Abstract
Purpose
To determine an optimal osteotomy criterion for patients with Cierny-Mader stages III and IV chronic osteomyelitis.
Methods
Seventy patients with Cierny-Mader stages III and IV chronic osteomyelitis admitted to the Department of Orthopedics of a Class III Grade A Hospital from January 2018 to March 2022 were selected for retrospective analysis and study. The following patient data were collected: gender, age, site of infection, bacterial culture results, internal fixation status, bone defect length, BMI, history of diabetes mellitus, smoking history, and history of preoperative antibiotic use. The patients were treated with sensitive antibiotics after surgery, followed up regularly, and venous blood C-reactive protein (CRP), sedimentation (ESR), white blood cells (WBC) and muscle strength (MTT scale), joint mobility (neutral 0° method), and bony healing time were measured to observe the recurrence rate of osteomyelitis and to assess the recovery of limb function according to the Enneking scale.
Results
Among the 70 patients, 20 cases were guided by X-ray, 30 cases by MRI, and 20 cases by SPECT. All patients underwent thorough debridement under the guidance of imaging modalities followed by external fixation. All cases were followed up and with a mean follow-up time of (12.2 ± 3.2) months. The recurrence rate of 35% in patients with X-ray as a guide was significantly higher than that of patients with MRI as a guide (10%) and SPECT as a guide (5%), and the difference between the three groups was statistically significant (P < 0.05).
Conclusion
For patients with osteomyelitis without metal internal fixation, the osteotomy surgical technique with MRI to guide the expansion of 0.5 cm distally and proximally, or with SPECT imaging to guide the surgical procedure in the area with 30–40% of the radioactive count contour (isocontour, ISO) had the advantages of low recurrence rate and good recovery of limb function, and the differences were not statistically significant. For patients with osteomyelitis with metal internal fixation, the osteotomy surgical technique with SPECT to guide the surgical procedure had the advantages of low recurrence rate and good recovery of limb function. In patients with osteomyelitis with metal internal fixation, SPECT was used as a guide to determine the extent of the osteomyelitis lesion, and osteotomy in the area with 30–40% of ISO was more effective than MRI.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12891-025-09121-w.
Keywords: Cierny-Mader stages III and IV chronic osteomyelitis, Osteotomy range, X-ray, MRI, SPECT
Introduction
Osteomyelitis is a serious infection of the bone, also referred to as a “second cancer” [1]. In recent years, with the advances in antibiotics and development of surgical techniques, the diagnosis and treatment of osteomyelitis have improved over the last few years and achieved certain results, but its recurrence rate is still as high as 20–30% [2, 3]. Surgery is the main treatment for chronic osteomyelitis, and thorough debridement is the key to treating severe osteomyelitis [4], but the uncertainty regarding the extent of surgical debridement often leads to recurrent infections. Treatment of osteomyelitis using segmental osteotomy followed by external fixator fixation has the advantage of low recurrence rate [3], but there is no standard in the literature for the extent of osteotomy required.
The radiographic features of chronic osteomyelitis include: periosteal reaction, bone destruction with osteosclerosis, dead bone, and bone abscess [5]. Therefore X-rays are used as a guide when osteosclerotic borders are used as a criterion for osteotomy. The bone necrosis and bone encrustation are characteristic features of chronic osteomyelitis [6]. The bone crust is a thickened and sclerotic envelope around the dead bone, which will form an inflammatory edema area visible on MRI, so we use the contour of the inflammatory edema area as the standard for osteotomy when MRI is used for guidance. In recent years, after its development, SPECT imaging has been used in the treatment of osteomyelitis. Using the radioisotope technetium 99 (99mTc) to label methylene diphosphate (MDP), single-photon emission computed tomography/computed tomography(SPECT/CT) fusion images revealed that the radioactivity levels are high in bone tissue with high MDP deposition and low in bone tissue with low MDP deposition, showing a decreasing performance from large to small, which is consistent with the gradual reduction of inflammatory stimulation and thus the clinical manifestation can be detected by ISO [7]. We found in our clinic that the bone tissue gradually showed a normal trend in terms of color and texture when the ISO was within the range of 30–40%, and the bone quality was essentially normal in the range of less than 30%. Therefore, we chose the ISO in the range of 30–40% for osteotomy, which can effectively remove the necrotic bone tissue and avoid the adverse consequences due to a too large extent of osteotomy.
Information and methods
General data
A total of 70 patients with Cierny-Mader stages III and IV chronic osteomyelitis admitted to the Department of Orthopedics of a Class III Grade A Hospital from January 2018 to March 2022 were selected for this study, all of whom were treated with surgical debridement osteotomy plus external fixation and postoperative application of sensitive antibiotics. X-ray guided osteotomy was performed in 20 patients in group A, MRI guided osteotomy was performed in 30 patients in group B, and SPECT guided osteotomy was performed in 20 patients in group C. The differences in general conditions between the two groups were not statistically significant (P < 0.05) and were comparable. Among the 70 patients included in this study, the mechanisms of bone defect included post-traumatic fracture-related infection (85%, n = 59), hematogenous infection (10%, n = 7), and other causes (5%, n = 4). The bacterial culture positivity rate was 81.4% (n = 57), with Staphylococcus aureus (43.9%, n = 25), Pseudomonas aeruginosa (21.1%, n = 12), and α-hemolytic Streptococcus (15.8%, n = 9) being the top three pathogens. Fifty-eight patients (82.9%) had received ≥ 2 weeks of oral or intravenous antibiotic therapy preoperatively, of whom 42 cases (72.4%) were treated with broad-spectrum β-lactams.
Diagnostic criteria
(1) history of trauma and fracture; (2) local erythema, pain, and sinus tracts with repeated pus flow; (3) laboratory tests, relevant imaging examinations, and intraoperative tissue bacterial culture and pathological tests, clearly diagnosed as Cierny-Mader stages III and IV chronic osteomyelitis.
Inclusion criteria
(1) Those who met the above diagnostic criteria and were infected after traumatic fracture surgery; (2) those who had chronic osteomyelitis by intraoperative tissue sampling for pathological examination; (3) those who had Cierny-Mader stages III or IV; (4) those who were in good physical condition, without major medical diseases and could tolerate surgery; (5) those who agreed to undergo surgical external fixation treatment.
Exclusion criteria
(1) those with incomplete follow-up data; (2) those patients who follow up with shedding.
Treatment method
After the patient was admitted to our hospital, the relevant examinations were completed, and a bacterial culture and drug sensitivity test were performed with the secretion of the sinus tract, and the anti-infection treatment was started after screening for sensitive antibiotics. Preoperatively, the extent and length of the osteotomy were determined based on the patient’s imaging data. In group A patients, the contour of the osteosclerotic area was used as the standard for osteotomy until the “red pepper” sign was observed with fresh blood leakage (Fig. 1). In group B patients, the contour of the inflammatory edema area was used as the standard when using MRI for the guidance, and the osteotomy was performed by expanding 0.5 cm distally and proximally accordingly (Fig. 2). In group C patients, the osteotomy was performed in the area with ISO of 30–40% using SPECT for guidance (Figs. 3 and 4). Preoperative measurements of the osteotomy boundaries (superior and inferior margins) and length were performed using bony landmarks on coronal and sagittal imaging planes. Intraoperative fluoroscopic guidance was utilized to confirm the resection range. In cases of discordance where potential bone involvement lacked definitive radiological pathology but warranted consideration of the “red pepper sign,” the osteotomy primarily referenced SPECT-defined regions with ISO of 30%−40%. Concurrently, intraoperative exploration was integrated: visually identified suspicious necrotic tissues were prudently resected even if they did not meet the “red pepper sign” criteria. This protocol prioritized thorough debridement while maximizing preservation of viable bone tissue. As the presence of metal internal fixation at the onset site had an impact on the discernment of the extent of the lesion in some patients, the recurrence rates in patients with or without internal fixation devices in groups B and C were compared. Intraoperatively, if there was an internal fixation device, the internal fixation was removed intraoperatively, and necrotic and granulation tissues were thoroughly removed, using scalpel instead of electric knife in order to observe the edges of the normal tissue. During the surgery, extensive irrigation was performed using normal saline, povidone-iodine, and Benzalkonium Bromide Solution in alternating sequence, followed by placement of a negative-pressure drainage tube for continuous drainage over 48–72 h. Post-debridement bacterial cultures were obtained using cotton swabs sampled from different surgical sites. Bone defect reconstruction strategies were determined by defect size: autologous bone grafting was employed for defects ≤ 5 cm, while the Ilizarov bone transport technique (distraction rate: 1 mm/day) was adopted for defects > 5 cm. Debridement of bone ends and bone grafting should be performed when the transported bone segment is nearing the docking site during bone transport. Primary closure was performed when skin conditions permitted; otherwise, vacuum sealing drainage (VSD) negative pressure suction was initially applied followed by secondary wound closure. The closing of the skin defect was performed with a large area of second-stage skin grafting, and sensitive antibiotics were administered intravenously in the hospital for one week after surgery according to the bacterial culture results and drug sensitivity test according to the standard, and the corresponding oral dosage of sensitive antibiotics was given for five weeks after discharge (Fig. 5).
Fig. 1.
X-Ray image and osteotomy range of osteomyelitis
Fig. 2.
MRI image and osteotomy range of osteomyelitis
Fig. 3.
SPECT image and osteotomy range of osteomyelitis
Fig. 4.
SPECT image and osteotomy range of osteomyelitis
Fig. 5.
Picture of a surgical osteotomy
Observation indexes and evaluation criteria
Inflammatory index testing
After the operation, we followed up every two weeks in the outpatient clinic, and measured venous blood inflammatory indexes CRP, ESR and WBC and recorded the data.
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Functional evaluation
One month after the operation, X-ray films were taken to observe bone growth, and functional assessment was performed, including muscle strength (MTT scale), joint mobility (0° in neutral position), and final bone healing time was recorded. The patients’ limb function recovery was also assessed according to the Enneking scale (excellent: 24–30 points; good: 19–23 points; acceptable: 12–18 points; poor: <12 points). Primary endpoint: Recurrence-free status at 1 year postoperatively, defined as absence of localized erythema/swelling, sinus tracts, normalized CRP/ESR levels, and no radiographic evidence of new osteolytic lesions. Secondary endpoints: Time to radiographic bone union and achievement of Enneking score ≥ 19 (indicating good or excellent functional outcomes).
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Recurrence rate
Recurrence of infection was based on local symptoms and signs, such as sinus tract formation, exudation, erythema, and X-ray manifestations, as well as systemic symptoms, such as elevated CRP and ESR, and fever.
Statistical analysis
SPSS 26.0 (IBM Corporation, Armonk, NY, USA) software was used for statistical analysis. Quantitative data were statistically analyzed by t-test and one-way ANOVA, and count data were statistically analyzed by χ2 test and Fisher’s exact test. The confidence interval was set at 95%, and P < 0.05 was considered statistically significant.
Results
The intraoperative osteotomy length was consistent with the preoperative assessment of the range in all patients, and all patients were followed up for a mean follow-up period of 12.2 ± 3.2 months. Post-debridement bacterial cultures were uniformly negative.
Baseline characteristics
No significant intergroup differences in demographics, infection sites, or risk factors (BMI, diabetes, smoking) were observed (Table 1, P > 0.05).
Table 1.
Comparison of patients’ general conditions
| Group | A | B | C | χ2/F | p | ||||
|---|---|---|---|---|---|---|---|---|---|
| n | 20 | 30 | 20 | ||||||
| Gender | Male | 12 | 16 | 13 | 0.697 | 0.706 | |||
| Female | 8 | 14 | 7 | ||||||
| Age(x ± s, years) | 54.75 ± 7.48 | 54.75 ± 7.48 | 54.75 ± 7.48 | 1.641 | 0.201 | ||||
| Area | Femur | 5 | 9 | 4 | 2.644 | 0.852 | |||
| Tibia | 8 | 12 | 12 | ||||||
| Humerus | 5 | 7 | 3 | ||||||
| radius | 2 | 2 | 1 | ||||||
| Bacterial culture | Positive | 17 | 25 | 16 | 0.184 | 0.912 | |||
| Positive rate | 85% | 83.3% | 80% | ||||||
| Internal fixation | Yes | 6 | 7 | 11 | 0.559 | 0.062 | |||
| No | 14 | 23 | 9 | ||||||
| BMI(kg/m2) | 23.3 ± 4.5 | 23.4 ± 4.0 | 23.5 ± 3.6 | 1.813 | 0.922 | ||||
| Smoking | Yes | 4 | 10 | 5 | 1.144 | 0.564 | |||
| No | 16 | 20 | 15 | ||||||
| Diabetes | Yes | 2 | 6 | 3 | 0.917 | 0.632 | |||
| No | 18 | 24 | 17 | ||||||
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Primary outcomes stratified by imaging modality and risk factors
As shown in Table 2, the differences in recurrence rates and osteotomy length among the three groups were statistically significant. The osteotomy length ranged from 3.5 to 12.8 cm (mean 6.3 ± 2.1 cm), with mean bone defect measurements of 5.6 ± 1.8 cm in Group A, 6.8 ± 2.1 cm in Group B, and 6.4 ± 1.7 cm in Group C. Bone reconstruction strategies were selected based on defect dimensions: autologous bone grafting was implemented for defects ≤ 5 cm (Group A: n = 8; Group B: n = 12; Group C: n = 7), while the Ilizarov bone transport technique was utilized for defects > 5 cm (Group A: n = 12; Group B: n = 18; Group C: n = 13). The results revealed as shown in Table 3, that there was a difference in bone healing time and osteotomy length between group A and groups B and C, which was statistically significant (P < 0.05), but there was no statistically significant difference between groups B and C (P = 0.743). Table 3 demonstrates that Group A achieved the highest recurrence regardless of internal fixation status. The SPECT group had a lower recurrence rate with internal fixation and the MRI group had a lower recurrence rate without internal fixation.
Table 2.
Comparison of bony healing time and recurrence
| Group | n | Bone healing time/months |
Recurrence(number%) | osteotomy length(x ± s, centimeter) | |
|---|---|---|---|---|---|
| Recur | Recurrence rate | ||||
| A | 20 | 9.6±3.17 | 7 | 35% | 5.6 ± 1.8 |
| B | 30 | 11.6±4.37 | 3 | 10% | 6.8 ± 2.1 |
| C | 20 | 11.2±3.95 | 1 | 5% | 6.4 ± 1.7 |
| F/χ2 | 3.357 | 6.903 | 2.354 | ||
| p | 0.041 | 0.03 | 0.023 | ||
Table 3.
Recurrence stratified by internal fixation across all groups
| Group | With Internal Fixation | Without Internal Fixation | ||||
|---|---|---|---|---|---|---|
| n | Recurrence | Rate | n | Recurrence | Rate | |
| A | 6 | 3 | 50.0% | 14 | 4 | 28.6% |
| B | 7 | 3 | 42.9% | 23 | 0 | 0.0% |
| C | 11 | 0 | 0.0% | 9 | 1 | 11.1% |
| P | 0.003 | 0.012 | ||||
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Secondary outcomes (functional recovery, inflammatory markers)
Comparison of inflammatory indexes: The WBC, CRP, and ESR of the three groups patients all returned to the normal range two weeks after surgery, and the differences were not statistically significant (P > 0.05) (Table 4). In addition, there was no statistically significant difference between the three groups in terms of muscle strength, joint mobility and other limb function recovery (Table 5).
Table 4.
Comparison of venous blood test indexes at 2 weeks after surgery
| Group | n | WBC/×10·9 L−1 | ESR/mm·h−1 | CRP/mg·L−1 |
|---|---|---|---|---|
| A | 20 | 7.98±1.59 | 13.15±6.34 | 6.51±3.19 |
| B | 30 | 8.69±1.62 | 14.60±6.78 | 7.77±3.37 |
| C | 20 | 8.24±1.77 | 15.05±7.13 | 7.58±3.47 |
| F | 1.181 | 0.442 | 0.917 | |
| p | 0.313 | 0.645 | 0.405 |
Table 5.
Comparison of recovery of limb function (number%)
| Group | n | Excellent | Good | Acceptable | Poor | χ2 | P |
|---|---|---|---|---|---|---|---|
| A | 20 | 12(60) | 5(25) | 1(5) | 2(10) |
3.158 0.819 |
|
| B | 30 | 15(50) | 5(16.7) | 5(16.7) | 5(16.7) | ||
| C | 20 | 10(50) | 4(20) | 4(20) | 2(10) | ||
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Subgroup analyses
Table 6 showed that in the MRI-guided group (Group B), the recurrence rate of diabetic patients (33.3%) was significantly higher than that of non-diabetic patients (6.7%, P = 0.041). Obesity (BMI ≥ 30 kg/m²) significantly increased the risk of recurrence, especially in the X-ray-guided group (Group A: OR = 6.0, P = 0.041). In the MRI and SPECT-guided groups, the recurrence rate of obese patients was as high as 50%, significantly higher than that of non-obese patients (Group B: OR = 16.0, P = 0.021; Group C: P = 0.033). Notably, obesity increased the risk of recurrence by at least six times under all imaging guidance methods. Smoking significantly delays bone healing time (Table 7). In the overall cohort, the average healing time for smokers was 13.2 ± 4.1 months, which was 2.9 months longer than that of non-smokers (10.3 ± 3.2 months) (P < 0.001). This delay was most pronounced in the X-ray guided group (Group A): the healing time for smokers was 14.5 ± 3.8 months versus 8.9 ± 2.7 months for non-smokers (Δ = 5.6 months, P = 0.003). In the MRI and SPECT guided groups, the healing time for smokers was also prolonged by 2.3 months (P = 0.019) and 1.8 months (P = 0.038), respectively.
Table 6.
Correlation analysis of risk factors and recurrence rate
| Risk factors | Group | Yes(n) | Recurrence Rate | No(n) | Recurrence Rate | OR (95% CI) | P |
|---|---|---|---|---|---|---|---|
| Diabets | A | 2 | 50.0% | 18 | 27.8% | 2.5 (0.2–32.1) | 0.462 |
| B | 6 | 33.3% | 24 | 6.7% | 5.0 (1.1–22.5) | 0.041 | |
| C | 3 | 33.3% | 17 | 0% | / | 0.067 | |
| Smoking | A | 4 | 50.0% | 16 | 25.0% | 3.0 (0.3–30.6) | 0.307 |
| B | 10 | 20.0% | 20 | 5.0% | 4.0 (0.7–23.0) | 0.157 | |
| C | 5 | 20.0% | 15 | 0% | / | 0.106 | |
| BMI ≥ 30 | A | 3 | 66.7% | 17 | 23.5% | 6.0 (1.1–32.8) | 0.041 |
| B | 4 | 50.0% | 26 | 5.8% | 16.0 (1.8-142.2) | 0.021 | |
| C | 2 | 50.0% | 18 | 0% | / | 0.033 |
Table 7.
Smoking significantly delays bone healing time
| Group | Smoking (n = 19) | No Smoking (n = 51) | Average deviation | P |
|---|---|---|---|---|
| Total | 13.2 ± 4.1 | 10.3 ± 3.2 | + 2.9 | < 0.001 |
| A | 14.5 ± 3.8 | 8.9 ± 2.7 | + 5.6 | 0.003 |
| B | 12.8 ± 4.3 | 10.5 ± 3.4 | + 2.3 | 0.019 |
| C | 12.1 ± 3.9 | 10.3 ± 3.1 | + 1.8 | 0.038 |
Discussion
Staphylococcus aureus and coagulase-negative staphylococci are among the most common causative agents of osteomyelitis [8], and the current standard treatment is surgical debridement + antibiotic therapy [9, 10]. However, surgery cannot achieve complete debridement, and sometimes debridement is incomplete in an effort to preserve bone tissue, and incomplete removal of infected lesions often leads to recurrence of osteomyelitis [11], and eventually even amputation. According to current statistics, the recurrence rate of osteomyelitis is higher than 30% [12–14]. Although the diagnostic accuracy with current technologies is high, it is difficult to clearly determine the extent of bone infection. According to the recommendations of the American College of Radiology, X-ray and MRI are the two basic imaging examinations required for the diagnosis of osteomyelitis [12], and the specificity and sensitivity of X-ray for the diagnosis of osteomyelitis are 81.5 and 75.4%, respectively, while the specificity and sensitivity of MRI for the diagnosis of osteomyelitis are 80.7% and 95.6%, respectively [15]. MRI has been widely used for the diagnosis of osteomyelitis and plays an important role in guiding the surgical procedure. However, due to its inherent limitations, MRI is susceptible to metal internal fixation devices [16], especially in cases where metal internal fixation devices are left at the site of osteomyelitis onset, and as a result it is extremely difficult to distinguish the contour of the lesion. Therefore, we also used SPECT, which is not affected by metal internal fixation, with the radioisotope 99mTc to label MDP, to image the amount of MDP deposition on the SPECT/CT fusion image, and assess the amount of deposition by ISO to determine the contour of osteomyelitis, which can be used as a guide for the extent of surgical debridement. This imaging modality is not affected by metal internal fixation devices and thus compensates for the shortcomings of MRI. We found that there is no international standard for the extent of surgical debridement of osteomyelitis, which is usually based on the personal experience of the surgeon. The determination of the “red pepper” sign is mainly based on a subjective determination by the surgeon [17, 18]. This approach is likely to lead to residual lesions or excessive expansion of the debridement area, resulting in prolonged treatment time for patients. Therefore, imaging is required to clarify the diagnosis, localize the lesion and assess the extent of the lesion before debridement to achieve complete debridement, while at the same time reducing trauma to the patient and shortening the treatment time. In the case of incomplete debridement, necrotic tissue and dead bone fragments within the lesion are good culture media for bacteria [19]. Since necrotic tissue has no blood supply, it is difficult for intravenous antibiotic infusion to reach the bone. As a result, the use of antibiotics alone not only cannot cure osteomyelitis, but also causes bacterial dysbiosis in the human body and weakens the immunity of the body due to long-term use of antibiotics [20, 21]. In addition, bacteria may also become drug-resistant, which exacerbates osteomyelitis and expands the range of infection. Therefore, in this study, a retrospective comparative analysis was conducted to explore an optimal lesion clearance standard for chronic osteomyelitis in Cierny-Mader stages III and IV to reduce the recurrence rate of osteomyelitis and improve the quality of life of patients.
When comparing the osteotomy lengths and bone healing times among the three imaging modalities, we found that MRI- and SPECT-guided osteotomies resulted in significantly longer osteotomy lengths and bone healing times compared to X-ray guidance (The values were respectively p = 0.041 and p = 0.023). Despite the prolonged healing period, these imaging-guided approaches achieved lower recurrence rates without compromising final limb functional outcomes (Enneking scores). This discrepancy relates to their differential sensitivity to pathological changes: X-ray only detects advanced bony alterations, demonstrating higher sensitivity for acute suppurative osteomyelitis but lower sensitivity/specificity for chronic cases. In contrast, MRI and SPECT identified subtle lesions beyond gross morphological changes, whereas X-ray guidance relied heavily on intraoperative “red pepper sign” assessment. Although no significant differences in Enneking scores were observed among groups (P = 0.819), the SPECT group exhibited superior joint range of motion and muscle strength recovery within equivalent timeframes, likely due to precise osteotomy minimizing traumatic injury.
Analysis of potential recurrence risk factors (BMI, diabetes, smoking history) revealed no statistically significant intergroup differences in baseline distribution (P > 0.05). However, subgroup analysis revealed that the recurrence rate among patients with diabetes was more than 2.5 times higher. Additionally, compared with non-smokers, smokers had an average of 2.9 months longer bone healing time (P < 0.001), and even 5.6 months longer in Group A. This might be due to the microvascular damage caused by smoking. Subgroup analyses revealed that diabetes was an independent predictor of recurrence. This aligns with evidence that hyperglycemia impairs immune response and microvascular perfusion. These findings suggest that metabolic and lifestyle factors may indirectly influence outcomes despite lacking direct statistical significance in the overall cohort.
The impact of preoperative antibiotic therapy remains underexplored in this study. Although 82.9% of patients received ≥ 2 weeks of preoperative antibiotics, we did not analyze its association with recurrence due to the uniformity of postoperative negative cultures and the lack of standardized antibiotic regimens. Notably, 72.4% of these patients received broad-spectrum β-lactams, which may have contributed to transient suppression of subclinical infections without eradicating biofilm-embedded pathogens. Future prospective studies should stratify patients by antibiotic duration and spectrum to clarify this relationship.
X-rays are the most widely used diagnostic imaging technique and can be used as a preliminary examination for chronic osteomyelitis [13, 22], but is less sensitive and specific in detecting acute cases, and its limited bone marrow assessment does not allow for good determination of the extent of infection. Even if intraoperative debridement has revealed “red pepper” sign, the presence of some local necrotic bone tissue and soft tissue lesions that are difficult to detect with the naked eye can easily lead to recurrence. MRI has been widely used as an effective technique for the diagnosis and treatment of chronic osteomyelitis. We found that, in the absence of metal internal fixation, good imaging results can be achieved by MRI, and thus can be used as a guide to determine the extent of surgical debridement. On the other hand, in the presence of metallic internal fixation, the use of MRI will be limited [23–25]; as we cannot distinguish the contour between infected and normal tissues due to the influence of the internal fixation [24, 26]. Using the radioisotope 99mTc to label MDP, we found that the bone tissue gradually showed a normal trend in terms of color and texture when the ISO was within the range of 30–40%, and the bone quality was basically normal in the range of less than 30% [27]. This quantifies the extent of osteomyelitis debridement, which not only sets the upper limit of the debridement range to avoid excessive debridement, but also establishes the range of debridement to avoid incomplete debridement, thereby improving the cure rate of chronic osteomyelitis. Compared with SPECT, MRI is more widely used in the diagnosis and treatment of osteomyelitis. MRI has an advantage over SPECT in imaging soft tissue lesions, whereas SPECT imaging of bone tissue is not affected by metal internal fixation devices, which is also a shortcoming of MRI, and most patients clinically have internal fixation at the onset site of osteomyelitis. Crucially, X-ray guidance yielded 28.6% recurrence even without internal fixation (Table 3), underscoring its inadequacy in delineating infection margins. SPECT remained superior in metal-implant cases (0% recurrence), while MRI excelled in soft tissue assessment. Therefore, when the onset site is affected by metal internal fixation, SPECT can be used to determine the infected lesion area more accurately. However, MRI has more advantages for the determination of the extent of soft tissue lesions. Despite its diagnostic and therapeutic guidance advantages, SPECT technology faces clinical implementation barriers, primarily including prohibitively high equipment costs and substantial procedural expenses that restrict widespread adoption. Furthermore, the relatively low spatial resolution of SPECT imaging may compromise visualization clarity for subtle lesions.
Through this study, it was found that determining the extent of osteomyelitis debridement based on MRI and SPECT greatly reduced the recurrence rate of osteomyelitis compared with X-ray, and that SPECT was more advantageous in the presence of metal internal fixation. However, there are still recurrence cases in this, and the reasons for this are summarized as follows: (1) inadequate flushing during surgery, resulting in residual dead bone; (2) poor imaging of soft tissues by SPECT, resulting in incomplete removal of surrounding necrotic tissue; and (3) possible re-infection due to irregular postoperative dressing changes.
In conclusion, this study summarizes a clinical treatment standard based on MRI and SPECT to determine the extent of lesion clearance in Cierny-Mader stages III and IV chronic osteomyelitis, which is of practical significance to establish osteomyelitis treatment standards. Several limitations should be acknowledged. First, the study did not analyze the impact of bacterial infection types (e.g., Staphylococcus aureus vs. Pseudomonas aeruginosa) and preoperative antibiotics on recurrence rates, as the primary focus was imaging-guided osteotomy techniques, but we found that the detection rate of Staphylococcus aureus was the highest, reaching 52%. While postoperative cultures were uniformly negative, preoperative bacterial profiles may still influence treatment outcomes through variations in biofilm formation or antibiotic resistance patterns. This exclusion limits our understanding of potential microbiological confounders and should be addressed in future studies. This paper lacks sufficient analysis of the interaction between internal fixation and other factors, which is a limitation of this study. We will take this as a starting point for subsequent research. The absence of time-to-event analyses for recurrence and survival endpoints warrants further investigation through multicenter trials with extended observation periods.
Supplementary Information
Acknowledgements
Not applicable.
Author contributions
Yong-kui Zhang and Wen-peng Xie contributed to the study conception and design. Material preparation, data collection and analysis were performed by Xu Wang and Fei Liu. The first draft of the manuscript was written by Xu Wang and Fei Liu，Dao-tong Yuan and Zhi-meng Zhang undertook part of statistical analysis. All authors read and approved the final manuscript. Yong-kui Zhang and Wen-peng Xie jointly directed this work and should be considered co-corresponding author. Xu Wang and Fei Liu contributed equally to this article and should be considered the co-first author.
Funding
The authors did not receive support from any organization for the submitted work.
Data availability
The datasets used and/or review during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
All experimental protocols were approved by the Ethics Committee of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine. The first application for the approval number：2018-062-03, Project completion application approval number 2022-071-01. Because this was a retrospective analysis, the Ethics Committee of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine waived informed Consent.
All clinical investigations were conducted in accordance with the guidelines of the Declaration of Helsinki.
Consent for publication
Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.
Competing interests
The authors declare no competing interests.
Consent to participate
Verbal informed consent was obtained prior to the interview.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Xu Wang and Fei Liu contributed equally to this work and are co-first author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or review during the current study are available from the corresponding author on reasonable request.