Chronic Osteomyelitis: staging and treatment

G. Gualdrini*, R. Ben Ayad°, A. Giunti*.
* VII Division of Orthopaedic and Traumatology,
Director Prof. Armando Giunti, Orthopaedic Institute, Bologna, Italy
° Traumatology Department, Central Tripoli Hospital, Director A. Shakshoki

> Presentazione

Chronic Osteomyelitis (CO) is still now a frequent complication. The treatment of this pathology is difficult and very expensive for the Health System. In Italy, there are about 20,000 new cases per year and the real cost of the treatment has not been estimated. To properly approach this pathology, it is necessary to stage the patients with CO. The Cierny Mader Staging System is a useful method to plan the appropriated treatment and to provide the healing percent of the disease.
The Cierny Mader Staging System include 4 anatomic types of bone lesions:

• Type I: Medullary Osteomyelitis
• Type II: Superficial Osteomyelitis
• Type III: Localised Osteomyelitis
• Type IV: Diffuse Osteomyelitis

Based on this classification three groups of patients can be identified:

• Group A: patients with good immune system and delivery
• Group B: Patients locally or Systemically compromised
• Group C: Patient with modest symptoms or judged not a surgical candidate

Type I: medullary localisation is typical of haematogenous osteomyelitis and a septic complications for intramedullary synthesis. Surgical treatment requires the surgical toilet of the septic cavities for the first case and the removing of the nail for the second one. In both cases, it is recommended a continuous postoperative washing for 4 or 5 days with aseptic substances.
Type II: the cortical bone is partially compromised therefore the surgical treatment requires the removal of necrotic bone to reach the bone normally vascularized. In this type, the soft tissue ( cutaneous district) is compromised, this implies that orthopaedic and plastic surgeons cooperate to cover the exposed bone surface by a muscle transplantation or vascularized muscle graft.
Type III: the infection is extended to the cortical bone and to medullary bone cavity which requires a wide sequestrectomy. Similarly to the treatment of Osteomyelis Type II, it must be necessary to cover the cleaned area by a vascularized muscle graft.

Type IV: in this type of osteomyelitis are also included pseudo septic non-unions. The surgical treatment is similar to that applied for localized tumor.
Homerous: septic non-union of the homerous is generally treated by wide bone resection to remove septic bone. The stabilization in compression is achieved by an external fixator.
Forearm: pseudoarthrosis is similarly treated by bone excision and removing of infected tissues. The cavity is filled with antibiotic impregnated cement. After one month, synthesis of radio or/and ulna is obtained by applying a metal plates with a cortical bone opposite plate and by a bone graft between the plates, obtained from muscoloskeletal bank or from the patient.
Femur: If the non-union is characterized by bone losses lower than 3 cm, after septic bone resection, stabilization is achieved by an external fixation with Ilizarov device. If the bone loss is over 3 cm, it is applied the corticotomy and the bone transfer Illizarov technique.
Tibia: infected tibial pseudoarthrosis are treated by wide bone resection of the septic bone and the bone transfer like Ilizarov technique after a metafiseal corticotomy. Elderly patients ( 60-65 ys) can be operated with “Fibular transplantation to the tibia” after bone transfert, to remove earlier the Ilizarov external device.
On the basis of this analysis, we can conclude that the treatment of Osteomyelitis is multidisciplinary. The benefits of an appropriate surgical treatment are enhanced by a synergic stimulation of the immune system, discouraging smoking in smoker patients, an by a hyper baric oxygen therapy. All these approaches can improve the critical situation of a patient affected by Chronic osteomyelitis, favouring his inclusion in a group with a higher possibility of therapeutical success.
For instance, considering the Cierny-Mader staging system, it is an useful approach to include patient from the B clinical group to the A one, or from the group BS to the group BL.