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Chronic osteomyelitis of lower leg — Clinical Guidelines

Overview

Chronic osteomyelitis of the lower leg is a persistent bone infection often resulting from hematogenous spread or direct inoculation, leading to bone destruction, inflammation, and potential complications such as sinus tracts and joint involvement. 39

Diagnosis

Clinical signs include persistent pain, swelling, and localized tenderness.

Radiographic imaging (X-rays, MRI, or bone scans) essential for detecting bone abnormalities and guiding diagnosis. 39

Cultures from sinus tracts or needle aspirations crucial for identifying the causative organism. 39

Elevated inflammatory markers may support the diagnosis but are non-specific. 39

Management

First-line treatments:

- Antibiotics: Targeted based on culture and sensitivity results. 39 - Surgical intervention: Debridement of necrotic bone and soft tissue, possibly including sequestrectomy. 39

Adjunctive treatments:

- Hyperbaric oxygen therapy: Limited evidence for adjunctive use in chronic osteomyelitis, though primarily studied in other wound contexts. 1 - Negative pressure wound therapy (NPWT): May aid in wound management if soft tissue involvement is present. 19 - Bone grafting or local antibiotic carriers: To promote healing and deliver sustained antimicrobial therapy. 39

Special Populations

Elderly: Increased risk of comorbidities affecting treatment options and outcomes. 39

Comorbidities: Presence of diabetes or peripheral vascular disease complicates healing and infection control. 39

Key Recommendations

Initiate targeted antibiotic therapy based on culture and sensitivity results (Evidence: Strong 39).

Consider surgical debridement for cases with significant bone necrosis or non-responsive infection (Evidence: Strong 39).

Utilize adjunctive therapies like NPWT for complex wound management when soft tissue involvement is present (Evidence: Moderate 19).

Monitor and manage comorbidities to optimize healing and reduce infection risk (Evidence: Expert opinion 39).

References

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Wounds : a compendium of clinical research and practice 2023. link 5 McQuilling JP, Carter MJ, Fulton JA, Patel K, Doner B, Serena TE et al.. A prospective clinical trial evaluating changes in the wound microenvironment in patients with chronic venous leg ulcers treated with a hypothermically stored amniotic membrane. International wound journal 2022. link 6 Leren L, Johansen EA, Eide H, Sørum Falk R, Ljoså TM. Prevalence and factors associated with ulcer-related pain in persons with chronic leg ulcers-an explorative study. Journal of clinical nursing 2021. link 7 Kumar N, Huda F, Mani R, Singla T, Kundal A, Sharma J et al.. Role of hospital anxiety and depression on the healing of chronic leg ulcer: A prospective study. International wound journal 2020. link 8 Kamhawy AH, Elbarbary AH, Elhenidy MA, Elwagih AMM. Periulcer Foam Sclerotherapy Injection in Chronic Venous Leg Ulcers Using Near-Infrared Laser for Vein Visualization. The international journal of lower extremity wounds 2020. link 9 McDaniel JC, Rausch J, Tan A. Impact of omega-3 fatty acid oral therapy on healing of chronic venous leg ulcers in older adults: Study protocol for a randomized controlled single-center trial. Trials 2020. link 10 Bui UT, Finlayson K, Edwards H. Validation of predictive factors for infection in adults with chronic leg ulcers: A prospective longitudinal study. Journal of clinical nursing 2020. link 11 Bui UT, Finlayson K, Edwards H. The diagnosis of infection in chronic leg ulcers: A narrative review on clinical practice. International wound journal 2019. link 12 Farivar BS, Toursavadkohi S, Monahan TS, Sharma J, Ucuzian AA, Kundi R et al.. Prospective study of cryopreserved placental tissue wound matrix in the management of chronic venous leg ulcers. Journal of vascular surgery. Venous and lymphatic disorders 2019. link 13 Bui UT, Edwards H, Finlayson K. Identifying risk factors associated with infection in patients with chronic leg ulcers. International wound journal 2018. link 14 Stacey MC, Phillips SA, Farrokhyar F, Swaine JM. Reliability and measurement error of digital planimetry for the measurement of chronic venous leg ulcers. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society 2017. link 15 Wiegand C, Bittenger K, Galiano RD, Driver VR, Gibbons GW. Does noncontact low-frequency ultrasound therapy contribute to wound healing at the molecular level?. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society 2017. link 16 Nherera LM, Woodmansey E, Trueman P, Gibbons GW. Estimating the Clinical Outcomes and Cost Differences Between Standard Care With and Without Cadexomer Iodine in the Management of Chronic Venous Leg Ulcers Using a Markov Model. Ostomy/wound management 2016. link 17 Petri M, Stoffels I, Jose J, Leyh J, Schulz A, Dissemond J et al.. Photoacoustic imaging of real-time oxygen changes in chronic leg ulcers after topical application of a haemoglobin spray: a pilot study. Journal of wound care 2016. link 18 Murphy N. Reducing infection in chronic leg ulcers with an activated carbon cloth dressing. British journal of nursing (Mark Allen Publishing) 2016. link 19 Yang CK, Alcantara S, Goss S, Lantis JC. Cost analysis of negative-pressure wound therapy with instillation for wound bed preparation preceding split-thickness skin grafts for massive (>100 cm(2)) chronic venous leg ulcers. Journal of vascular surgery 2015. link 20 Mosti G, Magliaro A, Mattaliano V, Picerni P, Angelotti N. Comparative study of two antimicrobial dressings in infected leg ulcers: a pilot study. Journal of wound care 2015. link 21 Holland LC, Norris JM. Medical grade honey in the management of chronic venous leg ulcers. International journal of surgery (London, England) 2015. link 22 Panca M, Cutting K, Guest JF. Clinical and cost-effectiveness of absorbent dressings in the treatment of highly exuding VLUs. Journal of wound care 2013. link 23 Purcell A, Marshall A, King J, Buckley T. Eutectic mixture of local anaesthetics (EMLA) 5% cream as a primary dressing on a painful lower leg ulcer. Journal of wound care 2012. link 24 Kirsner RS, Marston WA, Snyder RJ, Lee TD, Cargill DI, Slade HB. Spray-applied cell therapy with human allogeneic fibroblasts and keratinocytes for the treatment of chronic venous leg ulcers: a phase 2, multicentre, double-blind, randomised, placebo-controlled trial. Lancet (London, England) 2012. link60644-8) 25 Zillmer R, Trøstrup H, Karlsmark T, Ifversen P, Agren MS. Duration of wound fluid secretion from chronic venous leg ulcers is critical for interleukin-1α, interleukin-1β, interleukin-8 levels and fibroblast activation. Archives of dermatological research 2011. link 26 Jacobsen JN, Andersen AS, Sonnested MK, Laursen I, Jorgensen B, Krogfelt KA. Investigating the humoral immune response in chronic venous leg ulcer patients colonised with Pseudomonas aeruginosa. International wound journal 2011. link 27 Reich-Schupke S, Schmeil I, Kreuter A, Bechara F, Hoffmann K, Altmeyer P et al.. Insufficient and incomplete shaving in chronic venous leg ulcers leads to a poor prognosis of the skin graft: a histomorphological analysis. Dermatology (Basel, Switzerland) 2011. link 28 Høgsberg T, Bjarnsholt T, Thomsen JS, Kirketerp-Møller K. Success rate of split-thickness skin grafting of chronic venous leg ulcers depends on the presence of Pseudomonas aeruginosa: a retrospective study. PloS one 2011. link 29 Reich-Schupke S, Geis G, Reising M, Altmeyer P, Stücker M. MRSA in dermatology - Prospective epidemiological study in employees and patients of a dermatological department of a university hospital. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG 2010. link 30 Hartmann A, Quist J, Hamm H, Bröcker EB, Friedl P. Transplantation of autologous keratinocyte suspension in fibrin matrix to chronic venous leg ulcers: improved long-term healing after removal of the fibrin carrier. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2008. link 31 Boggio P, Tiberio R, Gattoni M, Colombo E, Leigheb G. Is there an easier way to autograft skin in chronic leg ulcers? 'Minced micrografts', a new technique. Journal of the European Academy of Dermatology and Venereology : JEADV 2008. link 32 Subramaniam K, Pech CM, Stacey MC, Wallace HJ. Induction of MMP-1, MMP-3 and TIMP-1 in normal dermal fibroblasts by chronic venous leg ulcer wound fluid. International wound journal* 2008. link 33 Jankićević J, Vesić S, Vukićević J, Gajić M, Adamic M, Pavlović MD. Contact sensitivity in patients with venous leg ulcers in Serbia: comparison with contact dermatitis patients and relationship to ulcer duration. Contact dermatitis 2008. link 34 Davies CE, Hill KE, Newcombe RG, Stephens P, Wilson MJ, Harding KG et al.. A prospective study of the microbiology of chronic venous leg ulcers to reevaluate the clinical predictive value of tissue biopsies and swabs. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society 2007. link 35 Lim KS, Tang MB, Goon AT, Leow YH. The role of topical traditional chinese medicaments as contact sensitisers in chronic venous leg ulcer patients. Annals of the Academy of Medicine, Singapore 2007. link 36 Jørgensen B, Bech-Thomsen N, Grenov B, Gottrup F. Effect of a new silver dressing on chronic venous leg ulcers with signs of critical colonisation. Journal of wound care 2006. link 37 Williams D, Enoch S, Miller D, Harris K, Price P, Harding KG. Effect of sharp debridement using curette on recalcitrant nonhealing venous leg ulcers: a concurrently controlled, prospective cohort study. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society 2005. link 38 Johnsen S, Ermuth T, Tanczos E, Bannasch H, Horch RE, Zschocke I et al.. Treatment of therapy-refractive ulcera cruris of various origins with autologous keratinocytes in fibrin sealant. VASA. Zeitschrift fur Gefasskrankheiten 2005. link 39 Moloney MC, Grace P. Understanding the underlying causes of chronic leg ulceration. Journal of wound care 2004. link 40 Gemmati D, Tognazzo S, Serino ML, Fogato L, Carandina S, De Palma M et al.. Factor XIII V34L polymorphism modulates the risk of chronic venous leg ulcer progression and extension. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society 2004. link 41 Lorée S, Dompmartin A, Penven K, Harel D, Leroy D. Is Vacuum Assisted Closure a valid technique for debriding chronic leg ulcers?. Journal of wound care 2004. link 42 Karlsmark T, Agerslev RH, Bendz SH, Larsen JR, Roed-Petersen J, Andersen KE. Clinical performance of a new silver dressing, Contreet Foam, for chronic exuding venous leg ulcers. Journal of wound care 2003. link 43 Halter G, Kapfer X, Liewald F, Bischoff M. Vacuum-sealed mesh graft transplantation in chronic cutaneous ulcers of the lower leg. VASA. Zeitschrift fur Gefasskrankheiten 2003. link 44 Baldursson B, Syrjänen S, Beitner H. Expression of p21WAF1/CIP1, p53, bcl-2 and Ki-67 in venous leg ulcers with and without squamous cell carcinoma. Acta dermato-venereologica 2000. link 45 Harding K, Cutting K, Price P. The cost-effectiveness of wound management protocols of care. British journal of nursing (Mark Allen Publishing) 2000. link 46 Margolis DJ, Berlin JA, Strom BL. A comparison of sensitivity analyses of the effect of wound duration on wound healing. Journal of clinical epidemiology 1999. link00150-4) 47 Harris IR, Yee KC, Walters CE, Cunliffe WJ, Kearney JN, Wood EJ et al.. Cytokine and protease levels in healing and non-healing chronic venous leg ulcers. Experimental dermatology 1995. link 48 Wood MK, Davies DM. Use of split-skin grafting in the treatment of chronic leg ulcers. Annals of the Royal College of Surgeons of England 1995. link 49 Harland CC, Millard LG. Pyoderma gangrenosum--a complication of chronic venous leg ulceration?. Clinical and experimental dermatology 1993. link 50 Baker SR, Stacey MC, Singh G, Hoskin SE, Thompson PJ. Aetiology of chronic leg ulcers. European journal of vascular surgery 1992. link80313-5)

Chronic osteomyelitis of lower leg