Surgical Management of
Infected Bone Cavities
Ehnb Negrn, MD*, Ahmed Abdel Aziz Ahmed MD**
Ahmed Hassan Abou Helow. MD***
ABSTRACT
Thirty patients with chronic bone infection and infected
bone cauities in different skeletal sites were treated surgically
by radical debridement and obliteration of the dead space
either by cancellous bone grafting or by local muscle
#ransposition, together with specific antibiotic therapy after
proper identification of the infecting bacteria. These cases
were done in the period from I994 to 1337. Half of the eases
(group I) (fifteen cases) were treated surgically by radical
debridement and obliteration of the dead space by cancellous
bone grafting. The other m e e n cases (group LI) were treated
by radical debtidement and obliteration of the dead space by
local muscle transposition. Results were evaluated both
clinically and statistically. Clinically local muscle transposition for obliteration of bone cauities gaue better results (93%
eradication of infection) then cancellous bone grafting 180%
eradication of infection). Statistically there are no significant
differences between both methods of treatment.
INTRODUCTION
C
hronic osteomyelitis
is a condition that is
extremely serious
and disabling. In our society, there has been an
increased number of skeletal trauma and consequently
an increased number of infection from the trauma itself or from the operative
treatment of the trauma.
T h e m a n a g e m e n t of
chronically infected bone cavities remains a challenging
problem. Most surgeons
agree that the first step in
treatment is debridement
-
* Assistant Professor of Orthopeedic
Sugery F a d @ of Medicine, Caim
Untvem'ty
" Pmfessor of Orihopaedic Sugary
Faoulty of Medicine, Cairn Univeraity
mOrihopaedic Surgeon
Vol. (6) No. fIYJanrrnry 2002
with excision of all devitalized and infected bone and
soft tissue. Often, as a consequence of &is, a sizable cavity
will result. The best method
t o obliterate this cavity
(whether primary or secondary as a result of debridement) is still a matter of
controversy between orthopaedic surgeons since bone,
being a rigid structure does
not collapse to fill the defect
as soft tissue would.
MATERIALS & METHODS:
The material of this work
includes thirty patients with
chronic bone infection and
infected bone cavities in different skeletal sites. These
cases were recorded from
1994-1997. All patients were
mlected w i t h #tag@ I,
a,TVI
osteomyelitis according to
anatomical classificahon of
a d u l t osteomyelitis by
Cierny and Mader (1987)"'2',
with an infected bone cavity
situated in one of the long
bones involving not less than
30% of the diameter of the
bone affected. The ages range
from nine to sixty-five years.
Among the thirty patients,
twenty-seven were males
(90%) and only three patients were females (10%)
(Table 1,2).
Twenty-six patients had
chronic post traumatic osteomyetitis (86.7%) and four
patients had osteomyelitis of
haematogenous origin
(13.3%). The infected focus
was located in the tibia in
twenty cases (66.7%), in the
femur in eight cases (26.7%)
in the radius in only one case
(3.3%) in the thumb in only
one case (3.3%). In twentyfive patients (83.3%) there
were sinus discharging pus
and in five patients (16.7%)
no skuses could be detected
(Table 1,2).
The bacteria responsible
for the infection has been
isolated from tissue sampled
at the time of debridement
(Table 3). Whenever possible
an antibiotic regimen tailored
t o the sensitivities of all organisms isolated from biopsy
material wed (Table 4). Pa-
tienta were divided into two
groups; group I and group 11.
Surgical Mmwement of Imficted Bone Cavities
Ehab Negnr, MD ex a€
Vol. (61No. (1J(J m u w y 2002
Surgical Mc~agempntof Infeeted Bone Caulties
used for 6xation and in one
patient with infected bone
cavity of the femur no fixation was done and t r a c t i ~
was used for one month.
Table (3): Bacteriology of bone lnfectlon l,n thirty pdbnts
studles.
Group II:
(Table 21,(Fig. 22)
Group I:
(Table 11, (Fig. 1)
Half of the cases &ben
patients) were treated surgically by radical debridement
and obliteration of the dead
space by cancelIous bone
grafting. In fourteen cadlea
(93.3%)bone graR was taken
from the iliac bone and onlpin
one case (6.746) bone grafk
was taken &om the upper
end of the tibia. In thirteen
cases (86.7%) the procedure
waa performed in one stage
(debridement, bone grafting,
and ahp1e skin closure) following the techniqae of De
Oliveria and aseociates
-
(1071)'~'. In two aatients infection was exteaeivL, more
than one debridement was
needed and cancellous bone
grafting was performed afker
the infection kad been wntrolled. The procedure was
performed through three
s t a m following the technique of Papinean and ass&a b s (197~)'~'.
Re+prding the fixation, it
was performed by external
fkator in two patients, and
by plate and screws in five
patients. One case with infected bone cavity of the
thumb was fixed by R wire,
in six patients plaster waa
Table (4): Antiblottc used in the afudled groups.
-
The other fifteen eases
were treated by radical debridement and obliteration of
the d d space by local mnscle transposition. In five patients, exhrnal fixator was
used for fixation, in two
patients plaster of Paris
cmt, and in eight patients no
fixation was used.
In six patients (40%)with
infected bone cavities of the
middle third of the tibia, the
soleus rpnusele WES used for
local transposition flap. The
soleus muscle receives dominant vascular pedicles in its
proximal third from the popliteal, posterior tibial, and
peroneal arteries. The muscle
also receives minor pedides
distally that require division
when the muscle transposition is performed for middle
leg ro~erage'~'.
In three patients (20%) the
medial head of gastrocnemius
was used for obliteration of
bone aavities in the upper
third of the tibia. The blood
supply to the two heads comes
from the popliteal artery
a) 48-yew-old male with sinus on the &medial
rtspect of tbe Bt. Leg.
b) Bone eaviw &r debridment.
c) Caneellotw bane &ips ready for grafting.
d) Good akk healing.
e) Preoperathre *-fay.
0 Postoperativex-~ayaRer one stage debridement, hone graft& and pzinuuyskin closure.
g)Foliow-pp x-ray aRer 18 months.
$ur&al MarwgenperrS of hfeated Bone
Cayitiep
a) 42yeardIdmale with post tramtic Wecied earity on the upper JJ3 of the left tibia, preoperative =my.
b) Medid gastmcnemius muscle fIap.
c) Postoperetive, a
h primacy skirt grattlng.
dl w m,lmliw.
e)Follow-up x-ray aRer t w years.
~
Pan Arab J. Orth. Treuma
re&&'wm con&bred good if
it' was fear paints, fair if ic
was three poitits and failed if
it was %ii @PintsQrI&%Ili
twelve p-nb
in%&on was
exadi6ake4, lame cavitfes
were h a 1 d and' skin ,was
comp1pZ.d~healed, the red&:
in &esw twelve pathats
were swd @a%). In three
patients infaction was not
eradicM amd t& results in
these patie93.b were considered f
a (20% (Table 5 )
~n
fp*owp G fifteed wea
wejre
by radical deb&+
&emeatandloeal muscle Rap.
'The flexor digitprofundw.inusicle was m&
only
ip one as?tb obli&rate bone
mvi$ inthe lowerthird of the
The av&age f o l h - u p wrts
2p~ar8
(rangeof x2 moatha to
& ~-&&.&
i
d
ewe -atedl
..
fiats:
&wways:
Su~gicalManagement of Infected Bone Cavities
Table (S): ~RewEQof patient. t r e e d by open cancellous bow graft.
Table (6): Rssul* of patlents treated by local musde flap.
1
-
Cspes
Resobtton of lnfwlion
1
ErarHfated
ErdeEM
EradicIded
2
3
11
6
I
61
11
,,
It
12
f3
14
16
I
I
I
-
R6sM
Good
3
Good
Owd
3
3
w e
Good
I
Good
Good
I
9
3
Eratncatad
1
Owd
1
3
Emdlcsted
E~dlceted
Eladloated
Not eradicated
Eradlwted
I
Good
I
3
3
Eradlcsted
Elamcatad
Good
Good
Falkd
0
Gwd
3
3
Good
I
Gwd
11
I
Good
I
Good
Gwd
Owd
Failed
Owd
11
I
variables and by T tests for
failed patients osteomye- (4) In three patients (75%)
quantitative variables. Some
litis was due t.u polymiof the failed cases, the
important points of thia aminfected bone cavities
crobial infection (Table
lysis were:
were located in the dia7).
phyeis of the tibia and in
The mean duration for
one
patient the infected
hospital stay for group I (3)The meohaniw, of infecfocus was located in the
was 38.4 days and for
tion in all failed cases "4
diaphysie of the femur.
group Xi was 37.3 days.
patients" was traumatie,
Polymicrohial infection
may be due to lengthy (5) l k e e patients of the
was found in 23 patientdl
complieated treatment
failed cases were claeei(76.7961, in 12 patients
as a resalt of aseociated
fied as stage I (medullary
bone and mf&tissue in(40%) two organisms
osteompelitie), one pajuries
could be detected. In all
tient wae classified as
Ehob N-,
&W at 01
Table (7): Analyela of the results in relation to the number of organisms in Che studied groups.
Table (8): Anaiysib of the rertlltsfn rewon to Me stwe of infsction of the studled groups.
stage 111 (localized osteomyelitis) and no faiied
patient was from stage
N (diffuse osteomyelitis)
(Table 8).
I n group I good cases
represent 80% of the
oases (12 patients) and
in group II good cases
represent 93% of the
cases (14cases)
(7) After comparative an*sis of the results of #e
two groups and analysis
of all factors affecting
the results, i t was clear
that the P-values for all
analytic studies was
more than 0.05. This
means that there was no
significant difference between the two methode of
treatment.
DISCUSSION:
The purpose of this study
is to present the preliminary
findings after using eancelloua bone graft1.ag or loeal
muscle flap transposition to
treat thirty patients with
infected bone cavities, and bo
compare t b results betweep
techniques to establish the
best method to treat osteomyelitis with bone cavities.
These techniques baing either
to start primatily by debride
ment and obliteration of the
c a w or defect by bone grafting, or to start first by debridement and obliteration of
the bone cavity by loeal muscle flap to eradicate the infection, and the non-healed
osseoua defect can be treated
in a delayed manner by bone
graffing.
The use of bone grafts for
infected bone defects was
universally not accepted by
many authors since the beginning of the century after early
fsilutes. The accepted practice was ko wait fos one or
even two yema after the end
of suppuration before graRs
were used, taking into consideration the basic principle
of biology that bone t r a m
planks are unable to survive
in an infected cavity, and that
free bone grafts in an infected
environment may create new
sequestra and so propagate
the infection. Other authors
challenged this theory and
emphasized the great resistance of cancellous bone chips
to infection and the advantage of their use in reconstructive surgery of the
~keleton.'~'
Papineau 11979) popularized the technique of use of
c a n d o u s bone grafting in
the treatment of infected
bone cavities, his protocol of
treatment was divided into
three stages.'4' Papineau in
his study obtained satisfactory results in 66 out of 39
p a t i e n t s . Sachs e t al.,
(1988)(1°' using the same
staged Papineau technique
succeeded in eradication of
the infection in 12 out of 13
patients. Other authors also
report satisfactory results
usin
this techni-
que,d % 1 3 , 1 4 )
Still other authors be-
lievet3 &,at ~ @Potp@ea$
~e
prois ,.
mn&&q, seqairas. pzoIonged
hospitalization and that t h ~
problem of secbadaty S a c tion in open wound sh_auldbe
conaidered. M~Mallg(1993),
wggested bvo st&-5. teohniteohniteohni
pi; with &age £ ipcladin~
radicaI debridement o f all
aomprontired tigsues with
early psdafan. sf bed+%
v a d e z e d Bi)&'tiszluew e ?
+&-elfinaof the.
$p.&ce.-8
IX h&&s
layea auh&enonsboge gxrzfeh.Uskg fhh teobnigrre: he;
d
l
& BeIibt. kzh&ue, he
treated 8 T p.atieoi;a wiithh
. t h ~ o d cboae infectiion and
bone &feet$ ,mat aehfeved
;nfmtion free: bme union in
%patients :(~;l.9%&0~~
Qthx
atattrw ruggestad one stageoperation .with *
p
sut&g
@ftha w o a d whep
condition p&b.(g.
16),
are: Lxiwps bra&ii mm1.e..
&tvhsor
c m p i d n d s muscle, flexor &&tom
profundns muscle, brachioradialis
nrusde and prmator quadrates husele.
R&le and associates mcweded in eradication of X e e
tion in 38 out of 82 p a t i i ~ t s
with dvo&c osteomyelitis
treated with debridement,
parentral antimiembial therapy, and l o 4 muscle flap.'20J
AmciliX tragted 4 patients
with chronic osteamyelitis
and bone cavities with exten802 &igi.fo,xum t u r h - a o ~ n
musele flaps, tn all cgses
bone infection was eradicated 6th ~&oIogicdand
clinical evidence of bony W-
ion or cai+iy e r a d i . ~ t i ~ n . ' ~ ~
Pa{ba%akisreviewed the
results of twenty-four p.ah t s
dhrofiZCos@amyelitis treated with local inuscle
.flaps.In :d
patients no masde flap Was lo&, there.wss h b
major htraoperative or pest,op.aativ@
complications. Onlg
&e patient had spontaneous
r&div&on of :&eomyeli&i
&cg it had been ~ u q i ~ m t ? ~ ) '
Ankhony ek. al., (1992)reported 89% summa rate in 27
patients edith the singlestage
procedure ofdebxidementand
,5qmediate e w l e &
J
, OOVered 'withskin gra~ft.
In this studfr, fifteen patient~with &tonic oateomyeMis -with infected bone
+
miti&W@B @@td by lod
transposition musole flaps
a i k s mdh1 debad&&littc
ob1ihera-h .the born oaviky
Cgmq a).B e . we of this
kWq'bte &j.M t;ha s h pkie of flap elefpatkin and
& +&
+:fina d -1&%e
bone defeeta. In f o m patients .(93.3.%)infe@$on was
eradicated and only i n one
pal;ieilt musUscJe
flap f d b d to
control infection.
From
m d y we recoinmend t h e for treatment of
i.nfgctedb m e cavities:
The firat choice line of
treataient f o type
~ ~1 Cmedd1%) a& b e ?(localimd)
Il
infected bane cadti& laccording @ the aeatogic c b dfi'cakion of Gierqy and
&dm, 1987.(~@' is oblit,eration: of the @pity with a Iocal
muscle flap and beatment, of
bone 'loss or regictoal bone
cavities in a delayed manner
if needed either through the
margins oftbe flap or though
a completely new and dear
route. 'The dead space mu&
be anatomic.allylo@%edin ah
@ea that permits &axispa&
tion of the local muscle flap.
The second alternative is
the cancellous bune grafting
especially in areas where a
muscle flap can not be transposed or its transposition will
dismpt its vascular supply or
if the idectien is generalized
(Type IW or utssoebted with
non-united fracture. If the
surgeon is sure that all the
sclerosed, infected scar tissue
can be remumd and the bed of
the flap is wen vascula&ed,
the technique can be per-
hmed iB m~
B)-
o,hr-
wise t h e three stages of
1. Ui-y
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