Cierny-Mader Type III chronic osteomyelitis: the results of patients treated with debridement, irrigation, vancomycin beads and systemic antibiotics

Abstract

Cierny-Mader (C-M) Type III osteomyelitis is defined as a localised lesion with both medullary and cortical involvement that is stable mechanically after debridement. The treatment of C-M Type III osteomyelitisis is difficult and requires a precise protocol to achieve a disease-free longterm follow-up. We report here the results of our study on 26 patients (19 men and 7 women; average age: 34.7 years) with C-M Type III osteomylelitis who were treated with radical debridement, irrigation, vancomycin-impregnated custom-made beads and culture-specific systemic antibiotics. Those patients with metaphyseal involvement were treated with deroofing of the cortex and debridement by means of a "trough" (16 patients); those with diaphyseal involvement were treated with both intramedullary reaming and debridement from a trough (ten patients). Antibiotic cement rods were used as an additional therapy in five patients with diaphyseal involvement. Recurrence developed in three patients and was attributed to inadequate debridement; all three patients were treated again in the same manner with success. The mean follow-up is currently 3.6 years (range: 2-6 years). All of the patients have normal clinical, radiographic and laboratory parameters, and all are ambulatory and have returned to their pretreatment level of activity or better. We conclude that C-M Type III chronic osteomyelitis can be safely treated with this protocol.Résumé L'ostéomyélite de type III Cierny-Mader (C-M) peut se définir comme une localisation de lésions localisées à la fois sur la médullaire et la corticale et qui reste stable sur le plan mécanique après mise à plat. Son traitement est difficile et demande un protocole précis. Pour cette étude, nous avons suivi les résultats de 26 patients (19 hommes et 7 femmes) dont l'âge moyen était de 34.7 ans, traités par mise à plat, irrigation, et billes de vancomycine. Dans les lésions métaphysaires, la mise à plat est réalisée à travers une fenêtre (16 patients), dans les lésions diaphysaires on réalise à la fois un alésage des lésions et une mise à plat par la fenêtre (10 patients). En addition aux billes de vancomycine, un ciment aux antibiotiques a été utilisé chez 5 patients avec lésions diaphysaires. Trois patients ont présenté une récidive secondaire à une mise à plat insuffisante. Tous ces patients ont été à nouveau traités de la même manière et avec succès. Le suivi moyen a été de 3.6 ans (2 à 6 ans) et aucun patient n'a présenté d'anomalie post-opératoire des différents paramètres clinique, radiographique et biologique. Les patients peuvent marcher et ont retrouvé leur activité d'avant le traitement. L'ostéomyé-lite chronique de type III de CM peut être traitée avec succès selon ce protocole.

Comparison of various surgical methods in the treatment of implant-related infection

“…This study revealed that antibiotic embedded autogenous bone is not superior to débridement and parenteral antibiotic administration in implant-related infection. At this point we agree with Kinik et al that the quality of surgical débridement is the most important parameter for the success of treatment of bone infections [10].…”

“…This result correlates well with recent literature. Many in vitro and in vivo studies have suggested that antibiotic-impregnated PMMA beads are very effective against eradication of infection [7][8][9][10][11]. However, antibiotic-impregnated PMMA beads have certain disadvantages.…”

“…S. aureus is also capable of producing a protective exopolysaccharide biofilm which plays a major role in infection especially with respect to treatment, even though its role in the development of infection is weak [5]. The use of local antibiotic delivery systems, especially antibiotic-loaded bone cement, is a well established procedure in the treatment of musculoskeletal infections [6][7][8][9][10][11]. On the other hand, antibiotic-loaded cement beads have several disadvantages including the need for a second operation to remove the cement beads and the possibility of local immune compromise [8,9].…”

Vancomycin-loaded nano-hydroxyapatite pellets to treat MRSA-induced chronic osteomyelitis with bone defect in rabbits

“…Other studies have focused on the effect of administering vancomycin systemically or using a local drug carrier method [2]. Moreover, studies show that MRSA is sensitive to high local concentrations of vancomycin, and the high success rate that was achieved is encouraging for the clinical use of vancomycin for MRSA-induced bone infections.…”

“…At present, the treatment of osteomyelitis primarily involves the surgical debridement of necrotic tissue, irrigation with an antiseptic solution, and the application of a course of systemic antibiotics for 6 weeks [1]. Vancomycin is recognized as an effective antibiotic against MRSA [2]. However, large doses of vancomycin do not penetrate efficiently into local sites due to the development of malformations secondary to the infection and may be associated with nephrotoxicity, ototoxicity, gastrointestinal side effects, increased costs, and low patient compliance.…”