One-stage debridement and bone transport versus first-stage debridement and second-stage bone transport for the management of lower limb post-traumatic osteomyelitis

Abstract

Background Treatment of lower limb post-traumatic osteomyelitis used to be a staged process, with radical debridement of bone and soft tissues at first stage, followed by a second-stage limb reconstruction operation to restore the limb integrity. Some studies recently reported that achieving infection eradication and limb reconstruction at single-stage seems to be an effective method for lower limb infection, but a comparative study remains lacking. This study aims to compare the results of radical debridement combined with a first/second-staged osteotomy and bone transport, for the management of lower limb post-traumatic osteomyelitis. Methods From January 2013 to June 2018, a total of 102 patients with lower limb post-traumatic osteomyelitis met the criteria were included for analysis, in which 70 patients received one-stage debridement, antibiotic-loaded implantation, metaphysis osteotomy and bone transport were named as one-stage group, while 32 patients with first-stage debridement and antibiotic-loaded calcium sulfate implantation, second-stage osteotomy and bone transport were devised as two-stage group. The outcomes of hospitalization (hospital stay, costs of treatment, surgical time, antibiotic usage) and follow-up (infection-free, treatment failure, infection recurrence, external fixation index (EFI) and docking site union) between the two groups were retrospectively compared. Results For outcomes of hospitalization, patients in the one-stage group had batter results on hospital stay (18.2 days versus 28.9 days, P ​< ​0.05), surgical time (164.8 ​min versus 257.4 ​min, P ​< ​0.05), cost of treatment (¥101726.1 versus ¥126718.8, P ​< ​0.05) and the course of antibiotic usage (10.3 days versus 12.0 days, P ​< ​0.05). During the follow-up, 87.1% (61/70) patients in the one-stage group compared to 93.8% (30/32) patients in the two-stage group achieved infection-free (P ​> ​0.05) without any additional debridement operation. 94.3% (66/70) patients in the one-stage group earned wound healing after the operation, comparing to 96.9% (31/32) patients healed in the two-stage group (P ​> ​0.05). Uncontrolled infection was observed on 4 (5.7%) patients in the one-stage group and 1 (3.1%) patients in the two-stage group (P ​> ​0.05), with a result of three achieved infection free in the one-stage group and one patient suffered from amputation in each group respectively. 5 (7.2%) patients in the one-stage group and 1 (3.2%) patient in the two-stage group encountered with infection recurrence (P ​> ​0.05) and were well-managed with re-debridement and antibiotics usage. Significance was not found between two groups on EFI (74.8 days/cm versus 69.0 days/cm, P ​> ​0.05) and docking site nonunion rate (14.5% versus 18.9%, P ​> ​0.05), indicating that bone transport in different stages played a less essential role on bone generation process. The other complications, such as prolonged aseptic drainage [24.3% (17/70) versus 21.9% (7/32)], re-fractur...

Comment on “Bioactive glass S53P4 vs. autologous bone graft for filling defects in patients with chronic osteomyelitis and infected non-unions – a single center experience” by Steinhausen et al. (2021)

“…This problem was identified in the 1970s and prompted the use of antibioticloaded PMMA beads by Klemm and Buchholz (Klemm, 1993). There is now encouraging evidence around the use of single-stage surgery, facilitated by modern local antibiotic carriers, with few complications and high infection eradication rates, even in the most complex cases (Masrouha et al, 2018;McNally et al, 2016;Ferguson et al, 2014;Lam et al, 2019;Pincher et al, 2019;Lorentzen et al, 2020;Drampalos et al, 2018;Jiang et al, 2020;Pesch et al, 2020;Hutting et al, 2021;Mifsud et al, 2020;Zhou et al, 2021).…”

Debridement-Reconstruction-Docking Management System Versus Ilizarov Technique for Lower-Extremity Osteomyelitis

“…Surprisingly, the DRD group had lower EFI (49.7 days/cm) and shorter EFT (380.3 days) than the Ilizarov group (56.6 days/cm and 431.7 days). In previous studies, the mean EFI ranged from 0.7 months/cm to 74.8 days/cm 34,36,37,50 . The use of a multiple-osteotomy (multifocal) technique could shorten the distraction period, and a low EFI is often associated with improvement in postoperative functional recovery 36,50 .…”

“…However, this technique has several drawbacks: long operative time, a high rate of unplanned operations, and recurrent infections. Therefore, many modified bone-transport techniques with satisfactory outcomes have been described [34][35][36][37][38][39][40][41] .…”

Does the Use of Local Antibiotics Affect Clinical Outcome of Patients with Fracture-Related Infection?

“…McNally et al reported on the application of an absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite ceramic and found a recurrence rate of only 6% in 100 patients treated with a single-stage operation for chronic osteomyelitis (including 71 FRIs) [ 19 ]. Zhou et al found a recurrence rate of 6% in 100 patients treated for posttraumatic osteomyelitis with an antibiotic-loaded calcium sulfate vehicle [ 41 ]. Furthermore, a review by Pesch et al evaluated the treatment of FRI/osteomyelitis cases with a ceramic bone substitute in eight studies, including their own patient cohort and found a mean recurrence rate of 8.3% (range: 0–14.3%) [ 42 ].…”