Ankle and foot osteomyelitis: treatment protocol and clinical results.
BACKGROUND
A management protocol for ankle and foot osteomyelitis and the outcome in 84 patients treated in a unit with special interest in musculoskeletal infection, is presented.


METHODS
Patients' mean age was 50.7+/-16.5 years and mean follow-up 31.5+/-18.2 months. Systemic antibiotics were administered initially empirically, and later according to cultures. Surgical treatment included surgical debridement and bead-pouch technique, minor amputation (ray or toe), below knee amputation, and joint fusion. "Second-look" procedures were performed after 48-7h. Vascularised grafts or Ilizarov's technique were used for bone defect reconstruction. Soft tissues were managed according the 'reconstructive ladder' concept.


RESULTS
Host-type (Cierny's classification) was A in 25, B in 53 and C in 6 patients. Seventy-six infections were chronic. Causes were: open trauma without fracture (45/84), open fractures (9/84), ORIF of closed fractures (25/84) and elective surgery (5/84). Patients underwent 3.0+/-1.5 (range 1-10) operative procedures and spent 14.8+/-12.2 (range 3-60) days in hospital. Two (host-C) patients died. Complications requiring reoperations occurred in 20/84 (2/25 host-A, 16/53 host-B, 2/6 host-C; significant difference between host-A versus host-B and -C patients, p<0.001). Infection recurrence occurred in 12 (none host-A; significant difference between host-A versus host-B and -C patients, p<0.001). Multiple organisms were isolated in 39/84. Ankle arthrodesis using external fixation was performed in 9 (fusion rate 8/9). The free vascularised fibula graft was used in 2 and distraction osteogenesis in 8 patients with a mean bone defect of 5.4 cm (range 3-13). Below knee amputations were performed in 5/84 (3/53 host-B, 2/6 host-C) and foot ray amputations in 8/84 (6/53 host-B, 2/6 host-C). Soft tissue coverage required: free muscle flap transfer in 6/84, reverse soleus flap in 1/84, local fasciocutaneous flaps in 7/84, split thickness skin grafts in 5/84, and vacuum assisted closure in 5/84 patients. Eighty-two surviving patients, including amputees, were able to mobilise independently and were satisfied with the result of treatment.


CONCLUSIONS
Host-B and -C patients had more complications and infection recurrences and occasionally required amputations. Reconstructive procedures were performed for limb salvage in patients with soft tissue and bone defects and restoration of a functional limb was achieved.
Malizos
Konstantinos N
KN
Department of Orthopaedic Surgery & Musculoskeletal Trauma, Faculty of Medicine, School of Health Sciences, University of Thessalia, University Hospital of Larissa, Larissa, Greece. malizos@med.uth.gr
Gougoulias
Nikolaos E
NE
Dailiana
Zoe H
ZH
Varitimidis
Sokratis
S
Bargiotas
Konstantinos A
KA
Paridis
Dionysios
D
D000293:Adolescent; D000328:Adult; D000368:Aged; D016512:Ankle Injuries / Q000150:complications / Q000453:epidemiology / Q000628:therapy*; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D001424:Bacterial Infections / Q000453:epidemiology / Q000382:microbiology / Q000628:therapy*; D002908:Chronic Disease; D002985:Clinical Protocols; D017719:Diabetic Foot / Q000150:complications / Q000453:epidemiology / Q000601:surgery; D004338:Drug Combinations; D005260:Female; D018409:Foot Injuries / Q000150:complications / Q000453:epidemiology / Q000628:therapy*; D050723:Fractures, Bone / Q000150:complications / Q000601:surgery; D005672:Fusidic Acid / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000379:methods / Q000534:rehabilitation; D010019:Osteomyelitis / Q000628:therapy*; D019904:Polymethyl Methacrylate / Q000627:therapeutic use; D019651:Plastic Surgery Procedures / Q000379:methods* / Q000534:rehabilitation; D020127:Recovery of Function; D012086:Reoperation; D017695:Soft Tissue Injuries / Q000188:drug therapy / Q000453:epidemiology / Q000601:surgery; D016896:Treatment Outcome; D014640:Vancomycin / Q000008:administration & dosage; D055815:Young Adult
D000900:Anti-Bacterial Agents; D004338:Drug Combinations; D005672:Fusidic Acid; D014640:Vancomycin; D019904:Polymethyl Methacrylate