Aims. Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. Methods. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy. Results. A total of 3,303 records were screened, of which 99 studies were included. Most studies were case series (77/99; 78%) and assessed one method of reconstruction (68/99; 69%). A total of 511 outcomes were reported, which were grouped into 58 distinct outcomes. Overall, 143/511 of all outcomes (28%) were provided with a clear, in-text definition, and 231 outcomes (45%) had details reported of how and when they were measured. The most commonly reported outcome was ‘recurrence of osteomyelitis’ (62; 12%). The single-most patient-reported outcome measure was ‘pain’. Conclusion. This study has highlighted significant inconsistencies in the defining, reporting, and measuring of outcomes across studies investigating surgical management for chronic osteomyelitis of the lower limb in adults. Future studies should clearly report complete details of how outcomes are defined and measured, including timing. The development of a standardized core outcome set would be of significant benefit in order to allow evidence synthesis and comparison across studies. Cite this article: Bone Jt Open 2023;4(3):146–157

Aims. The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit. Methods. We analyzed the retrospective record review from 2014 to 2020 of patients with long bone COM. All were managed by multidisciplinary infection team (MDT) protocol. Adequate debridement was employed for all cases, and no case of wide resection was included. Results. A total of 53 patients (54 bones) with median age of 45.5 years (interquartile range 31 to 55) and mean follow-up of 29 months (12 to 59) were included. In all, ten bones were Cierny-Mader type I, 39 were type III, and five were type IV. All patients were treated with single-staged management, except for one (planned two-stage stabilization). Positive microbial cultures grew in 75%. Overall, 46 cases (85%) had resolution of COM after index procedure, and 49 (90.7%) had resolution on last follow-up. Four patients (7%) underwent second surgical procedure and six patients (11%) had complications. Conclusion. We challenge the need for wide tumour-like resection in all cases of COM. Through detailed preoperative evaluation and planning with MDT approach, adequate debridement and local delivery of high concentration of antibiotic appears to provide comparable outcomes versus radical debridement. Cite this article: Bone Jt Open 2023;4(8):643–651

Aims. Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. Methods. A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4). Results. At final follow-up, six patients (six bones) had recurrent infection; thus 94% were infection-free. Three infections recurred in the first year, two in the second year, and one 4.5 years postoperatively. Recurrence was not significantly related to the physiological class of the patient (1/20 Class A (5%) vs 5/80 Class B (6.25%); p = 0.833), nor was it significantly related to the aetiology of the infection, the organisms which were cultured or the presence of nonunion before surgery (1/10 with nonunion (10%) vs 5/90 without nonunion (5.6%); p = 0.570). Organisms with intermediate or high-grade resistance to gentamicin were significantly more likely in polymicrobial infections (9/21; 42.8%) compared with monobacterial osteomyelitis (7/79 (8.9%); p < 0.001). However, recurrence was not significantly more frequent when a resistant organism was present (1/16 for resistant cases (6.25%) vs 5/84 in those with a microbiologically sensitive infection (5.95%); p = 0.958). Conclusion. We found that a single-stage protocol, including the use of a high-delivery local antibiotic ceramic carrier, was effective over a period of several years. The method can be used in a wide range of patients, including those with significant comorbidities and an infected nonunion. Cite this article: Bone Joint J 2022;104-B(9):1095–1100

We studied prospectively a consecutive series of 50 patients with chronic osteomyelitis. Patients were allocated to the following treatment groups: 1) wide resection, with a clearance margin of 5 mm or more; 2) marginal resection, with a clearance margin of less than 5 mm; and 3) intralesional biopsy, with debulking of the infected area. All patients had a course of antibiotics, intravenously for six weeks followed by orally for a further six weeks. No patients in group 1 had recurrence. In patients treated by marginal resection (group 2), 8 of 29 (28%) had recurrence. All patients who had debulking had a recurrence within one year of surgery. We performed a survival analysis to determine the time of the recurrence of infection. In group 2 there was a higher rate of recurrence in type-B hosts (p < 0.05); no type-A hosts had recurrence. This information is of use in planning surgery for chronic osteomyelitis

The treatment of chronic osteomyelitis requires both appropriate surgical and antibiotic management. Prolonged intravenous antibiotic therapy followed by oral therapy is widely utilised. Despite this, the long-term recurrence rate is approximately 25%. The aim of this cohort study was to examine the effectiveness of marginal surgical resection in combination with local application of antibiotics (Collatamp G - gentamicin in a collagen fleece). Post-operatively this was followed by a short course of intravenous antibiotics, then oral antibiotics, to 6 weeks in total. A cohort of 50 patients from a 10-year period, 2000 to 2010, with chronic osteomyelitis was identified. Most were male (n= 35, 70%) and the average age is 40.9 years (SD 15.9). The mean follow-up duration was 3.2 years (SD 1.8). The average length of admission was 9.8 days (SD 11.4). 6 patients (12%) suffered recurrence of infection requiring further treatment. We used the Cierny and Mader classification to stratify the patients further. There were 24 (48%) ‘A’ hosts and 26 (52%) ‘B’ hosts. ‘A’ hosts had a shorter duration of admission (7.1 days) than ‘B’ hosts (12.3 days). There was no significant difference between recurrence rates of ‘A’ and ‘B’ hosts. The available pre-operative C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels did not predict disease recurrence. Overall, the disease-free probability for this cohort was 0.80. A similar cohort treated with prolonged systemic and oral antibiotics reported by Simpson and colleagues (JBJS Br 2001) had a disease-free probability at 0.68. Local administration of gentamicin in a collagen fleece leads to improved disease-free probability when compared with prolonged systemic antibiotic treatment. We believe this is a useful component in the management of chronic osteomyelitis

We report our experience using a biodegradable calcium sulphate antibiotic carrier containing tobramycin in the surgical management of patients with chronic osteomyelitis. The patients were reviewed to determine the rate of recurrent infection, the filling of bony defects, and any problems with wound healing. A total of 193 patients (195 cases) with a mean age of 46.1 years (16.1 to 82.0) underwent surgery. According to the Cierny–Mader classification of osteomyelitis there were 12 type I, 1 type II, 144 type III and 38 type IV cases. The mean follow-up was 3.7 years (1.3 to 7.1) with recurrent infection occurring in 18 cases (9.2%) at a mean of 10.3 months post-operatively (1 to 25.0). After further treatment the infection resolved in 191 cases (97.9%). Prolonged wound ooze (longer than two weeks post-operatively) occurred in 30 cases (15.4%) in which there were no recurrent infection. Radiographic assessment at final follow-up showed no filling of the defect with bone in 67 (36.6%), partial filling in 108 (59.0%) and complete filling in eight (4.4%). A fracture occurred in nine (4.6%) of the treated osteomyelitic segments at a mean of 1.9 years (0.4 to 4.9) after operation. We conclude that Osteoset T is helpful in the management of patients with chronic osteomyelitis, but the filling of the defect in bone is variable. Prolonged wound ooze is usually self-limiting and not associated with recurrent infection. Cite this article: Bone Joint J 2014; 96-B:829–36

Aims. Treatment of chronic osteomyelitis (COM) for young patients remains a challenge. Large bone deficiencies secondary to COM can be treated using induced membrane technique (IMT). However, it is unclear which type of bone graft is optimal. The goal of the study was to determine the clinical effectiveness of bone marrow concentrator modified allograft (BMCA) versus bone marrow aspirate mixed allograft (BMAA) for children with COM of long bones. Methods. Between January 2013 and December 2017, 26 young patients with COM were enrolled. Different bone grafts were applied to repair bone defects secondary to IMT procedure for infection eradication. Group BMCA was administered BMCA while Group BMAA was given BMAA. The results of this case-control study were retrospectively analyzed. Results. Patient infection in both groups was eradicated after IMT surgery. As for reconstruction surgery, no substantial changes in the operative period (p = 0.852), intraoperative blood loss (p = 0.573), or length of hospital stay (p = 0.362) were found between the two groups. All patients were monitored for 12 to 60 months. The median time to bone healing was 4.0 months (interquartile range (IQR) 3.0 to 5.0; range 3 to 7) and 5.0 months (IQR 4.0 to 7.0; range 3 to 10) in Groups BMCA and BMAA, respectively. The time to heal in Group BMCA versus Group BMAA was substantially lower (p = 0.024). Conclusion. IMT with BMCA or BMAA may attain healing in large bone defects secondary to COM in children. The bone healing time was significantly shorter for BMCA, indicating that this could be considered as a new strategy for bone defect after COM treatment. Cite this article: Bone Joint Res 2021;10(1):31–40

An unusual form of chronic osteomyelitis in children is described. Three children presented with clinical signs of acute infection and radiographs revealed a pre-existing destructive bone lesion. Exploration of the lesions did not release pus, and cultures for pathogens were negative. The lesions healed but the symptoms returned intermittently over many years with the development of sclerosis and disturbance of bone growth. The lesions did not respond to antibiotics or operative treatment. All the patients were fully investigated and although the erythrocyte sedimentation rate was increased the white blood count was seldom abnormal. There were no neurological abnormalities. Two of the three cases required an osteotomy to correct malalignment. A comparison is made between the findings in these three patients with similar cases reported recently and possible causes are discussed

Twenty-nine bone defects caused by chronic osteomyelitis have been treated by radical excision of necrotic bone followed by packing the cavities with cancellous homografts held in position by a fibrin sealant. At follow-up three years after operation all except one had healed, though one case had needed a repeat operation. Good incorporation and remodelling of the grafts was observed even when the osseous bed was severely sclerosed

We describe our medium-term results for the management of chronic osteomyelitis in long bones using the Lautenbach procedure. Seventeen consecutive patients (18 segments) were treated prospectively. Osteomyelitis had been present for a mean of 12.5 years (1 to 31). A discharging sinus was present in all cases. Nine of the associated fractures had failed to unite and a further two needed correction of malunion. The Lautenbach procedure involves debridement, intramedullary reaming and the insertion of double-lumen tubes to establish both a local antibiotic delivery system and cavity analysis for volume and culture. The end-point of treatment is when the irrigate produces three consecutive clear cultures with improvement in the blood indices and obliteration of the cavity volume. The mean length of treatment was 27 days (14 to 48). One patient required a second procedure and another local debridement for recurrence of the infection. Two patients had Papineau grafting because of cortical defects. All the patients have subsequently remained free from infection. After treatment 11 had internal or external fixation for treatment of non- or malunion or a joint replacement, including two successful limb-lengthening procedures. Two further patients, while cured of infection, underwent amputation for other reasons. The mean length of follow-up was 75 months. This procedure allows precise control over the osteomyelitis until objective assessment suggests that infection has been cleared and the cavity obliterated. We recommend this procedure for long-standing complex cases in which basic techniques using debridement and antibiotics have failed

The treatment of chronic osteomyelitis often includes surgical debridement and filling the resultant void with antibiotic-loaded polymethylmethacrylate cement, bone grafts or bone substitutes. Recently, the use of bioactive glass to treat bone defects in infections has been reported in a limited series of patients. However, no direct comparison between this biomaterial and antibiotic-loaded bone substitute has been performed. . In this retrospective study, we compared the safety and efficacy of surgical debridement and local application of the bioactive glass S53P4 in a series of 27 patients affected by chronic osteomyelitis of the long bones (Group A) with two other series, treated respectively with an antibiotic-loaded hydroxyapatite and calcium sulphate compound (Group B; n = 27) or a mixture of tricalcium phosphate and an antibiotic-loaded demineralised bone matrix (Group C; n = 22). Systemic antibiotics were also used in all groups. After comparable periods of follow-up, the control of infection was similar in the three groups. In particular, 25 out of 27 (92.6%) patients of Group A, 24 out of 27 (88.9%) in Group B and 19 out of 22 (86.3%) in Group C showed no infection recurrence at means of 21.8 (12 to 36), 22.1 (12 to 36) and 21.5 (12 to 36) months follow-up, respectively, while Group A showed a reduced wound complication rate. Our results show that patients treated with a bioactive glass without local antibiotics achieved similar eradication of infection and less drainage than those treated with two different antibiotic-loaded calcium-based bone substitutes. Cite this article: Bone Joint J 2014; 96-B:845–50

We treated 37 patients with chronic osteomyelitis of the tibia (25), femur (9), radius (2) and humerus (1) by a two-stage technique, comprising radical debridement of all infected bone and soft tissue with the provision of soft-tissue cover, and delayed autogenous bone grafting when necessary. All patients were reviewed at an average of 49 months (12 to 121). Infection-free bone union was achieved in 34. No patient required amputation. Wide excision of all compromised tissue and the closure of bone within a healthy vascularised soft-tissue envelope are essential if infection is to be eradicated. The combined assessment and management of such patients by an orthopaedic surgeon and a plastic surgeon are advocated

We treated 11 patients with chronic osteomyelitis of the tibia or the foot by local excision and transfer of a peroneal myocutaneous island flap. This flap, pedicled proximally or distally on the peroneal artery and veins, provides viable muscle to fill the dead space in bone and skin to close the defect. Ten patients reviewed more than three years after operation were all free of drainage with no clinical or radiographic evidence of recurrence

A case is reported four years after successful total replacement of the left humerus for chronic osteomyelitis of six years' duration, with an axillary sinus that had persisted despite repeated operations and more distally a pathological fracture that had failed to united after bone grafting. The disability was such that the patient had requested amputation, but he returned to his previous work as a driver six months after the total replacement and there has been no recurrence of infection

We present a retrospective review of 167 patients aged 18 years and under who were treated for chronic haematogenous osteomyelitis at our elective orthopaedic hospital in Malawi over a period of four years. The median age at presentation was eight years (1 to 18). There were 239 hospital admissions for treatment during the period of the study. In 117 patients one admission was necessary, in 35 two, and in 15 more than two. A surgical strategy of infection control followed by reconstruction and stabilisation was employed, based on the Beit CURE radiological classification of chronic haematogenous osteomyelitis as a guide to treatment. At a minimum follow-up of one year after the end of the study none of the patients had returned to our hospital with recurrent infection. A total of 350 operations were performed on the 167 patients. This represented 6.7% of all children’s operations performed in our hospital during this period. One operation only was required in 110 patients and none required more than three. Below-knee amputation was performed in two patients with chronic calcaneal osteomyelitis as the best surgical option for function. The most common organism cultured from operative specimens was Staphylococcus aureus, and the tibia was the bone most commonly affected. Polyostotic osteomyelitis occurred in four patients. We believe this is the largest reported series of patients treated for chronic haematogenous osteomyelitis

Aims. Dead-space management, following dead bone resection, is an important element of successful chronic osteomyelitis treatment. This study compared two different biodegradable antibiotic carriers used for dead-space management, and reviewed clinical and radiological outcomes. All cases underwent single-stage surgery and had a minimum one-year follow-up. Methods. A total of 179 patients received preformed calcium sulphate pellets containing 4% tobramycin (Group OT), and 180 patients had an injectable calcium sulphate/nanocrystalline hydroxyapatite ceramic containing gentamicin (Group CG). Outcome measures were infection recurrence, wound leakage, and subsequent fracture involving the treated segment. Bone-void filling was assessed radiologically at a minimum of six months post-surgery. Results. The median follow-up was 4.6 years (interquartile range (IQR) 3.2 to 5.4; range 1.3 to 10.5) in Group OT compared to 4.9 years (IQR 2.1 to 6.0; range 1.0 to 8.3) in Group CG. The groups had similar defect sizes following excision (both mean 10.9 cm. 3. (1 to 30)). Infection recurrence was higher in Group OT (20/179 (11.2%) vs 8/180 (4.4%), p = 0.019) than Group CG, as was early wound leakage (33/179 (18.4%) vs 18/180 (10.0%), p = 0.024) and subsequent fracture (11/179 (6.1%) vs 1.7% (3/180), p = 0.032). Group OT cases had an odds ratio 2.9-times higher of developing any one of these complications, compared to Group CG (95% confidence interval 1.74 to 4.81, p < 0.001). The mean bone-void healing in Group CG was better than in Group OT, in those with ≥ six-month radiological follow-up (73.9% vs 40.0%, p < 0.001). Conclusion. Local antibiotic carrier choice affects outcome in chronic osteomyelitis surgery. A biphasic injectable carrier with a slower dissolution time was associated with better radiological and clinical outcomes compared to a preformed calcium sulphate pellet carrier. Cite this article: Bone Joint Res 2023;12(7):412–422

Nonunion of the humerus with bone loss and shortening due to osteomyelitis is rare but difficult to treat. We describe our experience with a callus distraction technique using a monolateral external fixator for the treatment of this condition.

Between October 1994 and January 2004, 11 patients were treated. There were seven males and four females, with a mean age of 14 years (10 to 17). The mean bone loss was 1.9 cm (1 to 2.7) and the mean length discrepancy in the upper limb was 5.6 cm (3.5 to 8.0).

The mean follow-up was for 106 months (54 to 166). The mean external fixation index was 34.8 days/cm (29.8 to 40.5). The mean lengthening was 9.5 cm (5.5 to 13.4). There were seven excellent results, three good and one poor. There were nine excellent functional results and two good.

The treatment of humeral nonunion with bone loss and shortening due to osteomyelitis by callus distraction is a safe and effective means of improving function and cosmesis.

From a global point of view, chronic haematogenous osteomyelitis in children remains a major cause of musculoskeletal morbidity. We have reviewed the literature with the aim of estimating the scale of the problem and summarising the existing research, including that from our institution. We have highlighted areas where well-conducted research might improve our understanding of this condition and its treatment

We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty

Between November 1994 and June 1999, 35 patients referred to our Problem Fracture Service with chronic diaphyseal osteomyelitis were treated using a closed double-lumen suction irrigation system after reaming and arthroscopic debridement of the intramedullary canal. This is a modified system based on that of Lautenbach. Between June and July 2007 the patients were reviewed by postal questionnaire and telephone and from the case notes. At a mean follow-up of 101 months (2 to 150), 26 had no evidence of recurrence and four had died from unrelated causes with no evidence of recurrent infection. One had been lost to follow-up at two months and was therefore excluded. Four had persisting problems with sinus discharge and one had his limb amputated for recurrent metaplastic change. Our results represent a clearance of infection of 85.3% (29 of 34), with recurrence in 11.8% (4 of 34). They are comparable to the results of the Papineau and Belfast techniques, but with considerably less surgical insult to the patient

Introduction. The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis. Methods. A retrospective review of cases treated consecutively from 2006 to 2010 was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36). Results. There were 31 patients (22 male, 9 female). The mean age was 47 years (20–67). Twenty-five cases were post-surgery (6 open fractures) and 6 were haematogenous in origin. The median duration of osteomyelitis was 1.6yrs. The bones affected were 42% femur, 45% tibia, 3% radius and 10% humerus. 11 cases had diffuse as well as intramedullary involvement. 9 cases underwent segment resection and bone transport. We identified Staph. Aureus in 16 and Coag. Neg. Staph. in 6 cases. The median follow-up was 1.7 years (0.5–5.6). The median scores attained were: AOFAS-78, DASH-32, IOWA-71, Oxford-32. There were two recurrences. Discussion. Dead space management of intramedullary infections is difficult. We describe a method for delivery of local antibiotics and provide early evidence to its efficacy. The treatment success to date is 93%. Conclusion. Bioabsorbable carriers of antibiotics are efficacious adjuncts to surgical treatment of intramedullary osteomyelitis

An unusual case of bilateral chronic sclerosing osteomyelitis of the clavicles is reported. A culture of resistant Staphylococcus aureus was obtained. Curettage of the lesions resulted in healing and symptomatic relief. There has been no recurrence on follow-up at one year

Cite this article: Bone Joint Res 2024;13(3):124–126.

We describe 22 patients who presented between the ages of 4 and 14 years with gradual onset of malaise and pain at the sites of multiple bone lesions. The symptoms from the bone lesions were sometimes sequential in onset and often relapsing. The radiological findings were typical of osteomyelitis. Radioisotope bone scans identified some clinically silent lesions. Bone biopsies were performed in 20 patients and the changes of osteomyelitis were seen in 17; microbiological culture was positive in only one. Seven patients had polyarthritis, two had palmoplantar pustulosis and one had psoriasis. Some symptomatic relief was obtained with anti-inflammatory agents and, to a less extent, with antibiotics. No patient had primary immunodeficiency. The mean duration of symptoms from the bone lesions was two years (1 to 4). When arthritis was present the joint symptoms lasted considerably longer (mean 7 years; range 4 to 10). The long-term prognosis was generally good. There was no evidence of altered bone growth or abnormal joint development. One patient developed a progressive kyphosis requiring fusion, but no other surgical intervention was necessary.

Fracture related infection, in particular chronic osteomyelitis, requires complex management plans. Meta analyses and systematic reviews have not found a gold standard of treatment for this disease. In 2017 an alternative treatment protocol was undertaken in our institution; whereby staged surgery with the use of cheaply manufactured tailored antibiotic cement rods was used in the treatment of chronic osteomyelitis, secondary to traumatic long bone fractures. Short term outcomes for this protocol demonstrated a 75.7% microbiological resolution to a negative culture and a good clinical outcome of 84.2% overall was demonstrated in terms of sinus resolution, skin changes, pain and function. Our aim now was to assess the long term outcomes of this treatment strategy. A cross-sectional study of patients who had previously undergone the set treatment protocol was performed. Patient satisfaction, effects on activities of daily living, return to work and clinical improvement at 5 years following the intervention were assessed using a patient questionnaire and the validated AAOS lower limb score. The average AAOS lower limb score was 88 which was en par to other similar studies. 80% of patients had returned to some form of work. Ongoing mild pain was a persistent problem for 50% of the patients however 98% of the patients were overall satisfied with the treatment satisfaction at 5 years. Only 1 patient required further treatment. 8 patients could not be located for follow up. Chronic osteomyelitis remains a complex disease to treat. This treatment protocol demonstrates favourable microbiological, serological and clinical short term outcomes and favourable patient satisfaction and functional long term outcomes at 5 years. Our study highlights antibiotic targeted cement rods as a feasible treatment option in managing chronic osteomyelitis

Introduction. Open tibial fractures (OTF) rank first among lower limb fractures in sub-Saharan Africa and bone infection remains the main challenge. The aim of this study was to identify the factors associated with chronic bone infection after OTF in a limited-resource setting. Methods. Patients aged 18 years and older, who underwent OTF treatment in a tertiary care hospital during the period from December 2015 to December 2020 were included in this retrospective study. Patients were contacted via phone calls and invited for a final clinical and radiological evaluation. Patients who met diagnostic criteria of chronic osteomyelitis were identified. Logistic regression was used to determine the predictive factors of OTF related chronic osteomyelitis. Results. With a mean follow-up period of 29.5±16.6 months, 33 patients out of 105 (31.4%) presented with chronic osteomyelitis. We found that time to first debridement within 6 hours (OR=0.18, 95% CI: 0.05 – 0.75, p=0.018) and severity of OTF according to Gustilo-Anderson classification (OR=2.06, 95% CI:1.34 – 3.16, p=0.001) were the independent predictive factors of chronic bone infection. Neither age, gender, socio-economic level, polytrauma, HIV status, diabetes mellitus, time to definitive surgery, were associated with chronic osteomyelitis. Conclusion. The rate of chronic bone infections after OTF is still high in the sub-Saharan African context. In addition to the overall improvement in the management of open leg fractures in those settings, emphasis should be placed on very early initial debridement to reduce the burden of these infections. Keys words. open tibial fractures, chronic bone infection, predictive factors

Materials & Methods. Chronic osteomyelitis is a complex and challenging condition the successful treatment of which requires a specialist multidisciplinary approach. Prior to tertiary referral to a specialist Orthoplastic Unit, patients often receive multiple courses of antibiotics, in usually unsuccessful attempts, to eradicate infection. This often results in the development of chronic polymicrobial infection. We reviewed the intra-operative cultures of patients treated in our Orthoplastic unit over a 9-year period from 2012–2021 to determine the spectrum of polymicrobial cultures and the relationship to pre-operative cultures. Results. We reviewed the electronic care records and laboratory results of all patients referred to or directly admitted to our unit with a diagnosis of chronic osteomyelitis between 2012–2021. We checked all culture results, antibiotic sensitivities and prescription for treatment. We also checked for any recurrence of infection within 1 year. 60 patients were treated over the 9-year period. 9 upper and 51 lower limbs. The most common referral sources were from the surgical specialties of Trauma & Orthopaedics and Plastic Surgery (62%) while an equal amount came from the Emergency Department and other inpatient medical teams, each making up 15%. A small cohort (8%) developed the infection while still being followed up post fixation. Aetiology of Infection were post fracture fixation 41 (68%), spontaneous osteomyelitis 10 (17%), soft tissue infection 4 (7%). The remaining 5 patients (8%) had a combination failed arthroplasty, arthrodesis and chronic infection from ring sequestrum. 58 patients (97%) had positive cultures with 26 being polymicrobial. 12 cultures were gram negative (G-ve), 11 G+ve 12, 4 anaerobic and 1 Fungal. In 24 patients (40%) the pre-operative cultures and antibiotic sensitivities did not correspond to the intra-operative cultures and sensitivities. 55 patients (92%) required dual or triple therapy with 8% requiring further debridement and extended therapy. 2 (3%) patients had failed treatment requiring amputation. Conclusions. Chronic osteomyelitis is a complex and challenging condition the successful treatment of which requires early referral to a specialist Orthoplastic unit. Less than half of organisms cultured pre-operatively reflect the causative organisms cultured intra-operatively with 52% of these infections being polymicrobial. After initial treatment, 8% of patients will require a further combination of extended antibiotic therapy and surgery to eradicate infection

Aim. The localization of sequestrum in chronic osteomyelitis (COM) is crucial in preoperative planning. The identification of sequestrum on plain X-ray could be difficult. CT and MRI were reported to show the sequestrum. We aimed to analyze the sequestrum characteristics on 18F-FDG-PET-CT images. Methods. A prospective study included all patients diagnosed with long-bone chronic osteomyelitis. All patients had preoperative 18F-FDG-PET-CT. Images were analyzed using RadiAnt DICOM Viewer. Axial cuts were used to measure the Standard Uptake Ratio (SUV)max in the Region of Interest (ROI) in the sequestrum, the surrounding area, and the normal bone in the same cut. Surgical debridement was done as standard; samples were taken for microbiology and histopathology, and the intraoperative finding was documented. Results. Nineteen patients (17 males/2 females) were operated on in one center between October/2021 and Jan/2023 at a mean age of 32±18. There were 10 tibias, 7 femurs, one ulna, and one fibula. Ten had postoperative COM, six open fractures, and three hematogenous OM. They all showed sequestrum on PET-CT; the dead bone appeared void, surrounded by a halo of increased uptake. There was a trend of lower uptake in the sequestrum compared to the halo around. The mean SUVmax at the sequestrum was 4.18±3.16, compared to the surrounding halo, 7.08±5.81. The normal bone has a mean SUVmax of 1.61±1.42. Sequestrum was removed successfully in all cases. Conclusion. 18F-FDG-PET-CT can precisely localize the sequestrum preoperatively, it has a lower uptake than tissues around it. This would facilitate planning and improve the quality of debridement

Aim. Magnetic resonance imaging (MRI) and 2-[. 18. F]-fluoro-2-deoxy-D-glucose (. 18. F-FDG) Positron Emission Tomography, paired with Computed Tomography (PET/CT) are two indicated advanced imaging modalities in the complicated diagnostic work-up of osteomyelitis. PET/MRI is a relatively novel hybrid modality with suggested applications in musculoskeletal infection imaging. The goal of this study was to assess the value of hybrid . 18. F-FDG PET/MRI for chronic osteomyelitis diagnosis and surgical planning. Method. Five suspected chronic osteomyelitis patients underwent a prospective . 18. F-FDG single-injection/dual-imaging protocol with hybrid PET/CT and hybrid PET/MR. Diagnosis and relevant clinical features for the surgeon planning treatment were compared. Subsequently, 36 patients with . 18. F-FDG PET/MRI scans for suspected osteomyelitis were analysed retrospectively. Sensitivity, specificity, and accuracy were determined with the clinical assessment as the ground truth. Standardized uptake values (SUV) were measured and analysed by means of receiver operating characteristics (ROC). Results. The consensus diagnosis was identical for PET/CT and PET/MRI in the prospective cases, with PET/CT missing one clinical feature. The retrospective analysis yielded a sensitivity, specificity, and accuracy of 78%, 100%, and 86% respectively. Area under the ROC curve was .736, .755, and.769 for the SUVmax, target to background ratio, and SUVmax_ratio respectively. These results are in the same range and not statistically different compared to diagnostic value for . 18. F-FDG PET/CT imaging of osteomyelitis in literature. Conclusions. Based on our qualitative comparison, reduced radiation dose, and the diagnostic value that was found, the authors propose . 18. F-FDG PET/MRI as an alternative to . 18. F-FDG PET/CT in osteomyelitis diagnosis, if available

Objectives. Our objectives were to describe the therapeutic aspects and assess the prognosis of chronic osteomyelitis in children. Materials and methods. We made a retrospective study from January 2007 to December 2016. The study concerned children from 0 to15 years, treated for chronic osteomyelitis and monitored in the pediatric surgery department of the teaching hospital Gabriel Toure, Bamako (Mali). The other types of bone infections, osteitis and bone tumors were not included in the study. In 10 years we received and treated 215 children with chronic osteomyelitis. This represented 3.56% of all the hospitalizations. The mean age was 8.8 (± 6.67) years with extremes of 28 days and 15 years. The patients were first seen by the traditional healer in 165 (76.7%) cases. The sex ratio was 1.26. The major clinical feature was local swelling associated with pain in 110 cases (51.2%). In 135 cases (62.8%) the staphylococcus aureus was found in direct examination or culture. After a year we performed a functional and morphological assessment according to the method of DIMEGLIO. Results. Surgical treatment was performed in all patients. The average delay of stay in hospital was 4.95 ± 4.57 weeks, with extremes of 2 and 12 weeks. The means follow-up was 13 months with extremes of 3 and 20 months. Good results were found in 115 patients, fair in 60 (40 in keloid knee valgus to 11 ° in 10, muscular atrophy 10), bad in 40 (shortening member in 25 non-union in 10 valgus to 18 ° in 5) According Dimeglio score. There was no significant association between the time of consultation, prior treatment received, the surgical technique and the occurrence of complications (p> 0.05). Conclusion. The management of the chronic osteomyelitis is well codified. The functional prognosis is dependent on an early care and sequels can be dramatic in children of school age. Keywords. Chronic osteomyelitis, Treatment, Prognosis, Children

Aims. Chronic osteomyelitis may recur if dead space management, after excision of infected bone, is inadequate. This study describes the results of a strategy for the management of deep bone infection and evaluates a new antibiotic-loaded biocomposite in the eradication of infection from bone defects. Patients and Methods. We report a prospective study of 100 patients with chronic osteomyelitis, in 105 bones. Osteomyelitis followed injury or surgery in 81 patients. Nine had concomitant septic arthritis. 80 patients had comorbidities (Cierny-Mader (C-M) Class B hosts). Ten had infected nonunions. All patients were treated by a multidisciplinary team with a single-stage protocol including debridement, multiple sampling, culture-specific systemic antibiotics, stabilisation, dead space filling with the biocomposite and primary skin closure. . Results. Patients were followed up for a mean of 19.5 months (12 to 34). Infection was eradicated in 96 patients with a single procedure and all four recurrences were successfully managed with repeat surgery. Adverse events were uncommon, with three fractures, six wound leaks and three unrelated deaths. Outcome was not dependant on C-M host class, microbial culture, wound leakage or presence of nonunion. Conclusion. This single-stage protocol, facilitated by the absorbable local antibiotic, is effective in the treatment of chronic osteomyelitis. It offers a more patient-friendly treatment compared with other published treatment options. Cite this article: Bone Joint J 2016;98-B:1289–96

Aim. To describe the histopathology of the first and last debrided bone tissue in chronic osteomyelitis and answer the following research question; is the last debrided bone tissue viable and without signs of inflammation?. Method. In total, 15 patients with chronic osteomyelitis were allocated to surgical treatment using a one stage protocol including extensive debridement. Suspected infected bone tissue eradicated early in the debridement procedure was collected as a clearly infected sample (S1). Likewise, the last eradicated bone tissue was collected as a suspected non-infected sample (S2), representing the status of the bone void. In all cases, the surgeon debrided the bone until visual confirmation of healthy bleeding bone. The samples were processed for histology, i.e. decalcification and paraffin embedding, followed by cutting and staining with Haematoxylin and Eosin. Immunohistochemistry with MAC-387 antibodies towards the calprotectin of neutrophil granulocytes (NGs) was also performed and used for estimation of a neutrophil granulocyte (NG) score (0, 1, 2 or 3), by the method described for fracture related infections (1). Results. For the S1 samples the median NG score was 3 which is considered confirmatory for infection. However, following debridement the median NG score was significantly (p = 0.032) reduced to 2. Often NGs were seen as single cells, but in seven S1 samples and in one S2 sample massive NG accumulations were observed. The S1 samples showed a mix of granulation tissue, fibrosis, viable bone, and bone necrosis. The S2 samples contained viable bone tissue and occasionally (10/15) small fragments of necrotic bone or bone debris were seen. Furthermore, a large number of erythrocytes were observed in most S2 samples. Conclusions. The present study shows that the inflammatory response still existents after debridement, although the response fades from the center of infection. Therefore, sampling of debrided bone tissue for histology must be performed initially during surgery, to avoid underestimation of the inflammatory response, i.e. the NG score. The last debrided bone tissue cannot by definition be considered completely viable and caution should be made to remove blood (rinse) before intraoperative evaluation of the viability of debrided cancellous bone. Remnant necrotic bone fragments or debris could represent low-vascular hiding places for leftover bacteria. Application of local antibiotics might have a central role in clearing of these small non-viable bone pieces at the bone void interface

Objectives. Meropenem may be an important drug in the treatment of open tibial fractures and chronic osteomyelitis. Therefore, the objective of this study was to describe meropenem pharmacokinetics in plasma, subcutaneous adipose tissue (SCT), and cancellous bone using microdialysis in a porcine model. Methods. Six female pigs were assigned to receive 1000 mg of meropenem intravenously over five minutes. Measurements of meropenem were obtained from plasma, SCT, and cancellous bone for eight hours thereafter. Microdialysis was applied for sampling in solid tissues. The meropenem concentrations were determined using ultra-high-performance liquid chromatography. Results. The penetration of meropenem into cancellous bone, expressed as the ratio of plasma to cancellous bone area under the concentration-curve from zero to the last measured value, was incomplete and delayed. The time with concentration above the minimal inhibitory concentration (T. >MIC. ), for an MIC of 0.5 μg/ml, was shorter for cancellous bone in comparison with both plasma and SCT. For MICs above 0.5 μg/ml, T. >MIC. in cancellous bone was only shorter than SCT. Considering an MIC of 4 μg/ml, no animals achieved the target of 40% T. >MIC. in plasma and cancellous bone, while less than 20% achieved it in SCT. Conclusion. The main finding of this study was short T. >MIC. in cancellous bone after intravenous administration of 1000 mg meropenem. Consequently, in order to achieve sufficient tissue concentration in the cases of open tibial fractures and chronic osteomyelitis, supplemental application of meropenem may be necessary. Cite this article: P. Hanberg, A. Lund, K. Søballe, M. Bue. Single-dose pharmacokinetics of meropenem in porcine cancellous bone determined by microdialysis: An animal study. Bone Joint Res 2019;8:342–348. DOI: 10.1302/2046-3758.87.BJR-2018-0308.R1

Aim. The liver is the major source of acute phase proteins (APPs) and serum concentrations of several APPs are widely used as markers of inflammation and infection. The aim of the present study was to explore if a local extra hepatic osseous acute phase response occurs during osteomyelitis. Method. The systemic (liver tissue and serum) and local (bone tissue) expression of several APPs during osteomyelitis was investigated with qPCR and ELISA in a porcine model of implant associated osteomyelitis (IAO) at 5, 10 and 15 days after inoculation with S. aureus or saline, respectively. Additionally, samples were also collected from normal heathy pigs and pigs with spontaneous, chronic, haematogenous osteomyelitis. Afterwards, immunohistochemistry towards different upregulated APPs was performed on the porcine osteomyelitis lesions and on bone biopsies from human patients with chronic osteomyelitis. Results. All infected porcine bone lesions (apart from Day 5 in the IAO model) were made up by necrosis, pus, and various degree of fibrotic encapsulation. A local, highly significant upregulation of Serum Amyloid A (SAA, up to 4000-fold upregulation), Complement component C3 (C3), and Inter-Alpha-Trypsin Inhibitor Heavy Chain 4 (ITIH4) were present in infected pigs compared to sterile controls. For the experimental IAO animals, the upregulation of C3 and ITIH4 increased over time, i.e., the highest expression was seen on day 15 after bacterial inoculation. In the liver, only C-reactive protein (CRP) and ITIH4 (not SAA or C3) were slightly upregulated in infected pigs. Serum concentrations of CRP, SAA and haptoglobin were only upregulated at day 5 in IAO infected animals. Immunohistochemically, comparable numbers of APP positive cells (leucocytes and bone cells) were found in human and porcine bone samples with chronic osteomyelitis. Conclusions. This is to our knowledge the first description of local APP up-regulation during chronic bone infection. Only small changes in the expression of APPs were found in the liver and serum samples. Thus, the presence of an osseous upregulation of APPs appears to be part of a predominantly local response that will be difficult to measure systemically. The importance of a local immune response in bone infections seems logical as the blood supply is severely impaired during osteomyelitis. There is a real need for supportive diagnostic bone infection criteria which should be based on a comprehensive understanding of the local inflammatory response. As seen from the present study, staining for SAA or C3 could potentially improve the diagnostic performance of histopathology

Aim. Chronic osteomyelitis of long bones is one of the most severe complications in orthopedics. Different options exist for treatment of this disease, however there is still no generally accepted comprehensive protocol that could potentially guide us in each particular step. There are many classifications that were designed to help us to make clinical decision, however even the most widely used Cierny-Mader classification does not count more a half of factors, assessment of which is essential for choosing the best treatment plan. This fact may be explained by the complexity of the disease process, diversity of treatment options and multistage approach to the management of these patients. Therefore, the purpose of this study was to work out a treatment protocol and clinical classification system, which will improve final outcomes in patients with chronic osteomyelitis of long bones. Method. Three orthopedic surgeons and one general surgeon who specialize on bone and joint infection independently of each other made a review of literature dedicated to the topic of chronic osteomyelitis. Each surgeon created a list of factors that are essential to assess for successful treatment of chronic osteomyelitis. After four lists were thoroughly matched and discussed, 10 most important factors were defined. Each surgeon proposed his own protocol of treatment, based on existent data and own experience. All four protocols were discussed and analyzed to come up with new the most comprehensive one. Therefore, the new protocol was created. After the list of factors and protocol were created, surgeons independently of each other defined the most important factors for every stage in the new protocol. Thus new multi-stage classification of chronic osteomyelitis (MSC-CO) was proposed. Results. We have defined the most important factors influencing on the decision making process in treatment of chronic osteomyelitis of long bones. The new comprehensive protocol and multi-stage clinical classification were developed. Conclusions. We assume, that the proposed tools may improve the results of chronic osteomyelitis treatment. However, the clinical trials should be conducted to assess the utility of new treatment protocol and MSC-CO in daily practice

Aim. Previous studies have indicated that TNF-α and lymphotoxin-α (LTA) gene polymorphisms associate with the development of several different inflammatory diseases. However, potential associations of such gene polymorphisms with the susceptibility to extremity chronic osteomyelitis remain unknown. This study aimed to investigate potential links between TNF-α gene polymorphisms (rs1800629, rs361525, rs1799964, rs1800630, rs1799724 and rs1800750) and LTA gene polymorphism (rs909253) and the risk of developing extremity chronic osteomyelitis in Chinese population. Method. A total of 233 patients with extremity chronic osteomyelitis and 200 healthy controls were genotyped for the above 7 polymorphisms of TNF-α and LTA genes using the genotyping method*. Results. Significant difference was found regarding the genotype distribution of rs909253 between patients and healthy controls (P = 0.002). The mutant allele C frequency of rs909253 in patient group was significantly higher than that in control group (P = 0.001). Significant associations were identified between rs909253 and the risk of developing chronic osteomyelitis by dominant model (P = 0.040), recessive model (P = 0.002) and homozygous model (P = 0.001). Additionally, the mutant allele T frequency in rs1799964 in patient group was significantly higher than that in control group (P = 0.035). Significant link was found between rs1799964 and susceptibility to chronic osteomyelitis by recessive model (P = 0.048). However, no significant outcomes were identified regarding other TNF-α gene polymorphisms between the two groups. Conclusions. The present study demonstrated that rs909253 and rs1799964 polymorphisms may associate with the risk of developing chronic osteomyelitis in Chinese population. *SNaPshot

Background. The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods. Twenty-eight patients (mean age 54.6 years, range 20–94) with Cierny-Mader stage IIIB chronic osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids. Results. All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot. Conclusion. Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities

Aim. Chronic osteomyelitis reflects a progressive inflammatory process of destruction and necrosis affecting bone architecture. It presents a challenge to manage, requiring multi-stage multidisciplinary interventions, and the literature reports a wide variety of treatment strategies. This systematic scoping review aims to map and summarise existing literature on treatment of chronic osteomyelitis of the femur and tibia and investigates the full range of treatments reported in order to enhance the reader's understanding of how to manage this complex condition. Method. A comprehensive computer-based search was conducted in PubMed, EMBASE, MEDLINE, Emcare and CINAHL for articles reporting treatment of chronic tibial/femoral osteomyelitis. Two reviewers independently performed a two-stage title/abstract and full-text screening, followed by data collection. Studies were included if they described any treatment strategy including at least one surgical intervention. Key information extracted included causative pathogens, treatment protocol and outcome i.e. both success rate, defined as remission achieved following initial treatment with no recurrence during followup, and recurrence rate. Results. A total of 1230 articles were identified, and 40 articles (2529 patients) ultimately included. Although a wide variety of treatment protocols are reported, all revolve around three key principles: removal of infected tissue, dead space management and antibiotic therapy. Variations are evident when considering use of extensive versus more conservative debridement techniques, and delivery and regime of antibiotic therapy, e.g. whether to use one of, or both systemic and local delivery. The majority (84.5%) of patients presented with stage III or IV disease according to the Cierny-Mader classification and staphylococcus aureus was the most commonly isolated organism. Although there is heterogeneity across studies in reporting outcomes, with only 29 studies reporting success rate as defined in this review, 25 (86.2%) of these reported a success rate of at least 80%. Conclusions. It is difficult to identify the optimal treatment strategy when reporting of outcomes is not standardised across studies, even in the context of similar techniques being used. Success rates across studies may also vary depending on patient demographics, comorbidities, severity, type and number of causative pathogens and follow-up length. It is now essential to identify specific patient and treatment related factors that may affect clinical outcomes. Given the current dominance of case series in the literature, there is a need for randomised controlled trials to yield further information that could aid future efficient management

Aim. Despite advances in surgical and antibiotic therapies the treatment of chronic osteomyelitis remains complex and is often associated with a significant financial burden to the National Health Service. The aim of this review was to identify the different types of single-stage procedures being performed for this condition as well as to evaluate their effectiveness. Method. Ovid Medline and Embase databases were searched for articles on the treatment of chronic osteomyelitis over the last 20 years. 3511 journal abstracts were screened by 3 independent reviewers. Following the exclusion of paediatric subjects, animal models, non-bacterial osteomyelitis and patients undergoing multiple surgical procedures we identified 13 studies reported in English with a minimum follow up of 12 months. Following a quality assessment of each study, data extraction was performed and the results analysed. Results. 505 patients with chronic osteomyelitis underwent attempted single-stage procedures. Following debridement a range of techniques are described to eliminate the remaining dead space. These include musculocutaneous flaps, insertion of S53P4 glass beads or packing with antibiotic loaded ceramic or calcium-sulphate pellets. The average follow-up ranged from 12 to 110 months. The most common organism isolated was Staphylococcus Aureus. Success was defined as resolution of pain with no recurrence of sinuses and no need for a second procedure to treat infection. Success rates ranged from 60%-100%. Conclusions. There are currently a wide range of single-stage procedures being performed for chronic osteomyelitis with varying success rates. Treating patients with these methods in specialist centres can result in resolution of infection and may lead to improved quality of life for the patient and a financial saving for the National Health Service. So far no one technique has been shown to be superior and further long term follow up data is required

Aim. Squamous cell carcinoma (SCC) is a rare but often devastating complication of chronic osteomyelitis. Optimum diagnosis and management are not well established. This paper aimed to develop a definitive, evidence-based approach to its diagnosis and management. Method. A systematic review of relevant published studies available in English from 1999-present was conducted. Strict inclusion criteria ensured that the diagnoses of osteomyelitis and SCC were explicit and valid. Additional cases from our institution were included using the same eligibility criteria. Data regarding patient demographics, osteomyelitis diagnosis, SCC diagnosis and its management and patient outcomes were collected. Statistical significance was assessed by Fisher's exact test. Results. Nineteen publications involving 98 patients plus eight patients managed locally were included. Eighty percent of patients were male, diagnosed with SCC at an average age of 59 years old (24–82 years), 31 years after their osteomyelitis diagnosis (3–67 years). Multiple bones were affected: tibia or fibula (59%), femur (17%), pelvis and sacrum (8%), bones of the foot and ankle (8%) and upper limbs (6%). Malignant transformation was associated predominantly with sinus (82%), ulceration (61%) and discharge (41%). SCC was diagnosed by biopsy (77%) or incidentally (23%) following definitive management for osteomyelitis. Twenty-two percent of patients had a staging CT scan. Seventy-six percent of patients underwent amputation, 16% underwent limb-sparing wide local excision and the remaining patients were palliated. Incidental diagnosis of SCC was associated with poorer outcomes in terms of death or disease recurrence (one year, p=0.052, five years p=0.021, Fisher's exact test) as was metastatic disease at SCC diagnosis (one year, p=0.006, five years, p=0.032, Fisher's exact test) and pelvic or sacral disease (one year p<0.001, five years p=0.002, Fisher's exact test). All patients who were not actively treated died within one year of SCC diagnosis. Data was suggestive that more patients who underwent amputation (versus wide local excision) were disease free at one and five years, but this was not statistically significant (one year, p=0.058, five years, p= 0.152, Fisher's exact test). Conclusions. SCC should be suspected in all cases of chronic osteomyelitis with skin changes, particularly where changes exceed 3 years duration and involve the pelvis. Multiple biopsies for histology should be taken in all suspected cases, as well as routinely during surgical excision of osteomyelitis when chronic skin changes are present. Once SCC is identified, staging CT scan should be performed to guide management. Amputation, where possible, should be considered

Objective. In the present study, we aimed to assess whether gelatin/β-tricalcium phosphate (β-TCP) composite porous scaffolds could be used as a local controlled release system for vancomycin. We also investigated the efficiency of the scaffolds in eliminating infections and repairing osteomyelitis defects in rabbits. Methods. The gelatin scaffolds containing differing amounts of of β-TCP (0%, 10%, 30% and 50%) were prepared for controlled release of vancomycin and were labelled G-TCP0, G-TCP1, G-TCP3 and G-TCP5, respectively. The Kirby-Bauer method was used to examine the release profile. Chronic osteomyelitis models of rabbits were established. After thorough debridement, the osteomyelitis defects were implanted with the scaffolds. Radiographs and histological examinations were carried out to investigate the efficiency of eliminating infections and repairing bone defects. Results. The prepared gelatin/β-TCP scaffolds exhibited a homogeneously interconnected 3D porous structure. The G-TCP0 scaffold exhibited the longest duration of vancomycin release with a release duration of eight weeks. With the increase of β-TCP contents, the release duration of the β-TCP-containing composite scaffolds was decreased. The complete release of vancomycin from the G-TCP5 scaffold was achieved within three weeks. In the treatment of osteomyelitis defects in rabbits, the G-TCP3 scaffold showed the most efficacious performance in eliminating infections and repairing bone defects. Conclusions. The composite scaffolds could achieve local therapeutic drug levels over an extended duration. The G-TCP3 scaffold possessed the optimal porosity, interconnection and controlled release performance. Therefore, this scaffold could potentially be used in the treatment of chronic osteomyelitis defects. Cite this article: J. Zhou, X. G. Zhou, J. W. Wang, H. Zhou, J. Dong. Treatment of osteomyelitis defects by a vancomycin-loaded gelatin/β-tricalcium phosphate composite scaffold. Bone Joint Res 2018;7:46–57. DOI: 10.1302/2046-3758.71.BJR-2017-0129.R2

Chronic osteomyelitis is historically treated in a two stage fashion with antibiotic-loaded polymethylmethacrylate (PMMA) as local antibacterial therapy. However, two-stage surgeries are associated with high morbidity, long hospitalization and high treatment costs. In recent years new biomaterials were developed that allow to change this treatment algorithm. S53P4 bioactive glass is such a novel biodegradable antibacterial bone graft substitute that enables a one-stage surgery in local treatment of chronic osteomyelitis. This study aimed to explore the eradication of infection and bone healing capacities of S53P4 bioactive glass in clinical practice. In this prospective longitudinal outcome study, clinical applicability of S53P4 bioactive glass in treatment of patients with chronic osteomyelitis was assessed. All patients with clinically, haematologically and radiologically evident chronic osteomyelitis were included. All patients were treated with an extensive debridement surgery, S53P4 bioactive glass implantation and systemic antibiotic administration. Primary endpoint of this study is eradication of infection. During follow-up eradication was analysed based on clinical outcomes, blood samples (inflammatory parameters) and radiological outcomes. The secondary endpoint, bone healing, is assessed using conventional radiographic images of the treated region. Between 2011 and 2016, 25 patients were included in this study, with a mean follow-up of 23 months (range 4 – 57). Hospital stay was short with a mean of 18 days (range 4 – 40) and patients required an average of 1,4 surgeries (range 1 – 4). The inflammatory parameter C-reactive protein (CRP) showed a normalization after a mean duration of 46 days (range 0 – 211). At the end of follow-up haematological and clinical outcomes showed eradication of infection in 24 (96%) of all patients. Radiologically none of all patients showed persisting signs of infection and bone healing was observed in 22 (88%) patients based on changes on conventional radiographic images. One patient had a persistent infection without any bone healing, this patient had an infected non-union prior to surgery. There were two other patients with an initial infected non-union fracture which was not consolidated at last follow-up, although they had successful infection treatment. Another patient had a femoral fracture after surgery that needed additional surgery which did not interfere with eradication of infection. Four (16%) of all patients had initial wound healing problems related to compromised skin and/or soft tissue prior to surgery. Based on the results of our clinical experience, S53P4 bioactive glass can successfully be used in a one-stage procedure for treatment of chronic osteomyelitis. Eradication of infection was successful in almost all patients and so far no patients required a second surgery due to infection recurrence. Bone healing (incorporation of the bioactive glass) was seen in all patients except for the patients with an initial infected non-union fracture. As a consequence of these results, we changed our institutional protocol for treatment of chronic osteomyelitis to a one-stage approach instead of a two-step approach

Osteomyelitis is an infection of bone or bone marrow with a concomitant inflammation involving the bone marrow and the surrounding tissues. Chronic osteomyelitis is historically treated in a two-stage fashion with antibiotic-loaded polymethylmethacrylate as local antibacterial therapy. Two-stage surgeries are associated with high morbidity, long hospitalization and high treatment costs. Next to antibiotic releasing biomaterials, S53P4 bioactive glass is a biomaterial that enables one-stage surgery in local treatment of chronic osteomyelitis. S53P4 bioactive glass is gaining interests in recent years in clinical treatment of chronic osteomyelitis in a one-stage fashion due to its antibacterial and bone regenerating capacities. By changing local pH and osmotic pressure S53P4 bioactive glass attack bacteria in a different way as compared to antibiotics. In this presentation, we will present current clinical treatment options for osteomyelitis, clinical results and level of evidence of various biomaterials used in osteomyelitis treatment. In addition, the clinical results and health-economic results of S53P4 bioactive glass will be detailed. Thereafter a summary of the current standing across the board in osteomyelitis treatment will be provided

Introduction. Diagnosis of chronic osteomyelitis (COM) is based mainly on the correlation between history, clinical picture, lab analysis, bacteriological, pathological, and imaging studies. Bone biopsy for culture and sensitivity is the gold standard for the correct identification of the causative organism. The present prospective study aims to evaluate the accuracy of FDG PET-CT in the diagnosis of COM in comparison to the bacteriological, pathological findings. Materials and Methods. 18 patients (16 males/two females) underwent FDG-PET/CT scanning for clinically or radiologically suspected COM of the lower extremity. Fourteen patients had septic non-union, three patients with aseptic non-union, and one with chronic diffuse sclerosing OM of Garre. Seven patients had implants at site of examination at the time of the scan. Diagnosis of COM was confirmed by deep surgical cultures and pathological analysis (index debridement done by s single surgeon in one centre) following PET/CT scanning. FDG-PET uptake was measured by SUV max (the highest uptake of the radioisotope in the infection area). These findings were correlated to the microbiological and histopathological results. Results. Infection was clinically evident at a mean of 15 weeks (range, 2 to 60 weeks) after the date of injury. Patients had a mean of 2.3 (range 0 – 7) operations, before index debridement. The mean SUV max on the affected side was (9.55 ± 5.22), While mean SUV max on the contralateral healthy side was (1.82 ± 0.98). The pattern of FDG-uptake was diffuse in nine (50%), localised in seven (38.9%), and intramedullary in two (11.1%) patients respectively. The sensitivity, specificity, accuracy, PPV and NPV of PET SUV max were 100%, 66.7%, 94.44%, 93.75% and 100% respectively in the diagnosis of COM at a cut-off value of (4.46). The present study included 15 true positive, two true negative and one false-positive PET/CT results. Conclusions. 18F-FDG PET/CT is a highly sensitive and specific method for the evaluation of chronic osteomyelitis in patients with or without trauma. PET/CT provides anatomical localisation and characterisation of the infected area and has a crucial role in preoperative planning

Aims. One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions. Methods. In this single-centre, case-control study, 57 patients who underwent one-stage revision arthroplasty for PJI of the hip and required resection of the proximal femur between 2009 and 2018 were identified. The control group consisted of 57 patients undergoing one-stage revision without bony resection. Logistic regression analysis was performed to identify any correlation with resection and the risk factors for re-revisions. Rates of all-causes re-revision, reinfection, and instability were compared between groups. Results. Patients who required resection of the proximal femur were found to have a higher all-cause re-revision rate (29.8% vs 10.5%; p = 0.018), largely due to reinfection (15.8% vs 0%; p = 0.003), and dislocation (8.8% vs 10.5%; p = 0.762), and showed higher rate of in-hospital wound haematoma requiring aspiration or evacuation (p = 0.013), and wound revision (p = 0.008). The use of of dual mobility components/constrained liner in the resection group was higher than that of controls (94.7% vs 36.8%; p < 0.001). The presence and removal of additional metal hardware (odds ratio (OR) = 7.2), a sinus tract (OR 4), ten years’ time interval between primary implantation and index infection (OR 3.3), and previous hip revision (OR 1.4) increased the risk of proximal femoral resection. A sinus tract (OR 9.2) and postoperative dislocation (OR 281.4) were associated with increased risk of subsequent re-revisions. Conclusion. Proximal femoral resection during one-stage revision hip arthroplasty for PJI may be required to reduce the risk of of recurrent or further infection. Patients with additional metalware needing removal or transcortical sinus tracts and chronic osteomyelitis are particularly at higher risk of needing proximal femoral excision. However, radical resection is associated with higher surgical complications and increased re-revision rates. The use of constrained acetabular liners and dual mobility components maintained an acceptable dislocation rate. These results, including identified risk factors, may aid in preoperative planning, patient consultation and consent, and intraoperative decision-making. Cite this article: Bone Joint J 2021;103-B(11):1678–1685

Aim. To evaluate the clinical outcome of a new absorbable, gentamycin loaded calcium sulfate/hydroxyapatite biocomposite (CERAMENT. ™. /G) as cavity filler after debridement and removal of infected metalwork in chronic osteomyelitis. Methods. We report the retrospective study of prospectively collected data from 36 patients with chronic osteomyelitis from implant infection. Treatment included a single stage protocol with removal of the metalwork, debridement augmented with application of CERAMENT. ™. /G, stabilization, culture-specific antibiotics and primary skin closure or flap. The biocomposite was used for dead space filling after resection of Cierny-Mader (C-M) stage III and IV chronic osteomyelitis. Data were collected on patient age, comorbidities, operation details, microbiology, postoperative complications and type of fixation or plastic surgery. Primary measure of outcome was recurrence rate. Results. According to the C-M classification 22 patients (63%) were defined as Type III and 13 (37%) as Type IV. A total of 26 (72%) patients were Class B hosts. In 9 cases (25%), there was an infected non-union and 1 patient had septic arthritis. Mean age was 52 years (range 22 to 81). Patients were followed for a mean of 20 months (range 6 to 36). Infection was eradicated in 32 patients. There were three (8.3%) recurrences (two cases of osteomyelitis and one of soft tissue/flap infection). Two of them were successfully managed with repeat surgery (one Class B and one Class A host) and one (Class B host) with suppressive antibiotic therapy as per patient's choice. In one infected nonunion the infection was eradicated but the nonunion persisted. Thirteen patients (36.6%) had a local or free fascio-cutaneus flap. Staphylococci (50%) and Enterococci (15%) were the most common microorganisms. Pseudomonas aeruginosa was more common in polymicrobial infection usually with Staphylococcus aureus. Conclusions. A multidisciplicary approach including augmented debridement with CERAMENT. ™. /G is effective for treatment of chronic osteomyelitis with infected metalwork

Long-term survival and favourable outcome of implant use are determined by bone-implant osseointegration and absence of infection near the implants. As with most diseases, prevention is the preferred approach. Silver ion doped calcium phosphate based ceramic coating (Silveron®) for implant coating has been shown previously to be a potent antimicrobial agent as indicated by in vitro testing. The present study reports on clinical experience using silver ion doped calcium phosphate based ceramic coated external fixator pins as surgical treatment in the management of chronic osteomyelitis and open fractures. Ten patients had external fixators: six for open fractures of ankle, three for chronic osteomyelitis of the femur, one for tibia pseudoarthrosis. The electrospray method was used for coating the external fixator pins with silver ion doped calcium phosphate-based ceramics. A radiofrequency energy source was used to sinter the coated pins. Microbiological, roentgenographic, toxic and biochemical analyzes of patients were carried out. Wound debridement, and subsequent wound care resulted in control of the infection in three chronic osteomyelitis and in healing of seven fractures after follow-up ranging from three to six months. In total 67 pins were used in 10 patients but only one pin was positive microbiologically in one patient. Collectively, these data clearly illustrate that the toxic effects of silver were not observed at the doses used. Silver ion doped calcium phosphate based ceramic coating (Silveron®) can be used to prevent infection associated with the implant

Introduction. Osteomyelitis is a challenge in diagnosis and treatment. 18F-FDG PET-CT provides a non-invasive tool for diagnosing and localizing osteomyelitis with a sensitivity reaching 94% and specificity reaching 100%. We aimed to assess the agreement in identifying the geographic area of infected bone and planned resection on plain X-ray versus 18F-FDG PET-CT. Materials & Methods. Clinical photos and X-rays of ten osteomyelitis patients were shown to ten consultant surgeons; they were asked to draw the area of infection and extent of planned surgical debridement; data will be compared to 18F-FDG PET-CT results. Results. We tested the agreement between the surgeons in every parameter. Regarding height, there was poor agreement between surgeons. Regarding perimeter, the ten surgeons showed low-moderate agreement. The ten surgeons showed a low-moderate agreement for circularity. Results document the variability of assessment and judgement based on plain X-rays. In comparison to PET-CT, All parameters were significantly different in favour of 18F-FDG PET-CT over X-ray (P < 0.001). Conclusions. 18F FDG PET-CT provides a three-dimensional tool for localizing the exact location of the infected bone and differentiating it from the normal bone. Thus, it could be beneficial in precise pre-operative planning and surgical debridement of chronic osteomyelitis

Bone infections due to fractures or implants are a big medical problem. In experimental medicine, many experimental models have been created on different animal species to simulate the disease condition and to do experience treatments. The aim of this paper was to present an antibacterial efficacy of using a bone allograft developed according to the Marburg system of bone bank on a model of chronic osteomyelitis induced in rabbits. In research was used 54 rabbits. Osteomyelitis was induced in rabbits by a human strain of St. aureus ATCC 43300, in the rabbit femur. There have been created 3 groups of animals. In 1. st. group used antibiotic impregnated biodegradable material “PerOssal”. In 2. nd. group used antibiotic impregnated whole bone allograft. In 3. rd. group used antibiotic impregnated perforated bone allograft. Evaluation of installation and evolution of the disease was done by microbiological. A separate study of microbiological data is presented here. This study showed, in the 1. st. and 3. rd. groups there is a persistent decrease in CFU by 14 knocks to 120.4 in the 1. st. group and to 3.5 in the 3. rd. group, and in the 2. nd. group, on the contrary, there is an increase in CFU to 237.33. This shows the lack of effectiveness of using a whole bone allograft. The results showed, after 7 days there was no statistically significant difference between the groups. After 14 days the perforated bone allograft impregnated with antibiotic was better than the biodegradable material “PerOssal”

The Masquelet technique, also known as the ‘induced membrane technique’ has been utilised in adult reconstruction with varied success. However, there is limited literature on its use in children and this study aims to share our experience. Materials & Methods. Between 2014 and 2022, 7 children underwent bone defect/infection reconstruction using Masquelet technique, four for complications of Congenital Pseudoarthrosis of Tibia (CPT) treatment, two with chronic osteomyelitis and one for Osteogenesis imperfecta with infected nonunion. The length of the defect relative to the length of the bone (index of reconstruction expressed as a percentage), time to union and complications were evaluated with standard radiographs and from electronic medical records. Results. The mean age was 11 years and the procedure was done in five tibiae, one femur and a metatarsal. The mean time interval was 7.1 weeks between the first and second stage surgery. The mean index of reconstruction was 25.8% and the mean follow up period was 17 months. Though six patients achieved union with a mean time to union of 6.5 months (range 4.5 to 10), two patients with multiple previous surgeries for CPT decided to have ablation despite union. The interosseous Masquelet technique of cross synostosis between the tibia and fibula is being highlighted. Conclusions. The Masquelet technique is a reliable method in complex aetiologies and complications that require methodical planning to achieve good results especially in rescue situations of the tibia

Acute Haematogenous Osteomyelitis (AHO) remains a cause of severe illness among children. Contemporary research aims to identify predictors of acute and chronic complications. Trends in C-reactive protein (CRP) following treatment initiation may predict disease course. We have sought to identify factors associated with acute and chronic complications in the New Zealand population. A retrospective review of all patients <16 years with presumed AHO presenting to a tertiary referral centre between 2008–2018 was performed. Multivariate was analysis used to identify factors associated with an acute or chronic complication. An “acute” complication was defined as need for two or more surgical procedures, hospital stay longer than 14-days, or recurrence despite IV antibiotics. A “chronic” complication was defined as growth or limb length discrepancy, avascular necrosis, chronic osteomyelitis, pathological fracture, frozen joint or dislocation. 151 cases met inclusion criteria. The median age was 8 years (69.5% male). Within this cohort, 53 (34%) experienced an acute complication and 18 (12%) a chronic complication. Regression analysis showed that contiguous disease, delayed presentation, and failure to reduce CRP by 50% at day 4/5 predicted an acutely complicated disease course. Chronic complication was predicted by need for surgical management and failed CRP reduction by 50% at day 4/5. We conclude that CRP trends over 96 hours following commencement of treatment differentiate patients with AHO likely to experience severe disease

Most patients treated at our clinical setting present during chronic osteomyelitis stage, which is anecdotally likely to be poly-microbial. Adults with poly-microbial infection have a predilection for gram-negative bacteria and anaerobes, a scenario that hypothetically leads to a higher morbidity of poly-microbial osteomyelitis following trauma. Our study looks into the epidemiology of poly-microbial osteomyelitis treated at our Tumour and Infection unit. Retrospective study of patients treated for osteomyelitis from 2016 to 2020. Records of eligible patients were retrieved for examination. Demographics such as age, sex and race were recorded. Clinical presentation, organisms cultured, including their anti-microbial sensitivities were documented. There were 63 participants in the study. 31 (49.21%) had mono-microbial osteomyelitis with 32 (50.79%) having poly-microbial osteomyelitis. Majority of the poly-microbial patients presented with a sinus (68.75%) mostly located in the tibia (50%). Multiple mixed pathogens (both gam-positive and gram-negative) were cultured in our patients and this comprised 71.21% of the total bacteria cultured. Staphylococcus Aureus was the commonest bacteria (30%) isolated, followed by Enterococcus faecalis (12%). The commonest gram-negative bacteriae cultured was Enterococcus cloacae (10%) followed by Acinetobacter baumannii (7%). Most enterobacteriacae species were sensitive to Ertapenem and Ceftazidime. A slightly higher incidence of poly-microbial osteomyelitis was found in our study than that reported in literature. Furthermore, our study demonstrated a wide variety of organisms found in poly-microbial osteomyelitis, with a large contribution made by gram-negative anaerobic rod-shaped bacteria

Introduction. Wide, tumor-like resection for chronic osteomyelitis (COM), a standard practice previously, has been challenged recently with adequate, local debridement. This paper reviews the evolution of surgical debridement for long bone osteomyelitis, and presents the outcome of adequate debridement in a tertiary bone infection unit. Materials & Methods. Retrospective review of records from 2014 to 2020 of patients with long bone osteomyelitis. All records were searched electronically and imaging reviewed. All patients were managed by Multidisciplinary Infection Team protocol. Results. 53 patients (54 bones) with median age of 45.5 years (IQR 31 to 55) and mean follow-up of 29 months (12 – 59) were identified. According to Cierny-Mader classification, ten bones were type I, 39 were type III, and five were type IV; via the BACH classification of long bone osteomyelitis 21 were uncomplicated, 32 were complex, and one had limited options. All patients were treated with single-staged management with one planned second stage stabilization. Seventy-five percent grew positive microbial cultures. Forty-six (85%) cases had resolution of COM after index procedure and 51 (94%) had resolution at last follow up. Four (7%) patients underwent second surgical procedure and six (11%) patients had complications. Conclusions. We report high COM resolution rate through detailed pre operative evaluation and planning with multidisciplinary team approach. We challenge the need for wide tumor-like resection and the need for regenerative procedures in all cases of COM. Adequate debridement and local delivery of high concentration of antibiotic appears to provide comparable outcomes

Paediatric bone and joint infections remain common in low- and middle-income countries (LMICs). We aimed to determine the complication rate and incidence of disseminated infection in paediatric bone and joint infections in an LMIC setting. Secondly, we aimed to elucidate factors associated with complications and disseminated disease. We retrospectively reviewed our database for children that presented with bone and joint infections between September 2015 and March 2019. Data were extracted to identify factors that were associated with development of complications and disseminated infection. We analysed 49 children. The median age at presentation was 6 years (range 1 month to 12 years). Locally advanced disease was present in 13 children (27%). The remaining 36 children were evenly divided (18/49 each, 37%) between isolated AHOM and SA, respectively. Disseminated disease was present in 16 children (33%) and was associated with locally advanced disease, an increase in number of surgeries and an increased length of stay. Twenty-six complications were documented in 22 (45%) children. Chronic osteomyelitis developed in 15/49 (31%) cases, growth arrest in 5/49 (10%), and pathological fracture, DVT and septic shock in 2/49 (4%) each. Complicated disease was associated with locally advanced disease, a higher number of surgeries, disseminated disease and an increased length of stay. Sixty five percent of cases cultured Staphylococcus aureus, while 25% (12/49) were culture negative. The median time from admission to surgery was one day, and the median time from onset of symptoms to surgery was seven days. We found a high complication rate. One third of patients had locally advanced disease, and this was associated with the development of complications and disseminated disease. Further studies are needed to be able to predict which children will have poor outcomes

Serial section electron microscopy (SSEM) was initially developed to map the neural connections in the brain. SSEM eventually led to the term ‘Connectomics’ to be coined to describe process of following a cell or structure through a volume of tissue. This permits the true three-dimensionality to be appreciated and relationships between cells and structures. The purpose of this study was to utilize this methodology to interrogate S. aureus infected bone. Bone samples were harvested from mice tibia infected with S. aureus and were fixed, decalcified, and osmicated. The samples were paraffin embedded and 5-micron sections were cut to identify regions of bacterial invasion into the osteocyte-lacuna-canalicular-network (OLCN). This area was cut from the paraffin block, deparaffinized, post-fixed and reprocessed into epoxy resin. Serial sections were cut at 60nm and collected onto Kapton tape utilizing the Automated Tape-collecting Ultramicrotome (ATUMtome) system. Samples were mounted onto 4” silicon wafers and post-stained with 2% uranyl acetate followed by 0.3% lead citrate and carbon coated. A ZEISS GeminiSEM 450 scanning electron microscope fitted with an electron backscatter diffusion detector was used to image the sections. The image stack was aligned and segmented using the open-source software, VASTlite. 264 serial sections were imaged, representing approximately 40 × 45 × 15-micron (x, y, z) volume of tissue. 70% of the canaliculi demonstrated infiltration by S. aureus. This study demonstrates that SSEM can be applied to the skeletal system and provide a new solution to investigate the OLCN system. It is feasible that this methodology could be implemented to investigate why some canaliculi are resistant to colonization and potentially opens up a new direction for the prevention of chronic osteomyelitis. In order to make this a realistic target, automated segmentation methodologies utilizing machine learning must be developed and applied to the bone tissue datasets

Aim. Chronic osteomyelitis of the calcaneus is a frequent problem in a population of diabetic patients, patients with neurologic disorders or bedridden patients with ulcers. Partial calcanectomy is an alternative option which avoid major amputation. The aim of this retrospective study was to determine the effectiveness of partial calcanectomy for treating chronic osteomyelitis of the calcaneux. Method. We conducted a retrospective review of patients who underwent in our department a partial calcanectomy between 2006 and 2015. All patients with a complete set of radiographs and adequate follow-up (minimum 2 years) were included. We reviewed these cases to determine healing rate, microbiological analysis, risk factors of failure (comorbidities), limb salvage rate and survival rate. We analyzed specifically the footwear and the functional subjective evaluation according to the LEFS score (Lower Extremity Functional Scale). Results. Twenty-four patients were included (24 foot). There were 17 men and the mean age was 65.2 years. The control of the infection and the healing was obtained in 15 cases. An additional surgery was required in 46% of the cases. A transtibial amputation has been realized in 9 cases because of uncontrolled infection. The existence of a preoperative vascular disease increased 5,9 times the risk of amputation after a partial calcanectomy (p=0,033). The type of germ was not related to the risk of recurrence. Soles were necessary for 60% of the patients with a successful partial calcanectomy (n=15). The average LEFS score was 51/80. Conclusion. The treatment of the chronic osteomyelitis of the calcaneus was a therapeutic challenge for these patients. The partial calcanectomy is a useful procedure for limb salvage, but the selection of patients must be rigorous. In our study, arteriopathic patients had a high risk of amputation after partial calcanectomy. When the healing is acquired, the patients were satisfied and presented a good function

Shoulder septic arthritis is uncommon and frequently misdiagnosed, resulting in severe consequences. This study evaluated the demographics, bacteriological profile, antibiotic susceptibility, treatment regimens, and clinical outcomes. This is a 10-year retrospective observational analysis of 30 patients (20 males and 10 females) who were treated for septic arthritis of the shoulder. The data collecting process utilised clinical records, laboratory archives, and x-ray archives. We gathered demographic information, pre- and post-intervention clinical data, serum biochemical markers, and the results of imaging examinations. All patients had a surgical arthrotomy and joint debridement in the operating room, and specimens were taken for culture and sensitivity testing. The specimens were cultivated for at least seventy-two hours. Shoulder joint ranges of motion, comorbidities, and the presence of osteomyelitis were assessed clinically to determine the outcome. All statistical analyses were conducted using the STATA 17 statistical software. Analysis of correlation between categorical variables was performed using the chi-squared test. The majority of the study patients were black Africans (97%). The age range of the group was from 8 days to 17 years. At presentation, 33% of patients had a low-grade fever, whereas the majority (60%) had normal body temperature. The average length of symptoms was 3.9 days (ranged from 1 day to 15 days), and the majority of patients had an increased white cell count (83%) and C-reactive protein (98%). There was accumulation of fluid in the joint of all individuals who received shoulder ultrasound imaging. We noted a significant incidence of gram-positive cocci, which were mostly susceptible to first-line antibiotics. Shoulder stiffness affected 63% of patients and chronic osteomyelitis affected 50% of individuals. Neither the severity nor the duration of the symptoms was related to an increased risk of osteomyelitis. The results of this study revealed that the clinical characteristics and bacterial profile of septic arthritis of the shoulder conform to typical patterns. The likelihood of osteomyelitis and an unfavourable prognosis is considerable

Osteomyelitis is an inflammatory condition accompanied by the destruction of bone and caused by an infecting microorganism. Open contaminated fractures can lead to the development of osteomyelitis of the fractured bone in 3-25% of cases, depending on fracture type, degree of soft-tissue injury, degree of microbial contamination, and whether systemic and/or local antimicrobial therapies have been administered. Untreated, infection will ultimately lead to non-union, chronic osteomyelitis, or amputation. We report a case series of 10 patients that presented with post-operative infected non-union of the distal femur with or without prior surgery. The cases were performed at Padmashree Dr. D. Y. Patil Hospital, Nerul, Navi Mumbai, India. All the patients’ consents were taken for the study which was carried out in accordance with the Helsinki Declaration. The methodology involved patients undergoing a two-stage procedure in case of no prior implant or a three-stage procedure in case of a previous implant. Firstly, debridement and implant removal were done. The second was a definitive procedure in form of knee arthrodesis with ring fixator and finally followed by limb lengthening surgery. Arthrodesis was planned in view of infection, non-union, severe arthritic, subluxated knee, stiff knee, non-salvage knee joint, and financial constraints. After all the patients demonstrated wound healing in 3 months along with good radiographic osteogenesis at the knee arthrodesis site, limb lengthening surgeries by tibial osteotomy were done to overcome the limb length discrepancy. Distraction was started and followed up for 5 months. All 10 patients showed results with sound knee arthrodesis and good osteogenesis at the osteotomy site followed by achieving the limb length just 1-inch short from the normal side to achieve ground clearance while walking. Our case series is unique and distinctive as it shows that when patients with infected nonunion of distal femur come with the stiff and non-salvage knee with severe arthritic changes and financial constraints, we should consider knee arthrodesis with Ilizarov ring fixator followed by limb lengthening surgery

Aim. Excision of chronic osteomyelitis (cOM) creates a dead space which must be managed to avoid early recurrence of infection. Systemic antimicrobials cannot penetrate this space in high concentration so local therapy has become an attractive adjunct to surgery. This study presents the mid- long-term results of local therapy with gentamicin in a bioabsorbable ceramic carrier. Method. A prospective series of 100 patients with Cierny & Mader Types III and IV cOM, affecting 105 bones, were treated with a single stage procedure, including debridement, deep tissue sampling, local and systemic antimicrobials, stabilization and immediate skin closure. cOM was confirmed with strict diagnostic criteria. Patients were followed up for a mean of 6.05 years (range 4.2–8.4 years). Results. At final follow-up, 6 patients had evidence of recurrent infection (94% infection-free). 3 infections recurred in the first year, with 2 in the second year and one at 4.5 years after surgery. Recurrence was not dependent on host physiological class (1/20 Class A; 5% vs 5/80 Class B; 6.25%. p=0.833). Nor was it related to aetiology of the infection, microbial culture or the presence of an infected non-union before surgery (1/10 with non-union; 10% vs 5/90 without non-union; 5.6%. p=0.57). Organisms which demonstrated intermediate or high-grade resistance to gentamicin were more likely in polymicrobial infections (9/21; 42.8%) compared to single isolate osteomyelitis (7/79; 8.9%)(p<0.001). However, recurrence was not more frequent when a resistant organism was present (1/16; 6.25% for resistant cases vs 5/84; 5.95% in sensitive culture infection) (p=0.96). Conclusions. This study shows that the single stage protocol, including a high delivery local antibiotic ceramic, was effective over several years. The method can be applied to a wide range of patients, including those with significant comorbidities and infected non-union

Aim. Free tissue transfer is an important tool in successful reconstruction of chronic osteomyelitis but can be challenging due to extensive scarring. Our unit follows a multidisciplinary approach including excision of osteomyelitis and immediate microvascular soft-tissue reconstruction simultaneously with orthopaedic reconstruction. We aim to evaluate the success of free tissue transfer and disease recurrence in patients with chronic osteomyelitis. Method. This is a retrospective consecutive cohort study between 2010–2015 inclusive by a single microvascular surgeon in a single centre. All patients had one stage excision of osteomyelitis, orthopaedic reconstruction and microvascular soft tissue reconstruction, with a minimum follow-up period of 1 year. Results. The total number of flap was 76 in 73 patients. The mean age was 45 (18–82). 63 (83%) were to cover the tibia. Flaps used were mainly gracilis (75%) and latissumus Dorsi (16%) with fibula, anteriolateral thigh, vastus lateralis and rectus abdominus also used. 40 patients had end to side anastomosis with 36 being end to end. 98% of the venous anastomosis were to the deep venae comitantes. The average flap ischaemic time was 83 minutes and the total operation time was on average 7.7 hours (5–16 hours). Total flap failure occurred in 3 patients (4%) with one additional flap having tip necrosis. All 3 patients who had total flap failure were successfully reconstructed with a 2nd free flap. 8 patients had residual infection that was successfully treated in 6 patient. Conclusions. Chronic osteomyelitis can be treated with simultaneous excision, orthopaedic reconstruction and free soft tissue reconstruction with high level of success (>90% infection-free at one year). Microvascular soft tissue reconstruction in these patients is almost always technically challenging and consequently a range of flaps and anastomotic techniques are required for these long operations. However, despite this, our study shows that free tissue transfer has a flap survival rate of >95%

Despite numerous advances in the management of chronic osteomyelitis, many questions remain. To date, no evidence-based guidelines exist in the treatment of chronic osteomyelitis. In essence the aim is to improve quality of life through either a curative or a palliative treatment strategy. The choice of treatment strategy is based on the physiological status of the host. This process of host stratification is, however, complicated by the fact that the definition of a C-host has never been standardized. Purpose;. The aim of the study was to investigate the short term outcome of the treatment of chronic osteomyelitis in adult patients where selection of a management strategy was based on a refined host stratification system. Methods;. A retrospective review was performed of adult patients with chronic osteomyelitis seen over a one year period. In total 116 patients were included in the study. A modified host stratification system was applied, incorporating predefined major and minor criteria, to determine each patient's host status. Results;. A high prevalence of HIV infection (28.6%) and malnutrition (15%) was present in the study population. Almost half the patients were classified as C-hosts (44.8% or n=52), followed by B-host classification in 39.7% of cases (n=46). At a mean follow-up of one year an overall success rate of 91.4% (95% CI: 84.7–95.8%) was achieved. Host status and outcome (remission, suppression or failure) was significantly dependent (p-value < 0.001). Success was achieved in 92.2% of patients treated curatively and 89.6% of patients treated palliatively. Conclusion;. By integrating the physiological status of the host (based on objective predefined criteria) with the appropriate curative, palliative or alternative treatment strategy we were able to achieve acceptable outcomes in both low and high risk cases and, in addition, avoid unnecessary amputation

Evaluation of the surgical approach and treatment outcomes in patients with chronic osteomyelitis of the tibia classified as anatomic type 3 and 4, physiologic class B (Cierny-Mader). Analysis of surgical treatment of 68 patients (average age of 45.6 years) with chronic osteomyelitis of the tibia covered the period from June 1, 2013 till January 1, 2015. There were 49 males (72%). The first (I) group included 39 patients with type 3 chronic osteomyelitis of the tibia, the second (II) group – 29 patients with type 4 osteomyelitis. The follow-up was for 1–18 months. Duration of the surgery, intraoperative blood loss, causes of osteomyelitis and the frequency of infection recurrence were evaluated. In the group I, 33.3% of patients underwent debridement of the infected site and replacement of the bone defect with an antibiotic-laden cement spacer. In 28.2% of cases, a biodegradable antibiotic delivery system was used for the replacement. 23.1% of cases involved muscle flap coverage of the bone and tissue defect, while 15.4% – treatment with external fixation. In the group II, the proportion of cases treated with external fixation was 58.6%. It was higher than in group I (p<0.01). 27.6% of patients in this group had their defects replaced with an antibiotic-laden cement spacer, whereas 10.3% had muscle flap coverage. One patient had amputation of the tibia. Duration of the surgery and blood loss in group II was 2.4 and 1.7 times higher than in group I. The frequency of infection recurrence in both groups was comparable (about 13%). The average time of its manifestation was 20.8 days in group II and 41.6 days in group I. Infection recurrence after muscle flap coverage was not observed. S.aureus was the most common pathogen in both groups (50–60%). Microbial associations were isolated in 28.3 and 38% of cases in groups I and II, respectively. 33.3% of patients experienced infection caused by P.аeruginosa. Differences in the blood loss and duration of the surgery were due to the larger volume of the affected tissues in type 4 chronic osteomyelitis of the tibia. High frequency of infection recurrence was observed in patients with microbial associations and P.aeruginosa. The surgical treatment of choice for these patients might be muscle flap coverage. It is necessary to consider the type of a pathogen for systemic and local antimicrobial therapy

A retrospective series of 45 cases of chronic osteomyelitis collected over a period of 14 years was histologically classified into tuberculous osteomyelitis (25) and chronic non-granulomatous osteomyelitis (20). The tuberculous osteomyelitis group was divided into three subgroups: a) typical granulomas (13 cases); b) ill-defined granulomas (seven cases), and c) suspected granulomas (five cases). An in-house polymerase chain reaction amplifying the 245 bp nucleotide sequence, and capable of detecting 10 fg of DNA of Mycobacterium tuberculosis, was used on the DNA extracted from the paraffin blocks. The polymerase chain reaction was positive in 72% of cases (18) of tuberculous osteomyelitis, but when typical cases of tuberculous osteomyelitis with confirmed granulomas were considered (13), this increased to 84.6% (11). The chronic non-granulomatous osteomyelitis group gave positive polymerase chain reaction results in 20% of the cases (4). Our preliminary study on tuberculous osteomyelitis shows that the polymerase chain reaction can be a very useful diagnostic tool, since a good correlation was seen between typical granulomas and polymerase chain reaction with a sensitivity of 84.6% and a specificity of 80%. In addition, our study shows that tuberculous osteomyelitis can be diagnosed in formalin-fixed paraffin-embedded tissues in the absence of typical granulomas

Aim. Local concentration of antibiotic at the site of infection is a major parameter for its efficiency. However, bone diffusion is poor leading either to their non-use (ex: gentamicin) or the use of high concentration (ex: vancomycin). Local administration could optimize their local concentration combined with lower side effects. We report the clinical experience and pharmacological results of an antibiotic loaded porous alumina used to replace infected bone in 4 patients. Method. Two patients had a destroyed sternum following mediastinitis; one presented a femoral chronic osteomyelitis due to MRSA and one had an infected ankle arthroplasty. The ceramic was loaded with gentamicin in three cases and vancomycin for the ankle infection. Local dosages thanks to Redon's drain and blood samples were performed. Loading was done to protect the device while implanted in an infected area and was combined with conventional antibiotic therapy. Results. In comparison to pharmacological parameters: C. max. /MIC>8 for gentamicin or AUC/MIC>400 for vancomycin, local concentrations were dramatically higher than the one needed (table). Vancomycin concentration was still high after H48. Meanwhile, blood samples didn't find the presence of gentamicin during the 48 hours following implantation. After more than one year of follow-up for all the patients, there is no relapse of infection or signs of device infection, whereas all samples perform during implantations grew with bacteria, meaning that loaded antibiotic played a major role avoiding device colonization in combination with surgical debridement and cleaning. Conclusions. This mode of administration allows an optimization of the antibiotic delivery, maximizing local concentrations while reducing systemic toxicity. In addition, ceramic mechanical characteristics allow bone replacement (strength >3 times the one of the cancellous bone and osseointegration) and thus enables one-stage surgery instead of two-stage like for the patient with chronic osteomyelitis thanks to a good primary stability. For any figures or tables, please contact the authors directly

Despite the increase of surgical procedures for extremities injuries and improvement of various fixation devices and surgical methods, the number of unsatisfactory osteosynthesis results reaches 2–7%. Chronic osteomyelitis after lower extremities long bones osteosynthesis occurs in 1.3–23% of cases, and the percentage of bone nonunion due to infections reaches 83%. We conducted a retrospective analysis of 237 patient treatment with chronic osteomyelitis following tibial and femoral bone osteosynthesis. Two groups were selected for the analysis: the first group contained 194 patients treated with sheets and the second one contained 43 patients treated with intramedullary locked nails. In cases of unconsolidated fractures and false joints, the necrectomy was performed with single-step or two-step replacement of internal fixation for external fixation. In this case segmental bone defects reached 20.9% in the first group and 3.6% in the second one. Here the treatment was performed using the Ilizarov method with the bone defect distraction replacement. Conclusions. 1. Chronic osteomyelitis following sheets usage, unlike the osteomyelitis following the intramedullary locked osteosynthesis, leads more often to the formation of edge and segmental bone defects, which significantly prolongs the treatment duration. 2. External fixation application for postoperative osteomyelitis treatment in case of the bone nonunion made it possible to eliminate the purulent process and restore the extremity support function. 3. The inflammatory process relapses reached 14.9% in the first group and 3.1% in the second one

Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability. A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications. Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods. Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery

Aim. Adequate debridement of necrotic bone is of paramount importance for eradication of infection in chronic osteomyelitis. Currently, no tools are available to detect the exact amount of necrotic bone in order to optimize surgical resection. The aim of the present study was to evaluate the feasibility of an intraoperative illumination method (VELscope. ®. ) and the correlation between intraoperative and pathohistological findings in surgically treated chronic fracture related infection patients. Method. Ten consecutive patients with chronic fracture related infections of the lower extremity were included into this prospectively performed case series. All patients had to be treated surgically for fracture related infections requiring bony debridement. An intraoperative illumination method (VELscope®) was used to intraoperatively differentiate between viable and necrotic bone. Tissue samples from the identified viable and necrotic bone areas were histopathologically examined and compared to intraoperative findings. Results. In all included patients, the intraoperative illumination was deemed helpful to differentiate between necrotic and viable bone tissues during bony debridement. The histopathological examination of the samples showed good correlation of the intraoperative illumination findings with histopathological signs of necrosis for areas deemed dead and histopathological signs of intact bone for areas deemed vital during illumination. Conclusions. The fluorescence-assisted, intraoperative detection of necrotic and viable bone using the VELscope. ®. is an easy-to-use procedure that can help surgeons to optimize intraoperative bone resection in chronic fracture related infections by unmasking viable from necrotic bone tissue. This may help to improve resection techniques and eventually treatment outcome in patients in the future

Aim. Eradication of infection in chronic osteomyelitis requires effective dead space management after debridement. Residual bacteria in biofilm may be resistant to normal levels of systemic antibiotic penetrating bone and will contribute to recurrence of osteomyelitis. This study evaluated a new antibiotic-loaded biocomposite in the eradication of chronic infection from bone defects. Patients and Method. We report a prospective study of 100 patients with Cierny and Mader types III and IV chronic osteomyelitis, in 105 bones. Osteomyelitis followed open fracture or ORIF of closed fractures in 71%. Nine had concomitant septic arthritis. 80% had comorbidities (Cierny-Mader Class B hosts). Ten had infected non-unions. All patients were treated by a multidisciplinary team with a single-stage protocol including; debridement, multiple sampling, culture-specific systemic antibiotics, stabilisation, dead space filling with Cerament G™ and immediate primary skin closure. Stabilisation was required in 21 cases and 5 required joint fusion as part of the initial surgery. Plastic surgical skin closure was needed in 23 cases (18 free flaps). Patients were followed up for a minimum of one year (mean 19.5 months; 12–34). Results. Staphylococci were the commonest organism (41.8%), with MRSA in six patients. Proteus mirabilis and Pseudomonas spp were more common in polymicrobial infection, often with a gram-positive organism (usually Staphylococcus aureus). Sixteen patients cultured organisms which were shown to be gentamicin resistant using EUCAST breakpoints. Gentamicin resistance was just as likely to be present in patients with haematogenous infections (3/19; 15.8%) as in post-trauma (13/81; 16%) (Chi-square: p=0.978) Gentamicin resistant organisms were more likely to be found in polymicrobial infections (9/21; 42.8%) than in single isolates (7/79; 8.9%) (Chi-square: p<0.001). Infection was eradicated in 96% with a single procedure and all four recurrences were successfully managed with repeat surgery. All 5 fusions healed and 8/10 non-unions healed with the primary surgery alone. Adverse events were uncommon, with 3 fractures, 6 wound leaks and 3 deaths, unrelated to the infection or surgery. Outcome was not dependant on C-M host class, aetiology of infection, microbial culture, wound leakage or presence of non-union. Conclusions. This protocol, facilitated by the absorbable local antibiotic, was effective in the treatment of C-M types III and IV chronic osteomyelitis. The single-stage approach with high bioavailability local antibiotics is a robust management strategy, applicable across a wide range of patients, including those with significant co-morbidities. It offers a more patient-friendly treatment compared to other published treatment options

Background:. – A multidisciplinary approach is essential to treat chronic osteomyelitis. Surgical debridement of macroscopic infection precedes targeted antibiotics to eradicate microscopic infection. This study analyses early results of our single-stage protocol for chronic osteomyelitis using antibiotic-impregnated calcium sulphate beads (Stimulan). Methods:. – We retrospectively analysed patients with primary or secondary chronic osteomyelitis treated with Stimulan. Patients with incomplete metal-work removal or follow up less than 3 months were excluded. Our study focused on 15 patients (10 male) with an average age of 40.5 years (16–73 years), average follow up of 10.6 months (3 – 21 months). There were 12 cases of secondary osteomyelitis (3 primary). Majority of cases involved the tibia, femur or humerus. Following debridement Stimulan mixed with Vancomycin and/or tobramycin was placed to obliterate dead space and deliver local antibiotics. Intravenous antibiotics, typically piperacillin/tazobactam and/or teicoplanin, were administered post-operatively until tissue culture results were known – rationalised long term antibiotic regimen followed thereafter. Results:. – Staphylococcus aureus was the commonest organism. Follow up monitoring indicated absorption of Stimulan typically by 3 months and no evidence of recurrence based on clinical, radiographic and biochemical parameters. Conclusion:. – Single stage osteomyelitis treatment with Stimulan shows early promising results, is cost effective and decreases the morbidity of further surgery

Aims. CERAMENT|G is an absorbable gentamicin-loaded biocomposite used as an on-site vehicle of antimicrobials for the treatment of chronic osteomyelitis. The purpose of the present study was to investigate the sole effect of CERAMENT|G, i.e. without additional systemic antimicrobial therapy, in relation to a limited or extensive debridement of osteomyelitis lesions in a porcine model. Methods. Osteomyelitis was induced in nine pigs by inoculation of 10. 4. colony-forming units (CFUs) of Staphylococcus aureus into a drill hole in the right tibia. After one week, the pigs were allocated into three groups. Group A (n = 3) received no treatment during the study period (19 days). Groups B (n = 3) and C (n = 3) received limited or extensive debridement seven days postinoculation, respectively, followed by injection of CERAMENT|G into the bone voids. The pigs were euthanized ten (Group C) and 12 (Group B) days after the intervention. Results. All animals presented confirmatory signs of bone infection post-mortem. The estimated amount of inflammation was substantially greater in Groups A and B compared to Group C. In both Groups B and C, peptide nucleic acid fluorescence in situ hybridization (PNA FISH) of CERAMENT|G and surrounding bone tissue revealed bacteria embedded in an opaque matrix, i.e. within biofilm. In addition, in Group C, the maximal measured post-mortem gentamicin concentrations in CERAMENT|G and surrounding bone tissue samples were 16.6 μg/ml and 6.2 μg/ml, respectively. Conclusion. The present study demonstrates that CERAMENT|G cannot be used as a standalone alternative to extensive debridement or be used without the addition of systemic antimicrobials. Cite this article: Bone Joint Res 2020;9(7):394–401

A number of series report limb length discrepancy in long bone chronic osteomyelitis, however in most cases, it is shortening of the affected bone. This is thought to be due to damage in the affected growth plate leading to early growth arrest. However, it is known that the inflammatory state of chronic osteomyelitis results in an increased blood supply and, as in other conditions such as rheumatoid arthritis, the increased blood supply results in overgrowth of the affected bone. In order to study the effect of long bone chronic osteomyelitis on limb length, we designed a prospective trial of 42 consecutive patients presenting to our unit with chronic osteomyelitis of a long bone. The inclusion criteria were all patients presenting with a long bone osteomyelitis. There were no exclusion criteria. The mean age at presentation was 10.3 years. The mean duration of symptoms of 18.2 months prior to presentation. For 37 (88%) of patients the cause of osteomyelitis was haematogenous. On examination, 3 (7%) patients had shortening of the long bone compared to the unaffected side (of an average of 2.5cm), whilst 13 (31%) patients had overgrowth of the affected bone (average overgrowth 2.2cm). The most common bone affected was the tibia (20/42, 48%), followed by the femur (8/42, 19%) and the humerus (6/42, 14%). All patients underwent radiographic analysis, and the average percentage of long bone affected was 59%. 8/42 (12%) of patients had at least one physis affected (2 of these patients had undergrowth and 1 had overgrowth). This large prospective series of patients is the first in the world literature to show the effect of osteomyelitis on the growth of long bones, in particular an overgrowth rate of 31%. We suggest that the mechanism for this is related to the duration of symptoms. In areas of the world where there is poor access to health care, there is consequently a prolonged period of increased blood supply as a result of inflammation. This increased blood supply may make limb length discrepancy is more likely to be due to overgrowth rather than undergrowth

Squamous Cell Carcinoma (SCC) is a rare complication of chronic osteomyelitis (OM), arising in a sinus tract (Marjolin's Ulcer). We routinely send samples for histological analysis for all longstanding sinus tracts in patients with chronic osteomyelitis. We reviewed the clinical features and outcomes of patients with SCC arising from chronic osteomyellitis. A retrospective study was performed of patients with osteomyelitis between January 2004 and December 2014 in a single tertiary referral centre. Clinical notes, microbiology and histo-pathological records were reviewed for patients who had squamous cell carcinoma associated with OM. We treated 9 patients with chronic osteomyelitis related squamous cell carcinoma. The mean age at time of diagnosis was 51 years (range 41–81 years) with 4 females and 5 males. The mean duration of osteomyelitis was 16.5 years (3–30 years) before diagnosis of SCC. SCC arose in osteomyelitis of the ischium in 5 patients, sacrum in 1 patient, femur in 1 patient and tibia in 2 patients. Osteomyelitis was due to pressure ulceration in 7 patients and post-traumatic infection in 2 patients. The histology showed well differentiated SCC in 4 cases and moderately differentiated SCC in 2 cases with invasion. Two patients had SCC with involvement of bone. One patient had metastatic SCC to bowel. All patients had polymicrobial or Gram-negative cultures from microbiology samples. Four patients (57%) in our series died as result of their cancer despite wide resection. The mean survival after diagnosis of SCC was 1.3 years and mean age at time of death was 44.7 years. Two of these patients had ischial disease and were treated with hip disarticulation, hemi-pelvectomy and iliac node clearance. Five patients remain disease free at a mean of 3.4 years (range 0.1 – 7yrs) after excision surgery. One patient in this group underwent a through-hip amputation, one underwent an above knee amputation and one underwent excision of ischium and surrounding sinuses. Of note, all these patients had clear staging scans at time of diagnosis. This case series demonstrates the consequences of an uncommon complication of osteomyelitis. In our series only 3 patients underwent biopsy for suspected SCC due to clinical appearances. The other cases were all identified incidentally after routine histological sampling, demonstrating the importance of this practice

Background. Chronic osteomyelitis with intramedullary sequestrum resulting in persistent infection is a challenging orthopaedic problem that often involves multiple surgical operations and unfortunately has a significant recurrence rate. Reasons for this may include difficulty in eradicating all intramedullary microsequestra making subsequent prolonged antibiotic therapy less effective. Use of the Reamer-Irrigator-Aspirator (RIA) has many advantages for management of intramedullary infections in chronic osteomyelitis. The RIA technique allows irrigation of sterile large quantities of saline with simultaneous bony debridement with very sharp reamers that are specially designed to allow simultaneous fluid aspiration. Purpose. We will illustrate the pearls and pitfalls associated with the RIA technique, based on our experience so far. Method. We retrospectively reviewed a number of 6 (six) patients with chronic osteomyelitis of tibia (n=2) and femur (n=4). In an average follow up of 9.6 months post treatment (range 3–18 months) using a protocol including treatment with RIA we noticed immediate control of infection. Complications. Include pin tract infection, pin site pain and fungal infection (due to prolonged use of antibiotics). Conclusion. Based on our patient series so far, the encouraging results we have seen with regard to eradication of infection lead us to believe that RIA has a valuable role to play in the treatment of chronic osteomyelitis

In case when a cavity is detected in the place of a diagnosed osteomyelitis and when the location of the lesion is in the metaphyseal area, a revision can be done by an endoscopic method, using a standard arthroscopic device. This method was called as “medulloscopy”. In our paper we would like to introduce our first experiences with this method. We performed six surgeries of a chronic tibia osteomyelitis by an endoscopic method (medulloscopy) between January 2012 and December 2014. In four surgeries we treated a proximal metaphyseal tibia osteomyelitis and in two surgeries a distal tibial metaphysis. The group of patients consisted of one female and five male of an average age 50.8 years, with ages ranging between 36 and 82 years. Mean duration of local difficulties preoperatively caused by chronic osteomyelitis was 96 months (from 3 to 304 months). We followed the patients averaged 17.5 months (4–24 months). By April 2015 all six patients (100%) were without need of reoperation for relapse of chronic osteomyelitis. In our opinion the medulloscopy belongs to the spectrum of procedures for the revision of the long bones metaphyses, especially the tibia. The balance sheet for the use of this surgical method must be reasonable in relation to the type of surgery, the limits of arthroscopic instruments and experience of the surgeon. Acknowledgements. Internal grant of University Hospital Motol, Advanced Therapies, NO: 9777, TAČR, NO: TA04010879 and Internal grant of University Hospital Motol, NO: 6010

Aims. Dead space management is an important element in the surgical management of chronic osteomyelitis and can be addressed with the use of a biodegradable local antibiotic carrier. We present the clinical and radiographic outcomes in two different biodegradable antibiotic carriers used in the management of chronic osteomyelitis. Method. A single centre series reviewed between 2006–2017. The initial cohort (2006–2010) of 180 cases (Group A) had a calcium sulphate carrier containing tobramycin (Osteoset. ®. T, Wright Medical). The second cohort (2013–1017) of 162 cases (Group B) had a biphasic calcium sulphate, nano-crystalline hydroxyapatite carrier containing gentamicin (Cerament. TM. G, Bonesupport AB). All cases were Cierny-Mader Grade III and IV and had a minimum of one-year clinical follow-up. Clinical outcomes reviewed included infection recurrence rate, wound leak, and subsequent fracture involving the treated segment. All cases with a minimum one-year radiographic follow-up were reviewed and bone void filling was assessed as percentage filling on the final follow-up radiograph to the nearest five percent increment. Results. Mean follow-up in Group A was 4.2 years (range 1.3–10.5 years) and in Group B it was 1.8 years (1–4.7 years). Group A had a significantly higher rate of infection recurrence (19/180 (10.6%) Vs. 7/163 (4.4%) p=0.030), wound leak (33/180 (18.3.%) Vs. 16/162 (9.9%) p=0.026) and subsequent fracture rate (11/180 (6.1%) Vs. 3/162 (1.9%) p=0.047) compared to Group B. Of the cases with a minimum of one-year radiographic follow-up Group A had 96 cases (mean follow-up 3.3 years, range 1.0–10.5 years) and Group B had 137 cases (mean follow-up 1.6 years, range 1.0–4.7 years). The mean bone void healing in Group B was significantly better than Group A (74.0% Vs. 41.7%, p <0.00001). Conclusions. Cerament. TM. G has significantly better bone healing compared to a calcium sulphate carrier and was associated with a lower rate of recurrent infection, wound leak and subsequent fracture risk

Aim. The current treatment concepts of acute and chronic osteomyelitis are associated with unsolved challenges and problems, underlining the need for ongoing medical research. The invention and prevalence of an absorbable, gentamicin-loaded ceramic bone graft, that is well injectable for orthopedic trauma and bone infections, enlarges the treatment scope regarding the rise of posttraumatic deep bony infections. This substance can be used either for infection, dead-space, or reconstruction management. The bone cement, eluting antibiotics continuously to the surrounding tissue, outperforms the intravenous antibiotic therapy and enhances the local concentration levels efficiently. This study aims to evaluate the power and practicability of bone cement in several locations of bony infections. Method. The occurrence of posttraumatic infections with acute or chronic osteomyelitis increases in trauma surgery along with progression of high impact injuries and consecutively high incidence of e.g. open fractures. We present a case-series of 33 patients (18w/15m; 56,8±19,4 years) with posttraumatic osteomyelitis at different anatomic sites, who were treated in our level I trauma center. All of these patients received antibiotic eluting bone cement (Cerement® G) for infection and reconstruction management. Results. With admission to our trauma-center all patients with obvious or suspected osteomyelitis undergo an interdisciplinary pre-work up, including thorough clinical examination and different measures of diagnostic imaging, ultimately leading to the definition of an individual treatment plan. We diagnosed 33 bone infections anatomically allocated to the proximal and distal femur (12x), the pelvis (2x), distal tibia (3x), tibial diaphysis (10x), the ankle joint (4x) and calcaneus (2x). According to Cierny-Mader we diagnosed grade I (6), II (7), III (13) and IV (7). These 33 patients were treated (1) with surgical debridement, (2) with Cerament G, (3) bone stabilisation (including nail osteosynthesis, arthrodesis nails, plates, or external ring fixation), (4) optionally VAC-conditioning, and (5) optionally soft tissue closure with local or free flaps. The overall number of surgery was 2.9±2.26. We observed very good clinical, functional and radiological results by using bone cement augmented with gentamicin. The overall recurrence rate of infection is low (12%, 4/33). “White fluid” secretion was observed in six cases. Conclusions. Current concepts for treatment of osteomyelitis include radical surgical debridement and additional antibiotic therapy. It could be demonstrated that the usage of an antibiotic biocement with osteoconductive characteristics enlarges the success rate in septic bone surgery. The treatment concepts, however, remain complex, time consuming, require a high patient compliance, and are highly individually

Aims. The use of local antibiotic carriers in the treatment of chronic osteomyelitis is an important adjunct in dead space management. We present the outcomes of two different biodegradable antibiotic carriers used in the management of chronic osteomyelitis. Method. A single centre series between 2006–2017. The initial cohort (2006–2010) of 137 cases, Group A, had Osteoset® T (calcium sulphate carrier containing tobramycin). The second cohort (2013–1017) of 160 cases, group B, had CeramentTM G (biphasic calcium sulphate, nano-crystalline hydroxyapatite carrier containing gentamicin). Only Cierny-Mader Grade III and IV cases were included with a minimum six-month radiographic follow-up. Infection recurrence rate, wound leakage, subsequent fracture involving the treated segment, and radiographic void filling were assessed at a minimum of 6 months following surgery. Results. Mean follow-up in Group A was 2.5 yrs (0.5–10.5) and in Group B it was 1.4 yrs (0.6–4.7). Group A had a significantly higher rate of infection recurrence (16/137 (11.7%) Vs. 7/160 (4.4%) p=0.0278), wound leakage (26/137 (19.0%) Vs. 16/160 (10.0%) p=0.0304) and subsequent fracture rate (11/137 (8.0%) Vs. 3/160 (1.9%) p=0.0143) compared to Group B. Average time to recurrence was 1.07 years (0.1–2.6) in Group A and 1.02 (0.2–2.1) in Group B. The mean bone void healing in Group B was significantly better than Group A (73.2% Vs. 40.0%, p <0.00001). Conclusions. Cerament™ G has significantly better bone healing compared to a calcium sulphate carrier and was associated with a lower rate of recurrent infection, wound leakage and subsequent fracture risk

Aim. Chronic osteomyelitis still remains challenging and expensive to treat in spite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure. Methods. We retrospectively identified eight patients (5 Females) with mean age of 63 yrs (Range 40–71 yrs) Case notes were reviewed for co morbidities, Pre and post treatment inflammatory markers (plasma viscosity and CRP) and clinical staging. Mean follow up was 3 yrs (Range 1–6 yrs). All the patients were jointly operated by orthopaedic and plastic surgeons and underwent thorough debridement and muscle flap (Seven free flaps and one rotational flap) in the same sitting. All the patients were reviewed regularly by plastic and orthopaedic surgeons. Seven patients had free Gracilis flap and one had Triceps flap. Clinical assessment of reinfection was made on presence of erythema and wound discharge. Primary outcome measure was resolution of infection. Results. All patients had full resolution of osteomyelitis as evident by clinical examination and inflammatory markers. One patient had minor wound discharge at three years which settled with conservative management. One further patient developed eczematous dermatitis around the flap which was managed successfully by the dermatologist. Conclusions. We believe this to be the only study in which both the procedures (debridement and muscle flap) are performed in one sitting. This technique is a successful and useful addition to the armamentarium of surgeons in the management of chronic osteomyelitis

Aim. Chronic bone infections and infected fractures are often treated with excision of the dead bone and implantation of biomaterials which elute antibiotics. Gentamicin has been a preferred drug for local delivery, but this could induce renal dysfunction due to systemic toxicity. This is a particular concern in patients with pre-existing chronic renal disease treated with new antibiotic carriers which achieve very high peak levels of gentamicin in the first few days after surgery. Method. 163 patients (109 males; average age 51.6 years) with Cierny-Mader Type 3 or 4 chronic osteomyelitis had a single-stage operation with excision of the dead bone, filling of the osseous defect with a calcium sulphate-hydroxyapatite carrier, containing gentamicin and immediate soft tissue closure. 2. No patient was given systemic gentamicin or other renal toxic antibiotics. Mean carrier volume was 10.9mls (range 1–30mls) and mean gentamicin dosing was 190.75mg (maximum 525mg). Seven patients had pre-existing renal disease (4 diabetic nephropathy, 1 nephrotic syndrome, 1 renal transplant and 1 previous acute kidney injury). Serum creatinine levels were collected pre-operatively and during the first seven days post-operatively. Glomerular filtration rate (GFR) was calculated using the CKD-epi creatinine equation. Renal function was defined using the Chronic Kidney Disease (CKD) Staging system. Results. 155 cases had adequate data to allow calculation of pre- and post-operative GFR. Pre-operative CKD staging demonstrated 118 Class I (normal renal function), 30 Class II, 3 Class IIIa, 3 Class IIIb, and 1 Class V disease. Mean pre-operative GFR (99.7ml/min/1.73m. 2. , SD 21.0) was no different to post-operative GFR (103.2ml/min/1.73m. 2. , SD 21.3), p= 0.0861. Four cases had a >10% decline in GFR below normal, with only one case dropping a CKD stage, from I (normal) to II (mildly decreased). Only 1/7 cases with pre-existing renal disease had a GFR drop of >10% (from 11ml/min/1.73m. 2. to 8ml/min/1.73m. 2. ). 70/155 (45.2%) had a temporary GFR drop post-operatively, with the biggest drop occurring a mean 3.06 days following surgery (SD 2.1). No patient had clinical signs of new acute renal impairment post-operatively. Conclusions. Renal function is not significantly affected by local implantation of gentamicin up to 525mg. The presence of pre-existing renal disease is not a contraindication to local gentamicin therapy

The treatment of chronic osteomyelitis requires both appropriate surgical and antibiotic management. Prolonged intravenous antibiotic therapy followed by oral therapy is widely adopted. Despite this, the long-term recurrence rate is around 20% to 30%. The aim of this cohort study was to examine the effectiveness of surgical marginal resection in combination with local application of antibiotics (Collatamp G - gentamicin in a collagen fleece). Post-operatively this was followed by a short course of intravenous antibiotics, then oral antibiotics, to 6 weeks in total. A cohort of 50 patients from a 10-year period, 2000 to 2010, with chronic osteomyelitis was identified. Most were male (n= 35, 70%) and the average age is 40.9 years (SD 15.9). The mean follow-up duration was 3.2 years (SD 1.8). The average length of admission was 9.8 days (SD 11.4). 6 patients (12%) suffered recurrence of infection requiring further treatment. We used the Cierny and Mader classification to further stratify the patients. ‘A’ hosts had a shorter duration of admission (7.1 days) than ‘B’ hosts (12.3 days). There was no significant difference between recurrence rates of ‘A’ and ‘B’ hosts. Where available, we found pre-operative C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels had no correlation with disease recurrence. Disease-free probability for this cohort compared favourably with a cohort treated with prolonged systemic and oral antibiotics (Simpson and colleagues, JBJS Br 2001). We believe local administration of gentamicin in a collagen fleece is a useful component in the management of chronic osteomyelitis

AIM. Chronic osteomyelitis still remains challenging and expensive to treat inspite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure. METHODS. We retrospectively identified eight patients (5 Females) with mean age of 63 yrs (Range40–71 yrs) Case notes were reviewed for co morbidities, Pre and post treatment inflammatory markers (plasma viscosity and CRP) and clinical staging. Mean follow up was 3 yrs (Range 1–6 yrs) All the patients were jointly operated by orthopaedic and plastic surgeons and underwent thorough debridement and muscle flap (Seven free flaps and one rotational flap) in the same sitting. All the patients were reviewed regularly by plastic and orthopaedic surgeons. Seven patients had free Gracilis flap and one had Triceps flap. Clinical assessment of reinfection was made on presence of erythema, wound discharge, pain and swelling. Primary outcome measure was resolution of infection. RESULTS. Seven patients had full resolution of osteomyelitis as evident by clinical examination and inflammatory markers. Three patients had graft problems to start with, but theses settled within six months One patient had minor wound discharge at three years which settled with conservative management. One further patient developed eczematous dermatitis around the flap which was managed successfully by the dermatologist. CONCLUSIONS. We believe this to be the only study in which both the procedures (debridement and muscle flap) are performed in one sitting. This technique is a successful and useful addition to the armamentarium of surgeons in the management of chronic osteomyelitis. Though our study is small but our results are encouraging

Introduction. The treatment of chronic bone infection often involves excision of dead bone and implantation of biomaterials which elute antibiotics. Gentamicin is a preferred drug for local delivery, but its systemic use carries a well-established risk of nephrotoxicity. We aim to establish the risk of renal injury with local delivery in a ceramic carrier. Materials and Methods. 163 consecutive patients with Cierny-Mader Type 3 or 4 chronic osteomyelitis were treated with a single-stage operation which included filling of the osseous defect with a calcium sulphate-hydroxyapatite carrier containing gentamicin. The mean carrier volume used was 10.9mls, leading to a mean implanted gentamicin dose of 191.3mg (maximum 525mg). Serum creatinine levels were collected pre-operatively and during the first seven days post-operatively. Renal impairment was graded using the Chronic Kidney Disease (CKD) Staging system, and AKI was assessed using the RIFLE criteria. Results. 155 cases had adequate data to allow calculation of pre- and post-operative GFR. 7 patients had pre-existing renal disease. 70 patients (45.2%) had a temporary eGFR drop post-operatively, with the greatest decrease occurring a mean 3.06 days following surgery. Twenty cases had a >10% decline in eGFR, but 12 resolved within 7 days. 7 patients transiently fell into the “Risk” category according to RIFLE criteria, but no patient had a change consistent with “Injury”, “Failure” or “Loss” of renal function and none had clinical signs of new acute renal impairment post-operatively. Conclusions. The implantation of up to 525mg of gentamicin contained within Cerament G, as part of the surgical treatment of osteomyelitis, is safe and carries minimal risk of significant acute kidney injury. A small, transient increase in serum creatinine may be observed in the early post-operative period, and attention should be paid to limit patients exposure to other nephrotoxic agents. The majority of patients will return to their baseline renal function within 7 days following the operation. The presence of pre-existing renal disease is not a contraindication to local gentamicin therapy

Purpose of study: Long bone chronic osteomyelitis may result in limb length discrepancy by shortening of the affected bone when the physis is damaged. Little is known about the rates of overgrowth of infected long bones. This study documents the relative rates of overgrowth and undergrowth in a large series of chronic osteomyelitis patients. Methods: Forty-two consecutive patients presenting to our unit with chronic osteomyelitis of a long bone were included. There were no exclusion criteria. The mean age at presentation was 10.3 years. The mean duration of symptoms was 18.2 months prior to presentation. For 37 (88%) of patients the cause of osteomyelitis was haematogenous. Results: Three (7%) patients had shortening of the long bone compared to the unaffected side (average 2.5cm), whilst 13 (31%) patients had overgrowth of the affected bone (average overgrowth 2.2cm). The tibia was most commonly affected (20/42, 48%), followed by the femur (8/42, 19%) and the humerus (6/42, 14%). The average proportion of long bone involved on X-ray was 59%. At least one physis was affected in 8/42 (12%) patients (2 had undergrowth, 1 overgrowth). Conclusions: This large prospective series of patients shows the effect of osteomyelitis on the growth of long bones, in particular an overgrowth rate of 31%. The mechanism for this is probably related to the duration of symptoms. In areas of the world with poor access to health care, there is consequently a prolonged period of increased blood supply as a result of inflammation. This increased blood supply may make overgrowth limb length discrepancy more likely than undergrowth

Aims: to present a new classification of haematogenous chronic osteomyelitis based on the clinical and radiographic presentation so that a reliable post-surgery prognosis can be done. Methods: between January 2002 and December 2008, 864 children underwent 1632 surgeries for haematogenous osteomyelitis. The clinical and surgical notes were reviewed. Three groups were identified based on clinical and radiographic findings: the first consisting of 565 patients with “ordinary” osteomyelitis requiring treatment of the infection through a sequestrectomy. The second group, classified as “difficult” osteomyelitis, included 134 patients who needed more than one surgery to cure the bone infection. The third group consisted of 165 patients with “complex” osteomyelitis in need of treatment of the infection and its complications, such as pathological fractures, bone loss, and septic arthritis. In the latter group techniques of bone transport, bone graft and radio-ulna/fibula-tibia fusion were used. Results: all the cases of haematogenous osteomyelitis in our series could be classified in one of the following categories and the prognosis and the length of treatment needed to cure this condition appear to be closely related to these. The first group in the CoRSU classification is “Ordinary Osteomyelitis”. The sequestrum is clearly defined and there is a good involucrum on X-ray film. Surgery under tourniquet is possible. In most cases the surgical treatment achieves the healing of the bone and recurrence is uncommon. The second group is classified as “Difficul osteomyelitis”. The bone involved presents with multiple erosions-cavities and there is no clear sequestrum on X-ray film. This category also includes those cases where surgery under tourniquet is impossible. Blood for transfusion must be available. Despite treatment, this type of osteomyelitis often recurs and further surgeries are often needed. All the cases of multiple osteomyelitis are included in this group as well. The third category covers “Complex Osteomyelitis”, whereby chronic osteomyelitis is associated with a pathological fracture or septic arthritis. There is axial deformity, bone loss and non-union. Some sort of reconstruction is always required. Conclusions: Haematogenous chronic osteomyelitis in African children accounts for about 30% of the total number of orthopaedic surgeries performed in our Unit. The classification that is presented here facilitates the planning of the surgery, predicting the prognosis and the length of treatment needed to cure this condition

One of the most challenging cases encountered by orthopaedic surgeons is chronic osteomyelitis. The mainstays of successful treatment include: radical debridement, stabilisation of the bone if necessary; control of infection and finally skin cover or closure. Negative pressure dressings have been used for over 10 years in the treatment of acute and chronic wounds with recognised benefits. Topical negative pressure wound therapy with instillation of solution in the local area (VAC Instill Therapy System®) is a new device available in the armamentarium of a limb reconstruction surgeon. This device automatically delivers instillation fluid into the infected wound, where this fluid is held for a while before application of topical negative pressure. This cycle helps remove infectious material leading to clean closed moist environment for better wound healing. Senior authors (MGD and SLR) have used this VAC Instill therapy in 10 cases of chronic osteomyelitis from April 2007 to November 2008. All patients have been included in this study. All patients had (thorough) bony and soft tissue debridement followed by application of VAC Instill therapy with local delivery of antibiotics. All patients were male with mean age of 39 years (range 20–56 years). There were eight cases of tibial osteomyelitis, one distal radial and one calcaneal osteomyelitis. Most had mixed growth, with Staphylococcus being most common infecting organism. Average duration for VAC Instill therapy was 32 days (range 20–71 days). Average hospital stay was 33 days (range 15–85 days) and average time to wound closure was 39 days (range 19–90). There were two failures of treatment one later had Lautenbach procedure and other had below knee amputation. We conclude that VAC Instill therapy is very successful in the management of chronic osteomyelitis. These are the only early results available in the literature. Further studies are needed to back these findings

Chronic osteomyelitis is a very difficult condition to treat. It presents a considerable challenge. A structured approach with a multidisciplinary team is important. Fifty-three patients with chronic femoral osteomyelitis were treated. Thirty-one cases followed fracture fixation, fourteen haematological, two knee fusion and two iatrogenic. Cierny and Mader grade was IV in twenty-eight cases(twelve non-unions). Union was achieved in eleven of twelve nonunions. 85% of cases were infection free with the current treatment. 92% union rate was achieved. Eradication of infection and functional preservation can be achieved by wide local debridement with good soft tissue coverage and skeletal stabilisation. Chronic osteomyelitis is a very difficult condition to treat. It presents a considerable challenge. A structured approach with a multi-disciplinary team is important. 85% of cases were infection free with the current treatment. 92% union rate was achieved. Eradication of infection and functional preservation can be achieved by wide local debridement with good soft tissue coverage and skeletal stabilisation. Fifty-three patients with chronic femoral osteomyelitis were treated. Mean age at onset was thirty-one years and mean duration of infection was one hundred and six months (range 2–504). Thirty-one cases followed fracture fixation, fourteen haematological, two- knee fusion and two iatrogenic. Cierny and Mader grade was IV in twenty-eight cases(twelve non-unions), III in twelve, II in two and I in eleven cases. Intramedullary disease was treated by reaming and cortical disease by local excision. Radical excision was done for local disease. Radical/segmental excision reserved for type IV disease. This was followed by dead space management (local antibiotics in thirty-eight patients), stabilization and iv antibiotics(four to six weeks). Infected nonunion was treated with excision and stabilization or Ilizarov reconstruction. Union was achieved in eleven of twelve nonunions. 85% of cases were infection free at a mean follow-up of thirty months (7–48)

Aim. This study aimed to define the increased costs incurred by a return to theatre for cases requiring free tissue transfer for surgical treatment of chronic osteomyelitis. We hypothesised that there would be a significantly greater cost when patients required re-exploration of the free flap. Method. We retrospectively analysed the costs of a consecutive series of sixty patient episodes treated at the Bone Infection Unit in Oxford from 2012 to 2015. Treatment involved excision of osteomyelitis with free tissue transfer for immediate soft tissue cover. We compared the costs of uncomplicated cases with those who returned to theatre and determined the profit/loss for the hospital from remuneration through the UK National Health Service Tariff Structure. Results. Hospital income according to UK HRG tariff was compared to the actual cost of treatment and these 60 cases were significantly underfunded overall (P < 0.005). In just 1 case, the cost to the hospital was completely covered by tariff. Six patients (10%) returned to theatre for urgent flap re-exploration with five flaps salvaged and one failed, requiring another free flap reconstruction (1.7%). These six patient episodes had a significantly higher mean cost compared to the uncomplicated cases. The average financial loss to the hospital for patients who did return to theatre was £18992 (range £8103 to £48380) and in those who did not was £9600 (range – £600 to £23717). The case requiring further free tissue transfer cost a total of £74158, £48380 more than the hospital was paid: the most extreme discrepancy. The overall loss for this group of 60 patients was £590766. Conclusions. Surgery for chronic osteomyelitis is multidisciplinary, complex and therefore expensive. However, this study demonstrates that the hospital currently makes a financial loss on almost all patients but especially if flap complications occur. This study has implications for the long term viability of specialist units treating this important disease

The current standard recommendation for antibiotic therapy in the management of chronic osteomyelitis is intravenous treatment for six weeks. We have compared this regime with short-term intravenous therapy followed by oral dosage. A total of 93 patients, with chronic osteomyelitis, underwent single-stage, aggressive surgical debridement and appropriate soft-tissue coverage. Culture-specific intravenous antibiotics were given for five to seven days, followed by oral therapy for six weeks. During surgery, the scar, including the sinus track, was excised en bloc. We used a high-speed, saline-cooled burr to remove necrotic bone, and osseous laser Doppler flowmetry to ensure that the remaining bone was viable. Infected nonunions (Cierny stage-IV osteomyelitis) were stabilised by internal fixation. In 38 patients management of dead space required antibiotic-impregnated polymethylmethacrylate beads, which were exchanged for an autogenous bone graft at six weeks. Free-tissue transfer often facilitated soft-tissue coverage. These 93 patients were compared with 22 consecutive patients treated previously who had the same surgical management, but received culture-specific intravenous antibiotics for six weeks. Of the 93 patients, 80 healed without further intervention. Of the 31 Cierny-IV lesions, 27 healed without another operation, and four fractures required additional bone grafts. No more wound drainage was needed. Treatment was successful in 91% of patients, regardless of the organism involved. There was no difference in outcome in terms of these variables when the series were compared. We conclude that the long-term administration of intravenous antibiotics is not necessary to achieve a high rate of clinical resolution of wound drainage for adult patients with chronic osteomyelitis

Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical debridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience of distraction osteogenesis with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb shortening produced as a result of radical debridement of chronic osteomyelitis. Sixteen patients aged 16 to 63 years underwent radical debridement to treat nonunion associated with chronic osteomyelitis of 8 tibias and 8 femurs. The lesions were staged as Cierny and Mader type IVA (10) and IVB (6). The resulting segmental defects and any limb length discrepancy were then reconstructed by distraction osteogenesis over an intramedullary nail. A monolateral frame was used for the femur, and a ring type external fixator for the tibia. Two patients required local gastrocnemius flaps. Free non-vascularised fibula grafts were added to the regenerate for augmentation of a femoral defect at the time of external fixator removal and locking of the nail. At the latest follow-up, functional and radiographic results were evaluated using the Paley’s criteria. In the femur, the mean defect was 10 centimeters (range 6 to 13 centimeters), while in the tibia it was 8.4 centimeters (range 5 to 11 centimeters). The mean external fixator index was 13.5 days per centimeter, the consolidation index was 36 days per centimeter and the mean time to union at the docking site was 9 (range 5–16) months. The average follow-up was 31.3 months. We obtained 81.25% (13 of 16) excellent results in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, infection was controlled and the non-unions healed. This combined method may prove to be an improvement on the classic techniques for the treatment of long bone nonunions associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. These appears to be no increase in the risk of complications, and the earlier removal of the external fixator is associated with patient comfort, decreases the complication rate and facilitates convenient and quick rehabilitation

The June 2012 Foot & Ankle Roundup. 360. looks at: the Achilles tendon Total Rupture Score (ATRS); endoscopic treatment of Haglund’s syndrome; whether it is worth removing metalwork; hyaluronic acid injection; thromboembolic events after fracture fixation in the ankle; whether surgeons are as good as CT scans for OCD of the talus; proximal fractures of the fifth metatarsal; nerve blocks for hallux valgus surgery; chronic osteomyelitis in the non-diabetic patient; Charcot arthropathy

The appearance of a tumor as a result of chronic osteomyelitis is a relatively rare complication and of late-onset, with a low frequence in the modern world. For the majority of patients, the interval between the onset of primitive osteomyelitis and malignant degeneration is of several decades. We present our cases and the protocol of treatment used. From January 1977 to December 2014 we treated 36 patients (33M, 3F) suffering from squamous cell tumor out of a series of 247 tibial and 74 calcaneal osteomyelitis. 26 patients had chronic osteomyelitis of tibia, 10 of the calcaneus. Based on the functional needs of patients after resection of the tumor, in 18 we applied the Ilizarov apparatus, in 14 we opted for a two steps surgery, with the help of plastic surgeon; four required amputation. 29 patients healed. After 2-years of follow up 3 patients underwent to an amputation in the proximal third of the leg, 4 had a local recurrence. All patients were assessed by SF32 and the QoL test. Squamous cell tumor is the most common malignant tumor in chronic osteomyelitis. For the diagnosis of malignant transformation from a chronic ulcer there is a thorough process. Serial biposies must be performed, especially with the emergence of new clinical signs (increased pain, a bad smell, and changes in secretion by the wound). The definitive treatment is often amputation proximal to the tumor or wide local excision in combination with adjuvant chemotherapy and radiotherapy in selected patients. Early detection can sometimes allow limb salvage. However, the most effective treatment is prevention with the definitive treatment of osteomyelitis, including appropriate debridement, wide excision of the affected area, and early reconstruction

Chronic osteomyelitis is a challenging problem and a growing burden for the National Health Service. Conventional method of treatment is 2 stage surgery, with debridement and prolonged courses of antibiotics. Recently single stage treatment of chronic osteomyelitis is gaining popularity due decreased patient morbidity and cost effectiveness. Dead space management in single stage treatment is accomplished by either a muscle / myocutaneous or antibiotic loaded calcium sulphate beads. We analysed the cost effectiveness of two dead space management strategies in single stage treatment of osteomyelitis. Study is designed to analyse the health economics at 2 time points; 45 days post surgery and 2 years post surgery. We report preliminary results at 45 days post surgery. Setting – Level 1 trauma centre and university hospital. Approval – Ethics committee approved study. 10 patients in each group were retrospectively analysed through patient records. Each group was identified for standard demographics, duration of procedure, hospital stay, type and duration of postoperative antibiotics, number of out patient visits in first 45 days and recurrence of infection. Table attached details the results of both groups. In health technology assessment four quadrant model, CSB appears in quadrant II suggesting that it is more cost effective. Based on small data set and on assessment only evaluating cost, at 45 days assessment, antibiotic calcium sulphate beads from a Health Economic Cost Effectiveness Analysis offers a better economic outcome. This is holding constant the morbidity of the patients and effectiveness, assuming both treatments are standards of care, which is best evaluated at 24 months. Acknowledgements. Biocomposites for funding the cost of health economist

Aim. The ultimate diagnostic proof of chronic osteomyelitis (COM) is the association of a compatible clinical presentation with an unequivocal positive deep bone sample culture. Intraoperative deep bone samples cultures has been widely considered the gold standard in this setting but the preoperative identification of the infecting microorganism through a bone biopsy is of paramount importance in the diagnostic and treatment protocol of any COM. Unfortunately, preoperative bone biopsies have proven to have a broad range of sensitivity values and the most useful biopsy technique remains unknown. The correlation of the preoperative and intraoperative microbiological results is a matter of concern. The purpose of this study was to assess the diagnostic accuracy of a percutaneous bone biopsy (PBB) and an open bone biopsy (OBB) in isolating the infecting organism in cases of lower extremity chronic osteomyelitis. Methods. A retrospective study was done involving 29 patients suspected of COM and where either a PBB or OBB was performed during the preoperative diagnostic workup. Culture results from PBB and OBB were compared with intraoperative tissue cultures at the time of surgery. Epidemiologic data was recorded, Cierny-Mader type, number of samples, susceptibility profile, and technique-related complications. Only tibia and femur osteomyelitis were considered. Results. Finally 29 patients were included in the analysis, twenty were men, with a mean age of 45 years old. In 19 cases the tibia was the involved bone. Type-IV osteomyelitis was the most frequent type of infection. The procedure was made percutaneously in sixteen cases (55%) and open biopsy was performed in thirteen patients. The most common pathogen encountered in our series were the Gram-positive cocci (Staphylococcus aureus in 13.8% of the cases, Coagulase negative Staphylococcus (CoNS) in 27.6% and Streptococus viridans in 3.45% of the cases). Overall, the preoperative bone biopsy sensitivity was 48.2% while the specificity was 52.2%. Positive and negative predictive values were 54.2% and 46.15% respectively. In the case of the drugs most frequently used how local antibiotics, 50% of all Staph. aureus were resistant to gentamicin, 37.5% among CoNS and 20% among Gram-Negative Bacilli. No gram-positive resistance against Vancomycin was founded. Conclusions. According our data, routine bone biopsy does not add a relevant diagnostic value in the preoperative microbiological diagnosis of COM. Although our accuracy is higher than normally reported in the literature, the cost, invasive nature, and the possibility of complications makes necessary to identify which patients could benefit from this diagnostic technique

Aim. Treatment principles of chronic osteomyelitis include debridement, clean sampling, excision of dead bone, stabilization, dead space management, soft tissue closure and systemic antibiotic therapy. Dead space management becomes very complicated, if the bone infection is caused by multi-resistant bacteria. The aim of this investigation was to evaluate the effect of a new vancomycin-loaded hydroxyapatite / calcium sulfate composite. *. in the treatment of chronic osteomyelitis (OM) caused by multi-resistant bacteria. Method. From June 2015 to November 2015, 7 patients (4 males, 3 females, average age 52.6y) were treated according to the above mentioned principles using the new vancomycin-loaded hydroxyapatite / calcium sulfate composite. *. Infections were caused by methicillin-resistant Staphylococcus aureus (MRSA), multi-resistant Staphylococcus epidermidis (MRSE) and polymicrobial, vancomycin-sensitive bacteria. We used a two-stage protocol with debridement, excision of bone and external stabilization in the first stage, followed by bone defect reconstruction. To fill the residual bone defects, in 3 patients the new vancomycin-loaded hydroxyapatite / calcium sulfate composite. *. (10mL) was used on its own and in 4 patients combined with 18mL of an unloaded calcium sulfate / hydroxyapatite composite. **. Post-operative follow-up was evaluated clinically and by radiographs and CT scans at 6, 14 and 24 weeks. Results. In 6 of 7 patients rapid control of infection was achieved. Soft tissue reactions and prolonged white wound drainage (caused by calcium sulfate dissolution) was seen in 3 of 7 patients. In 6 of 7 patients recurrence of infection has not been observed so far. Radiographs showed different elution intervals of the radiocontrast agent (Iohexol), depending on anatomical location. Bone remodelling or replacement of the composite by new bone was not uniform in the patients and showed specific radiographic signs. In addition to the so-called „puddle sign“, we found septae, membranes, vacuoles and sometimes arc-like structures. Therefore, we suggest the name “arc-sign” for these formations. Conclusions. During the follow-up of the first 7 patients treated with the unloaded calcium sulfate / hydroxyapatite composite. **. in 6 of 7 cases no recurrence of infection was observed. This is very promising in the difficult situation of bone infections caused by multi-resistant bacteria. Follow-up radiographs and CT-scans showed specific patterns during the resorption of the composite and the formation of new bone, which have not been described in other bone graft substitutes so far. The bone defects are not completely filled yet, but the affected bones are clinically stable and patients can ambulate with full weight bearing

To evaluate the clinical outcome of three different local antibiotic delivery materials, used as bone defect fillers after excision of chronic osteomyelitis. We reviewed all patients receiving Collagen Fleece with Gentamicin (Septocoll E)(n=74), Calcium Sulphate with Tobramycin pellets (Osteoset T)(n=166) or Calcium Sulphate/Hydroxyapatite biocomposite with Gentamicin (Cerament G)(n=73) for dead space filling after resection of C-M Stage III and IV chronic osteomyelitis. Data was collected on patient comorbidities, operation details, microbiology, postop complications and need for plastic surgery or external fixation. All operations were performed by two surgeons. All patients had similar systemic antibiotic therapy and rehabilitation. Primary outcomes were recurrence rate, fracture rate and wound leakage rate. All three groups had very similar mean age and range, microbiological cultures, need for free muscle flaps or local flaps, proportion of femur, tibia and upper limb bones and use of external fixation. There were small differences in the proportion of C-M Class B hosts and anatomic Type IV cases, between the groups. All patients were followed up for at least one year. Mean follow-up was 1.75 years for Septocoll E, 1.96 years for Osteoset T and 1.78 years for Cerament G. After surgery, there were fewer prolonged wound leaks with Cerament G (leakage persisting for more than 2 weeks). Fracture rates and infection recurrence were twice as common with Osteoset T compared with Cerament G at between one and two years after operation (see Table). The use of a biocomposite material delivering local aminoglycoside was associated with lower recurrence rates and few wound problems, compared with collagen or calcium sulphate alone. This may reflect the higher levels of antibiotic in the defect and controlled release profile. The improved recurrence rate was despite a higher percentage of compromised Class B hosts

Bone infection occurring after fractures or orthopedic surgery can progress to the chronic stage and lead to poor results of treatment. Optimal treatment of chronic osteomyelitis are stabilization the fracture, biological recovery of bone defects and destroy bacterial infection. Traditional methods of treatment are systemic administration of antibiotics and surgical treatment of active infection focus. Systemic antibiotics are part of the standard therapy after surgical treatment of infected bone, but their effectiveness is limited due to malnutrition and low absorption at the site of infection. Moreover, long-term treatment and higher doses are associated with serious side effects. The aim of this investigation was to study the results of the complex treatment of patients with chronic osteomyelitis using biodegradable nanomaterials “PerOssal” as antibiotic delivery system. The study was performed at Regional center traumatology and orthopedics, Karaganda, Kazakhstan. A total 20 patient with post-traumatic/post-operative osteomyelitis were included in this open-label, prospective study. Bacteriological examination was taken with the determination of culture and sensitivity test preoperatively, during and postoperatively. After radical surgical debridement and ultrasound cavitation, the bone cavity was full filled with Perosal which can be loaded with different antibiotics depending from the antibiotic sensitivity test. Postoperative wound is completely was sutured. Systemic antibiotic treatment are allowed. The course of infection was monitored by determination leukocyte count and blood sedimentation rate; blood samples were taken befor, 24 hours after surgery, and on days 3, 7, 10, 14. Wound healing was assessed on days 2, 3, 7, 10, and at the time of removal of sutures. Resorption of implanted beads and bone reconstruction were evaluated by X-ray at after operation and at approximately one, three and six months after implantation. A total of 20 patients (mean age 38,1 (26 to 53), 14 male, 6 female) were treated with Perossal pellets (AAP, Germany) from October 2013 to April 2015. Mean leukocyte counts and blood sedimentation rate were within the normal laboratory range and did not indicate infectious complications during the first 21 days after surgery. Primary wound healing occurred in 18 patients and secondary wound healing in two patients. There were two cases of re-infection during the course of the study, one of them related to an incomplete eradication of infected tissue and multidrug-resistant strain occurring during the course of the study, the other is occurred that patient non-compliance. Radiographic analysis six months after surgery showed progressive resorption of the implanted pellets, but only 10 cases have decreasing size of defects on X-ray. This study in adult patients with chronic post-traumatic/post-operative osteomyelitis demonstrated that these biodegradable bone filler pellets which can be loaded with different antibiotics are a clinically useful local antibiotic delivery system and bone substitute which can be used as an alternative to other anti-infective implants. The implantation of the pellets was safety and well tolerated in all patients. This composite can provide adequate protection against bacterial infection during the first weeks after implantation and to support the bone healing process

Background:. Wide resection of infected bone increases the chances of eradication of infection in patients with chronic osteomyelitis. Aggressive debridement is, however, frequently complicated by the creation of large bone defects. The use of antibiotic-impregnated PMMA spacers, as a customized dead space management tool, has recently grown in popularity. In addition to certain biological advantages, the spacer also offers a therapeutic benefit by serving as a vehicle for delivery of local adjuvant antibiotics. Methods:. This retrospective case series involved 11 patients with chronic osteomyelitis, managed with tibial bone transport through an induced membrane using circular external fixation. All patients were treated according to a standardized treatment protocol and we review the anatomic nature of the disease, the physiological status of the host, the surgical procedures performed, as well as the outcome of treatment in terms of eradication of infection, time to union and the complications that occurred. Results:. Nine patients, with a mean bone defect of 6 cm (range: 2–8 cm) were included in the study. At a mean follow-up of 24 months (range: 14–45 months) eradication of osteomyelitis was achieved in all patients without the need for reoperation for infection. Failure of the skeletal reconstruction occurred in two patients. Six major and four minor complications were experienced. After a mean time of 70 weeks (range: 30 to 104 weeks) in the circular external fixator all but one docking site had united and all regenerated segments were consolidated. Conclusion:. Bone transport, using circular external fixation, through the induced membrane created by the temporary insertion of a PMMA appears to be a useful technique in the management of post-infective tibial bone defects larger than 4 cm in size. Patient selection appears to be a crucial step in ensuring a successful outcome in terms of the resolution of infection

Osteomyelitis is one of the oldest diseases known. It took many years before the acute infection could be brought under control with antibiotics and chronic osteomyelitis remains difficult to manage. The modern history of the disease is reflected in the pages of the

Chronic posttraumatic osteomyelitis (CPTO) is a complex condition that results in considerable morbidity and may be limb threatening. Tibia is the most common site of CPTO, with an average infection rate of 10% for open fractures and 1% for closed fractures. In most cases osteomyelitis is polymicrobial. Staphylococcus aureus is the most common infecting organism present either alone or in combination with other pathogens in 65 to 70% of patients. Adequate soft-tissue coverage is one of the cornerstones in chronic osteomyelitis management. Vacuum-assisted closure (VAC) is frequently used for the treatment of posttraumatic osteomyelitis of the extremities. After debridement and repeated VAC dressing changes, the wounds are closed by secondary suture, split-thickness skin grafts or local flaps. Free muscle flaps are recommended in distal third tibial defects. We present our experience with two case reports. The authors present two cases of type IIIA osteomyelitis according to Cierny-Mader classification, following previous distal third tibial open fractures. Both patients presented with limb deformity, insidious local pain and chronic purulent discharge (without significant local inflammatory signs) after 11 and 24 years of trauma. They were treated with radical debridement of all nonviable and infected tissue, VAC instillation therapy for 3 weeks and transverse rectus abdominis muscle (TRAM) flap defect coverage. Intra-operative cultures were positive for multiple pathogens. Specific antibiotic therapy was performed for each case for 8 weeks. Symptomatic relieve was achieved and C-reactive protein and white blood cell count returned to normal values. No complications were documented. 1 year post-surgery, both patients remain asymptomatic, with no signs of infection, with full flap integrity and gait without assistance. Despite the challenging management of chronic posttraumatic osteomyelitis of the tibia, infection control and a satisfactory functional outcome can be achieved. The cornerstones of management include infection control with surgical debridement, microbial-specific antibiotic administration and soft tissue coverage. VAC instillation therapy has an important role promoting granulation tissue formation and infection eradication. The aggressive approach, even with delay on diagnosis, is the key factor for a worthy outcome. Despite the good results, recrudescence of osteomyelitis is known to occur even years after the original offense is treated

The management of chronic osteomyelitis is fraught with difficulties; a multi-disciplinary team approach is recommended for optimum outcome. Thorough debridement, dead space management and organism targeted antibiotic therapy the gives best clinical results. Calcium sulphate beads impregnated with antibiotic is an absorbable option for prolonged local antibiotic elution and dead space management. This study aims to analyse the early results of single stage management of osteomyelitis with antibiotic impregnated calcium sulphate beads. Following surgical debridement, calcium sulphate impregnated typically with tobramycin and/or vancomycin is inserted to obliterate the dead space. Intravenous antibiotics – typically teicoplanin and piperacillin-tazobactam – are administered until culture results permit rationalisation to narrow spectrum agents. Patients are followed up in Infectious Diseases and Orthopaedic clinics for a period of 12 months and discharged if quiescence is achieved. We conducted a retrospective analysis of our prospective database to identify patients treated with our single stage protocol for chronic osteomyelitis. We excluded patients that had (1) less than 6 months of follow up, (2) incomplete metal-ware removal, (3) patients lost to follow up. Fourteen patients (9 men, 5 women) with mean age of 41 (16–73) years and mean follow up of 9 (6–12) months were included in study. Eleven patients had previous surgeries involving internal fixation; the rest were primary osteomyelitis. Seven patients had washouts and removal of metal-ware procedures for osteomyelitis prior to referral to the bone infection service. Clinical, radiographic, and laboratory (microbiological, biochemical and haematological) methods were used to monitor response to treatment. Cierney-Mader classification determined that 8 patients were classed as type A (normal hosts); 4 as BS (systemically compromised); 2 as BLS (locally and systemically compromised). Anatomic analysis suggested 7 were Type 1 (medullary osteomyelitis); the remaining 7 were type 3 (localised disease). Five patients were staged IA; three each staged IIIA and IIIBS; and one each staged IBs, IBLS, IIIBLS. Staphylococcus Aureus was the commonest causative organism. Follow up radiograph monitoring indicated absorption of the beads by 3 months. There has been no evidence of recurrence based on clinical, radiographic and blood based parameters in all patients. Short-term results of single stage osteomyelitis treatment with calcium sulphate beads impregnated with antibiotics are promising