Single‐stage versus two‐stage bone flap reconstruction in chronic osteomyelitis: Multicenter outcomes comparison

Abstract

AbstractBackgroundChronic osteomyelitis is an invalidating disease, and its severity grows according to the infection's particular features. The Cierny‐Maiden criteria classify it according to the anatomical aspects (I to IV) and also by physiological class (A host being in good immune condition and B hosts being locally (L) or systemically (S) compromised). The surgical approach to chronic osteomyelitis involves radical debridement and dead space reconstruction. Two‐stage management with delayed reconstruction is the most common surgical management, while one‐stage treatment with concomitant reconstruction is a more aggressive approach with less available literature. Which method gives the best results is unclear. The purpose of this study is to compare single and two‐stage techniques.MethodsThe authors carried out a retrospective multicentric cohort study to compare two primary outcomes (bone union and infection healing) in one versus two‐stage reconstructions with vascularized bone flaps in 23 cases of limb osteomyelitis (22 patients, 23 extremities). Thirteen subjects (56.5%) sustained a single‐stage treatment consisting of a single surgery of radical debridement, concomitant soft tissue coverage, and bone reconstruction. Ten cases (43.5%) sustained a two‐stage approach: radical debridement, simultaneous primary soft tissue closure, and antibiotic PMMA spacers implanted in 7 patients.ResultsNo statistical differences were observed between one‐ and two‐stage approaches in bone union rate and infection recurrence risk. Even though bone union seems to be higher and faster in the two‐stage than in the one‐stage group, and all infection relapses occurred in the one‐stage group, data did not statistically confirm these differences. Two of the six cases (33.3%) of bone nonunion occurred in compromised hosts (representing only 17.4% of our sample). The B‐hosts bone union rate was 50.0%, while it reached 78.9% in A‐hosts, but the difference was not statistically significant (p = .5392). Infection recurrence was higher in B‐hosts than in A‐hosts (p = .0086) and in Pseudomonas aeruginosa sustained infections (p = .0208), but in the latter case, the treatment strategy did not influence the outcome (p = .4000).ConclusionsBone union and infection healing rates are comparable between one and two‐stage approaches. Pseudomonas aeruginosa infections have a higher risk of infection relapse, with similar effectiveness of one‐ and two‐stage strategies. B‐hosts have a higher infection recurrence rate without comparable data between the two approaches. Further studies with a larger sample size are required to confirm our results and define B‐hosts' best strategy.Level of EvidenceLevel III of evidence, retrospective cohort study investigating the results of treatments.