Combination of Girdlestone Pseudoarthroplasty and Negative Pressure Wound Therapy with Instillation and Dwell in the Treatment of Invasive Osteomyelitis of the Proximal Femur

Abstract

Osteomyelitis is a progressively destructive invasive infection of the bone that can result in both localized and systemic illness. This includes an acute suppurative infection, generalized weakness, a failure to thrive, a pathological fracture, and non-healing ulcers. When chronic osteomyelitis develops, therapeutic options are limited, as antimicrobial agents cannot penetrate the necrotic bone, and repeated surgical debridement may be needed. Re-establishing full thickness coverage of the wounds and ulcers associated with osteomyelitis is challenging due to factors such as ongoing pressure injury, malnutrition, and resistant microorganisms. Classically, Girdlestone pseudoarthroplasty has been used to manage a resistant and invasive infection of the acetabular cavity and proximal femur, but it is now rarely employed because of the morbidity of removing the femoral head and leaving a wound to heal by secondary intention. Negative pressure wound therapy with instillation and dwell (NPWTi-d) offers a powerful adjunct to the management of complex infections and wound healing. In this case series of invasive osteomyelitis of the proximal femur in non-ambulatory patients, we demonstrate that the combination of the Girdlestone and negative pressure wound therapy with instillation and dwell allows for delayed closure within a week of the initial procedure, with favorable outcomes and no recurrence of osteomyelitis. The case log of a single surgeon was analyzed retrospectively over an 18-month period. The case series includes all patients who underwent the Girdlestone procedure for invasive osteomyelitis of the femoral head after failed antibiotic management, were non-ambulatory, and were greater than age 18. A total of 10 patients with 11 Girdlestone operations were found. Patients were predominantly male. The average age was 40 years. All patients were treated with NPWTi-d and then underwent a delayed primary or partial closure on an average of 4.5 days after the initial debridement. All four patients with no pre-existing pressure ulceration of the greater trochanter underwent primary closure without wound complication. Of the remaining patients with pre-operative ulcers of the greater trochanter, three were closed successfully or completely healed secondarily and four had substantial wound healing and reduction in size in the post-operative time period. All but one patient who had pre-operative ulcers of the ipsilateral ischium also had a noted improvement of ulcer dimensions in the postoperative follow-up period. Two patients developed new pressure ulcers on the contralateral side and two patients had a worsening of their pre-existing contralateral pressure ulcers more than 30 days post-operatively. No patient had a recurrence of their osteomyelitis. During the same time period, one patient refused surgical intervention and died secondary to overwhelming sepsis. Girdlestone pseudoarthroplasty is a radical therapy for refractory invasive osteomyelitis. While it has been historically associated with prolonged or failed wound healing, combining this surgery with negative pressure wound therapy with instillation and dwell allows for the successful eradication of infection. In addition, this facilitates wound healing and closure, providing a powerful alternative to the challenge of refractory invasive osteomyelitis of the hip, an ultimately life-threatening infection.