TWO-STAGE MANAGEMENT OF CHRONIC

OSTEOMYELITIS OF THE LONG BONES

THE BELFAST TECHNIQUE

M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN

From Musgrave Park Hospital and the Ulster Hospital, Northern Ireland

We treated 37 patients with chronic osteomyelitis of the al 1985). “The hallmark of chronic osteomyelitis is
tibia (25), femur (9), radius (2) and humerus (1) by a two- infected, dead bone within a compromised soft-tissue
stage technique, comprising radical debridement of all envelope” (Cierny and Mader 1984). This is an important
infected bone and soft tissue with the provision of soft- summary of the disease process, as it highlights those
tissue cover, and delayed autogenous bone grafting when features which contribute to chronicity and which need
necessary. All patients were reviewed at an average of 49 to be dealt with if eradication of infection is to be
months (12 to 121). Infection-free bone union was achieved achieved.
in 34. No patient required amputation. The need for surgery in the treatment of chronic
Wide excision of all compromised tissue and the osteomyelitis is well recognised, but there is no consensus
closure of bone within a healthy vascularised soft-tissue on the best method. In 1946, Stark described the
envelope are essential if infection is to be eradicated. The treatment ofpost-traumatic chronic infection by debride-
combined assessment and management of such patients by ment and reconstruction with a pedicled muscle flap. He
an orthopaedic surgeon and a plastic surgeon are advocated. stressed the importance of radical removal of dead bone
and the inadequacy of simple sequestrectomy. This has
J Bone Joint Surg [Br] 1993 ; 75-B : 375-80.
been supported by more recent work by Cierny and
Received 29 May 1992; Accepted 24 September 1992
Mader (1984), Gordon and Chiu (1988) and Yoshimura
et al (1989). Papineau described his technique of excision
The development ofnew antimicrobial agents with wide- and bone grafting with delayed closure in 1973. This was
spectrum activity and high bioavailability has greatly a significant advance with a good initial cure rate
improved the treatment of infection in many body tissues, (Papineau et al 1979). The technique, however, is time-
but this is not the case in infection of bones and joints. consuming, requires prolonged hospitalisation and has a
Most patients with established bone infection are not considerable associated morbidity. A 5% amputation
cured by prolonged antibiotic therapy and almost all rate has been reported and secondary infection of the
require surgical intervention (Waidvogel, Medoff and open wound is a problem (Meyer, Weiland and Willeneg-
Swartz 1970; Waidvogel and Vasey 1980; Fitzgerald et ger 1975).
In 1982, Mathes, Alpert and Chang showed that
muscle flaps (either local or free-transfer) were highly
resistant to infection and that they provided the “cellular,
non-cellular and oxygen environment” necessary for the
eradication of infection and wound ischaemia associated
with chronic osteomyelitis. Local muscle flaps (Ger 1977;
Fitzgerald et al 1985), delayed free flaps (Weiland, Moore
and Daniel 1984; Gordon and Chiu 1988) and myocuta-
M. A. McNally, FRCS, Orthopaedic Registrar, British Orthopaedic
Association Wishbone Research Fellow
neous island flaps (Yoshimura et al 1989) have been used
R. A. B. Mollan, MD, FRCS, FRCS I, Professor of Orthopaedic extensively in the management ofchronic infection with
Surgery
Department of Orthopaedic Surgery, Musgrave Park Hospital, Stock- encouraging results, but problems remain with the long
man’s Lane, Belfast BT9 7JB, UK. duration and high cost of treatment, recurrence of
J. 0. Small, FRCS I, Consultant Plastic Surgeon infection and requirement of theatre time. Several
The Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast
BT16ORH, UK.
workers have reported the need for amputation despite
H. 0. Tofighi, MD, Consultant Orthopaedic Surgeon
extensive surgery (Ger 1977; Papineau et al 1979; Hall,
Department ofOrthopaedic Surgery, University ofTabriz, Iran. Fitzgerald and Rosenblatt 1983; Fitzgerald et al 1985;
Correspondence should be sent to Mr M. A. McNally. Gordon and Chiu 1988).
©l993 British Editorial Society ofBone and Joint Surgery We describe a series of patients managed by a
0301-620X/93/3557 $2.00 technique specifically designed to avoid the failings of

VOL. 75-B, No. 3. MAY 1993 375

376 M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN

the existing procedures and to reduce the time spent in findings. In all cases the excision of bone was radical
hospital, with its attendant morbidity and high cost. with no attempt at a limited resection. All bone showing
an abnormal appearance was removed. Careful assess-
ment of the medullary canal was made by de-roofing
PATIENTS
cortical bone. When the debridement was complete, the
We treated 37 patients with chronic infection ofthe tibia defect was copiously irrigated with saline or noxythiolin
(25), the femur (9), the radius (2) and the humerus (1). solution. The tourniquet was then deflated and the
There were 28 men and 9 women with a mean age of 42 pattern of bleeding from the bone surfaces was observed.
years (18 to 75), and a median duration of infection of 22 Any area which failed to bleed was excised back to
years (1 to 59). All patients had suffered recurring bleeding bone. This meticulous exploration and debride-
symptoms with pain and sinus drainage, and had been ment of all infected tissue usually took 30 to 60 minutes
treated for prolonged periods with wide-spectrum anti- to complete. All resected material was sent for anaerobic
biotics. Most had undergone multiple surgical procedures and aerobic culture.
including sinus curettage, drainage of abscesses and The management ofthe potential dead space created
sequestrectomy. Two had been treated by a modified by the debridement was thought to be important. In the
Papineau technique. cases with a large bone cavity which were suitable for
Chronic infection had followed a compound fracture direct closure of the skin, a few strings of gentamicin-
(25), plating of a closed tibial fracture (3), gunshot impregnated beads were used to fill the dead space.
wounds (3), acute haematogenous osteomyelitis (5) and Where a muscle flap was used for soft-tissue cover, this
internal fixation of a pathological fracture after excision was raised in such a way that it would fill the bone cavity
of an osteoclastoma (1). In those cases in which culture completely.
was positive, multiple organisms were invariably found, The treatment of soft tissues followed one of several
including Staphylococcus aureus, Proteus mirabiis, group plans. In 23 patients the skin was closed directly. Ten
D streptococci, Bacteroides fragiis and Pseudomonas were managed by free microvascular transfer of a muscle
aeruginosa. Most cultures had a Gram-negative isolate. flap (five rectus abdominis, four latissimus dorsi and one
All organisms were sensitive to combinations of fluclox- gracilis), two by local flaps (one soleus and one gastroc-
acillin, Fucidin, Ciproxin, cephamandole, gentamicin nemius flap), and two by free composite flaps from the
and metronidazole. deep circumflex iliac artery (incorporating a large portion
of iliac crest bone). Muscle flaps were most often
transferred without overlying skin, and thus required
TREATMENT
meshed split-skin grafting after anastomosis. Closed-
We designed the staged ‘Belfast technique’ for use in any suction drainage was used in most cases.
long bone, based on the following principles : radical The limb was usually protected in a plaster-of-Paris
debridement of all compromised tissues ; early provision back-slab or a split cast. External fixation was used only
of healthy vascularised soft-tissue cover with elimination when bone debridement had resulted in skeletal instabil-
of dead space ; delayed autogenous bone grafting when ity.
necessary ; and reduction of inpatient time during Postoperatively, strict bed rest was imposed for five
treatment. days with elevation of the affected limb. Thereafter, non-
The patients were assessed preoperatively by a weight-bearing mobilisation was begun. A period for
plastic surgeon and an orthopaedic surgeon to ascertain wound healing was then allowed, averaging 33 days. The
the extent of infected and compromised bone and soft antibiotic regime started before surgery was continued
tissue. Investigation included bacteriology, plain radio- with oral preparations of the chosen drugs. During this
graphy, tomography, sinography, blood tests and bone time most patients were able to leave hospital.
scanning when appropriate. The degree of debridement Stage two. This was carried out between three and six
required, the method of fixation to be used and the weeks after stage one, when the soft tissues had
requirement for soft-tissue reconstruction were then adequately healed. Under tourniquet, the bone defect
determined for each patient. At least two antibiotics was exposed through the same incision or along the
were given before surgery. margin of the flap, avoiding the vascular pedicle. Any
Stage one. The limb was explored under tourniquet. Skin antibiotic beads were removed and the cavity was
incisions were placed along the lines of existing wounds carefully inspected. Exuberant granulations were gently
where possible to minimise further damage to the soft curetted back to healthy vascularised tissue. A search
tissues. Sinuses, when present, were excised elliptically was made for areas not covered by fresh granulation
within the incision. If there was extensive soft-tissue tissue, suggesting non-viability of bone, and any such
scarring, wide excision of the poor-quality skin was area was further debrided. A cancellous bone graft was
undertaken. then harvested from the iliac crest, cut into small
Debridement of bone was guided in part by the segments and packed into the cavity. Care was taken to
preoperative investigations but mainly by the operative ensure tension-free closure of the skin. No drainage was

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 TWO-STAGE MANAGEMENT OF CHRONIC OSTEOMYELITIS OF THE LONG BONES 377

Table I. Details of 37 patients with chronic osteomyelitis treated by the two-stage Belfast technique
Age Duration of Follow-up

Case (yr) Bone Aetlology of infection infection yr) Skin cover (mdi) Complications Result

I 41 Tibia Acute haematogenous 27 Direct closure 86 None Cured

2 42 Tibia Compound fracture 6 Direct closure 69 None Cured

3 29 Tibia Compound fracture 11 Direct closure 88 None Cured

4 31 Tibia Compound fracture 9 Direct closure 79 Split-skin graft to wound Cured

2 weeks post-op
5 51 Tibia Compound fracture 49 Direct closure 76 Gastrocnemius flap at 2 Cured
weeks post-op

6 51 Tibia Compound fracture 46 Direct closure 84 None Cured

7 23 Tibia Excision of osteoclastoma 3 Direct closure 40 Elective repeat. Infected Cured

wound haematoma
8 21 Tibia Compound fracture 9 Lat. dorsi free flap 33 None Cured

9 58 Tibia Compound fracture 18 Soleus local flap 41 None Cured

10 63 Tibia Compound fracture 41 Gracilis free flap 12 None Cured

II 49 Tibia ORIF closed fracturet 16 Lat. dorsi free flap 22 None Cured

12 66 Tibia Compound fracture 59 Rectus abdo. free 20 None Cured

flap

13 30 Tibia ORIF closed fracture 3 Direct closure 22 Rectus abdo. flap at 2 Cured
weeks

14 30 Tibia Gunshot wound 7 Direct closure 33 None Cured

15 24 Tibia Compound fracture 2 Direct closure 31 None Cured

16 27 Tibia Compound fracture 9 Direct closure 22 Discharge at I 2 months Recurrences

17 64 Tibia Compound fracture 39 Direct closure 12 None Cured

18 55 Tibia Compound fracture 34 Rectus abdo. free 77 None Cured

flap

19 30 Tibia Compound fracture Unknown Rectus abdo. free 16 None Cured

flap

20 47 Tibia Compound fracture 4 Composite DCIA 100 None Cured

flaps

21 18 Tibia Compound fracture 1 Lat. dorsi free flap 49 Discharge at 24 months Recurrence

22 29 Tibia Compound fracture 1 Rectus abdo. free 57 None Cured

flap

23 26 Tibia Compound fracture I Composite DCIA 121 Minor scar revision at 2

Cured
flap years

24 21 Tibia Compound fracture Lat. dorsi free flap 67 None Cured

25 41 Tibia ORIF closed fracture 18 Rectus abdo. free 27 Secondary infection Recurrence
flap

26 38 Radius Acute haematogenous 16 Direct closure 65 None Cured

27 32 Radius Compound fracture 3 Direct closure 90 None Cured

28 46 Humerus Gunshot wound 4 Direct closure 30 None Cured

29 75 Femur Compound fracture 58 Direct closure 62 None Cured

30 48 Femur Compound fracture 35 Direct closure 66 None Cured

31 62 Femur Compound fracture 42 Direct closure 35 None Cured

32 65 Femur Gunshot wound 40 Gastrocnemius 58 None Cured

local flap
33 46 Femur Brodie’s abscess 2 Direct closure 37 None Cured

34 38 Femur Compound fracture 13 Direct closure 13 None Cured

35 24 Femur Acute haematogenous 22 Direct closure 31 None Cured

36 27 Femur Acute haematogenous 13 Direct closure 29 None Cured

37 73 Femur Compound fracture Unknown Direct closure 25 None Cured

* infection-free bone union

t ORIF, open reduction and internal fixation
infection-free bone union at ten months after a repeat operation
§ DCIA, deep circumflex iliac artery

VOL. 75-B, No. 3, MAY 1993

378 M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN

used after stage two. Again a period of bed rest was the infection. This was evacuated but it was decided to
imposed with leg elevation. Mobilisation was started and repeat both stages of the technique rather than risk
the patient was discharged when the wounds were healed. extension to the underlying tibia. These four patients are
Five patients did not have a second stage to their now an average of 54 months from surgery (minimum
treatment. In three the bone defect was small and did not 22) and all have progressed to sound infection-free union.
require grafting, and in two a large vascularised bone Illustrative case report. A 66-year-old man (case 1 2) was
graft was provided in a composite free flap at stage one. referred to the orthopaedic clinic with severe osteo-
Stabilisation and antibiotics were continued until arthritis of the right hip. He also had an extensive area
there was radiological and clinical evidence of union. ofatrophic skin with discharging sinuses over the anterior
surface of his right tibia (Fig. 1). Radiography showed
widespread infection ofthe entire diaphysis and proximal
RESULTS

All 37 patients were followed up for a mean of49 months

(12 to 121). Eradication of infection with bone union was
achieved in 34 (92%). No case resulted in amputation.
Details of the patients are given in Table I.
Three limbs had recurrence of deep infection, all in
patients with tibial disease. One of these (case 25)
developed an abscess under a rectus abdominis free flap.
At the second stage the bone cavity was seen to be well
lined with granulation tissue and there was no evidence
of residual dead tissue or infection. The abscess was
thought to be due to secondary infection at the time of
the stage-two operation.
Two patients (cases 16 and 21) returned at 12 and 24
months respectively with symptoms and signs of recurrent
deep infection. Case 1 6 was a 27-year-old man who had
had chronic infection of his tibia for nine years after a
compound fracture. After stage one there was no difficulty
with direct skin closure and healing proceeded rapidly
with no evidence of underlying infection. Five weeks
after stage one, a bone graft was inserted. At this stage
the cavity was clean and infection-free. With the bone
chips in place, however, it was much more difficult to
effect direct skin closure although this was achieved.
Postoperatively, the wound remained inflamed and at 12
months it broke down and discharged infected material.
Fig. 1 Fig. 2
We repeated our technique using a gracilis free flap for
skin cover, but this flap failed. The resulting skin defect Case 12. Figure 1 - The appearance of the tibia at presentation. Chronic
infection had resulted from a compound fracture 59 years previously.
was then treated by a local fasciocutaneous flap. This
Figure 2 - The radiograph shows extensive involvement of the proximal
patient has been followed for ten months since then and metaphysis and almost all the diaphysis.
is symptom-free with a healed wound and a united
fracture. metaphysis (Fig. 2) which had followed a compound
Case 21 returned with a swollen, painful leg and a fracture to his tibia 59 years previously. The tibia was
discharging sinus two years after his operations and constantly painful and periodically discharged pus and
radiography confirmed the presence of a recurrence of pieces ofdead bone. He had undergone several operations
deep infection. including sinus curettage and sequestrectomy.
Four patients developed wound problems in the He was treated by the standard two-stage Belfast
three weeks after stage two. All had been managed technique. At stage one we performed a radical clearance
initially by direct skin closure, and all required revision of all necrotic tissue and widely excised all atrophic or
of their skin cover. One (case 4) required split-skin infected skin (Fig. 3). The defect was closed by a free
grafting at three weeks, one (case 5) required a local rectus abdominis muscle-only flap covered with meshed
gastrocnemius muscle flap at two weeks, and one (case split-skin graft, and the limb was protected in a plaster
I 3) was treated by a free rectus abdominis muscle flap at back-slab. The postoperative radiograph shows the extent
two weeks. The fourth patient (case 7) developed an ofthe bone resection (Fig. 4). A period ofnine weeks was
infected haematoma at the margin of a rectus abdominis allowed for full wound healing and during this time he
free flap, applied during a previous attempt to eradicate was allowed home, non-weight-bearing on crutches. At

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 TWO-STAGE MANAGEMENT OF CHRONIC OSTEOMYELITIS OF THE LONG BONES 379

stage two, the flap was lifted along its lateral edge,
avoiding the vascular pedicle, and a thorough inspection
of the area undertaken. The large cavity was seen to be
fully lined with healthy granulation tissue and no further
debridement was necessary. Iliac crest bone graft was
inserted as bone chips and the wound was closed and a
back-slab provided.

Fig. 5

Nine months after the stage-two operation, and six

months after a THR, the patient had a good range of hip,
knee and ankle movements.

Fig.3 Fig.4

Figure 3 - Stage one of the operation. Wide excision of all dead

and compromised bone and soft tissue has been carried out. The
resulting defect was filled by a free rectus abdominis muscle flap.
Figure 4 - The postoperative radiograph shows the extent of the
bone resection.

Postoperatively, he made excellent progress with

rapid wound healing and mobilisation. At three months
there was no sign of infection and good consolidation of Two years later, the limb
the bone graft had occurred. At this time it was considered remains well healed with
a tibia free of infection
that he should have treatment for his osteoarthritis and for the first time in 60
we performed a Charnley cemented total arthroplasty years.

without complication. He regained a full range of hip,

knee and ankle movements (Fig. 5). When reviewed 20
months after his first operation he was symptom-free
with well-healed wounds (Fig. 6). He now feels well, has
an improved appetite and is gaining weight after many
years of ill health.

DISCUSSION

We have shown that the Belfast technique effectively Fig. 6

treated established bone sepsis, and achieved eradication

of infection and bone union in 34 out of 37 cases. (1985) have shown that non-viable bone stimulates
Recurrence can also be treated by repeating the two adherence and colonisation by pathogenic bacteria. This
stages ofthe procedure. The technique works by breaking then leads to further ischaemia and further multiplication
the cycle of bone death, sequestrum formation, spread of of bacteria. Such areas of tissue are poorly accessible to
infection and further bone death. Chronicity is encour- the host’s immune system. We believe that the success of
aged by local ischaemia (Trueta 1953), and Gristina et al surgical treatment depends mainly on the total removal

VOL. 75-B, No. 3, MAY 1993

380 M. A. McNALLY, J. 0. SMALL, H. G. TOFIGHI, R. A. B. MOLLAN

of the ischaemic tissues. In our patients the debridement REFERENCES

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