Treatment of Chronic Osteomylitis with Antibiotic- impregnated Polymethymetacrylate (PMMA) – The Cierny Approach, Is the Second Stage Necessary?

Introduction: Local antibiotics delivery has been tried for many years in chronic osteomyelitis. The advantage is high local tissue concentration with relatively low serum levels.

In situ antibiotics delivery is performed by using of methylmethacrylat antibiotics impregnated (PMMA-AB), the 2-stage technique as described by Cierny and Mader: Debridement and insertion of the PMMA in the first, removal of the PMMA and bone grafting in the second.

Since the second stage requires a further surgery, in our work we elected to avoid it in most of our patients.

Materials and Methods: Twenty two patients, 17 males and 5 females, with chronic osteomyelitis for an average of 54 months (range 2-180), were treated in our department. The average age at presentation was 43 years (range, 12 – 76 years). The bones affected were 7 femurs, 13 tibias and 2 homerai.

The infections were anatomicaly classified according to Cierny and Mader. Nine patients were treated with the two - stage technique, in 13, only the first stage was adopted.

The first stage included extensive debridement of the infected bone, and implantation of PMMA impregnated with antibiotics, fashioned either into forms of beads or rods.

The second stage: removal of the PMMA and bone grafting.

Results: Nineteen patients healed the infection. One patient suffering from Complex Regional Pain Syndrome (CRPS), underwent below knee amputation. In two patients (one sufferes from Sickle Cell anemia, the second is a drug addicted) the infection was not eradicated.

In 18 patients (one lost to follow-up) at a mean follow-up of 67 months (range, 2 – 204), the infection was completely eradicated. The patients treated with the Cierny first stage only were followed for 53 months (2 – 144).

Conclusion: We proved that the second stage of treatment protocol can be avoided, saving an additional opertion especialy in old or debilitated patients.