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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 67-72

Continuous irrigation as dead space management for fracture-related Type 1 intramedullary chronic osteomyelitis


1 Department of Surgical Sciences, Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
2 Department of Orthopaedics, School of Clinical Medicine, University of Kwazulu-Natal, Durban, South Africa

Date of Submission23-Mar-2022
Date of Decision22-May-2022
Date of Acceptance23-May-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Jan-Petrus Grey
Department of Surgical Sciences, Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town 7505
South Africa
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_7_22

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  Abstract 


Introduction: Dead space management following intramedullary debridement and reaming can be challenging and several alternatives have been described. The main objective of this study was to investigate the clinical outcome and resolution rate in patients treated for fracture-related Cierny and Mader anatomical type 1 intramedullary chronic osteomyelitis by means of continuous irrigation (modified Lautenbach system) as dead space management following intramedullary reaming. Materials and Methods: A consecutive series of thirty patients with Cierny and Mader type 1 chronic osteomyelitis, treated between May 2016 and September 2019, were evaluated retrospectively. Patient history and clinical information, including imaging and laboratory results, were reviewed. Treatment procedures and antibiotic profiles were also recorded. Results: The initial cohort included 30 cases with 18 tibias, 11 femurs, and one humerus. Seven patients were excluded; three patients did not return for follow-up and four patients had <6 months of follow-up. Of the remaining 23 patients, 91% (21/23) achieved resolution of infection over a median follow-up period of 16 months (interquartile range [IQR] 7–21 months). Infecting organisms where isolated in 65% (15/23). The median duration of hospital stay was 6 days (IQR 4–7 days). Postoperative complications were noted in two cases and involved a tibial and femoral refracture, respectively. Both patients however achieved union without recurrence of infection following surgical intervention. Conclusion: Continuous irrigation is a cost-effective single-stage surgical option for dead space management during the treatment of intramedullary chronic osteomyelitis. It provides the advantage of instilling high dose intramedullary antibiotics and negates the need for a second surgical procedure while achieving similar outcomes than other dead space management techniques. Level of Evidence: IV, single-center retrospective study

Keywords: Chronic osteomyelitis, continuous irrigation, dead space management, fracture-related infection, Lautenbach method


How to cite this article:
Grey JP, Burger M, Marais LC, Ferreira N. Continuous irrigation as dead space management for fracture-related Type 1 intramedullary chronic osteomyelitis. J Limb Lengthen Reconstr 2022;8:67-72

How to cite this URL:
Grey JP, Burger M, Marais LC, Ferreira N. Continuous irrigation as dead space management for fracture-related Type 1 intramedullary chronic osteomyelitis. J Limb Lengthen Reconstr [serial online] 2022 [cited 2022 Aug 9];8:67-72. Available from: https://www.jlimblengthrecon.org/text.asp?2022/8/1/67/349423




  Introduction Top


Chronic osteomyelitis remains one of the most challenging problems in orthopedic surgery.[1],[2] It is a major cause of morbidity with considerable socio-economic and health implications including extended antibiotic usage, as well as multiple hospital admissions and theatre visits.[3],[4]

Intramedullary nailing remains the preferred method of fixation in tibia and femur shaft fractures. With a steady increase in trauma volumes resulting from road traffic accidents as well as gunshot victims, low- and medium-income countries will face a proportionate increase in fracture-related infection following intramedullary fixation.[5],[6],[7] Open fractures on average have a 3.2 times increased risk of overall infection compared to closed fractures following intramedullary fixation.[5],[8]

In established chronic osteomyelitis, a local environment of poorly perfused tissue, sequestrum, and biofilm limit the efficacy of systemic antibiotic therapy.[3],[9] The commonly used classification system for chronic osteomyelitis was described by Cierny et al., in 2003.[10] This classification system distinguishes chronic osteomyelitis cases according to four anatomical types and three physiological host classes, to define the 12 clinical stages.[9],[10],[11],[12] Fracture-related infection following intramedullary nailing typically results in anatomical type 1 infections, if the fracture has united, where the infection is limited to the medullary canal.

The principles in surgical management of chronic osteomyelitis include judicious bone and soft tissue debridement with collection of deep tissue specimens, management of the dead space, followed by soft tissue cover, and bone reconstruction as required.[13],[14],[15],[16],[17],[18] Surgical debridement is augmented with adjunctive local antimicrobial therapy to increase the clinical cure rate.[17] Currently, there is a lack of evidence regarding the optimal method of intramedullary dead space management.[16],[18],[19] Debridement without adequate dead space management is associated with higher recurrence rates.[20] We hypothesize that the resolution rate with continuous irrigation as dead space management in type 1 intramedullary chronic osteomyelitis may be comparable to other described techniques for intramedullary dead space management.

Dead space management following removal of infected nails and intramedullary reaming (so-called indirect unroofing) is challenging. Surgical options include custom-made antibiotic-impregnated polymethyl-methacrylate nails and biodegradable calcium sulfate pellets with 4% tobramycin have been described.[9],[21],[22] The use of wound irrigation in the management of chronic osteomyelitis was initially described in the early 1900s.[23] Intramedullary, irrigation was later introduced by Weber and Lautenbach for infected total hip arthroplasties as well as pan diaphyseal chronic osteomyelitis.[24] Lautenbach achieved an 80% resolution rate with the technique of using a closed double-lumen suction irrigation system.[24] Despite promising early results, few studies have been published on the potential use of continuous irrigation as dead space management following intramedullary reaming of type 1 chronic osteomyelitis of the appendicular skeleton.[1],[2],[3]

The main aim of the present single-center retrospective study was to investigate the clinical outcomes and resolution rates in patients treated for Cierny and Mader anatomical type 1 intramedullary chronic osteomyelitis by means of continuous irrigation (the modified Lautenbach system) as dead space management following intramedullary reaming. The secondary objective was to compare the resolution and complication rates of the modified Lautenbach system to other techniques of intramedullary dead space management described in the current literature.


  Materials and Methods Top


Patients and study design

A single-center retrospective review of a prospectively collected database, of all consecutive patients treated between May 2016 and September 2019 for Cierny and Mader anatomical type 1 intramedullary chronic osteomyelitis with continuous irrigation as dead space management following intramedullary reaming, was conducted. Ethical approval as well as hospital board approval was obtained prior to data collection. Patients were excluded if they did not meet the criteria of type 1 chronic osteomyelitis, if they had <6 months follow up or if they required further surgical fixation due to fracture nonunion, malunion, or deformity correction. To be considered eligible for the procedure the fracture had to be deemed united by X-rays at a minimum of 6 months following definitive fracture fixation. The collected data included patient demographics, comorbidities, smoking history, fracture related history, duration and details of hospital stay, and the microbiological results.

Patient history and clinical presentation were recorded and imaging of the affected limb, including radiographs as well as laboratory investigations were reviewed. Computerized tomography (CT) was performed in cases where fracture union or occult sequestrum was suspected. At the time of treatment a blood profile was taken, including the full blood count, iron studies, renal and liver function tests, nutritional profile, leucocyte count (WCC), C-reactive protein, and an erythrocyte sedimentation rate. This provided good insight into the quantification of the host's physiological status and disease burden.

Defining chronic osteomyelitis and recurrence of infection

Chronic osteomyelitis was defined as a fracture-related infection, where the causative organisms were thought to have persisted either intracellularly or in interactive biofilm-based colonies.[14] Recurrence of infection was defined as clinical, biochemical or radiological evidence of ongoing infection following the initial definitive eradication surgery.

Surgical technique and assessment

The beginning of treatment was regarded as the day of surgical intervention when deep tissue specimens were obtained, and empiric antibiotic therapy was started. Standard surgical technique involved removal of all implants, deep tissue sampling, intramedullary reaming, and irrigation, followed by the insertion of a continuous irrigation system. After the removal of the screws, the distal locking holes were enlarged to an oblong aperture using a high-speed burr. The distal metaphyseal region was then curetted through this window to remove any biofilm. Sequential intramedullary reaming was then performed over a guidewire until the maximum passable reamer size was reached. During reaming suction was applied at the distal window to remove debris and biofilm. Biofilm obtained at all sites, including the nail entry point, screw holes, and reaming contents were sent for microscopy, culture, and sensitivity.

Following reaming, the canal was irrigated with saline using a pulse lavage system. Our modification to the original Lautenbach technique included a single lumen 6 mm perforated tube, from a standard closed suction system, that was passed along the length of the intramedullary canal. Distally, the tube was connected to a continuous infusion of 0.9% normal saline with gentamycin. Proximally, the tube was secured to a urinary catheter collection bag to allow free drainage by gravity and monitoring of the effluent [Figure 1]. This modification provided the advantage of decreased postoperative fluid leakage, and subsequent patient discomfort and nursing difficulties, due to improved bone and tube interface from the oblong orientated bony windows as well as the connection to the gravity assisted free drainage system.
Figure 1: (A) Continuous infusion of 0.9% normal saline with 80 mg gentamycin. (B) Infusion set at a rate of 125 ml/h. (C) Collection bag to allow free drainage by gravity and monitoring of the effluent

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Irrigation consisted of 1000 ml 0.9% normal saline with 80 mg Gentamycin at a rate of 125 ml/h. This equates to 240 mg of additional local antibiotic administration every 24 h via the irrigation solution. The limb was elevated in the ward so that the distal segment (inlet) was higher than the proximal segment (outlet) to facilitate gravity-assisted drainage. The irrigations solution was replaced 8 h until the irrigation system was removed. Once the blood-stained effluent became clear in color the irrigation tube was removed in the ward and dry dressings applied. Effluent volume was monitored but it was not cultured, and routine serum antibiotic levels were not performed. All operations were performed by a single surgeon. Protected weight bearing with the use of crutches was prescribed following removal of the irrigation system.

All preoperative antibiotics were stopped at least 7 days prior to surgery. Empiric postoperative broad spectrum intravenous antibiotic therapy consisted of meropenem and vancomycin until culture and sensitivity results became available. The antibiotic regime was subsequently adjusted to directed oral preparations according to the culture and sensitivity profile. This consisted of dual therapy including at least one agent with anti-biofilm activity. In cases where no growth was observed the intravenous therapy was changed to oral co-trimoxazole and rifampicin. Antibiotic therapy was then continued for a total duration of 6 weeks.

Standard outpatient follow-up consisted of 2-week, 6-week, 3-month, 6-month, and 12-month postoperative reviews.

Statistical analysis

Data were analyzed using Statistica v13 (Tibco Software) and are reported as means ± standard deviations or medians (interquartile ranges [IQR]) for parametric and nonparametric data, respectively. Categorical variables are reported as frequencies and counts.


  Results Top


Patient characteristics

Thirty patients were managed with continuous irrigation following medullary reaming during the study. Seven patients were excluded; four patients had <6 months follow up and three patients were lost to follow-up. The final cohort comprised 16 men and seven women with a mean age of 34.7 ± 10.5 years (range 16–55) [Table 1]. All cases were classified as Cierny and Mader anatomical type 1 chronic osteomyelitis. The anatomical segment of infection included 13 tibias, 9 femurs, and one humerus. A history of open fractures was noted in 13 (13/23, 57%) of cases. All cases had prior insertion of intramedullary devices. All fractures were deemed to be united prior to surgery. Twenty-one (21/23, 91%) patients presented with a chronic draining sinus. Two (2/23, 9%) presented with abscess formation that required initial debridement. Seven (7/23, 30%) patients were noted to be active smokers.
Table 1: Participant demographic information (n=23)

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Follow-up

The follow-up period for the cohort ranged from 6 to 25 months, with median follow-up of 16 months (IQR 7–21 months) [Table 2].
Table 2: Follow-up and clinical outcome (n=23)

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Clinical outcome

An overall resolution rate of 91% (21/23) was achieved following the removal of the intramedullary device, intramedullary reaming, and continuous irrigation as dead space management [Table 2]. The median length of hospital stay was 6 days (IQR 5.0–6.0 days). Postoperative recurrence of infection was noted in two cases (2/23, 9%). The first had recurrence after noncompliance with antibiotic treatment following incarceration and was still awaiting re-operation at the time of writing this manuscript. The second patient was a known smoker with recurrence of femoral osteomyelitis. After subsequent sequestrectomy, this patient achieved resolution of infection.

Organisms

Infecting organisms were isolated in 65% (n = 15) of the 30 cases [Table 3]. Staphylococcus aureus isolates were the most common Gram-positive bacteria and Proteus mirabilis and Pseudomonas aeruginosa were the most common Gram-negative bacteria cultured.
Table 3: Bacterial isolates

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Complications

Postoperative complications, other than recurrence of infection, were observed in two cases (2/23, 9%) in the present study. Both patients sustained a long bone refracture following treatment. The first patient sustained a femoral refracture 4 months after treatment. This patient was noted to have full resolution of infection at the time of fracture. After intramedullary fixation the patient progressed to union without recurrence of infection. The second patient sustained a tibial refracture early after treatment and union was achieved after application of a circular fixator and the patient was noted to be infection free at the 12 months follow up.


  Discussion Top


Lautenbach introduced the intramedullary closed double-lumen suction irrigation model as dead space management for pan diaphyseal chronic osteomyelitis in 1975. They reported an 80% resolution rate over a 7-year period.[24] This technique was affordable, reproducible and allowed for a single surgical intervention. In addition, local antibiotic instillation could be achieved without accompanying systemic toxic effects.[1],[25],[26] The main objective of this study was to investigate the clinical outcomes and resolution rates in patients treated for Cierny and Mader anatomical type 1 intramedullary chronic osteomyelitis following fracture fixation by means of continuous irrigation as dead space management following intramedullary reaming.

The main finding of the study was an infection resolution rate of 91% (21/23), observed after a median follow-up period of 16 months. This finding agrees with that reported by Hashmi et al. in their series of 17 patients with fracture-related infection treated using the Lautenbach method where they reported a resolution rate of 94.4% after a mean follow-up of 75 months.[1] In a different study, using a modified irrigation system that was based on that of Lautenbach, Caesar et al. reported a resolution rate of 85.3% at a mean follow-up of 101 months.[3] The lower resolution rate may be attributed to their longer follow-up period. Late recurrence of infection has been noted years after clinical resolution as reported by McNally and Nagarajah with their review of 344 cases.[21] At 2 year follow-up, the authors reported a resolution of infection in 98.5% of cases, whilst after four years a resolution of infection in 92% of cases and at 5 years 90% of those cases remained infection-free.[21]

In comparison to the modified Lautenbach method, the antibiotic-impregnated cement rod is a well-described alternative for intramedullary dead space management. Kanakaris et al. reviewed 24 patients treated with intramedullary reaming and antibiotic cement rod placement as dead space management and reported a resolution rate of 96% after a mean follow-up of 21 months. Although their reported resolution rate is comparable to our study, it is important to keep in mind that a second operation was required to remove the rod after a mean of 2.6 months following the initial operation.[7] The requirement for hardware removal, which includes the additional cost of re-admission and the second operation as well as the inherent risk of removal and occasional failure of removal. These are the most important criticism against this method and have resulted to further research to find an alternative, single-stage, surgical solution including the use of biodegradable products.[18],[22]

Another option for dead space management includes the use of biodegradable calcium-sulfate pellets containing 4% tobramycin, following debridement. Ferguson et al. reported on 195 patients, falling within all four Cierny and Mader anatomical subtypes.[22] Although the authors reported a 100% resolution rate in the Cierny and Mader anatomic type 1 subgroup (n = 12) over a mean follow-up period of 44.4 months, they observed prolonged wound drainage in 15.4% of cases.[22] Calcium sulfate pellets may provide the opportunity for a single-stage treatment solution, although its increased cost might not be feasible in a resource-constrained environment. This is illustrated in the limited data on the use of biodegradable products as dead space management from low-and medium-income countries, where the burden of disease is high, but the resources available for treatment are limited.[18]

The second finding of this study was a positive microbiological culture result in 65% (15/23) of the cohort. The low culture-positive yields in the current study could be explained by the presence of fastidious pathogens that have lost viability prior to culture, or exposure to antibiotics, including those given preoperatively. Bacterial isolate findings from the present study are similar to those from a recent systematic review which included 13 studies that reported Staphylococcus aureus to be the most common organism isolated.[18] Where methicillin-resistant S. aureus accounted for 28.4% of isolates in the Pincher et al.'s review, we only encountered this resistant strain in 4.3% of isolates.[18] The predominant Gram-negative organisms included Pseudomonas species. Similar outcomes were also reported by Mthethwa et al. in 2017, after reviewing cultures on 60 patients with chronic osteomyelitis treated curatively in a South African study.[27] The authors reported that in fracture-related infections, which comprised 55% (n = 33) of the cohort, the most common organisms cultured included methicillin-sensitive S. aureus, Serratia marcescens and Pseudomonas aeruginosa.[27] Similarly, Caesar et al. also reported a comparable positive microbiological diagnosis on 62.9% of cases with S. aureus and Pseudomonas the most cultured organisms.[3]

Two patients (2/23, 9%) experienced a recurrence of infection in the present study. Following CT scan, one patient proved to have residual sequestrum at the previous fracture site. It is important to note that cortical sequestra might not be adequately addressed following medullary during reaming. Refracture was observed in two patients. Similar complications have been reported in a retrospective study which included 11 patients with intramedullary osteomyelitis, the authors noted a postoperative complication in one case with a distal tibia refracture 4 months after intermedullary debridement.[28] It is important to note that the technique of reaming the infected intramedullary canal may lead to temporary decreased biomechanical properties of the long bone to withstand physiological load. Although fractures following intramedullary reaming are rare, protected weight bearing should be advised to err on the side of caution.

The study is not without limitations. The small sample size and short follow-up period of this study is the first limitation because osteomyelitis may recur months after treatment, even after initial quiescence was achieved.[21] Tice et al. showed the 78% of recurrences occur within 6 months after surgery while 95% of all recurrences manifest within 1 year of surgery.[29] Although we do accept that the shorter follow-up period may result in an overestimation of the efficacy of the treatment technique it is important to note that, at present, our outcomes are in keeping with the international described resolution rates. This provides an ideal opportunity for future research, to investigate the long-term follow-up outcomes of intramedullary osteomyelitis treated with continuous irrigation as dead space management. Another limiting factor of the present study is the high number of cases that defaulted follow-up. Loss to follow-up is not unique in the South African setting, and this has been reported in several previous studies, specifically in the context of Orthopaedic surgery.[30],[31],[32] This may possibly be attributed to the long travel distances and the poor socio-economic factors in the South African setting.[33],[34]


  Conclusion Top


Continuous irrigation is a cost-effective single-stage surgical option for dead space management during the treatment of intramedullary chronic. It provides the advantage of instilling high-dose intramedullary antibiotics and negates the need for a second surgical procedure while achieving similar outcomes than other dead space management techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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