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Osteomyelitis: Debridement of Sequestra

- See: tibial infection and debridement of tibial fractures

- Discussion:
    - see cierny classifcation
    - a sequestrum is infected dead bone resulting from osteomyelitis;
    - it is secluded from host immune system and is secluded from antibiotics;
    - result is a chronic and persistent of infection;
    - if large sequestra form, continued suppuration may result in formation of sinus tracts that burrow through the soft tissues, exit through skin, and result in the drainage of pus;
    - this chronic form of osteomyelitis is difficult to eradicate and can persist for many years;
    - when chronic osteomyelitis is controlled, disease may become quiescent for long periods;
    - reactivation of quiescent osteomyelitis can occur many years after the original infection;
    - Marjolin’s ulcer:
           - malignant transformation (squamous cell carcinoma) which occurs in response to a chronic draining sinus;
           - may occur in upto 1% of those with draining sinus tract;
           - references:
                 - Malignant lesions arising in chronic osteomyelitis.
                 - Marjolin's ulcer on frostbite.
                 - Images in clinical medicine. Marjolin's ulcer.
                 - Thirty-one cases of Marjolin's ulcer.
                 - Squamous-cell carcinoma complicating chronic osteomyelitis.

- Radiographic Studies: 
    - see radiographic findings in hematogenous om
    - look for bone resorption, periosteal or endosteal new bone formation, cortical irregularities, and sequestration;
    - plain radiographs or tomograms may show a sequestrum, and sinograms may delineate extent of infected area;
    - CT or MRI may help plan the debridement in some cases (if internal hardware is not present);
    - bone labeling techniques:
           - tetracycline bone labeling w/ a Wood's Lamp illumination in the OR  may aid in the debridement of devascularized bone, since well vasculared bone incorporates the tetratcycline, which fluoresces under the Wood's lamp;

- Non Operative Treatment:
    - generally, the presence of a sequestra will not allow successful treatment with antibiotics alone, because antibiotics cannot penetrate avascular tissue;
    - this is analogous to the management of a soft tissue abscess which requires incision and drainage in addition to ATB; 
    - antibiotics for OM

- Operative Treatment:
    - debridement of tibial osteomyelitis
    - tetracycline bone labeling w/ a Wood's Lamp illumination in the OR may aid in the debridement of devascularized bone, since well vasculared bone incorporates the tetratcycline, which fluoresces under the Wood's lamp;
    - intramedullary reaming for debridement: (see reaming of tibia fractures)
           - consider reaming the tibial medullary canal to assist with debridement (including decompression of the sequestrum);
    - debridement should consist of drainage of infected area including any sequestrum;
    - often the draining sinus will exit thru the anteromedial skin (which typically is of poor quality and will not allow primary or secondary closure if included in the debridement);
            - if the anteromedial skin surrounding the sinus is debrided, then flap coverage is often necessary;
            - as an alterantive, consider making a small longitudinal incision over the anterior compartment, in order to gain access to the sequestrum;
                   - w/ this technique, wound closure is not a problem, and following debridement and appropriate antibiotics, drainage from the sinus will cease (and soft tissue coverage is not required);
    - hardware removal:
           - for infections after internal fixation in which fixation is stable, implant may be left in place until union occurs, and then internal hardware is removed along w/ any necrotic or devascularized tissue;
           - i.e., a stable infected union is better than an unstable infected non union;
           - if implant failure has occurred, however, implant usually should be removed & external fixator applied for stability;
    - outcomes:
            - in the report by Simpson, et al (2001),  prospectively studied a consecutive series of 50 patients with chronic osteomyelitis.
                   - patients were allocated to the following treatment groups:
                           - wide resection, with a clearance margin of 5 mm or more;
                           - marginal resection, with a clearance margin of less than 5 mm;
                           - 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
                   - Chronic Osteomyelitis. The Effect of the Extent of Surgical Resection on Infection-Free Survival.

Osteomyelitis of the calcaneus in children.  

Osteomyelitis of the calcaneum.

Partial calcanectomy for the treatment of large ulcerations of the heel and calcaneal osteomyelitis. An amputation of the back of the foot.

Gram-negative osteomyelitis following puncture wounds of the foot.

An aggressive surgical approach to the management of chronic osteomyelitis.

Treatment of sequestra, pseudarthroses, and defects in the long bones of children who have chronic hematogenous osteomyelitis

Fluorescent tetracycline labeling as an aid to debridement of necrotic bone in the treatment of chronic osteomyelitis.

Intracellular Staphylococcus aureus. A mechanism for the indolence of osteomyelitis.

In vivo internalization of Staphylococcus aureus by embryonic chick osteoblasts.

Fatal pulmonary embolization after reaming of the femoral medullary cavity in sclerosing osteomyelitis: a case report.