An integrated approach to adult chronic osteomyelitis.
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Date
2014
Authors
Marais, Leonard Charles.
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Abstract
No evidence-based guidelines exist on the treatment of chronic osteomyelitis of long
bones in adults. Management is still largely based on expert opinion and consensus
guidelines are not available. Choosing between a palliative and curative treatment
strategy requires consideration of several factors. Principle amongst these is the
host’s physiological status, which determines the patient’s ability to cope with the
rigours of limb salvage surgery. This fact was recognized by Cierny and Mader,
when they developed their popular staging system. The authors suggested palliative
treatment in C-hosts, who will not be able to cope with the metabolic demands of an
aggressive treatment plan. The problem however, is that the C-host was never
accurately defined. Cierny and Mader predicted in their original paper that, as a
result of the inadequate definition, the selection of surgical candidates would vary
from institution to institution until there was standardization of this concept.
The limitations of existing classification systems prompted the development of a
novel approach to chronic osteomyelitis for use in South Africa. This involved the
establishment of an objective definition of a C-host, as well the development of a
novel classification system and an algorithmic guideline to treatment strategy
selection. By integrating the physiological status of the host (based on pragmatic
predefined criteria) with the selection of the appropriate curative, palliative or
alternative treatment strategy we were able to achieve favourable short term
outcomes in both low and high risk cases and in addition reduce the rate of
amputation. Furthermore, we were able to report novel data on the outcome of palliative treatment, as well as the outcome of treatment of chronic osteomyelitis in
HIV infected patients.
While the preliminary results appear promising, long term follow-up will be required
in order to determine the rate of recurrence of infection. The proposed approach was
designed specifically with the South African clinical environment in mind and
additional development of the algorithm may be required in order to render it useful
in other clinical settings. The implementation of a refined host stratification, which
incorporates objective criteria for C-host classification will, however, enable the
comparison of results from studies employing different therapeutic interventions in
the future. In addition, selection of patient-matched treatment options closes the gap
in successful outcomes between healthy and compromised patients. The major
benefit of the proposed approach is therefore the fact that the integrated approach
places appropriate emphasis on the importance of host factor modification prior to
surgical intervention.
Description
Master of Medical Science in Clinical Medicine. University of KwaZulu-Natal, Durban 2014.