BACKGROUND: This study presents the outcomes of the management of chronic osteomyelitis of the appendicular skeleton according to an integrated approach at a dedicated bone infection unit in South Africa. METHODS: A retrospective record review identified 80 patients who were treated between January 2016 and December 2018. RESULTS: Sixty patients (75%) presented with fracture-related infections, 17 patients (21%) developed chronic osteomyelitis following haematogenous spread and three (4%) from contiguous wounds. According to the Cierny and Mader classification, 21 patients presented with anatomical type I, 14 with type II, 24 with type III and 21 with type IV chronic osteomyelitis. Positive microbial cultures were obtained in 63 (79%) cases. Follow-up for the cohort ranged from 1 to 29 months, with a mean follow-up of 10.4 months. The overall complication rate for the cohort was 6% and included sterile drainage from the surgical site after management with bioactive glass (S53P4), refracture after hardware removal, and development of non-union. Five patients experienced recurrence after the initial procedure to eradicate infection, resulting in an overall resolution rate of 94%. CONCLUSION: Using single-stage surgeries and tailored dead space management strategies according to a comprehensive integrated approach developed in South Africa, results comparable to international literature can be achieved. Level of evidence: Level 4. Keywords: chronic osteomyelitis, dead space management, bioactive glass, Lautenbach technique

Introduction: Dead space management following intramedullary debridement and reaming can be challenging and several alternatives have been described. The main objective of this study was to investigate the clinical outcome and resolution rate in patients treated for fracture-related Cierny and Mader anatomical type 1 intramedullary chronic osteomyelitis by means of continuous irrigation (modified Lautenbach system) as dead space management following intramedullary reaming. Materials and Methods: A consecutive series of thirty patients with Cierny and Mader type 1 chronic osteomyelitis, treated between May 2016 and September 2019, were evaluated retrospectively. Patient history and clinical information, including imaging and laboratory results, were reviewed. Treatment procedures and antibiotic profiles were also recorded. Results: The initial cohort included 30 cases with 18 tibias, 11 femurs, and one humerus. Seven patients were excluded; three patients did not return for follow-up and four patients had <6 months of follow-up. Of the remaining 23 patients, 91% (21/23) achieved resolution of infection over a median follow-up period of 16 months (interquartile range [IQR] 7–21 months). Infecting organisms where isolated in 65% (15/23). The median duration of hospital stay was 6 days (IQR 4–7 days). Postoperative complications were noted in two cases and involved a tibial and femoral refracture, respectively. Both patients however achieved union without recurrence of infection following surgical intervention. Conclusion: Continuous irrigation is a cost-effective single-stage surgical option for dead space management during the treatment of intramedullary chronic osteomyelitis. It provides the advantage of instilling high dose intramedullary antibiotics and negates the need for a second surgical procedure while achieving similar outcomes than other dead space management techniques. Level of Evidence: IV, single-center retrospective study