Is Osteomyelitis Primarily A Surgical Disease?
Yes, Dr. Dujela points to key principles and case studies that convey the need for surgical treatment in facilitating curative results. The notion that osteomyelitis is “primarily” a surgical disease does not discount the importance of adjunctive antibiotic therapy. However, in the presence of established osteomyelitis, surgical treatment should be the mainstay with antibiotics playing a supporting role. The basic philosophy in the surgical treatment of osteomyelitis is foot salvage. Essentially, we are attempting to achieve a balance between resecting adequate bone for curative results while maintaining sufficient bone and structure for stability. Three general goals of treatment for osteomyelitis and infections should guide our therapy. • Facilitate an optimum environment and physical characteristics for soft tissue and bone healing. • Strive for a functional and plantigrade foot. • Preserve as much of the functional foot as possible. While I am a proponent of surgical treatment and limb salvage in osteomyelitis, I recognize that patients are sometimes better served by a definitive and healed amputation that allows ambulation and resumption of daily living activities. For some patients, this is more appropriate than leaving someone incapacitated by prolonged non-weightbearing, total contact casting or chronic wound care regimens to save a marginally viable segment of the foot. One Case Study To Consider While I was a resident, I had the opportunity to work with an overweight diabetic patient whose husband had severe chronic obstructive pulmonary disease. She had chronic MRSA osteomyelitis of the calcaneus secondary to a longstanding heel ulceration. She was often seen towing her wheezing husband in a wheelchair caboose-style with her power scooter 20 mph through the corridors of the hospital. The patient was initially treated with long term IV antibiotics and wound care as an outpatient. The infection progressed and she was treated with a partial calcanectomy. The chief resident had written an order for complete postoperative bed rest. Two hours after surgery, during her period of complete bed rest, she fractured the remaining segment of her calcaneus while returning to bed after a “cigarette break.” After prolonged IV antibiotic therapy and difficult wound management, the patient was treated with a total calcanectomy after refusing an amputation. Initially, she did quite well, but after some time had passed, the osteomyelitis, which had partially affected her midfoot, overwhelmed her and she finally agreed to have an amputation. Within two months, she returned to the office 30 pounds lighter. She wore a prosthesis and was ambulating for the first time in over a year. She proudly presented us with a batch of homemade cookies (that the residents fondly called “MRSA bombs”) and told us that she should have had the surgery months before. It’s important to recognize that physicians and patients often spend a great deal of energy and resources trying to salvage an extremity that is beyond preservation. In some cases, one should view amputation as the most conservative option in treating osteomyelitis. What You Should Know About The Location Of The Infection It’s also essential to consider the location of the infection as it plays a key role in choosing the appropriate therapy. For example, osteomyelitis frequently occurs with digital ulcerations. Keep in mind that phalangeal bone infections are rarely cured by antibiotics alone and usually require partial or complete amputation. Osteomyelitis of the sesamoids is another cause of chronic non-healing wounds that generally do not respond to IV therapy. Osteomyelitis of the metatarsals often requires surgical treatment via bone debridement or ray resections. Surgical treatment often alleviates the deformity that caused the ulceration and eventual bone infection. Consider the common hallux interphalangeal joint ulceration. Reduction of this prominence via a Villaneuva procedure or an IPJ arthroplasty often not only results in surgical cure of the osteomyelitis but diminishes the risk of recurrence. Many other examples of this scenario occur in the foot such as a plantar first metatarsal head ulceration or collapsed medial column with navicular prominence in Charcot osteoarthropathy. One can often perform primary closure or early delayed primary closure that allows earlier return to function and alleviates the need for long-term wound care.