Objective To investigate the clinical significance of the distally-based sural musculocutaneous flap for the treatment of chronic calcaneal osteomyelitis. Methods From January 2002 to October 2005, 7 patients (4 males, 3 females; age range, 15-68 years ) were treated with the distallybased sural musculocutaneous flap, who had chronic calcanealosteomyelitis after calcaneal fracture. After the radical debridement for all the nonviable and poorly vascularized tissues, all the chronic calcaneal osteomyelitis patients, who had suffered from open calcaneal fracture or closed calcaneal fracture, were treated with the open reduction, the internal fixation, and thebone graft. The ulcer lasted for 3-12 months before diagnosis of osteomyelitis. The musculocutaneous flaps ranged in size from 8 cm×4 cm to 12 cm×7 cmand the muscle flaps ranged from 4 cm×3 cm to 6 cm×5 cm. The donor defects were closed primarily in 5 patients and were resurfaced with the splitthicknessskin graft in 2 patients. Results All the musculocutaneous flaps survived completely and all the wounds healed smoothly. All the patients followed up for 2-6 months had no recurrence of osteomyelitis or return to their preoperative ambulatory status.Conclusion It is feasible to use the distallybased sural musculocutaneous flap for treatment of chronic calcaneal osteomyelitis.
Bacterial biofilms are associated with at least 80% of human bacterial infections. The clinical treatment of biofilm infection is still arduous, and therefore many new treatment options are under study, such as probiotics and their derivatives, quorum sensing inhibitors, antimicrobial peptides, phage therapy, organic acids, light therapy, and plant extracts. However, most of these schemes are not mature, and it is important to develop new research directions of anti-biofilms.
ObjectiveTo evaluate the bone repair efficacy of the new nano-hydroxyapatite (n-HA)/polyurethane (PU) composite scaffold in the treatment of chronic osteomyelitis in tibia.MethodsA novel levofloxacin@mesoporous silica microspheres (Lev@MSNs)/n-HA/PU was successfully synthesized. Its surface structure was observed by scanning electron microscopy (SEM). Fifty adult female New Zealand rabbits were randomly selected, and osteomyelitis was induced in the right tibia of the rabbit by injecting bacterial suspension (Staphylococcus aureus; 3×107 CFU/mL), which of the method was described by Norden. A total of 45 animals with the evidence of osteomyelitis were randomly divided into 4 groups, and the right medullary cavity of each animal was exposed. Animals in the blank control group (group A, n=9) were treated with exhaustive debridement only. The remaining animals were first treated by exhaustive debridement, and received implantations of 5 mg Lev@PMMA (group B, n=12), 1 mg Lev@MSNs/n-HA/PU (group C, n=12), and 5 mg Lev@MSNs/n-HA/PU (group D, n=12), respectively. At 12 weeks postoperatively, the right tibia of rabbits were observed by X-ray film, and then gross observation, methylene blue/acid fuchsin staining, and SEM observation of implant-bone interface, as well as biomechanical test (measuring the maximal compression force) were performed.ResultsX-ray films showed that the infection were severer than those of preoperation in group A, while the control of inflammation and bone healing of rabbits in group D were obviously better than those at preoperation. The gross observation showed extensive bone destruction in group A, a significant gap between bone tissue and the material in groups B and C, and close combination between bone tissue and the material in group D. The histology of the resected specimens showed that there was no obvious new bone formation around the materials in groups B and C, and there was abundant new bone formation around the periphery and along the voids of the materials and active bone remodeling in group D. The SEM observation of the bone-implant interface demonstrated that no new bone formation was observed at the bone-implant interface in groups B and C. However, bony connections and blurred boundaries were observed between the material and host bone tissue in group D. The biomechanical test showed the maximal compression force of groups B and D were significantly higher than that of groups A and C (P<0.05), but there was no significant difference between groups B and D (P>0.05).ConclusionThe novel synthetic composite Lev@MSNs/n-HA/PU exhibit good antibacterial activities, osteoconductivity, and biomechanical properties, and show great potential in the treatment of chronic osteomyelitis of rabbits.
Objective To investigate the effect ofstaphylococcal lipoteichoic acid (LTA-sa) on RAW264.7 cells differentiation into osteoclasts. Methods RAW264.7 cells were cultured with LTA-sa of 100 ng/mL (group A), LTA-sa of 200 ng/mL (group B), LTA-sa of 400 ng/mL (group C), receptor activator of nuclear factor κB (NF-κB) ligand (RANKL) of 100 ng/mL as positive control (group D), and equal volume of PBS as blank control (group E) respectively for 5 days. And then, tartrate resistant acid phosphatase staining (TRAP) was used to detect the formation of osteoclast-like cells, Image-Pro Plus 6.0 software to measure the areas of bone resorption pits in Corning Osteo Assay Surface (COAS) wells, and MTT assay to observe the proliferation activity of RAW264.7 cells in group A, B, C, and E. Results After cultured for 5 days, the formation of osteoclast-like cells and bone resorption pits were observed in all groups. The number of osteoclast-like cells and the area of bone resorption pits in groups A, B, C, and D were more than those in group E. And with the increased concentration of LTA-sa, the indexes in groups A, B, and C increased gradually, but were lower than those in group D, and differences were significant between groups (P<0.05). At 5 days after culture, there was no significant difference in absorbance value among the experimental groups (groups A, B, C, and E) (P>0.05). Conclusion LTA-sa has promoting effect on RAW264.7 cells differentiation into osteoclasts.
ObjectiveTo investigate the effectiveness of modified induced membrane technique and pedicled skin (myocutaneous) flap for chronic tibial osteomyelitis in patients with diabetes. Methods A clinical data of 22 diabetic patients with chronic tibial osteomyelitis between January 2017 and March 2019 was retrospectively analyzed. There were 15 males and 7 females with an average age of 52 years (range, 44-65 years). The course of diabetes was 3-12 years (mean, 6.1 years). The course of chronic osteomyelitis was 4 months to 7 years (mean, 3.3 years). The chronic osteomyelitis was rated as type Ⅲ in 9 cases and as type Ⅳ in 13 cases according to the Cierny-Mader classification criteria. Bacterial culture showed 21 cases of single bacterial infection and 1 case of mixed bacterial infection. Preoperative color Doppler ultrasound and CT angiography confirmed that the anterior and posterior tibial arteries were unobstructed. In the first stage of treatment, the bone and soft tissue defects were filled with antibiotic bone cement after the lesion was thoroughly debrided; the length of bone defect was 4-9 cm (mean, 5.6 cm), and the size of soft tissue defect was 5 cm×2 cm to 10 cm×7 cm. After 7-10 days, the bone cement was removed and a new antibiotic bone cement was filled into the bone defect. Meanwhile, the pedicled skin (myocutaneous) flap was performed to repair the wound. After 7-12 weeks, the inflammatory indexes returned to normal, autogenous iliac bone or combined with artificial bone was used to repair the bone defect in the second stage of treatment. The wound healing, bone defect healing, complications, and the number of successful treatments were recorded. The satisfaction of the skin flap efficacy and the function of the affected limb were evaluated. ResultsLocal necrosis of the skin flap occurred in 3 cases after operation, leading to delayed healing of the wound; the other 19 flaps survived successfully, leading to primary healing of the wound. The skin grafts survived completely and the incisions healed by first intention. All cases were followed up 13-28 months with an average of 20 months. The infection recurred in 2 cases within 12 months after operation, and the bone defects healed after treated by modified induced membrane technique. The bone defect healing rate was 100%; the bone healing time was 6-10 months, with an average of 8.9 months; the infection control rate and successful treatment rate were 90.9% (20/22) and 90.9% (20/22), respectively. At 12 months after operation, according to the satisfaction evaluation standard of skin flap efficacy formulated by ZHANG Hao et al., all were satisfied. According to Johner-Wruhs adjacent joint function method, the limb function recovery was excellent in 13 cases, good in 7 cases, and fair in 2 cases, with an excellent and good rate of 90.9%. ConclusionFor the treatment of chronic tibial osteomyelitis in patients with diabetes without vascular occlusion, the modified induced membrane technique and pedicled skin (myocutaneous) flap can repair bone and soft tissue defects, and control the infection at the same time, the short- and medium-term effectiveness are good.
ObjectiveTo investigate the effectiveness of flap combined with induced membrane technique in treatment of post-traumatic tibial osteomyelitis with soft tissue defect. Methods A clinical data of 33 patients with post-traumatic tibial osteomyelitis with soft tissue defect who met the selection criteria between August 2015 and October 2018 was retrospectively analyzed. There were 21 males and 12 females. The age ranged from 19 to 70 years, with an average of 39 years. The osteomyelitis located in the upper 1/3 of tibia in 8 cases, in the middle 1/3 of tibia in 14 cases, and in the lower 1/3 of tibia in 11 cases. According to Cierny-Mader classification standard, 19 cases of osteomyelitis were type Ⅲ and 14 cases were type Ⅳ. The duration of osteomyelitis ranged from 2 months to 20 years (median, 3 months). In the first-stage operation, after radical debridement, the length of bone defect was 1.5-12.5 cm (mean, 5.0 cm) and the size of soft tissue defects ranged from 5 cm×4 cm to 15 cm×12 cm. Bone cement containing antibiotics was implanted into the bone defect and the personalized flap was used to repair the wound. After the wound healed at 6-8 weeks and the infection was controlled, bone grafting was performed to repair bone defects in the second-stage operation. Results The flaps survived completely after the first-stage operation in 29 cases. Partial necrosis of the flap occurred in 4 cases and healed after surgical dressing change. All the incisions healed by first intention after the second-stage operation. All patients were followed up 24-32 months (mean, 28 months). All the bone grafts healed after operation, and the radiographic healing time was 3-9 months (mean, 5 months). The clinical healing time was 4-14 months (mean, 8 months). There was no recurrence of osteomyelitis during follow-up. At last follow-up, according to Johner-Wruhs evaluation criteria, the limb function was excellent in 27 cases, good in 4 cases, and fair in 2 cases, with an excellent and good rate of 93.9%. Conclusion For the post-traumatic tibial osteomyelitis with soft tissue defect, the flap combined with induced membrane technique is a reliable and effective method and can effectively restore the function of lower limbs with satisfactory effectiveness.
Objective To summarize the treatment of chronic osteomyel itis of the skull and its effectiveness. Methods Between January 2004 and February 2009, 24 patients with chronic osteomyel itis of skull were diagnosed and treated, including 16 males and 8 females with an average age of 45.6 years (range, 18-56 years). The mean disease duration was 5.8 years (range, 3-11 years). The causes included infection after craniotomy in 3 cases, burn in 15 cases, and electrical injury in 6 cases, and the leision was located at the frontal and parietal of the skull in 10 cases, at the temporal and parietal of skull in 8 cases, and at the occipital of the skull in 6 cases. The soft tissue defects ranged from 7 cm × 6 cm to 19 cm × 12 cm, and the skull defects ranged from 5 cm × 4 cm to 10 cm × 7 cm. After wide thorough debridement of necrotic tissue, soft tissue defects were repaired with adjacent scalp flap in 12 cases, trapezius myocutaneous flap in 6 cases, and free anterolateral thigh flap in 6 cases; the flap size ranged from 8 cm × 7cm to 20 cm × 13 cm. The donor sites were sutured directly or covered with spl itthickness skin. Results All pathological examinations showed pyogenic osteomyel itis of the skull, and local ized squamous carcinoma was found in 1 case. One patient had sub-flap infection at 2 weeks after operation, and heal ing was achieved after surgical removal of residual tissue; the remaining flaps survived, and incision healed by first intention. All patients were followed up 10 months to 4 years with an average of 2 years after operation. The color and texture of the flaps were good. No recurrence of osteomyel itis happened during follow-up. The patient diagnosed as having local ized squamous carcinoma was followed up 4 years without recurrence. At 3 to 6 months after operation, 8 patients had headache or felt dizzy, and the skull was reconstructed by the titanium meshes. Conclusion In patients with chronic osteomyel itis of skull, the infected foci should be cleaned out thoroughly as early as possible, and the skin flap or myocutaneous flap is used to repair the wounds, thus the good results can be achieved.
Objective To probe the repair method and effect of freesegmented-fibula transplantation to treat chronic osteomyelitis complicated by long bone defect in tibia in the first intention. Methods From March 1996 to December 2003, 67 cases of chronic osteomyelitis complicated by long bone defect were reconstructed with vascularized fibula graft after the long inflammable bone and soft tissue focus were resected. Their age ranged from 8 to 42 years. The course of disease was 6 months to 8 years. There were 14 cases of hematogenous osteomyelitis and 53 cases of traumatic osteomyelitis. Of them, 18 cases complicated by fracture of fibula; 21 cases by defect of skin ( 2 cm×4 cm-4 cm×10 cm) and bone exposure;53 cases by pathological fracture and nonunion; and 46 cases by 1-3 fistula of osteomyelitis. The length of bone defect was from 8 cm to 22 cm(mean 12 cm), andthegermiculture results of all cases were positive. Forty-six cases were treated with vascularized fibula graft, the other 21 cases with the skin flap. The segmentedfibula was 10-28 cm, skin flap size was 4 cm×7 cm6 cm×12 cm. Results After a follow-up of 12-45 months, the healing rate of sinus was 93.5% while the 6.5% remainders healed by the second sinus cleaning-up. The graft bone healed after 4-6 months(mean 4.2 months) by X-ray examination. The limb inflammation was controlled after 2 weeks.All 21 skin flaps all survived and the function recovery of affectedlimb was 79% of normal limbs according to Enneking evaluation system, but 2 patients occurred secondary fracture. The act or process of augmenting of tibia under 18-year-old cases were sooner than those who were more than 18-year-old. Conclusion It is a choice to repair the chronic osteomyelitis complicated by longbone defect with vascularized fibula graft in the first intention. The operation to reconstruct long bone defect is a good method to control inflammation efficiently, shorten period of treatment and reduce the time of operation.
ObjectiveTo explore the effectiveness of vacuum sealing drainage (VSD) combined with open bone graft for tibial traumatic osteomyelitis. MethodsBetween June 2007 and December 2012, 23 cases of tibial traumatic osteomyelitis were treated, including 15 males and 8 females with an average age of 32.5 years (range, 22-48 years). The time from injury to admission was 7-18 months (mean, 8.6 months). There was local bone scarring in 15 cases, the size ranged from 8 cm×4 cm to 15 cm×8 cm. The CT multi-planar reconstruction was carried out preoperatively. Eleven cases had segmental bone sclerosis with a length of 1.5 to 3.8 cm (mean, 2.6 cm); 12 cases had partial bone sclerosis with a range of 1/3 to 2/3 of the bone diameter. On the basis of complete debridement, infection was controlled by VSD; bone defect was repaired by VSD combined with open bone graft. After there was fresh granulation tissue, the wound was repaired by free skin graft or local skin flap transfer. ResultsNail infection occurred in 2 cases, which was cured after the use of antibiotics. The wound healed at the first stage after repairing. All cases were followed up 10-18 months (mean, 13.5 months). In 11 cases of segmental bone sclerosis, the infection control time was 7-14 days (mean, 8.8 days); the bone healing time was 32-40 weeks (mean, 34.4 weeks); and the frequency of VSD was 3-6 times (mean, 4.5 times). In 12 cases of partial bone sclerosis, the infection control time was 7-12 days (mean, 8.3 days); the bone healing time was 24-31 weeks (mean, 27.3 weeks); and the frequency of VSD was 3-5 times (mean, 3.6 times). Infection recurred in 1 case, and the patient gave up the therapy. No infection recurrence was observed in the other patients. ConclusionThe VSD combined with open bone graft is an effective method for the treatment of tibial traumatic osteomyelitis.
Objective To evaluate the limbs shortening and re-lengthening in the treatment of tibial infectious bone defect and chronic osteomyelitis. Methods Between January 2011 and April 2016, 19 cases of tibial infectious bone defect and chronic osteomyelitis were treated with the limbs shortening and re-lengthening technique. There were 13 males and 6 females, aged from 22 to 62 years (mean, 44 years). The causes of injury included traffic accident injury in 16 cases, crush injury in 1 case, and falling from height in 2 cases. One patient was infected after plate internal fixation of closed tibial fracture and 18 patients after external fixation of open tibial fractures (Gustilo type IIIB). The mean previous operation times was 3 times (range, 2-5 times). The time from injury to bone transport operation was 3-11 months (mean, 6.5 months). The bone defect length was 2.0-5.5 cm (mean, 4.3 cm) after debridement. After tibial shortening, limb peripheral blood supply should be checked after release of the tourniquet. Seven wounds were closed directly, 5 were repaired with adjacent skin flap, 5 were repaired with sural neurovascular flap, 1 was repaired with medial head of gastrocnemius muscle flap, and 1 underwent skin grafting. Single arm external fixator or ring type external fixator were used, and completely sawed off between 2 sets of external fixation screws at proximal and distal metaphysis of the tibia. Limb lengthening was performed after 1 week with the speed of 1 mm/d. Results All patients were followed up 10-36 months with an average of 14 months. Two cases delayed healing of the wound after operation, and the other wounds healed primarily. Natural healing of the opposite end of the bone were found in 18 cases, and 1 case had nonunion in the opposite end of the bone because of incomplete removal of lesion bone. There were 5 cases of slow growth of the callus, and healed smoothly by " accordion” technology and injecting red bone marrow in 4 cases, and by bone grafting and internal fixation in 1 case. The time of bone lengthening was 1-3 months, the prolongation index was 1.6-2.7 cm/month (2.20 cm/month). The bone healing time was 7-13 months (mean, 11.1 months). According to tibial stem diagnostic criteria Johner-Wruhs score, 9 cases were excellent, 8 cases were good, 2 cases were fair, with an excellent and good rate of 89.5%. Conclusion Limbs shortening and re-lengthening is an effective method for the treatment of tibial infectious bone defect and chronic osteomyelitis, with the advantages of improving the immediate alignment of the osteotomy ends, significantly shortening the bone healing time of opposite ends of bone.