Table 2.
Different surgical techniques for treating chronic osteomyelitis
| Surgical technique | Advantages | Disadvantages |
|---|---|---|
| Conventional reaming of the IM canal | - Clearance of intramedullary sepsis | - Risk of fracture - Risk of bleeding - Need for fenestration of the distal diaphysis to allow drainage of the irrigation fluids |
| RIA technique | - Clearance of intramedullary sepsis - Less traumatic than convectional reaming |
- Risk of fracture - Risk of bleeding |
| Primary bone grafting / bone graft substitutes | - Single-stage procedure - Superior osteoconductivity and osteoinductivity of the bone graft |
- Confined to small defects / limited availability of bone graft - Risk of early resorption / highly depends on the soft tissue bed - Risk of relapse of infection - Graft incorporation is slow and unreliable - Donor site morbidity |
| Antibiotic-impregnated cement spacers / cement nails / antibiotic beads |
- Slow release of high concentrations of antibiotics, avoiding their systemic effects - Easy to mix - form into various shapes and sizes - Cement nails can provide some stability to associated fractures |
- Lack of biodegradability in some carriers / need for two-stage procedures - Concern that they can act as a foreign body, therefore harbouring infection - Increased risk of antibiotic resistance |
| Bioactive glass | - Anti-microbial, osteoconductive and angiogenic properties | - Depends on good soft-tissue coverage |
| Induced membrane (Masquelet) technique | - Combines the advantages of antibiotic-impregnated cement spacers with those of delayed bone grafting - The induced membrane is highly vascularised, rich in growth and osteoinductive factors - Offers a confined space for the application of the bone graft |
- Two-stage procedure - Increased risk of antibiotic resistance - Limited availability of bone graft - Can be associated with prolonged healing and recovery time |
| Circular external fixation devices and bone transport | - Increased blood flow in the area of corticotomy - Minimally-invasive nature |
- Distraction is often limited because of the neurovascular bundle contracture - Can be associated with pain for distraction > 2 cm - Pin-site complications - Need for specialised equipment - Need for re-interventions |
| Local flaps | - Transfer of well-vascularised tissue that aids wound and bone healing | - Limited by pedicle length - Donor-site morbidity |
| Vascularised free flaps | - Transfer of well-vascularised tissue that aids wound and bone healing | - Donor-site morbidity - Need for microsurgical anastomoses - Limited by peripheral artery disease - Prolonged operating time - High risk of early complications / risk of graft failure |
| Megaprosthesis | - Restores limb function quickly - No need for harvesting bone - ‘One-shot’ surgery |
- Risk of residual infection and early loosening - Risk of dislocation - Risk of revision surgery |
| Amputation | - Early mobilisation - One shot surgery |
- Soft tissue reconstruction procedures - Compromised function - Regular revisions of the prosthetic limb |
IM: intramedullary
RIA: Reamer/Irrigator/Aspirator