Successfully treated osteomyelitis with 20 years of evolution, covering the whole humerus (case report)

Successfully treated osteomyelitis with 20 years of evolution, covering the whole humerus (case


Introduction
Infections affecting the humerus are rarer than those of the lower extremities, but at the same time they represent a serious therapeutic challenge, especially when they are spread throughout the humerus and have a long evolution.Their origin can be both hematogenous and exogenous, have a diverse localization, affect stable or unstable bone segments 1,3,5 .In atypical courses of the disease, the differential diagnosis with bone tumors is mandatory 2 .Unsuccessfully treated osteomyelitis of the humerus can be the cause of severe disability due to joint contractures, damage to the n.radialis, and also intoxication of the organism.With a more favorable prognosis are localized infections, in stable segments, distant from large joints, namely -types A1 and A2, according to the proposed own classification of ostemyelitis.More difficult to treat are the cases of type A3-1, in which the lesions can affect the entire diaphysis, but are distant from the large joints and it is possible to apply a diaphysectomy, with subsequent autoosteoplasty 4 .The most difficult to treat lesions are type A3-2, where infection is spread over an extensive bone segment covering more than one-third of the length of the bone, but the lesions are in close proximity to a large joint, making excision of the affected segment impossible.The only favorable point in these cases is the preserved stability.This is the patient presented in the present report.

Patient and method
The presented patient is a 63-year-old man (IZ/4951), first admitted to the clinic in October 2021, with chronic osteomyelitis, with a 20-year evolution involving the entire right humerus -type A3-2.He has been operated on many times.There were old surgical cicatrixes along the lateral aspect of the right arm as well as two active fistulas.Movements in the shoulder joint were limited and painful, the elbow joint was in flexion contracture -300 (Fig. 1 a, b).Laboratory tests showed moderately elevated values of leukocytes, CRP, ESR, mild anemia.The performed CT confirmed the diagnosis, revealed the presence of cloacae in the proximal and middle third of the humerus, as well as abscess collections in the adjacent soft tissues (Fig. 1 c, d).
Fig. 1 (a, b, c, d).(a, b)diagnostic photographs -old operative cicatrix on the lateral side of the arm, as well as two active fistulas with purulent secretion; (c, d)diagnostic CT -presence of cloacae in the proximal and middle third of the humerus and abscessing collections in the adjacent soft tissues.
From the fistulas, and later from the medullary canal, St. was isolated.aureus.The operative intervention includedfistulectomy, evacuation of purulent collections around the bone, longitudinal fenestration of the humerus, along its entire length, during which a precise intramedullary debridement was performed, including the proximal and distal zones, in the area of the shoulder and elbow joints.A closed permanent flushing system was placed in the bone-brain canal (Fig. 2 a, b, c).Parenteral antimicrobial therapy administered in the postoperative period included Medaxon and Ciprofloxacin.

Results
The early postoperative period proceeded smoothly (Fig. 3 a, b, c).The surgical wound healed primarily, the bone infection was completely repaired, the right upper extremity was in good functional condition, with no evidence of circulatory or neurological problems (Fig. 4 a, b, c).

Discussion
Extensive fenestration of the bone is one of the four main methods for the treatment of osteomyelitis (according to the proposed own algorithm of surgical treatment), ensuring the necessary revascularization of the bone.It is the tool of choice in the treatment of extensive infections located in stable segments near large joints when total bone excision is impossible.In this case, through the described fenestration, extensive access was provided to the entire length of the medullary canal, the head and the distal part of the humerus, which is a prerequisite for performing precise intraosseous debridement and lavage, including in the joint areas, and also for the necessary revascularization of the bone through the adjacent soft tissues.

Conclusion
The presented patient is a vivid example that the key to the successful treatment of osteomyelitis is the correct choice of the main method, namely the method providing full revascularization of the bone or the replacement of the affected bone segment with autoosteoplastic material.
Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024, ISSN 2815-3715 20 Joint Endoprosthetics.For eleven years he led the Department of Orthopedics and Traumatology at the University Hospital in the city of Sabratha -Libya and was a consultant at the African Oncology Institute in the same city.He was awarded an honorary degree for his work.In 2010, he defended a dissertation devoted to bone infections and obtained the scientific degree "Doctor".He is the author of the monograph "Osteomyelitis".He is a member of the Union of Scientists.Since 2011, he has been working at the "Lozenets" Hospital and is an associate professor at the "St.Cl.Ohridski".He devoted about 30 years of his medical practice to the study and treatment of bone and joint infections.
Victor Vasilev is member of the Bulgarian Orthopedic and Traumatology Association (BOTA).He works as an ortopaedic surgeon at University Hospital "Lozenetz"-Sofia.

Fig. 2
Fig.2 (a, b, c)intraoperative finding and separate stages of the operative intervention.(a)full exposure of the humerus; (b) antero-lateral longitudinal fenestration of the entire bone; (c) placement of an intramedullary, closed permanent irrigation system, after precise intramedullary debridement involving the joint areas.

Fig. 4 (
Fig. 4 (a, b, c) -2 months after the operative intervention.(a)the surgical wound healed primarily; (b, c) -functional result normal neurological status of the hand.
Sofia in 1981.He completed his high school education at the National Science and Mathematics High School "Acad.L. Tchakalov".Graduated from Medical University of Sofia in 2008.He specializes in "Orthopaedics and traumatology" at the Military Medical Academy -Sofia.He currently works in the Clinic of Orthopedics and Traumatology at MHAT Lozenets, Sofia.Special interests in conservative and operative treatment of foot and ankle deformities and bone and joint infections.Member of the Bulgarian Orthopedic and Traumatology Association (BOTA) and the Bulgarian Society of Foot and Ankle Surgery.