Abstract
Purpose
Chronic osteomyelitis and infected nonunion are relatively rare conditions in pediatric patients and are more frequently seen in developing countries. Although relatively rare, they are medically and surgically challenging. Here we report a novel surgical technique used to manage five patients with chronic osteomyelitis of long bones.
Methods
Five skeletally immature patients with chronic osteomyelitis and infected nonunion of the long bones were treated surgically between 2010 and 2014 by a combination of resection of necrotic infected bone, debridement of surrounding soft tissue, and application of antibiotic-laden cement spacer inducing periosteal membrane before final bone reconstruction. Once inflammatory markers normalized, all the patients were re-operated for cement removal, bone graft substitution, and concomitant osteosynthesis of the affected bone, if needed. All patients underwent MRI, CT scan, and laboratory evaluation prior to surgery. The antibiotic regimen was started empirically and then adjusted according to culture and sensitivity results.
Results
Mean patient age at the time of diagnosis was 11 years (range 4–14), and all patients had at least 2-year follow-up (range 2–5). At last follow-up, clinical and laboratory evaluation had normalized, the bone had healed, and all patients had resumed daily living and sports activities.
Conclusion
Surgical debridement is the standard approach to chronic osteomyelitis. Use of antibiotic-laden cement is recommended to penetrate local infection, with antibiotic therapy playing an adjunctive role. The cement also induces membrane formation that aids bone reconstruction.
Level of evidence
IV.
Similar content being viewed by others
References
Samuel S, Ismavel R, Boopalan PR, Matthai T (2010) Practical considerations in the making and use of high-dose antibiotic-loaded bone cement. Acta Orthop Belg 76:543–545
Harik NS, Smeltzer MS (2010) Management of acute hematogenous osteomyelitis in children. Expert Rev Anti Infect Ther 8:175–181
Gutierrez K (2005) Bone and joint infections in children. Pediatr Clin N Am 52:779–794
Catalano-Pons C, Raymond J, Chalumeau M, Armengaud JB, Kalifa G, Gendrel D (2007) Case 2: paediatric chronic osteomyelitis: report of two cases. Case 1 diagnosis: pulmonary TB complicated by pneumomediastinum. Case 2 diagnosis: osteomyelitis caused by actinomyces. Acta Paediatr 96:1849–1852
Bar-On E, Weigl DM, Bor N, Becker T, Katz K, Mercado E, Livni G (2010) Chronic osteomyelitis in children: treatment by intramedullary reaming and antibiotic impregnated cement rods. J Pediatr Orthop 30:508–513
Matzkin EG, Dabbs DN, Fillman RR, Kyono WT, Yandow SM (2005) Chronic osteomyelitis in children: Shriners Hospital Honolulu experience. J Pediatr Orthop B 14:362–366
Auh JS, Binns HJ, Katz BZ (2004) Retrospective assessment of subacute or chronic osteomyelitis in children and young adults. Clin Pediatr 3:549–555
Paley D, Herzenberg JE (2002) Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases. J Orthop Trauma 16:723–729
Wang X, Wei F, Luo F, Huang K, Xie Z (2015) Induction of granulation tissue for the secretion of growth factors and the promotion of bone defect repair. J Orthop Surg Res 17(10):147
Masquelet AC, Fitoussi F, Bégué T, Muller GP (2000) Reconstruction of the long bones by the induced membrane and spongy autograft. Ann Chir Plast Esthet 45:346–353
Mansour TM, Ghanem IB (2015) Preliminary results of the induced membrane technique for the reconstruction of large bone defects. J Pediatr Orthop [Epub ahead of print]
Hollmig ST, Copley LA, Browne RH, Grande LM, Wilson PL (2007) Deep venous thrombosis associated with osteomyelitis in children. J Bone Joint Surg Am 89:1517–1523
Zalavras CG, Patzakis MJ, Holtom P (2004) Local antibiotic therapy in the treatment of open fractures and osteomyelitis. Clin Orthop Relat Res 427:86–93
Nourse C, Starr M, Munckhof W (2007) Community-acquired methicillin-resistant Staphylococcus aureus causes severe disseminated infection and deep venous thrombosis in children: literature review and recommendations for management. J Paediatr Child Health 43:656–661
Bouchoucha S, Benghachame F, Trifa M, Saied W, Douira W, Nessib MN et al (2010) Deep venous thrombosis associated with acute hematogenous osteomyelitis in children. Orthop Traumatol Surg Res 96:890–893
Karger C, Kishi T, Schneider L, Fitoussi F, Masquelet AC (2012) Treatment of posttraumatic bone defects by the induced membrane technique. Orthop Traumatol Surg Res 98:97–102
Woon CY, Chong KW, Wong MK (2010) Induced membrane A staged technique of bone-grafting for segmental bone loss. J Bone Joint Surg Am 92:196–201
Scholz AO, Gehrmann S, Glombitza M, Kaufman RA, Bostelmann R, Flohe S et al (2015) Reconstruction of septic diaphyseal bone defects with the induced membrane technique. Injury 46(Suppl. 4):S121–S124
Wang X, Luo F, Huang K, Xie Z (2016) Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis. Bone Joint Res 5:101–105
Xie B, Tian J, Jing YF, Zhou DP, Xiang LB (2015) Early effect of induced membrane technique for the reconstruction of chronic osteomyelitis defects in limbs of adult patients. Zhongguo Gu Shang 28:43–47
Marais LC, Ferreira N (2015) Bone transport through an induced membrane in the management of tibial bone defects resulting from chronic osteomyelitis. Strat Traum Limb Recon 10:27–33
Spiegl U, Pätzold R, Friederichs J, Hungerer S, Militz M, Bühren V (2013) Clinical course, complication rate and outcome of segmental resection and distraction osteogenesis after chronic tibial osteitis. Injury 44:1049–1056
Lindaman LM (2001) Bone healing in children. Clin Podiatr Med Surg 18:97–108
Buchholz HW, Engelbrecht H (1970) Depot effects of various antibiotics mixed with Palacos resins. Chirurg 41:511–515
Buchholz HW, Gartmann HD (1972) Infection prevention and surgical management of deep insidious infection in total endoprosthesis. Chirurg 43:446–453
Dovas S, Liakopoulos V, Papatheodorou L, Chronopoulou I, Papavasiliou V, Atmazidis E et al (2008) Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty. Clin Nephrol 69:207–212
Van Raaij TM, Visser LE, Vulto AG, Verhaar JA (2002) Acute local failure after local gentamicin treatment of an infected total knee arthroplasty. J Arthroplasty 17:948–950
Curtis JM, Sternhagen V, Batts D (2005) Acute renal failure after placement of tobramycin-impregnated bone cement in an infected total knee arthroplasty. Pharmacotherapy 25:876–880
Wahlig H, Buchholz HW (1972) Experimental and clinical studies on the release of gentamicin from bone cement. Chirurg 43:441–445
Cho SH, Song HR, Koo KH et al (1997) Antibiotic-impregnated cement beads in the treatment of chronic osteomyelitis. Bull Hosp Jt Dis 56:140–144
Walenkamp GH, Kleijn LL, de Leeuw M (1998) Osteomyelitis treated with gentamicin-PMMA beads: 100 patients followed for 1-12 years. Acta Orthop Scand 69:518–522
Springer BD, Lee GC, Osmon D et al (2004) Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty. Clin Orthop Relat Res 427:47–51
Cierny G III, Mader JT, Penninck JJ (2003) A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res 414:7–24
Bassey LO, Antia-Obong OE, Antia UE (1995) Sequestrectomy and local muscle flap implantation for chronic osteomyelitis in children and adolescents. East Afr Med J 72:787–790
Hoang NT, Staudenmeier R, Feucht A et al (2009) Effectiveness of free gracilis muscle flaps in the treatment of chronic osteomyelitis with purulent fistulas at the distal third of the tibia in children. J Pediatr Orthop 29:305–311
Acknowledgments
Institutional review board approval: The study was approved by the Clermont-Ferrand University Hospital Review Board.
Funding
None of the authors received financial support for this study.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflicts of interest in this research.
Ethical approval
All procedures and studies involving human participants were performed in accordance with the ethical standards of the national and/or institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent
No patients were involved. This is a retrospective study of patient’s data for which IRB approval was obtained.
Rights and permissions
About this article
Cite this article
Canavese, F., Corradin, M., Khan, A. et al. Successful treatment of chronic osteomyelitis in children with debridement, antibiotic-laden cement spacer and bone graft substitute. Eur J Orthop Surg Traumatol 27, 221–228 (2017). https://doi.org/10.1007/s00590-016-1859-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00590-016-1859-7