would save the health care The effectiveness of this treat-
system a significant amount ment, both alone and in con-
of money considering the cost junction with intravenous anti-
and logistical barriers to out- biotics, has been demonstrated
patient intravenous therapy. in animal models and human
A recent Cochrane review trials.17 However, local anti-
attempted to summarize the biotic strategies have not been
evidence for systemic anti- proven superior to intravenous
biotic treatment after surgi- administration and require sur-
cal debridement for chronic gical removal.
osteomyelitis.6 The authors Biodegradable antibiotic
found few quality studies, but delivery systems obviate the
those chosen demonstrated no need for a second surgical pro-
significant difference between cedure for removal and several
recurrence rates 12 months systems are being developed.
after oral and parenteral anti- Collagen fleece is a nontoxic,
biotic treatment.6 biocompatible antibiotic car-
371
■ trauma update
Figure 4: Algorithm of the authors’ preferred treatment methodology for the management of stage 4 osteomyelitis.
rier that offers a triphasic anti-
biotic release and strong clini-
cal results to date. Polyesters
are another alternative for
biodegradable delivery, offer-
ing a slower breakdown and
some evidence of intracellular
action. Calcium-based carri-
ers, including Plaster of Paris,
calcium sulphate, and calcium
hydroxyapatite, are promis-
ing because they allow tissue
and bone ingrowth as they de-
grade. Other potential delivery
systems not requiring surgical
removal are polyanhydrides,
amylose starch, and composite
carriers.
Surgical Intervention
The extent of surgical de-
bridement should be planned
to account for the host type,
area of involvement, and likely
need for soft tissue coverage
and stabilization. Adequate
debridement is the key to
treatment success, and all dead
and ischemic tissues and sinus
372
tracts should be removed.7
Simpson et al18 prospectively
studied the effect of extent of
surgical debridement on cure
rates and found 100% cure
rates with wide excision and
100% recurrence rates with
intralesional biopsy and local
debulking. Marginal resection
with less than 5-mm margins
exhibited a 28% recurrence
rate, all of which were found
in type B hosts.18
When debriding, healthy
bleeding tissue should be visu-
alized at all boundaries of the
surgical site, followed by thor-
ough irrigation.19 At this point,
the need for stabilization and
soft tissue coverage can be
assessed. Stage I infections
limited to the medullary canal
may be treated with intramed-
ullary reaming and occasional-
ly very localized unroofing and
curettage.7 If evidence exists
of metaphyseal involvement or
endosteal scalloping, a longi-
tudinal trough should be made
4 staged treatment have been
to access the canal for curet-
tage, which minimizes effects
on bony stability.20 Primary
closure can usually be attained
because the dead space is lim-
ited to the intramedullary ca-
nal.8 Stage II infections can be
addressed with soft tissue de-
bridement and decortication of
the bone adjacent to the infec-
tion. Coverage with a flap has
been described both simulta-
neously and during a second-
stage procedure,7 either with
local or free flap mobilization.
Stage III osteomyelitis usually
requires debridement of soft
tissue, sequestrum, and cortex,
as well as decompression of
the involved medullary canal.
Cierny et al7 referred to this
process as saucerization, al-
luding to the shape of the bone
left untouched. Stabilization,
soft tissue coverage, and
grafting may all be necessary
depending on the extent of
involvement, with more than
70% of the cortex required for
ORTHOPEDICS | Healio.com/Orthopedics
absolute stability.20 Stage IV
infections are the most chal-
lenging to treat surgically be-
cause they most often require
multiple staged procedures
and necessitate osseous sta-
bilization. Staged procedures
address the need for eradica-
tion of infection followed by
osseous reconstruction aiming
for union and stability once
the tissue is healthy. In Figure
4, the current authors present
their treatment algorithm.
For extensive involvement
with significant segmental
bone loss, several methods of
described, with no current
consensus on a gold standard.
A wide variety of studies ex-
ist, with many combinations
of early and late stabilization,
coverage, structural support,
and antibiotic delivery. Some
weaknesses in the literature
include a paucity of long-term
follow-up data and a lack of a
universal definition of cure.
The Papineau, or open air,
technique and its various per-
mutations have been widely
cited in the treatment of os-
teomyelitis. This method in-
volves radical debridement,
staged bone grafting, and de-
layed soft tissue coverage with
either natural granulation or
skin grafting.21 This technique
is often used in type III infec-
tions following saucerization
because the bone graft does
not offer significant structural
support.22 Meticulous wound
care is needed because the de-
brided area is left open with
the bone graft exposed. This
technique has somewhat fallen
out of favor in light of newer
plastic surgery techniques for
 ■ trauma update

6A 6B
5A 5B

5C 5D
6C 6D
Figure 5: Photographs showing the first stage of the Masquelet technique
Figure 6: Clinical photograph of the tibial segment affected by the infection
used to excise a large segment of the affected tibia. The skin is marked based
that has been cut in half to show the involvement of both the cortex and the
on magnetic resonance imaging findings and extension of the infectious pro-
medullary cavity (A). Clinical photograph showing that the sinus tract is clearly
cess (A). Photograph showing the application of a monotube external fixator
visible. Anteroposterior (C) and lateral (D) radiographs of the tibia with the
and resection of the affected segment with clear margins on the intraoperative
cement spacer in situ.
frozen section (B). Fluoroscopic imaging showing the affected bony segment
resection (C, D).

tissue transfer and grafting term treatment of bone defects.

but remains a foundational
approach to the surgical treat-
ment of osteomyelitis.
McNally et al23 first de-
scribed a staged procedure,
known as the Belfast tech-
nique, comprised of radical
debridement, early soft tissue
coverage (with or without an-
tibiotic beads) to eliminate
dead space, and delayed bone
grafting, if necessary. This
decreased the hospitalization
time necessary for treatment
compared with previous meth-
ods and led to a cure rate of
92%. They emphasized wide
resection of infected areas
with no attempt to salvage dis-
eased tissue as a key compo-
nent of treatment.23
The Ilizarov technique in-
volves placing a circular exter-
nal fixation device for the long-
It is both time- and cost-
intensive but has had success in
the treatment of osteomyelitis.
Marsh et al24 reported a 100%
cure rate at 1-year follow-up
using an Ilizarov frame on in-
fected long bones, although
3 patients failed to unite their
fractures in this time. This tech-
nique allows stabilization with
concurrent soft tissue treatment 7A 7B
as well as distraction osteo- Figure 7: Anteroposterior (A) and lateral (B) radiographs of the tibia following
the second stage of reconstruction using Masquelet technique. The bone graft
genesis to close a segmental
(30 mL) was harvested using a reamer-irrigator-aspirator from the ipsilateral
gap and can be combined with femur and inserted into the defect after removal of the antibiotic spacer.
other forms of treatment for op-
timal outcomes.
Vacuum-assisted closure of antibiotic therapy. One cidence of positive cultures
of soft tissue defects has study compared vacuum- after treatment completion.25
been used in many settings, assisted closure therapy to Vacuum-assisted closure
and recent evidence has conventional wound care and therapy has also been imple-
demonstrated its efficacy in found a significant reduction mented in combination with
the treatment of stage II, III, in infection recurrence, the the Papineau technique in
and IV infections after de- rate of necessary subsequent lieu of wet-to-dry dressings
bridement and the initiation flap treatment, and the in- with good results.26

MAY 2013 373

■ trauma update
Masquelet pioneered a
technique for the treatment
of segmental bony defects in-
volving initial wide debride-
ment and the placement of an
antibiotic-loaded cement spac-
er with temporary stabilization
with intramedullary nailing,
plating, or external fixation.
This is followed 8 weeks later
by removal of the spacer and
careful placement of autograft
into the induced membrane
rich in growth factors (Figures
5-7).27 However, this tech-
nique has not been specifically
studied in the treatment of os-
teomyelitis.
For infections that per-
sist despite debridement and
antibiotics, the Lautenbach
technique has been offered
as an alternative treatment.
This procedure was first de-
scribed in patients with total
hip arthroplasty infections and
involves intramedullary ream-
ing and placement of a closed
endosteal irrigation system.28
This system allows for the lo-
cal delivery of antibiotics and
continuous sampling of the in-
fected cavity for cultures and
narrowing of antibiotic ther-
apy. Hashmi et al29 reported
using this technique in 17 pa-
tients with chronic osteomy-
elitis. Therapy was continued
until 3 consecutive negative
cultures were obtained and
the endosteal cavity was filled
with granulation tissue, with a
mean treatment length of 27
days. They reported only 1 re-
currence, which resolved with
repeat treatment.29
Beals and Richard30 com-
pared the treatment of chronic
osteomyelitis of the tibia with
antibiotics and one of several
374
surgical techniques by the
same surgeon. They found
good results with debridement
and muscle flap, bone graft,
bone transport, the Papineau
technique, and an Ilizarov
frame. Twenty-seven of 30
patients had good outcomes,
suggesting that optimal results
can be obtained with any well-
planned surgical procedure.31
CONCLUSION
A plethora of reconstruc-
tive techniques exist, none of
which has been proven superi-
or in the setting of osteomyeli-
tis, but the key remains eradi-
cation of infection with wide
resection and adjuvant antibi-
otics. Failure of infection
elimination appears to be di-
rectly related to the extent of
resection.18 The philosophy
guiding the management of
long bone osteomyelitis
should be early aggressive
management along with opti-
mization of the host medical
and nutritional status, with a
focus on wide margins exci-
sion and debridement of all af-
fected tissues. Necessary
length of antibiotic treatment
is still debatable; however, in-
creasing rates of resistance un-
derscore the importance of ac-
curate cultures and targeted
therapy. New methods for soft
tissue coverage and bony re-
construction continue to be in-
troduced, and it is important to
refer patients to centers spe-
cialized in bone infection. An
algorithm, such as the one sug-
gested here (Figure 4), should
be used to guide management.
Future research should ideally
address the lack of prospec-
tive, controlled, randomized
trials comparing techniques
and identify a gold standard of
treatment for antibiotic length
and delivery.
REFERENCES
1. Lew DP, Waldvogel FA.
Osteomyelitis. Lancet. 2004;
364:369-379.
2. Perry CR. A historical per-
spective. In: Bone and Joint
Infections. London: Martin
Dunitz; 1996:1-8.
3. Klenerman L. A history of os-
teomyelitis from the Journal
of Bone Joint Surg. 1948-2006.
J Bone Joint Surg Br. 2007;
89:667-670.
4. Schenker ML, Yannascoli S,
Baldwin KD, Ahn J, Mehta
S. Does timing to operative
debridement affect infectious
complications in open long bone
fractures? A systematic review.
J Bone Joint Surg Am. 2012;
94:1057-1064.
5. Penn-Barwell JG, Bennett
PM, Fries CA, Kendrew JM,
Midwinter MJ, Rickard RF.
Severe open tibial fractures in
combat trauma: management
and preliminary outcomes. Bone
Joint J. 2013; 95:101-105.
6. Conterno LO, da Silva Filho
CR. Antibiotics for treating
chronic osteomyelitis in adults.
Cochrane Database Syst Rev.
2009; 3:1-30.
7. Cierny G, Mader JT, Penninck
JJ. A clinical staging for adult
osteomyelitis. Clin Orthop Relat
Res. 2003; (414):7-24.
8. Cierny G. Surgical treatment of
osteomyelitis. Plast Reconstr
Surg. 2011; 127:190S-204S.
9. Mader JT, Calhoun JH, Lazzarini
L. Adult long bone osteomyeli-
tis. In: Calhoun JH, Mader JT,
eds. Musculoskeletal Infections.
New York, NY: Marcel Dekker;
2003:149-182.
10. Lazzarini L, Mader JT, Calhoun
JH. Osteomyelitis in long bones.
J Bone Joint Surg Am. 2004;
86:2305-2318.
11. Sheehy SH, Atkins BA, Bejon
P, et al. The microbiology of
chronic osteomyelitis: preva-
lence of resistance to common
empirical antimicrobial regi-
mens. J Infect. 2010; 60:338-
343.
ORTHOPEDICS | Healio.com/Orthopedics
12. Gristina AG, Oga M, Webb LX,
Hobgood CD. Adherent bacteri-
al colonization in the pathogen-
esis of osteomyelitis. Science.
1985; 228:990-993.
13. Calhoun JH, Manring MM,
Shirtliff M. Osteomyelitis of the
long bones. Semin Plast Surg.
2009; 23(2):59-72.
14. Perry CR, Pearson RL, Miller
GA. Accuracy of cultures of
material from swabbing of the
superficial aspect of the wound
and needle biopsy in the pre-
operative assessment of osteo-
myelitis. J Bone Joint Surg Am.
1991; 73:745-749.
15. Pineda C, Vargas A, Rodriguez
AV. Imaging of osteomyelitis:
current concepts. Infect Dis
Clinic N Am. 2006; 20:789-825.
16. Ma LD, Frassica FJ, Bluemke
DA, Fishman EK. CT and MRI
evaluation of musculoskeletal in-
fection. Crit Reb Diagn Imaging.
1997; 38:535-568.
17. Haidar R, Boghossian AD, Atiyeh
B. Duration of post-surgical anti-
biotics in chronic osteomyelitis:
empiric or evidence-based? Int J
Inf Dis. 2010; 14:e752-e758.
18. Simpson AH, Deakin M, Lathan
JM. The effect of the extent of
surgical resection on infection-
free survival. J Bone Joint Surg
Br. 2001; 83:403-407.
19. Forsberg JA, Potter BK, Cierny
G, Webb L. Diagnosis and man-
agement of chronic infection. J
Am Acad Orthop Surg. 2011;
19:S9-S19.
20. Parsons B, Strauss E. Surgical
management of chronic os-
teomyelitis. Am J Surg. 2004;
188:S57-S66.
21. Papineau LJ. Excision-graft
with deliberately delayed clos-
ing in chronic osteomyelitis
[in French]. Nouv Presse Med.
1973; 2:2753-2755.
22. Papineau LJ, Allfageme A,
Dalcourt JP, Pilon L. Chronic
osteomyelitis: open excision and
grafting after saucerisation. Int
Orthop. 1979; 3:165-176.
23. McNally MA, Small JO, Tofighi
HG, Mollan RAB. Two-stage
management of chronic os-
teomyelitis of the long bones.
J Bone Joint Surg Br. 1993;
75:375-380.
24. Marsh DR, Shah S, Elliott J,
Kurdy N. The Ilizarov method
in nonunion, malunion, and in-