Does hyperbaric oxygen have a place in the treatment of osteomyelitis?

There are several specific mechanisms by which HBO restores normal cellular processes that are compromised by hypoxia, or by which HBO augments bactericidal events. All of these are potentially applicable to, and beneficial for, the osteomyelitis patient. At the University of Texas Medical Branch, we find that early osteomyelitis is usually amenable to appropriate medical and surgical therapy. Adjunctive HBO is generally reserved for treatment of advanced stages of osteomyelitis (3B and 4B). In addition, HBO is occasionally used when patient circumstances dictate suppression of osteomyelitis rather than definitive treatment. Our clinical impression is that HBO has a beneficial effect on treatment outcome in these selected patients. Fault-free clinical studies are difficult to perform in this complex and varied patient population. Several studies have suggested a beneficial effect with the addition of adjunctive hyperbaric oxygen to usual osteomyelitis treatment regimens, whereas other clinical studies have failed to demonstrate such a benefit. No study has shown any harmful effect of adjunctive HBO on the outcome of osteomyelitis treatment. We hope that clinical researchers will continue to address this question, despite the research design problems inherent in the osteomyelitis population.

The cylindrical titanium mesh cage for treatment of a long bone segmental defect: description of a new technique and report of two cases.

This report describes a new technique for treatment of a segmental defect in long bones that uses a cylindrical titanium mesh cage, in combination with cancellous bone allograft and demineralized bone matrix putty (Grafton), stabilized with a statically locked intramedullary nail. Two clinical cases of tibia defects treated with this technique are presented. At the one-year follow-up, radiographically both cases demonstrated excellent limb alignment, stability, and bony healing. Immediate full weight-bearing was initiated in each case, and early limb functional recovery was achieved. Preliminary data suggest that this technique may be a reasonable alternative to currently used methods for management of select long bone segmental defects.

Salmonella typhi osteomyelitis in a nonsickle cell patient. A case report.

Few cases of osteomyelitis caused by Salmonella typhi in nonsickle cell patients have been reported. In a 33-year-old woman with a history of chronic, intermittent drainage of the right lower leg, roentgenographs indicated middiaphyseal osteomyelitis of the fibula. Bone cultures obtained at surgical debridement grew S. typhi. The patient responded adequately to four weeks of intravenous antibiotic therapy, and the infection has remained arrested after 18 months. The characteristics of S. typhi osteomyelitis are as follows: All reported cases have affected female patients with no apparent immunocompromise; all had a history of S. typhi infection with long bone involvement; and all had a tendency to recurrence.

Positively charged dextran resin inhibits trabecular bone repair in the rabbit tibial physis.

Because exposure to positively charged dextran resin (PCDR) inhibits the growth of cultured rat and human bone cells, we tested the hypothesis that PCDR might inhibit bone repair in vivo. Central physeal defects were created by drilling 3.0-mm holes from the proximal tibial plateau into the metaphysis. The defects in left tibiae were packed with neutral resin (control); those in right tibiae were filled with PCDR. At the end of the 1st, 2nd, 3rd, and 10th postoperative weeks, the outcomes were quantitated by documenting the percent trabecular bone volume within the defect. The PCDR-filled defects showed a significant decrease in trabecular bone formation as early as the 2nd week. By the 10th postoperative week, formation of trabeculae had been reduced by nearly 40%. The inhibition conferred by PCDR suggests that the resin could be used as a suppressive interpositional material.

The Ilizarov fixator and polymethylmethacrylate-antibiotic beads for the treatment of infected deformities.

Eighteen of the 124 patients enrolled in the gentamicin methylmethacrylate bead (GMB; Septopal) study had infected deformities that were treated with the Ilizarov external fixator. Nine of these patients (Group 1) were treated with an initial debridement and intravenous antibiotics for four weeks. Nine patients (Group 2) were treated with GMB and, five days after operation, intravenous antibiotics. The two groups were similar. Group 1 included eight men and one woman (average age, 31.8 years) and Group 2, seven men and two woman (average age, 37.4 years). Both groups had multiple deformities, including nonunions, segmental defects, angulation, and shortness. The end results were identical. Eight patients in each group had their infection successfully arrested (88.9%), and eight patients in each group had their deformity successfully treated. The use of GMB with the Ilizarov fixator was as effective as long-term parenteral antibiotics with the Ilizarov fixator for the treatment of infected deformities.

The treatment of infected nonunions with gentamicin-polymethylmethacrylate antibiotic beads.

Fifty-two patients enrolled in the Septopal study of infected nonunions were prospectively examined in a randomized, controlled, closed study. Patients were divided into two groups. Group 1 consisted of 24 patients treated with debridement and intravenous antibiotics for four weeks. Group 2 consisted of 28 patients treated with debridement, gentamicin-polymethylmethacrylate (Septopal) beads, and perioperative broad-spectrum parenteral antibiotics. Both groups were treated with similar methods for reconstruction of the nonunions. The demographics of the two groups were similar. The average patient age in Group 1 was 38.4 years, and in Group 2, 37.1 years. Group 1 included 21 men and three women and Group 2, 23 men and five women. The nonunions in both groups ranged from simple hypertrophic nonunions to atrophic unions to segmental defects. The end results were good in both groups. Twenty patients in Group 1 and 25 patients in Group 2 had their infections successfully arrested (83.3% and 89.3%, respectively). Nonunions were successfully healed in the two groups, with similar results (Group 1, 83.3%; Group 2, 85.7%). Infected nonunions responded equally well to either systemic treatment with long-term intravenous antibiotics or local treatment with gentamicin-polymethylmethacrylate beads.