desbridamiento belfast

©l993 British Editorial Society ofBone and Joint Surgery0301-620X/93/3557 $2.00

VOL. 75-B, No. 3. MAY 1993 375

TWO-STAGE MANAGEMENT OF CHRONIC

OSTEOMYELITIS OF THE LONG BONES

THE BELFAST TECHNIQUE

M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN

From Musgrave Park Hospital and the Ulster Hospital, Northern Ireland

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.

J Bone Joint Surg [Br] 1993 ; 75-B : 375-80.

Received 29 May 1992; Accepted 24 September 1992

The development ofnew antimicrobial agents with wide-

spectrum activity and high bioavailability has greatly

improved the treatment of infection in many body tissues,

but this is not the case in infection of bones and joints.

Most patients with established bone infection are not

cured by prolonged antibiotic therapy and almost all

require surgical intervention (Waidvogel, Medoff and

Swartz 1970; Waidvogel and Vasey 1980; Fitzgerald et

M. A. McNally, FRCS, Orthopaedic Registrar, British OrthopaedicAssociation Wishbone Research FellowR. A. B. Mollan, MD, FRCS, FRCS I, Professor of OrthopaedicSurgeryDepartment of Orthopaedic Surgery, Musgrave Park Hospital, Stock-man’s Lane, Belfast BT9 7JB, UK.

J. 0. Small, FRCS I, Consultant Plastic SurgeonThe Ulster Hospital, Upper Newtownards Road, Dundonald, BelfastBT16ORH, UK.

H. 0. Tofighi, MD, Consultant Orthopaedic SurgeonDepartment ofOrthopaedic Surgery, University ofTabriz, Iran.

Correspondence should be sent to Mr M. A. McNally.

al 1985). “The hallmark of chronic osteomyelitis is

infected, dead bone within a compromised soft-tissue

envelope” (Cierny and Mader 1984). This is an important

summary of the disease process, as it highlights those

features which contribute to chronicity and which need

to be dealt with if eradication of infection is to be

achieved.

The need for surgery in the treatment of chronic

osteomyelitis is well recognised, but there is no consensus

on the best method. In 1946, Stark described the

treatment ofpost-traumatic chronic infection by debride-

ment and reconstruction with a pedicled muscle flap. He

stressed the importance of radical removal of dead bone

and the inadequacy of simple sequestrectomy. This has

been supported by more recent work by Cierny and

Mader (1984), Gordon and Chiu (1988) and Yoshimura

et al (1989). Papineau described his technique of excision

and bone grafting with delayed closure in 1973. This was

a significant advance with a good initial cure rate

(Papineau et al 1979). The technique, however, is time-

consuming, requires prolonged hospitalisation and has a

considerable associated morbidity. A 5% amputation

rate has been reported and secondary infection of the

open wound is a problem (Meyer, Weiland and Willeneg-

ger 1975).

In 1982, Mathes, Alpert and Chang showed that

muscle flaps (either local or free-transfer) were highly

resistant to infection and that they provided the “cellular,

non-cellular and oxygen environment” necessary for the

eradication of infection and wound ischaemia associated

with chronic osteomyelitis. Local muscle flaps (Ger 1977;

Fitzgerald et al 1985), delayed free flaps (Weiland, Moore

and Daniel 1984; Gordon and Chiu 1988) and myocuta-neous island flaps (Yoshimura et al 1989) have been used

extensively in the management ofchronic infection with

encouraging results, but problems remain with the long

duration and high cost of treatment, recurrence of

infection and requirement of theatre time. Several

workers have reported the need for amputation despite

extensive surgery (Ger 1977; Papineau et al 1979; Hall,

Fitzgerald and Rosenblatt 1983; Fitzgerald et al 1985;

Gordon and Chiu 1988).

We describe a series of patients managed by a

technique specifically designed to avoid the failings of

376 M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN

THE JOURNAL OF BONE AND JOINT SURGERY

the existing procedures and to reduce the time spent in

hospital, with its attendant morbidity and high cost.

PATIENTS

We treated 37 patients with chronic infection ofthe tibia

(25), the femur (9), the radius (2) and the humerus (1).

There were 28 men and 9 women with a mean age of 42

years (18 to 75), and a median duration of infection of 22

years (1 to 59). All patients had suffered recurring

symptoms with pain and sinus drainage, and had been

treated for prolonged periods with wide-spectrum anti-

biotics. Most had undergone multiple surgical procedures

including sinus curettage, drainage of abscesses and

sequestrectomy. Two had been treated by a modified

Papineau technique.

Chronic infection had followed a compound fracture

(25), plating of a closed tibial fracture (3), gunshot

wounds (3), acute haematogenous osteomyelitis (5) and

internal fixation of a pathological fracture after excision

of an osteoclastoma (1). In those cases in which culture

was positive, multiple organisms were invariably found,

including Staphylococcus aureus, Proteus mirabiis, group

D streptococci, Bacteroides fragiis and Pseudomonas

aeruginosa. Most cultures had a Gram-negative isolate.

All organisms were sensitive to combinations of fluclox-

acillin, Fucidin, Ciproxin, cephamandole, gentamicin

and metronidazole.

TREATMENT

We designed the staged ‘Belfast technique’ for use in any

long bone, based on the following principles : radical

debridement of all compromised tissues ; early provision

of healthy vascularised soft-tissue cover with elimination

of dead space ; delayed autogenous bone grafting when

necessary ; and reduction of inpatient time during

treatment.

The patients were assessed preoperatively by a

plastic surgeon and an orthopaedic surgeon to ascertain

the extent of infected and compromised bone and soft

tissue. Investigation included bacteriology, plain radio-

graphy, tomography, sinography, blood tests and bone

scanning when appropriate. The degree of debridement

required, the method of fixation to be used and the

requirement for soft-tissue reconstruction were then

determined for each patient. At least two antibiotics

were given before surgery.

Stage one. The limb was explored under tourniquet. Skin

incisions were placed along the lines of existing wounds

where possible to minimise further damage to the soft

tissues. Sinuses, when present, were excised elliptically

within the incision. If there was extensive soft-tissue

scarring, wide excision of the poor-quality skin was

undertaken.

Debridement of bone was guided in part by the

preoperative investigations but mainly by the operative

findings. In all cases the excision of bone was radical

with no attempt at a limited resection. All bone showing

an abnormal appearance was removed. Careful assess-

ment of the medullary canal was made by de-roofing

cortical bone. When the debridement was complete, the

defect was copiously irrigated with saline or noxythiolin

solution. The tourniquet was then deflated and the

pattern of bleeding from the bone surfaces was observed.

Any area which failed to bleed was excised back to

bleeding bone. This meticulous exploration and debride-

ment of all infected tissue usually took 30 to 60 minutes

to complete. All resected material was sent for anaerobic

and aerobic culture.

The management ofthe potential dead space created

by the debridement was thought to be important. In the

cases with a large bone cavity which were suitable for

direct closure of the skin, a few strings of gentamicin-

impregnated beads were used to fill the dead space.

Where a muscle flap was used for soft-tissue cover, this

was raised in such a way that it would fill the bone cavity

completely.

The treatment of soft tissues followed one of several

plans. In 23 patients the skin was closed directly. Ten

were managed by free microvascular transfer of a muscle

flap (five rectus abdominis, four latissimus dorsi and one

gracilis), two by local flaps (one soleus and one gastroc-

nemius flap), and two by free composite flaps from the

deep circumflex iliac artery (incorporating a large portion

of iliac crest bone). Muscle flaps were most often

transferred without overlying skin, and thus required

meshed split-skin grafting after anastomosis. Closed-

suction drainage was used in most cases.

The limb was usually protected in a plaster-of-Paris

back-slab or a split cast. External fixation was used only

when bone debridement had resulted in skeletal instabil-

ity.

Postoperatively, strict bed rest was imposed for five

days with elevation of the affected limb. Thereafter, non-

weight-bearing mobilisation was begun. A period for

wound healing was then allowed, averaging 33 days. The

antibiotic regime started before surgery was continued

with oral preparations of the chosen drugs. During this

time most patients were able to leave hospital.

Stage two. This was carried out between three and six

weeks after stage one, when the soft tissues had

adequately healed. Under tourniquet, the bone defect

was exposed through the same incision or along the

margin of the flap, avoiding the vascular pedicle. Any

antibiotic beads were removed and the cavity was

carefully inspected. Exuberant granulations were gently

curetted back to healthy vascularised tissue. A search

was made for areas not covered by fresh granulation

tissue, suggesting non-viability of bone, and any such

area was further debrided. A cancellous bone graft was

then harvested from the iliac crest, cut into small

segments and packed into the cavity. Care was taken to

ensure tension-free closure of the skin. No drainage was

Age

Case (yr)

I 41

2 42

3 29

4 31

Bone

Tibia

Tibia

Tibia

Tibia

Aetlology of infection

Acute haematogenous

Compound fracture

Compound fracture

Compound fracture

Skin cover

Direct closure

Direct closure

Direct closure

Direct closure

Complications

Follow-up

(mdi)

86

69

88

79

5 51 Tibia Compound fracture


7 23 Tibia Excision of osteoclastoma

None

None

None

Split-skin graft to wound

2 weeks post-op

Direct closure 76 Gastrocnemius flap at 2weeks post-op

Duration of

infection �yr)

27

6

11

9

49

46

3

9

18

41

16

59

8 21 Tibia

9 58 Tibia

10 63 Tibia

II 49 Tibia

12 66 Tibia

Compound fracture

Compound fracture

Compound fracture

ORIF closed fracturet

Compound fracture

13 30 Tibia ORIF closed fracture

14 30 Tibia

15 24 Tibia

16 27 Tibia

17 64 Tibia

18 55 Tibia

19 30 Tibia

Gunshot wound

Compound fracture

Compound fracture

Compound fracture

Compound fracture

Compound fracture

Direct closure 84 None

Direct closure 40 Elective repeat. Infected

wound haematoma

Lat. dorsi free flap 33 None

Soleus local flap 41 None

Gracilis free flap 12 None


Rectus abdo. free 20 Noneflap

3 Direct closure 22 Rectus abdo. flap at 2weeks

7 Direct closure 33 None

2 Direct closure 3 1 None

9 Direct closure 22 Discharge at I 2 months

39 Direct closure 12 None

34 Rectus abdo. free 77 Noneflap

Unknown Rectus abdo. free 16 Noneflap

4 Composite DCIA 100 Noneflaps

1 Lat. dorsi free flap 49 Discharge at 24 months

1 Rectus abdo. free 57 Noneflap

I Composite DCIA 121 Minor scar revision at 2

flap years


Rectus abdo. free 27 Secondary infectionflap



Result

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Recurrences

Cured

Cured

Cured

Cured

Recurrence

Cured

Cured

Cured

Recurrence

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Cured






25 41 Tibia ORIF closed fracture

26 38 Radius Acute haematogenous

27 32 Radius Compound fracture

28 46 Humerus Gunshot wound

29 75 Femur Compound fracture



32 65 Femur Gunshot wound

33 46 Femur Brodie’s abscess


35 24 Femur Acute haematogenous

36 27 Femur Acute haematogenous


18

16

3

4

58

35

42

40

2

13

22

13

Unknown

Direct closure

Direct closure

Direct closure

Direct closure

Gastrocnemiuslocal flap

Direct closure

Direct closure

Direct closure

Direct closure

Direct closure

30 None

62 None

66 None

35 None

58 None

37 None

13 None

31 None

29 None

25 None

* infection-free bone union

t ORIF, open reduction and internal fixation� infection-free bone union at ten months after a repeat operation§ DCIA, deep circumflex iliac artery

TWO-STAGE MANAGEMENT OF CHRONIC OSTEOMYELITIS OF THE LONG BONES 377

VOL. 75-B, No. 3, MAY 1993

Table I. Details of 37 patients with chronic osteomyelitis treated by the two-stage Belfast technique



used after stage two. Again a period of bed rest was

imposed with leg elevation. Mobilisation was started and

the patient was discharged when the wounds were healed.

Five patients did not have a second stage to their

treatment. In three the bone defect was small and did not

require grafting, and in two a large vascularised bone

graft was provided in a composite free flap at stage one.

Stabilisation and antibiotics were continued until

there was radiological and clinical evidence of union.

RESULTS

All 37 patients were followed up for a mean of49 months

(12 to 121). Eradication of infection with bone union was

achieved in 34 (92%). No case resulted in amputation.

Details of the patients are given in Table I.Three limbs had recurrence of deep infection, all in

patients with tibial disease. One of these (case 25)developed an abscess under a rectus abdominis free flap.

At the second stage the bone cavity was seen to be well

lined with granulation tissue and there was no evidence

of residual dead tissue or infection. The abscess was

thought to be due to secondary infection at the time of

the stage-two operation.

Two patients (cases 16 and 21) returned at 12 and 24

months respectively with symptoms and signs of recurrent

deep infection. Case 16 was a 27-year-old man who had

had chronic infection of his tibia for nine years after a

compound fracture. After stage one there was no difficulty

with direct skin closure and healing proceeded rapidly

with no evidence of underlying infection. Five weeks

after stage one, a bone graft was inserted. At this stage

the cavity was clean and infection-free. With the bone

chips in place, however, it was much more difficult to

effect direct skin closure although this was achieved.

Postoperatively, the wound remained inflamed and at 12

months it broke down and discharged infected material.

We repeated our technique using a gracilis free flap for

skin cover, but this flap failed. The resulting skin defect

was then treated by a local fasciocutaneous flap. This

patient has been followed for ten months since then and

is symptom-free with a healed wound and a united

fracture.

Case 21 returned with a swollen, painful leg and a

discharging sinus two years after his operations and

radiography confirmed the presence of a recurrence of

deep infection.

Four patients developed wound problems in the

three weeks after stage two. All had been managed

initially by direct skin closure, and all required revision

of their skin cover. One (case 4) required split-skin

grafting at three weeks, one (case 5) required a local

gastrocnemius muscle flap at two weeks, and one (case

I 3) was treated by a free rectus abdominis muscle flap at

two weeks. The fourth patient (case 7) developed an

infected haematoma at the margin of a rectus abdominis

free flap, applied during a previous attempt to eradicate

the infection. This was evacuated but it was decided to

repeat both stages of the technique rather than risk

extension to the underlying tibia. These four patients are

now an average of 54 months from surgery (minimum

22) and all have progressed to sound infection-free union.

Illustrative case report. A 66-year-old man (case 1 2) was

referred to the orthopaedic clinic with severe osteo-

arthritis of the right hip. He also had an extensive area

ofatrophic skin with discharging sinuses over the anterior

surface of his right tibia (Fig. 1). Radiography showed

widespread infection ofthe entire diaphysis and proximal

Fig. 1 Fig. 2

Case 12. Figure 1 - The appearance of the tibia at presentation. Chronicinfection had resulted from a compound fracture 59 years previously.Figure 2 - The radiograph shows extensive involvement of the proximalmetaphysis and almost all the diaphysis.

metaphysis (Fig. 2) which had followed a compound

fracture to his tibia 59 years previously. The tibia was

constantly painful and periodically discharged pus and

pieces ofdead bone. He had undergone several operations

including sinus curettage and sequestrectomy.

He was treated by the standard two-stage Belfast

technique. At stage one we performed a radical clearance

of all necrotic tissue and widely excised all atrophic or

infected skin (Fig. 3). The defect was closed by a free

rectus abdominis muscle-only flap covered with meshed

split-skin graft, and the limb was protected in a plaster

back-slab. The postoperative radiograph shows the extent

ofthe bone resection (Fig. 4). A period ofnine weeks was

allowed for full wound healing and during this time he

was allowed home, non-weight-bearing on crutches. At

Fig. 5

Fig. 6

TWO-STAGE MANAGEMENT OF CHRONIC OSTEOMYELITIS OF THE LONG BONES 379

VOL. 75-B, No. 3, MAY 1993

stage two, the flap was lifted along its lateral edge,

avoiding the vascular pedicle, and a thorough inspection

of the area undertaken. The large cavity was seen to be

fully lined with healthy granulation tissue and no further

debridement was necessary. Iliac crest bone graft was

inserted as bone chips and the wound was closed and a

back-slab provided.

Fig.3 Fig.4

Figure 3 - Stage one of the operation. Wide excision of all deadand compromised bone and soft tissue has been carried out. Theresulting defect was filled by a free rectus abdominis muscle flap.Figure 4 - The postoperative radiograph shows the extent of thebone resection.

Postoperatively, he made excellent progress with

rapid wound healing and mobilisation. At three months

there was no sign of infection and good consolidation of

the bone graft had occurred. At this time it was considered

that he should have treatment for his osteoarthritis and

we performed a Charnley cemented total arthroplasty

without complication. He regained a full range of hip,

knee and ankle movements (Fig. 5). When reviewed 20

months after his first operation he was symptom-free

with well-healed wounds (Fig. 6). He now feels well, has

an improved appetite and is gaining weight after many

years of ill health.

DISCUSSION

We have shown that the Belfast technique effectively

treated established bone sepsis, and achieved eradication

of infection and bone union in 34 out of 37 cases.

Recurrence can also be treated by repeating the two

stages ofthe procedure. The technique works by breaking

the cycle of bone death, sequestrum formation, spread of

infection and further bone death. Chronicity is encour-

aged by local ischaemia (Trueta 1953), and Gristina et al

Nine months after the stage-two operation, and sixmonths after a THR, the patient had a good range of hip,knee and ankle movements.

Two years later, the limbremains well healed witha tibia free of infectionfor the first time in 60years.

(1985) have shown that non-viable bone stimulates

adherence and colonisation by pathogenic bacteria. This

then leads to further ischaemia and further multiplication

of bacteria. Such areas of tissue are poorly accessible to

the host’s immune system. We believe that the success of

surgical treatment depends mainly on the total removal



of the ischaemic tissues. In our patients the debridement

was always extensive with no attempt to preserve diseased

bone or soft tissue. This radical approach creates large

defects which must then be filled ; the skills of a plastic

surgeon are most valuable during the first stage of the

procedure.

The work of Ger (1977) and Chang and Mathes

(1982) suggests that the provision of healthy soft-tissue

cover to an adequately debrided area allows revascular-

isation to occur. We have shown that in some cases it is

sufficient to close the wound directly without the need to

import new vascularised tissue. Direct closure should

only be considered if, after debridement, the wound can

be closed without tension and if the overlying skin is

healthy and free from scarring. Care must be taken to

eliminate dead space, and to this end we have used

antibiotic-impregnated beads in a few cases.

Three of our patients treated by direct closure of the

skin required revision within three weeks of stage two,

but none had difficulty after stage one. When bone chips

had been inserted into the bone cavity, the less supple

skin proved more difficult to close. We consider that

these three patients represent failures ofthe preoperative

planning ; all were assessed initially without the advice

ofa plastic surgeon. We now recommend that all patients

should bejointly examined before any surgical procedure.

The Belfast technique reduces the length of time

spent, and thus the cost incurred, in treatment. No

patient spent more than six weeks as an inpatient.

Assessment at an average follow-up of 49 months can

only be regarded as an early review in this most

recalcitrant of conditions. The removal of all affected

tissue, however, and the provision ofhealthy vascularised

soft-tissue cover have been shown to give, at least, long

periods of remission.

M. A. McNally wishes to thank the British Orthopaedic AssociationWishbone Appeal for their financial support.

No benefits in any form have been received or will be receivedfrom a commercial party related directly or indirectly to the subject ofthis article.

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