Surgical Treatment of Non Diabetic

Chronic Osteomyelitis Involving the

Foot and Ankle

Jae-Jung Jeong1 • Ho-Seong Lee2 • Sang-Woo Kim3 • Young-Rak Choi4 • Jeong-Ho Seo5

Department of Orthopedic Surgery,

The Catholic University of Korea, Daejeon St. Mary’s Hospital1, Asan Medical Center , College of Medicine, Ulsan University2,

Ulsan University Hospital, College of Medicine, Ulsan University3

CHA Bundang Medial Center, CHA University4,

Bumin Seoul hospital5

Surgical Treatment of Non Diabetic

Chronic Osteomyelitis Involving the

Foot and Ankle

Jae-Jung Jeong1 • Ho-Seong Lee2 • Sang-Woo Kim3 • Young-Rak Choi4 • Jeong-Ho Seo5

My disclosure is in the Final AOFAS Program Book.

I have no potential conflicts with this presentation.

Chronic Osteomyelitis of Foot

• Foot : unique environment for development of infections

• The foot’s environment is modified by footwear, trauma,

systemic illness, and poor soft tissue coverage

• Each of these factors : susceptibility of foot to infection

• Most Common cause in Foot : Diabetic ulcer

• Non diabetic foot infection : open fracture, after internal

fixation, puncture wound

Purpose

To evaluate the clinical characteristics

of COM involving the foot & ankle

To analyze the treatment outcomes following

debridement, dead space control, and

arthrodesis based on invasion of adjacent joint

MATERIALS

• Sep. 2004 - Mar. 2007

• 15 patients treated for COM in Foot & ankle

- F/U > 24m, M : F = 10 : 5

- Exclusion : immune compromised, DM

- No vascular problem

• Age : Mean 46.7yrs (25 – 72yrs)

• All pts. referred from other hospital

• Period of Tx. for COM : Mean 3.07yrs (6 -13yr)

Preoperative evaluation • ESR/CRP : 53.56 (2-120) / 2.86 (0.1-11.86) at OPD visit

• MRI for accurate extent, invasion of adjacent joint

forefoot : 1

Midfoot : 1

Distal tibia : 6

Ankle : 3

Calcaneus : 4

Surgical Technique ① 1st stage : Extensive margianl excision - until normal tissue, synovectomy & joint debridement - Dead space control : antibiotic-loaded cemet spacer ② 2nd stage : Arthrodesis with BG

Antibiotics mixed cement : 8 cases Bone graft : 10 cases curettage only : 2 cases (TBc of distal tibia, cuboid) cementing only : 1case (distal tibia) partial calcanectomy : 1case

Arthrodesis : 5cases - ankle fusion : 2cases - subtalar fusion : 1case - ankle & subtalar fusion: 1 - TMT fusion : 1case

Results

Cause Pathogen Fracture : 10 - open fx. : 5 - post. OR/IF : 5 Post. Arthroscopy : 1 Post. Flap surgery :1 Punctuating wound : 1 Recurred AOM : 1 Hematogeous : 1(TBc)

MRSA : 4

Pseudomonas : 4

MSSA, Enterobactor,

M. tuberculosis : 1

Burkholderia, anaerobe : 1

No growth : 1

Results

• Average of 2 surgeries (1- 3)

• Hospitalized for a mean period: 39.1 day(14-116)

• Keep cement spacer : mean 27day(14-67)

• 14/15pts : no recurrence

• 1 pt : iatrogenic septic arthritis : BKA

• Mean ESR/CRP : 14.7/0.13 at final F/U

CASE I M/41 9yrs ago TA

distal tibia open fx.

>10times I&D , Flap

ESR/CRP : 18/0.44

Culture : pseudomonas

CASE II M/56 3month ago

ankle open Fx. – D/L

>10 times debridement

pus discharge, medial

soft tissue defect

AVN of talus

ESR/CRP : 120/3.61

Culture : MRSA

SUMMARY

• M/C cause : fractures

• Extrinsic cause > intrinsic cause

• M/C pathogen: MRSA, pseudomonas

• Good result after staged operation

(wide debridement + dead space control)

• Check the involvement of adjacent Joint

selective joint arthrodesis

Chracteristics Of COM involving foot & ankle

CONCLUSION

Wide debridement

Dead space control

Selective Joint Arthrodesis

For successful Treatment Of COM

involving foot & ankle

References 1. Anthony, JP; Mathes, SJ; Alpert, BS: The muscle flap in the treatment of chronic lower extremity osteomyelitis; results in

patients over 5 years after treatment. Plast Reconstr Surg 88:311-318, 1991. 2. Caesar, BC; Morgan-Jones, RL; Warren, RE; Wade, RH; Roberts, PJ; Richardson, JB: Closed double-lumen suction irrigation in

the management of chronic diaphyseal osteomyelitis. J Bone Joint Surg Br 91:1243-8, 2009. 3. Cierny, G 3rd: Infected tibial nonunions (1981-1995). The evolution of change. Clin Orthop Relat Res 360: 97-105, 1999. 4. Ger, R: Muscle transposition for treatment and prevention of chronic post-traumatic osteomyelitis of the tibia. J Bone Joint Surg

Am 59:784-791, 1997. 5. Hashmi, MA; Norman, P; Saleh, M: The management of chronic osteomyelitids using the Lautenbach method. J bone Joint Surg

Br 86:269-275, 2004. 6. James, ET; Gruss, JS: Closure of osteomyelitis and traumatic defects of the leg by muscle and musculocutaneous flaps. J

Trauma 23: 411-419, 1983. 7. Keating, JF; Simpson, AHRW; Robinson, CM: The management of fractures with bone loss. J Bone Joint Surg Br 87B(2):142–

50, 2005. 8. Mader, JT; Shirtliff, ME; Bergquist, SC; et al: Antimicrobial treatment of chronic osteomyelitis. Clin Orthop Relat Res 360:47-

65, 1999. 9. Malizos, KN; Zalavras, CG; Soucacos, PN; Beris, AE; Urbaniak, JR: Free vascularized fibular grafts for reconstruction of

skeletal defects. J Am Acad Orthop Surg 12(5):360–9, 2004. 10. Patzakis, MJ; Zalavras, CG: Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management

concepts. J Am Acad Orthop Surg 13(6):417–27, 2005. 11. Taylor, SM; Kalbaugh, CA; Blackhurst, DW; et al: Preoperative clinical factors predict postoperative functional outcomes after

major lower limb amputation: an analysis of 553 consecutive patients. J Vasc Surg 42(2):227–35, 2005. 12. Sealey, RJ; Myerson, MS; Molloy, A; Gamba, C; Jeng, C; Kalesan, B: Sagittal plane motion of the hindfoot following ankle

arthrodesis: a prospective analysis. Foot Ankle Int 30:187-96, 2009. 13. Zarutsky, E; Rush, SM; Schuberth, JM: The use of circular wire external fixation in the treatment of salvage ankle arthrodesis. J

Foot Ankle Surg 44(1):22–31, 2005.