Understand the complexity and lack of standardization related to the diagnosis and treatment of posttraumatic long bone osteomyelitis
Provide guidance and treatment options when faced with a patient who requires workup and management of segmental defect
Highlight this chapter with a case example with a special emphasis on pearls and pitfalls.
Of note, the case example used in this chapter was previously published and utilized in an open access article: Chadayammuri et al. Patient Safety in Surgery (2015) 9:32 DOI 10.1186/s13037-015-0079-0 © 2015 Chadayammuri et al.
Osteomyelitis, or infection of the bone, represents a challenging clinical entity in the field of orthopedics. In 1951, Gallie et al reported a case of recurring osteomyelitis following a period of 80 years since onset of initial infection. The patient was a 90-year-old woman with a Brodie abscess localized to the distal femur. Given a largely asymptomatic presentation throughout the patient’s lifetime, diagnosis and treatment were exceedingly delayed. This case is but one of many that illustrates the complex nature of osteomyelitis.1
Two primary variants of osteomyelitis have been previously characterized: hematogenous and long bone posttraumatic osteomyelitis (PTOM). Classification may be further divided according to duration (Waldvogel et al) or disease stage (Cierny-Mader et al).2 In the Waldvogel classification, osteomyelitis is classified on the basis of being hematogenous, contiguous, or chronic in nature. In the Cierny-Mader classification, osteomyelitis is categorized by anatomic location into stage 1 (medullary), stage 2 (superficial), stage 3 (localized), and stage 4 (diffuse). The latter classification scheme also incorporates consideration of the host’s health status, divided into local factors (chronic lymphedema, venous stasis, arteritis, etc) or systemic factors (malnutrition, renal failure, diabetes mellitus, immunodeficiency status, etc). While these classification systems can be useful for diagnosis and treatment planning, they have shortcomings. The location within the bone (periarticular versus diaphyseal) is neglected in the Cierny-Mader classification, which has an impact on treatment options and outcome. Classifying the anatomical stage can also be difficult when hardware is present because MRI is often not useful due to interference.
The focus of the remainder of this chapter will be on long bone posttraumatic osteomyelitis (PTOM), defined as infection of the bone in conjunction with recent fracture or traumatic insult. Long bone PTOM is a frequent occurrence and may be involved in as many as 10% of all open fractures and 1% of all closed fractures.3 Several etiological factors have been previously described, including direct inoculation at time of injury, macrovascular or microvascular damage, surgical contamination, host immunodeficiency, and/or postoperative wound contamination.4-6 Importantly, untreated long bone PTOM may progress to fracture nonunion, sepsis, and ultimately, limb amputation.5
The clinical diagnosis of long bone PTOM is challenging, in large measure, owing to the nonspecific nature of its initial presentation. In addition to findings of localized pain, long bone PTOM classically presents ...