Surgical Treatment for

Acute & Chronic Osteomyelitis

By Mudib

Program Pendidikan Dokter Spesialis I Ilmu Bedah

FK UNS/RSUD Dr Moewardi
Surakarta
2020
 Introduction
• An inflammatory process of bone and bone marrow
caused by an infectious organism(s)
• Results in local bone destruction, necrosis and
apposition of new bone.
• The term osteomyelitis implies bone or joint infection

Birt, M. C., Anderson, D. W., Bruce Toby, E., & Wang, J. (2016). Osteomyelitis
 Hematogenous spread usually
involves the metaphysis of long
bones in children or the vertebral
bodies in adults

Direct inoculation of
microorganisms
into bone
penetrating injuries Microorganisms
and surgical in bone OSTEOMYELITIS
contamination are
most common
causes

Contiguous focus of
infection seen in patients
with severe vascular
disease
 A diagram showing three categories of
osteomyelitis

(A and B) Primary hematogenous (blood borne), (C and D) Contiguous bone infection

(direct contamination of bacteria (E) Vascular or neurologic disease associated
osteomyelitis

Birt, M. C., Anderson, D. W., Bruce Toby, E., & Wang, J. (2016). Osteomyelitis
Schematic drawing showing the vascular supply to the physis. The callout represents
a detailed view of the physis. The red arrow indicates an area of transition. These
transitional zones show increased turbulence and allow for local invasion
(Image used with permission from Dr. Kaye Wilkins)

Mauricio S. Baptista and João Paulo Tardivo: Osteomyelitis

 Pathology
These are end-artery branches of the nutrient artery

Acute inflammatory response due to infection

tissue necrosis, breakdown of bone

Obstruction

Avascular necrosis of bone

Sequestra formation

Chronic osteomyelitis
 Etiology

• All types of organisms, including bacteria, viruses,

parasites, and fungi, commonly caused by certain
pyogenic bacteria and mycobacteria (in some
countries)
• Staphylococcus aureus (S. aureus) is responsible for
80% to 90% of the cases of pyogenic osteomyelitis,
• Staphylococcus epidermidis (S. epidermidis) is seems
to predominately infect medical devices, including
orthopedic hardware implants and catheters.
Hematogenous Osteomyelitis
Contiguous Osteomyelitis
 Diagnosis and Types of Osteomyelitis

Clinical Guidelines for the Antimicrobial Treatment of Bone and Joint Infections
in Korea. Infect Chemother. 2014 Jun;46(2):125-138.
 Clinical Guidelines for the Antimicrobial
Treatment of Bone and Joint Infections in
Korea. Infect Chemother. 2014 Jun;46(2):125-
138.
 Management

• The ideal management of osteomyelitis

depends on several factors specific to each
patient and circumstance.
• Both medical and surgical methods are
available and often a combination of therapies
is necessary

Tiemann, Andreas Heinrich, and Gunther O Hofmann. “Principles of the therapy of

bone infections in adult extremities : Are there any new developments?.” Strategies
in trauma and limb reconstruction vol.4.2 (2009)
 Management

• The therapy of Osteomyelitis is based on two

principles:
– Radical surgical eradication of the affected bone
and soft tissue;
– Adjuvant systemic and local chemotherapy (with
antibiotics).

Tiemann, Andreas Heinrich, and Gunther O Hofmann. “Principles of the therapy of

bone infections in adult extremities : Are there any new developments?.” Strategies
in trauma and limb reconstruction vol.4.2 (2009)
 Management
Local surgical treatment is based on five
principles:
– Local bone and soft tissue debridement
– Stabilisation of the bone
– Local antibiotic therapy
– Reconstruction of the soft tissues
– Reconstruction of the osseous defect

Tiemann, Andreas Heinrich, and Gunther O Hofmann. “Principles of the therapy of

bone infections in adult extremities : Are there any new developments?.” Strategies
in trauma and limb reconstruction vol.4.2 (2009)
Agraphic depiction of the four anatomic types of osteomyelitismatched with a surgical
and reconstruction format for each. Adapted from Cierny G. Chronic osteomyelitis:
Results of treatment. In: Greene WB, ed. Instructional Course Lectures. Vol. 39.
Rosemont, Ill.: American Academy of Orthopaedic Surgeons. 1990;39:495.
 Clinical Suspicion of Osteomyelitis

Acute symptoms

Chronic symptoms Laboratory tests (CRP, ESR)

Positive Negative

Imaging Evaluation (MRI, TC) Imaging Evaluation (US, MRI) • Consider Different diagnosis
•Consider imaging evaluation

Bone Biopsy Bone Biopsy

Surgical Treatment Culture-based Antibiotic therapy

Culture-based
(Debridement and
Antibiotic therapy
bone defect filling) Effective Non Effective

Simultaneous Combined
Consider continuing therapy •Consider Surgical Treatment
Treatment •Consider Changing Antibiotic Therapy

Maffulli N., Papalia R., Zampogna et al. 2016. The Management of Osteomyelitis in the Adult.
The Surgeon, Jurnal of the Royal Colleges of Surgeons of Edinburgh and Ireland.
Acute Ostemyelitis Management

Acute osteomyelitis must be treated

surgically to drain pus and prevent
bone necrosis.

Antibiotics suitable to the patient's age and

the organism are given to control
hematogenous spread and to treat the local
infection
 Treatment Algorithm of Cierny-mader Stage 1, or Hematogenous,
Long Bone Osteomyelitis.
Cultures
Initial Antibiotic Selection
(Blood ± Bone)

Change or Confirm
(Based on Culture Results)

Poor Response Good Response

(after 48h adequate treatment)

Operative Treatment:
Abscess Drainage
Unroofing
IM Reaming
Continue 2 weeks Parenteral
4 weeks Oral Antibiotics

4 weeks Antibiotics

Failure Arrest

Re-Treat as Above

(From Lazzarini L, Mader JT, Calhoun JH. Osteomyelitis in long bones. J Bone Joint Surg Am 2004;86:2305–2318. Reprinted with permission
from The Journal of Bone and Joint Surgery, Inc.)
 Debridement Biopsy and Culture Initial Antibiotic Treatment

Change or Confirm
Hardware Removal (Based on Culture Results)
±

Deadspace Management 6 weeks of Antibiotics

Beads After Major Operative Debridement
Bonegraft
Muscle Flaps
±

Failure Arrest
Stabilization
External Fixation
Ilizarov Technique
±
Re-Treat as Above

Soft Tissue Coverage

Treatment algorithm of Cierny-Mader stages 3 and 4 long bone osteomyelitis. (From Lazzarini L, Mader JT, Calhoun JH.
Osteomyelitis in long bones. J Bone Joint Surg Am 2004;86:2305 – 2318. Reprinted with permission from The Journal of Bone and
Joint Surgery, Inc.) 
 I. Patient evaluation
Treatment
Algorithm II. Preoperative testing
for Adult Chronic
Osteomyelitis, 2010 – Laboratory testing: full metabolic panel, CBC
with differential, coagulation panel, UA, ESR, CRP,
colonization testing
– Diagnostics: vascular indices; ultrasound; oxygen
tensions (TcPO2)
– Radiology: plain films; MRI, CT Scan, PET scans;
angiography studies
– Tissue specimens: cultures; histology sections;
PCR

III. Clinical staging

• Anatomic type: I, medullary; II, superficial; III,
localized; IV, diffuse
• Physiologic class: A-host, B-host, C-host
Treatment IV. Treatment format
– Limb salvage
Algorithm – Amputation
for Adult Chronic – Palliation: C-hosts; no “treatment for cure”
Osteomyelitis, 2010

V. Host optimization: reverse amenable

comorbidities

VI. First Surgery

A. One-Stage Treatment
B. First of multistage treatments

VII. Outpatient follow-up: wound

surveillance; laboratory work (ESR/CRP);
physical rehabilitation
Treatment Algorithm
for Adult Chronic Osteomyelitis, 2010
One-stage treatment:
1.De´bridement/tissue specimens/antibiotics (all treatment
formats)
2.Dead space management (limb salvage, amputation)
• Wound: secondary intention; primary versus
delayed closures
• Bone: vascularized bone flaps; acute
shortening51,66,67
• Fixation: orthotics; external fixators
• Depots: antibiotic beads
 First of multistage treatments:
Treatment 1. De´bridement/tissue specimens/systemic
Algorithm antibiotics
for Adult Chronic 2. Double setup: change instruments,
Osteomyelitis, 2010 repreparation and redraping, new
gowns/gloves
3. Temporary fixation: external fixation;
antibiotic-coated hardware
4. Dead space management:
Wound: secondary intention; primary versus
delayed closures
Bone: bone transport; vascularized bone
flaps
Fixation: orthotics; external fixators;
hardware (coated)
Depots: antibiotic beads, antibiotic spacers
Treatment VIII. Second surgery (second stage)

Algorithm
for Adult Chronic
Osteomyelitis, 2010 A. Definitive reconstruction:
1. Prophylactic antibiotics/hardware removal/de
´bridement/tissue specimens (frozen biopsy
negative—no inflammation)
2. Double setup: change instruments, repreparation
and redraping, new gowns/gloves
3. Reconstruction:

B. Staged reconstruction no. 2:

1. Prophylactic antibiotics/hardware removal/de
´bridement/tissue specimens (frozen biopsy
positive—acute inflammation)
2. VI B (above) versus amputation
 IX. Outpatient follow-up:
wound surveillance; laboratory work (ESR/CRP);
physical rehabilitation
Treatment
Algorithm
X. Third surgery (third stage)
for Adult Chronic
Osteomyelitis, 2010
A. Definitive reconstruction: (frozen biopsy
negative—no inflammation)
1. VIIIA (above)
B. Staged reconstruction no. 3: (frozen biopsy
positive—acute inflammation)
1. VI B (above) versus amputation

XI. Fourth surgery:

biologic reconstructions‡ (no hardware, no
foreign bodies)

XII. Outpatient follow-up:

wound surveillance; laboratory work(ESR/CRP);
physical rehabilitation
Fifty-six-year-old male patient with chronic osteitis and fistula from a lower leg
Fifty-six-year-old male patient with chronic osteitis and fistula from a lower leg
fracture. The preoperative X-ray shows the bone lesion under the
fracture. The preoperative X-ray shows the bone lesion under the osteosynthesis
osteosynthesis material and also a sequestrum (a, b)
material and also a sequestrum (a, b)
 a. Intraoperative situation.
Exposure and removal of
the osteosynthesis
material

b. Segmental resection
of the tibia. The
stabilising external
fixator is already
partially installed

c. Resected bone material

 a. Postoperative situation with completed external transport fixator.
b, c Postoperative X-ray of the proximal lower leg. It shows the transport
corticotomy.
d, e Postoperative X-ray of the distal lower leg. It shows the bone defect
after tibial segment resection
a Critical soft tissue situation one week
after the initial operation. Local treatment
with repetitive debridement, lavage and
vacuum sealing. Continuation of the
transport as an open transport. 

b Advancing consolidation of
the soft tissue. Continuation of
the transport. 

c Consolidated soft tissue. Coverage

with mesh graft. Transport completed
 c, d X-ray of the docking zone after 9
months. It shows almost complete
a, b X-ray after 9 months. The transport
consolidation. Owing to the soft tissue
is finished and the external fixator is
conditions, the docking manoeuvre was
removed. Good callus formation in the
carried out as a compression docking
transport zone.
without additional plating or cancellous
bone graft
Clinical examination after 9 months. The soft tissue is
consolidated and full weight-bearing of the right leg. No further
signs of bone or soft tissue infection
Thank You