Simultaneous debridement, Ilizarov reconstruction and free muscle flaps in the management of complex tibial infection

Abstract

Abstract. Chronic bone infections often present with complex bone and soft tissue loss. Management is difficult and commonly delivered in multiple stages over many months. This study investigated the feasibility and clinical outcomes of reconstruction in one stage. Fifty-seven consecutive patients with chronic osteomyelitis (n=27) or infected non-union (n=30) were treated with simultaneous debridement, Ilizarov method and free muscle flap transfer. 41 patients (71.9 %) had systemic co-morbidities (Cierny-Mader group Bs hosts). Infection was confirmed with strict criteria. 48 patients (84.2 %) had segmental defects. The primary outcome was eradication of infection at final follow-up. Secondary outcomes included bone union, flap survival and complications or re-operation related to the reconstruction. Infection was eradicated in 55∕57 cases (96.5 %) at a mean follow-up of 36 months (range 12–146). No flap failures occurred during distraction but 6 required early anastomotic revision and 3 were not salvageable (flap failure rate 5.3 %). Bony union was achieved in 52∕57 (91.2 %) with the initial surgery alone. After treatment of the five un-united docking sites, all cases achieved bony union at final follow-up. Simultaneous reconstruction with Ilizarov method and free tissue transfer is safe but requires careful planning and logistic considerations. The outcomes from this study are equivalent or better than those reported after staged surgery.

Management of Post-Traumatic Osteomyelitis in the Lower Limb: Current State of the Art

“…When using a frame with a free flap, careful planning is required between the orthopaedic and plastic teams about pedicle position to allow immediate flap coverage through the frame. Fine wires can be safely placed though the flap as long as they are away from the pedicle 33 (►Figs. 3 and 4).…”

Comment on “Bioactive glass S53P4 vs. autologous bone graft for filling defects in patients with chronic osteomyelitis and infected non-unions – a single center experience” by Steinhausen et al. (2021)

“…This problem was identified in the 1970s and prompted the use of antibioticloaded PMMA beads by Klemm and Buchholz (Klemm, 1993). There is now encouraging evidence around the use of single-stage surgery, facilitated by modern local antibiotic carriers, with few complications and high infection eradication rates, even in the most complex cases (Masrouha et al, 2018;McNally et al, 2016;Ferguson et al, 2014;Lam et al, 2019;Pincher et al, 2019;Lorentzen et al, 2020;Drampalos et al, 2018;Jiang et al, 2020;Pesch et al, 2020;Hutting et al, 2021;Mifsud et al, 2020;Zhou et al, 2021).…”

Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect

“…Two-stage reconstruction for infected post-traumatic injuries has been widely accepted for the past 30 years, with reported success rates of 89-94% [5,6]. Others have reported favorable results with single-stage protocols [7][8][9]. Mifsud et al [9] recently presented 57 cases of chronic osteomyelitis (COM) and infected non-union resolved in a single reconstruction with simultaneous debridement, Ilizarov method and free muscle flap transfer, with high rates of infection eradication (96.5%) and bone union (91.2%).…”

“…Others have reported favorable results with single-stage protocols [7][8][9]. Mifsud et al [9] recently presented 57 cases of chronic osteomyelitis (COM) and infected non-union resolved in a single reconstruction with simultaneous debridement, Ilizarov method and free muscle flap transfer, with high rates of infection eradication (96.5%) and bone union (91.2%). A 5.3% rate of flap failure was observed.…”

“…Despite extensive literature devoted to the topic [5,6], the timing of address to the different components of the problem (infection, soft-tissue reconstruction, and bone defect) remains a matter of debate [7]. Management can either be completed in a single procedure or under a staged protocol; both approaches have their advantages and disadvantages [5][6][7][8][9]. The final outcome is influenced by additional variables, including pre-existing host factors, impaired local vascularity, the mechanism of injury, microbiology, and patient expectations [7].…”