Chronic osteomyelitis: clinical characteristics, surgical treatment modalities and early outcomes in patients at Moi Teaching and Referral Hospital, Eldoret, Kenya

Abstract

Background: Chronic osteomyelitis is progressive infective inflammatory process resulting in bone destruction and sequestrum formation. It is common in developing countries due to delay in diagnosis and instituting appropriate surgical intervention, hence contributing to a significant health burden. COM is noted to be on the increase at Moi Teaching and Referral Hospital based on the records. Patients managed surgically at MTRH for COM, have been noted with complications such as recurrent draining sinus, limb deformities and limb amputation. This study aimed at identifying clinical features for COM, establishing surgical treatment modalities and early outcomes to aid in developing COM management guidelines at MTRH. Objective: To describe clinical characteristics, surgical treatment modalities and early outcomes for patients with chronic osteomyelitis at Moi Teaching and Referral Hospital. Methods: This was a prospective descriptive study that was conducted between 1st January 2017 and 31st December 2017 at MTRH. Census of sixty patients with COM were recruited and managed operatively then followed-up for three months to establish early outcomes. Researcher administered questionnaire was used to collect data on clinical characteristics, surgical modalities and early outcomes. At 12 weeks postoperatively, the Disability of the Arm, Shoulder and Hand (QuickDASH) scoring tool for upper limbs and American Academy of Orthopedic Surgeons’ lower limb scoring tool (AAOS) was administered and functional assessment of limbs was established. The data was analyzed using SPSS version 19 and presented in prose, tables, box plots and whisker plots. Wilcoxon rank- sum test, Fisher’s exact test and T-test was used to check for associations between Cierny and Mader stages and age, gender and early outcomes. Results: Male to female ratio was 1.7:1 with 58.3% of the patients being children. Lower limb was mostly affected (85%) with most affected bone being tibia (46.7 %). The commonest clinical presentation was draining sinus (70%) and sequestrum (40%) as the most common radiological image. Staphylococcocus aureus (51.8%) organism was the commonest isolate while chronic wounds were the commonest predisposing factor (75%). Most patients were diagnosed at Cierny and Mader stage IIIB (80%). Flucloxacillin (80%) was the most prescribed antibiotic while sequestrectomy (40%) and Incision/Drainage (38.3%) were the commonest surgical treatment options. At 12 weeks of treatment seventy six percent of patients had clinically recovered while those with draining sinus recurrence (18.3%) and limb amputation (5%). Lower limb had AAOS median score of 18.8 (15.9, 18.6) which was considered good functional score in patients (78.6%) while upper limb had QuickDASH median score of 27.1 (20, 27.2) which was considered good functional score. There was statistically significant association between Cierny and Mader stages whereby lower limb functional score was better for stage III than stage IV (p=0.001) while in terms of age, Cierny and Mader stage IV where older than stage III (p=0.039). Conclusion: Majority of patients with COM presented with chronic wounds, draining sinus and sequestrum as a radiological image. Sequestrectomy and Incision and drainage were common surgical modalities used which gave good clinical and functional outcomes. Draining sinus recurrence, bone deformity and limb amputations were common complications. Cierny and Mader Stage III had good outcomes compared to stage IV. Recommendations: Develop management guidelines for COM at MTRH based on clinical characteristics and surgical modalities with good clinical and functional outcomes. Sensitize clinicians on early index of suspicion in diagnosis of COM and appropriate surgery.