The management of chronic osteomyelitis: Part II - Principles of post-infective reconstruction and antibiotic therapy

Abstract

Over the past few decades considerable progress has been made in terms of our ability to reconstruct post-infective soft tissue and bone defects. Soft tissue reconstruction is not always required and it is frequently possible to achieve a tension-free closure of well-perfused tissue following debridement. It is now generally accepted that primary closure of the wound, be it by direct suturing or tissue transfer, may be performed at the same sitting as the debridement. In cases were debridement has resulted in tissue loss, muscle or musculocutaneous flaps appear to be superior to random-pattern flaps in achieving resolution of infection. The management of bone defects is dependent on several factors including the host's physiological status, the size of the defect, duration of the defect, quality of the surrounding soft tissue, the presence of deformity, joint contracture / instability or limb length discrepancy, as well as the experience of the surgeon. Surgery remains the mainstay of treatment when a curative treatment strategy is selected. As is the case with chemotherapy for bone tumours, antibiotic therapy fulfils an adjuvant role in curative management strategies. The choice of antibiotic, in this setting, remains a very difficult one and there are many problems with the interpretation of 'cure rate' data. The controversy surrounding the optimal duration and route of antibiotic therapy has not been resolved. The second role of antibiotics in the management of chronic osteomyelitis is disease suppression as part of a palliative treatment strategy. Further studies are required to clarify which patients may successfully be treated with antibiotics alone.