A systematic review of the single-stage treatment of chronic osteomyelitis

BACKGROUND: Despite advances in surgery, the treatment of chronic osteomyelitis remains complex and is often associated with a significant financial burden to healthcare systems. The aim of this systematic review was to identify the different single-stage procedures that have been used to treat adult chronic osteomyelitis and to evaluate their effectiveness. METHODS: Ovid Medline and Embase databases were searched for articles on the treatment of chronic osteomyelitis over the last 20 years. A total of 3511 journal abstracts were screened by 3 independent reviewers. Following exclusion of paediatric subjects, animal models, non-bacterial osteomyelitis and patients undergoing multiple surgical procedures, we identified 13 studies reported in English with a minimum follow-up period of 12 months. Data extraction and quality assessment were performed for all studies. Non-recurrence was defined as resolution of pain without recurrence of sinuses or need for a second procedure to treat infection within the described follow-up period. RESULTS: A total of 505 patients with chronic osteomyelitis underwent attempted single-stage procedures. Following debridement, a range of techniques have been described to eliminate residual dead space including biologic and non-biologic approaches. These include musculocutaneous flaps, insertion of S53P4 glass beads or packing with antibiotic-loaded ceramic or calcium-sulphate pellets. The average follow-up ranged from 12 to 110 months. The most common organism isolated was Staphylococcus aureus (35.2%). Non-recurrence ranged from 0 to 100%. Debridement alone was statistically significantly inferior to approaches that included dead space management (54.5% versus 90% non-recurrence). Biologic and non-biologic approaches to dead space management were comparable (89.8% versus 94.2% non-recurrence). CONCLUSION: A wide range of single-stage procedures have been performed for the treatment of chronic osteomyelitis. In general, studies were small and observational with various reporting deficiencies. No one dead space management technique appears to be superior, but debridement alone that leaves residual dead space should be avoided.