An integrated approach to adult chronic osteomyelitis.

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.