The management of chronic osteomyelitis : Part I – Diagnostic work-up and surgical principles

Abstract

To date, no evidence-based guidelines for the treatment of chronic osteomyelitis exist. Owing to certain similarities, treatment philosophies applicable to musculoskeletal tumour surgery may be applied in the management of chronic osteomyelitis. This novel approach not only reinforces certain important treatment principles, but may also allow for improved patient selection as surgical margins may be customised according to relevant host factors. When distilled to its most elementary level, management is based on a choice between either a palliative or curative approach. Unfortunately there are currently no objective criteria to guide selection of the most appropriate treatment pathway. The pre-operative diagnostic work-up should be tailored according to the relevant objective, albeit confirming the clinical suspicion of the presence of infection, host stratification, anatomical disease classification, pre-operative planning or post-operative follow-up. MRI and PET-CT are emerging as the imaging modalities of choice. Interleukin-6, in combination with CRP, has been shown to have excellent sensitivity in the diagnosis of implant-associated infection. Molecular methods are growing rapidly as the method of choice in pathogen detection. Chronic osteomyelitis, as is the case with musculoskeletal tumours, can only be eradicated through complete resection of all infected bone. Chemotherapy, in the form of antibiotics, only plays an adjuvant role. Dead space management is essential following debridement, and the appropriate strategy should be selected according to the anatomical nature of the disease. Provision of adequate bony stability is crucial as it promotes revascularisation and maximisation of the host’s immune response. Although there is currently a variety of fixation options available, external fixation is generally preferred.