Surgical debridement for acute, chronic osteomyelitis in children
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Osteomyelitis is a microbial infection of the bone. Pediatric osteomyelitis is common and has increased with time.
The average incidence of acute osteomyelitis is eight to 10 per 100,000 children in well-resourced nations, while the incidence in resource-limited nations is 80 per 100,000 children. Common pathogens include Staphylococcus aureus, streptococci and H. influenzae type B. First-line treatment for pediatric osteomyelitis is antibiotic therapy; however, surgical debridement may be indicated in patients who have failed initial antibiotic therapy or patients who have an abscess.
Source: Brandon R. Ho, BS; Emma D. Grellinger, BS; Ishaan Swarup, MD
There is no consensus for indication of surgical debridement. Indications for surgery may include inappropriate response to antibiotic therapy, acute complicated osteomyelitis, chronic osteomyelitis, associated septic arthritis, evidence of necrotic bone, formation of a sinus tract, direct physeal invasion, presence of prosthetic material, subperiosteal abscesses and/or other deep fluid collections. Complications of surgical debridement can include avascular necrosis, pathologic fractures and growth disturbances. Surgical debridement for pediatric osteomyelitis in combination with appropriate antibiotic therapy has shown good clinical and functional outcomes.
Preoperative planning
The evaluation of a patient with osteomyelitis includes gathering patient history and performing a physical exam. During the physical exam, signs of cellulitis, subcutaneous abscess, anatomic location of point tenderness and the presence of any sinus tracts are used to determine the extent of infection and surgical approach. It is important to examine adjacent joints if there is concern for concomitant septic arthritis. Radiographs are used to localize the area of osteomyelitis, with specific findings including osteolysis and periosteal changes. An MRI is recommended to evaluate the extent of infection, presence of an abscess and soft tissue infection in septic arthritis. Incisions are planned based on the greatest area of disease burden, affected anatomic areas, critical anatomic structures and proximity to the physis.
Important tip: Preoperative radiographic imaging should be well-understood to identify the disease burden, localize critical structures, such as the physis and neurovascular structures, and plan the surgical approach.
Subperiosteal debridement
Pediatric patients undergoing surgical debridement for osteomyelitis are typically given general anesthesia, but regional anesthesia may be considered in some settings. If the patient is not septic and hemodynamically stable, antibiotics are withheld upon admission and at the start of surgery until cultures are obtained. The patient is positioned and draped based on the anatomic location of the infection, and the adjacent joint should remain exposed for extension of debridement, if necessary. If a tourniquet can be used, the extremity is elevated for exsanguination. Fluoroscopy can be used to help localize the area for incision and debridement.
In the case of an elevated or disrupted periosteum, a Cobb elevator or freer elevator is used to circumferentially dissect subperiosteally around the affected area to reach and decompress all areas of purulence. Thorough debridement of subperiosteal abscesses is necessary. Cultures (aerobic, anaerobic and, in some settings, fungal) should be sent from all areas of infection. Pathology can also be sent if the affected area intraoperatively is less consistent with infection.
Important tip: Avoid extensive periosteal stripping outside the infection zone to reduce risk of bone devascularization.
Cortical window creation
The site of the cortical window is first confirmed with radiographs. The cortical window should be created in an area with overlying muscles to provide vascularity and coverage to the site after the intramedullary canal has been debrided. A corticotomy can be made with a single drill hole or several drill holes can be made and connected to increase the size. Curved and straight curettes are useful in reaching different areas within the intraosseous space.
If the proximal or distal aspect of the bone needs to be reached, a flexible reamer, K-wire, burr or flexible nail may be used for intramedullary decompression, debridement and to stimulate bleeding. All sequestrum and necrotic material should be removed with bleeding or vascularized tissue free of gross contamination, indicating appropriate debridement. If the bone segment is unstable after debridement in children, postoperative immobilization may be indicated with casts or splints. External fixation is rarely indicated but may be used if needed.
Irrigation
After thorough debridement, irrigation is used to thoroughly clean the subperiosteal and interosseous space until the tissues are free of purulence. The overlying soft tissue can be irrigated using cystoscopy tubing, if available, or syringe irrigation. If cystoscopy tubing is available, a Frazier suction tip may be used to irrigate the intramedullary canal. The amount of irrigation depends on the patient’s size and extent of the infection; however, a minimum of 3 L of irrigation is used.
Important tip: Extensive irrigation is required for successful debridement, and we typically continue with irrigation until the outflow fluid is clear.
Antibiotic use, drain placement
Vancomycin powder may provide some benefits in the setting of MRSA infection, but there are limited data to support routine use. Antibiotic beads or cement should be considered for chronic or extensive osteomyelitis and may require subsequent surgery to remove exogenous material.
A deep drain is placed in areas with the greatest purulence. It is usually placed in line with the incision in case there is continued drainage and repeat debridement is needed. The drain can be removed when there is minimal output and clinical improvement.
Surgical sites are closed in a layered manner with unbraided sutures. Sites for repeat debridement can be marked with polydioxanone sutures (Ethicon), and interrupted sutures are helpful to allow for drainage.
Important tip: The dead space and wound should be closed in a layered manner, and dead space should be limited to decrease the possibility of accumulation of purulence.
Immobilization, drain removal
The dressings used allow for monitoring the surrounding soft tissue and are nonabrasive to allow for frequent removal and dressing changes. The affected extremity is immobilized, and weight-bearing should be limited, particularly in patients requiring a large cortical window. Vacuum-assisted closure of the wound can be used if there is significant soft-tissue infection or a plan for return to the OR in the following days. Indications for repeat surgical debridement include persistent infection that is nonresponsive to the initial debridement or antibiotics, isolation of highly virulent organisms and/or a critically ill patient.
Surgical drains are continued until output is minimal. During the physical exam, check soft tissues in the wound to assess cellulitis, fluctuates, swelling and drainage. Palpation and range of motion of adjacent joints are also indicated. Antimicrobial therapy can be continued in conjunction with consultation with infectious disease specialists. If there is limited improvement after debridement based on clinical exam or lab findings, a repeat MRI may be needed for reassessment and identification of areas that require further treatment.
Important tip: Check labs every 2 to 3 days to assess improvement in inflammatory markers (C-reactive protein and erythrocyte sedimentation rate) and white blood cell count.
Follow-up
Patients may be discharged if they show clinical improvement. Antibiotic regimen and duration should be determined in consultation with infectious disease specialists.
After discharge, patients are typically seen at 10 to 14 days for a wound check and they should continue follow-up with an infectious disease specialist while under active antimicrobial treatment. If the area of infection or debridement affected a critical area, such as the physis, long-term follow-up is indicated to monitor for growth arrest and deformity.
- References:
- Ekunseitan E, et al. JBJS Essent Surg Tech. 2023;doi:10.2106/JBJS.St.21.00039.
- Gornitzky AL, et al. JBJS Rev. 2020;doi:10.2106/JBJS.RVW.19.00202.
- For more information:
- Emma D. Grellinger, BS, and Brandon R. Ho, BS, can be reached at the school of medicine at the University of California, San Francsico. Ishaan Swarup, MD, can be reached at the department of orthopedic surgery at the University of California, San Francisco. Grellinger’s email: emma.grellinger@ucsf.edu. Ho’s email: brandon.ho2@ucsf.edu. Swarup’s email: ishaan.swarup@ucsf.edu.
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