Treatment of osteomyelitis

In all patients on osteomyelitis treatment is based on the principles of active surgical management of purulent wounds and combines conservative and surgical measures.

The ideal treatment option is a comprehensive approach with the participation of specialists in chemotherapy, traumatology, purulent surgery, plastic surgeons and, if necessary, other medical consultants.

Multicomponent intensive treatment is carried out in full to patients with common manifestations of inflammation - sepsis and extensive wounds. It includes the following areas: infusion, detoxification and antibacterial hemodynamic, respiratory and nutritional support; immunocorrection; prevention of deep vein thrombosis and the formation of stress-ulcers of the gastrointestinal tract (recommendations of the RAAS, 2004).

Surgical treatment of osteomyelitis

Currently, operative treatment of osteomyelitis is based on several basic generally accepted principles:

• radical surgical treatment;
• stable osteosynthesis;
• replacement of bone cavities with well-vascularized tissues;
• ensuring full replacement of soft tissue defects. Surgical treatment of a purulent focus. Its purpose is to remove
• non-viable and infected tissues, including necrotic bone sites. Bone processing is performed until the appearance of bleeding from the bone (a symptom of "bloody dew"). Necrotized segment of bone can be easily detected, but great skill is required to identify non-viable bone and infected material in the medullary canal. During the first and all subsequent treatments, repeat a biopsy for planting and cytological evaluation.

Depending on the clinical picture and the results of the examination, various types of surgical treatment of the purulent necrotic focus are performed. They include:

• sequestrectomy - an operation in which the excision of fistula moves is performed together with the free sequestration located in them;
• sequestralectectomy - removal of bone sequesters with resection of altered bone walls;
• trepanation of long bone with sequestralecrectomy - provides optimal access to sequesters located in the medullary canal; perform with mosaic damage to the bone, especially with hematogenous osteomyelitis;
• osteo-plastic trepanation of a long bone with sequestralectomy and restoration of the medullary canal - is indicated for an intraosseous location of a purulent necrotic focus;
• resection of bones - marginal resection is performed with marginal destruction of bone tissue; end and segmental - when the long bone is injured more than half its circumference or when osteomyelitis and a false joint are combined.

Even when all necrotic tissue is adequately removed, the remaining tissues should still be considered contaminated. The main surgical intervention - sequestralectectomy - can be recognized as a conditional-radical operation. To improve the efficiency of surgical treatment, physical methods of wound treatment are used, such as a pulsating jet of solutions of antiseptics and antibiotics, vacuuming, low-frequency ultrasound through solutions of antibiotics and proteolytic enzymes.

Surgery for osteomyelitis is usually completed by flow-aspirating drainage of the wound, bone cavity and bone marrow canal with perforated tubes. The need for adequate drainage of postoperative wounds arises, first of all, when they are closed. Drainage as an independent method without radical surgical intervention is not decisive in the treatment of osteomyelitis. If there is no confidence in the radical nature of surgical treatment, it is advisable to tampon the wound.

The success of the operation largely depends on the local treatment, which is aimed at preventing reinfection of the wound surface with highly resistant hospital strains of microorganisms. To this end, antiseptic ointments are used on a water-soluble basis (levosin, 10% ointment with mafenide, hinifuril, 1% iodopyron ointment, as well as antiseptics - 1% iodopyron solution, 0.01% myramistine solution, 1% dioxygen solution).

After surgery, a patient on osteomyelitis is prescribed bed rest and elevated limb position for 2 weeks. Immediately after the operation, an anticoagulant treatment is prescribed (heparin sodium, fractiparin, klexan), which is continued for 7-14 days. Then the treatment is continued with the help of disaggregants. If necessary, antibiotics are prescribed for up to 6 weeks after the last surgical treatment. During treatment, antibiotic therapy can be changed depending on the results of crops and other clinical data. After the operation, a monthly radiology check is performed to evaluate the formation of bone regenerations and fracture fusion.

Methods of immobilization

Treatment of patients with persistent, difficult-to-treat chronic osteomyelitis in the presence of non-disruption and tissue defects has always posed a complex problem for clinicians. External osteosynthesis is the most safe and universal way of fixation in the treatment of patients with this form of the disease. With hematogenous osteomyelitis, it is advisable to wear various orthoses for a long time with subsequent sparing operations.

External osteosynthesis

External osteosynthesis with replacement of segmental bone defects in osteomyelitis is a continuation of the development of the method of dosed percutaneous compression-distraction osteosynthesis, proposed by G.A. Ilizarov for the replacement of segmental defects of long bones. This method is based on the principle of distraction osteogenesis, as a result of which the reproduction of its own bone occurs with the restoration of its anatomy and function. Vascularized bone graft is formed by a semi-occluded subperiosteal osteotomy of the longest remaining bone fragments, followed by a gradual extension until the bone defect is filled. The blood supply of the osteotomous fragment is preserved due to the periosteum and soft tissues by the type of transplant on a constant feeding stem. In the early postoperative period, the unfree vascularized bone graft is dosed (1 mm / day) into a long bone defect. In the uncomplicated course of the distraction process, a complete bone regenerate is formed in the resulting diastase between the bone fragments, repeating in its cross section the anatomical shape of the long bone in the region of the osteotomy, followed by the formation of the cortical layer and the medullary canal. It should be noted that during osteotomy in the proximal metaepiphysis in the blood supply of the osteotomized fragment, in most cases, aa also participate. Nutriciae.

This method of replacing the defect of long bones differs from all other topics in that it does not require the use of transplants, foreign bodies and any complicated flaps. The soft tissue defect is gradually replaced by the surrounding tissues surrounding the wound, the wound is closed by akin to the skin, and the bone defect is filled with bone regenerate. At the same time, good blood supply and innervation of tissues remain, which contributes to their resistance to purulent infection. In 96% of cases of treatment of posttraumatic osteomyelitis of long bones, this type of reconstructive operations allows to restore the anatomical and functional integrity of the affected limb.

[1], [2], [3], [4], [5], [6], [7],

Substitution of soft tissue defects

Adequate closure of soft tissue defects around the bones is a necessary condition for the treatment of osteomyelitis. For extensive injuries and defects of soft tissues, if possible, the wound is closed with local tissues. There are the following methods of plastics:

• free skin graft;
• flap on the temporary feeder leg (Italian way);
• migrating stalk flap on Filatov;
• flap on a constant feeding vascular pedicle.

Small defects of soft tissue can be closed by a split skin flap. This method is simple, plastic and reliable. At the same time, he has some drawbacks: in connection with the lack of his own blood supply to the flaps in the late period, the development of connective tissue is observed with the formation of coarse, lightly scarred scars, which are often ulcerated. Epidermal transplantation should not especially be performed on nude bone, exposed muscles and tendons, as subsequent gross wrinkling and obstruction of the transplant may result in gross secondary functional disorders in the form of stiffness and contractures.

A full-skin dermal flap does not have the mentioned flaws of the epidermal flap. He is more resistant to trauma and more mobile. But a significant disadvantage of this flap is a much smaller ability to engraft it due to thickness. Very rarely take root skin flaps, taken together with subcutaneous fat, so their wide application should be considered unjustified.

The wound plasticization by Filatov's stem has a number of drawbacks: the duration of the migration stages, the patient's forced position, the decrease of the elasticity of the skin of the stem, the cessation of the secretory function of the skin, the decrease in the rate of blood flow in the stem with the development of its ischemia. In the case of plastics with a stalk flap, the flap taken at a distance must make several "steps" before it reaches its destination. The formation of large stems is not entirely desirable at a young age, as rough scars remain in open spaces. At present, this method is practically not used to replace extensive soft tissue defects.

In the presence of deep soft tissue defects or a defective soft tissue sheath, local musculoskeletal or muscle flaps can be transferred to the defect on a constant feeding stem from neighboring areas. Depending on the location of the lesion, use different muscles: mm. Gracilis, bicepsfemoris, tensor fasciae latae, rectus femoris, vastus medialis, vastus lateralis, gastrocnemius, soleus, extensor digitorum longus.

This method is not feasible in the jelly-free zones, especially in the distal part of the shin and foot. In similar situations, the method of transdermomioplasty was used on a temporary feeding stem. The negative side of this tactic is a prolonged forced position and restriction of the patient's movements to the healing of the transferred flap. The muscular flap on the feeding leg performs a draining function, prevents the accumulation of wound exudate in the bone cavity and, ultimately, the elimination of the purulent cavity.

Currently, flaps with axial type of blood supply are often used to replace soft tissue defects in osteomyelitis of long bones due to their resistance to infections. It is generally accepted that the length of the flap should not exceed its width by more than three times; the exception is flaps, where large feeding vessels pass through the leg, under which the flap can be long and narrow. They are suitable for both free plastic and wound plastics on the feeding vascular pedicle. These include: torcodorsal musculocutaneous flap (with the migration of av thorocodorsalis), a skull-cutaneous fascial flap (av circumflexa scapula), a flap of the latissimus muscle of the back (av thorocodorsalis), an inguinal skin-fascial flap (av epigastrica inferior), a saffron skin- a fascial flap (av saphenus), a radial flap from the anterior surface of the forearm with septal vessels (av radialis), a lateral flap of the shoulder (av collaterialis humeri posterior).

A free vascularized flap is suitable for the immediate closure of nude bones, tendons and nerves. Thanks to a good blood supply to the flap, the local infectious process is quickly suppressed. In addition, the vascularized tissue flap is less susceptible to sclerosis, is more elastic and is suitable for closing extensive defects in the area of the joints.

Transplantation of free grafts with the use of microvascular technology is used only in specialized hospitals, where appropriate equipment and qualified specialists are available. In the opinion of most authors, one should not forget that microsurgical plasty is a complicated, long and extremely time-consuming operation associated with a high risk of ischemic necrosis of the flap as a result of thrombosis of microanastomoses. The use of an islet flap is always preferable to the plastic of a free flap, since there is no need for superposition of vascular anastomoses. Therefore, the vast majority of surgeons use free grafting only in cases where the use of simpler methods is not possible.

Plasticity of bone defects

Adequate surgical treatment can leave a large defect in the bone, called the "dead patch". Absence of blood supply creates conditions for the subsequent development of infection. Treatment in the presence of a dead site, formed after treatment, is aimed at arresting inflammation and maintaining the integrity of the affected segment. The goal of the treatment is to replace the dead bone and scar tissue with well-blooded ones. Free neovascularized osseous plastic for the treatment of osteomyelitis is contraindicated. When transplanting the periosteum, one should bear in mind that only its deepest, so-called cambial, or osteogenic, layer directly adjacent to the bone has bone-forming properties. It is easy to separate this layer only in children; in adults it is closely connected with bone, and it can not be peeled off. Therefore, when taking a periosteal transplant in an adult subject, it becomes a mistake to simply detach it with a knife, because only the surface layer gets into the preparation.

Local soft tissue flaps on the feeding leg or loose flaps have long been used to fill the dead end. Unlike skin-fascial and muscle flaps, the number of vascularized bone grafts used today is much smaller. They are usually formed from the peroneal or ileal bones. A free transplantation of the vascularized bone graft from the iliac crest onto the surface envelopes of the iliac bone was performed for the first time by J. Taylar et al. In 1975. The use of a free vascularized fragment of the iliac crest is technically simpler than the use of a peroneal graft, but the closure of the donor bed can be accompanied by the development of a large number of complications, such as inguinal hernia, hematoma and lymphorrhea. The use of microvascular flaps from the ribs, radial and metatarsal bones, and scapula is limited in view of the insufficient size and low bone quality, limited possibilities for inclusion in the flap of the skin and muscles, and complications from the donor site.

For the first time, surgical treatment of chronic osteomyelitis of the femur with the use of free transplantation of the vascularized flap of the large omentum with the purpose of tamponade of osteomyelitic cavities was performed by Japanese microsurgeons in 1976. According to the figurative expression of the authors, "the omentum has excellent plastic properties and is a vascularizer of the dead zone."

Free plastic surgery of bone defects with vascularized flaps using microvascular technique is used in exceptional cases when other methods do not give a positive result.

Bioimplants in the treatment of chronic osteomyelitis

Since 1893, when G. Dreisman first published his materials on the replacement of bone cavities with gypsum with 5% carbolic acid, many suggestions appeared to fill the cavities with various fillings. Meanwhile, a large number of seizures of seals and relapses of osteomyelitis caused a revision of the views on the use of this method. The method of filling the bone cavities was found to be pathogenetically unreasonable and inefficient and with the introduction of muscle plasty lost its importance.

However, the idea of creating a universal, easy-to-use and non-surgical material close to the structure of bone tissue remained tempting. New prospects in solving the problem of replacement of the residual bone cavity after performing a radical sanitizing operation opens up the use of modern biocomposite biodegradable materials. Such implants serve as the skeleton intended for germination in the area of the defect of the primary vessels and osteoblasts from the bone bed. Osteoconductors gradually undergo biological degradation and are replaced by a newly formed bone. The representative of this class of drugs - the drug "Collapan" - consists of hydroxyapatite, collagen and various immobilized antimicrobial agents. Experimental studies have shown that on the surface of the "Collapse" granules implanted into the bone cavity, a full-fledged bone tissue is subsequently formed without the formation of connective tissue layers between the granules and bone trabeculae. Immobilization of antibacterial agents on the granules of hydroxyapatite promotes oppression of the infection. In the United States, crushed allogenic spongy bone and calcium sulfate - "Osteoset" are officially allowed for clinical use. In addition, it was noted that two other drugs - collagen sponge and polylactide-polyglycolide (PLA-PGA) - have significant potential for clinical use.

[8], [9], [10]

Choosing a method for treating osteomyelitis

The method of treatment of osteomyelitis is chosen in accordance with the type of disease. In medullary osteomyelitis (type I), complete removal of the infected contents of the medullary canal requires corticotomy or trepanation of the bone as a "final resection".

A number of authors believe that with medullary osteomyelitis, the modification of the method of Veer (1892) - bone-plastic trepanation of the long bone became the operation of choice. This operation allows to provide wide access to the lesion focus and to carry out a full sequestrum-necrectomy, to restore the patency of the medullary canal. Such interference is considered plastic, because as a result of it, tissue defects are not formed and the integrity of the bone is not compromised.

In the treatment of the cavity forms of chronic osteomyelitis of the femoral and tibia bones, we proposed a new modification of bone-plastic trepanation - the operation "bag". The essence of the method is that a vascularized "bone flap" is formed from the wall of a long bone on a feeding soft-tissue pedicle. At the same time on the femur, the musculo-muscular-bony valve is created, and on the tibia is the skin-bone. To do this, a longitudinal osteotomy with a length of 15-30 cm is made over the lesion with the help of electric saws. One wall is dissected completely, the opposite one - by 2/3 of the thickness. The ends of the saw cut extend in the transverse direction by 1-1.5 cm. An osteotomy is obtained in the form of the letter "C". In the bone cutting insert a few osteotomes, which as levers push the osseous leaf to the side - opens wide access to the medullary canal or into the bone cavity. Bone at the same time resembles an open carpet. Sequesternectectomy is performed before the appearance of the symptom of "bloody dew" with compulsory biopsy for bacteriological and morphological studies. When the medullary canal is obliterated by a milling cutter, it is reamed until the patency is restored (Figure 36-3). Access to the thigh bone - along the outer and anterior-external surface of the thigh, to the tibia - along the anterior surface of the shin. This produces a less traumatic arcuate incision of the skin over the lesion. Muscles exfoliate, but do not cross.

The danger of disturbance of blood circulation in the bone requires careful treatment of the periosteum. Therefore, the latter is dissected by a scalpel along the prospective osteotomy line, without flaking off the bone. To drain the medullary canal above and below the osseous flap, two holes with a diameter of 3-4 mm are drilled by an electric drill. Through them, a through perforated tube is passed, the ends of which are led out to the skin through separate incisions. Depending on the clinical situation, the drainage tube in the medullary canal can be 2-4 weeks. Then the vascularized soft-tissue-bone flap is returned to its former position - the "bag" is closed. Fixation of the flap is provided by sewing soft tissues.

On the thigh, the soft tissues are drained by a second through perforated tube, which, with a favorable course, is removed 2-3 days after the operation. In cases of pronounced inflammatory process and in case of doubt in the radical nature of surgical treatment, the wound is tamponed. The wound is closed postponed (7-10 days) after repeated surgical treatment. Sutures are removed on the 10-14th day. This operation allows us to perform a full-fledged sequestralectomy and restore the medullary canal without creating a defect in healthy tissues. After the operation, antibacterial treatment is mandatory. Depending on the clinical situation, its duration is 2-4 weeks.

Intraosseous reaming, considering simple technical execution, can also have the right to exist as an alternative to complex and traumatic methods, even giving better results.

With superficial osteomyelitis (type II) - the main emphasis is on soft-tissue closure after surgical treatment. Depending on the location and extent of the defect, this can be done using local tissues or require a soft tissue transplant. In chronic osteomyelitis, the use of muscle grafts is more indicated, since they are more resistant to a purulent infection. Treatment of superficial osteomyelitis requires considerable experience with complex movement of soft tissues. Ischemic soft tissue is excised, and the exposed bone surface is removed by tangent (decortication) until a symptom of "bloody dew" appears. The plastic with a flap on the leg or a free moved flap is performed simultaneously or as a delayed operation.

Localized (limited) osteomyelitis (type III) combines the features of the previous two types - cortical sequestration with the inflammatory process in the medullary cavity. Most lesions with limited osteomyelitis are post-traumatic. Surgical treatment for this type of osteomyelitis usually includes sequestralectomy, medullary decompression, excision of scar tissue and surface decortication. Preventive fixation is necessary in case of fracture hazard after extensive bone processing.

Muscular plastic plays an important role in the treatment of this form of osteomyelitis along with surgical treatment and antibacterial therapy. Numerous clinical studies have proved the effectiveness of local muscle flaps on the feeding vascular pedicle and transplantation of tissue complexes using microvascular techniques to replace bone cavities in osteomyelitis. The decisive conditions for successful plastic surgery are radical surgical treatment and the correct choice of the flap, the size of which would allow replacing the bone cavity without forming a "dead" space. In the treatment of chronic recurrent osteomyelitis of the extremities, especially when the process is localized in the distal metaphysis with a pronounced Rubcov process in soft tissues, a large omentum continues to be used. Possessing great resistance to purulent infection and plasticity, flaps from the large epiploon can fill large irregularly shaped bony cavities where local cutaneous and muscular plasty can not be applied. The deterrent for the use of a large omentum may be the development of various complications in the donor zone - abdominal pain, hernia and damage to the abdominal organs.

Diffuse osteomyelitis (type IV) combines the features of the previous three types with the involvement of the entire bone segment and bone marrow cavity in the inflammatory process. All infected fractures are referred to this type of osteomyelitis. Diffuse osteomyelitis is more often characterized by segmental bone lesions. Bone in this type is biomechanically unstable before and after surgical treatment. The risk of complications from the wound and bone increases significantly (non-growth and pathological fractures). The methods used in the treatment of diffuse osteomyelitis are supplemented by mandatory fixation of the limb before or after surgical treatment. In extremely severe cases, amputation is indicated.

Standard surgical treatment of osteomyelitis is not feasible in all cases, and some patients undergo conservative treatment or perform amputation. The use in recent years of methods of transplantation of blood supply flaps, the introduction of devices for external fixation, the use of controlled gradual distraction according to G.A. Ilizarov, the use of modern implants to fill the bone cavities and adequate antibiotic treatment created the conditions for more complete surgical treatment. This resulted in a significant improvement in treatment outcomes in more than 90% of the observations.

[11], [12], [13], [14], [15], [16], [17]

Antibacterial treatment of osteomyelitis

An obligatory component of complex treatment of osteomyelitis for more than 60 years remains antibacterial treatment. Antibacterial therapy of osteomyelitis, which is inherently etiotropic, is chosen on the basis of a number of factors - the type of pathogen, its sensitivity to the drug, the characteristics of the drug and the state of the patient's body. Antibacterial treatment is carried out in all cases with preparations of a wide spectrum of action, taking into account the species composition (aerobes, anaerobes) and sensitivity of microflora. Along with this, today the majority of leading experts are convinced that with chronic osteomyelitis, the use of antibiotics is not effective without surgical treatment. Infected, bloodless bone fragments are inaccessible to the action of drugs and become an excellent nutrient medium for pathogenic microflora. At the same time in serum, the concentration of drugs can sometimes reach levels unsafe for the patient. Long-term preservation of the purulent focus, unsystematic use of antibacterial drugs inevitably leads to selection in the osteomyelitic focus of the hospital flora, resistant to the traditionally used groups of antibiotics, to the development of dysbacteriosis and fungal infection until its generalization. Studies have shown that immunological disorders are not observed in patients with chronic osteomyelitis, therefore, immune medications (interferon alfa-2, immunoglobulins) are prescribed only for patients with septic manifestations.

Ideally, the use of antibacterial drugs should be based on the results of an expanded bacteriological study from the bone obtained by biopsy or during surgical treatment. In patients with fistulous form of osteomyelitis in the absence of severe manifestations of a purulent process and intoxication without surgical treatment, antibiotic therapy is not advisable. However, if there is an acute clinical situation (open fractures with extensive soft tissue damage, acute hematogenous osteomyelitis), antibiotic treatment should not be delayed in anticipation of these biopsies. In such situations, the drug is chosen empirically based on the localization and severity of the infection, which microorganisms are presumed to be pathogens, what is their most likely sensitivity to antimicrobial agents. Taking into account the activity data on the main pathogens of surgical infection, organotropic and antibiotic safety, now, along with traditional drugs (carbenicillin, gentamicin, lincomycin, etc.), new groups are prescribed - fluoroquinolones, carbapenems and glycopeptides.

Good prospects in the complicated course of osteomyelitis appeared with the introduction of drugs from the group of fluoroquinolones into the practice of medicine, as they possess good organotropic properties to bones and soft tissues. Oral treatment with fluoroquinolones in gram-negative infections is widely used in adult patients with osteomyelitis. Fluoroquinolones can successfully carry out long courses of stepwise therapy (intravenously-inward). The use of second-generation fluoroquinolones (pefloxacin, ciprofloxacin, ofloxacin, lomefloxacin) in chronic osteomyelitis is less effective, since these drugs have low activity against streptococci, enterococci and anaerobic microorganisms. Quinolones of the third generation (levofloxacin, gatifloxacin) are active against streptococci, but have minimal effect on anaerobes.

At present, extensive experience in the use of cephalosporins in the complex treatment of patients with acute and chronic osteomyelitis has been accumulated. Most researchers prefer ceftriaxone - a third generation cephalosporin, resistant to beta-lactamases, a broad spectrum of action that acts on gram-positive and gram-negative aerobic and some anaerobic bacteria. The advantage of ceftriaxone over other beta-lactam antibiotics is a long half-life (about 8 hours), which allows one-time administration during the day to maintain its antibacterial concentration. The use of cephalosporins III (cefotaxime, ceftriaxone) and IV (cefepime) of generations, carbapenems (imipenem + cilastatin), and also the use of cefalosporin III (cefotaxime, ceftriaxone) as well as a wide purulent soft tissue lesion in the wound of the association of anaerobic and aerobic microorganisms have been effectively used in the range of existing medicines for the treatment of patients with osteomyelitis. Clindamycin in combination with non-linimentin, ciprofloxacin or dioxidine.

The introduction into clinical practice of a drug from the group of oxazolidonov - linezolid, an antibiotic for oral and intravenous use, expands the possibilities of treating patients with osteomyelitis caused by highly resistant strains of Gram-positive flora, including methicillin-resistant staphylococci. The good penetration of linezolid into bone tissue, activity against vancomycin-resistant enterococci puts this drug on the first place in the treatment of patients with osteomyelitis of different location and origin, with infection after joint replacement.

Although the optimal timing of antibiotic therapy for osteomyelitis has not been clearly determined to date, most specialists use drugs for 4-6 weeks. This is due to the fact that after 4 weeks after the surgical treatment, revascularization of the bone tissue occurs. However, it should be noted that failures do not depend on the duration of antibiotic treatment, but are mainly associated with the emergence of resistant strains or with inadequate surgical treatment. In some cases, when surgical treatment is not feasible, as, for example, in case of infection around orthopedic implants, longer courses of suppressing antibiotic therapy are carried out. Ideal drugs for this should have a good bioaccumulation, have low toxicity and have good organotropic properties to bone tissue. To do this, use rifampicin in combination with other antibiotics, fusidic acid, ofloxacin, co-trimoxazole. Suppressive treatment is performed up to 6 months. If a relapse occurs after discontinuation of therapy, a new long-term inhibitory treatment regimen with antibiotics begins.

At present, the intra-arterial and endolymphatic administration of antibiotics for osteomyelitis has been abandoned. There is a tendency to increase the use of dosage forms for oral and topical administration. Based on the results of many clinical trials, high efficacy with clindamycin, rifampin, co-trimoxazole, and fluoroquinolones has been shown to be effective. So, clindamycin, which is active against most Gram-positive bacteria, is used inside after an initial (1-2 weeks) intravenous treatment.

In order to prevent the development of fungal infection, in addition to antibacterial drugs, nystatin, ketoconazole or fluconazole are prescribed in each case. To preserve the normal ecology of the intestine, it is necessary to include monocomponent (bifidumbacterin, lactobacterin, bactisporin, bactisuptil), polycomponent (bifilong, acylactate, acinol. Linex, biosporin) and combined (bifidumbacterin forte, bifilysis) probiotics in the complex treatment.

The success of treatment for osteomyelitis largely depends on local antibiotic therapy aimed at preventing reinfection of the wound surface with highly resistant hospital strains of microorganisms. For these purposes in recent years, successfully used:

• antiseptic ointments on a water-soluble basis - levosin, 10% ointment with mafenide, 5% dioxydin ointment, dioxycol, streptonitol, hinifuril, 1% iodopyron ointment (povidone-iodine ointment), protogenin ointment and lavendula;
• antiseptics - 1% solution of iodopyrone (povidone-iodine), 0.01% solution of the mystine world, 1% dioxygen solution, 0.2% polyhexanide solution;
• foaming aerosols - aminitrosol, dioxisole;
• wound coverings: gentacil, algipor, algimaf.

Treatment of patients with osteomyelitis dictates the need to use not only new antibacterial drugs, but also alternative ways of their introduction. It is promising to use various bioimplants to deliver antibiotics directly to the bone. Depending on the clinical situation, these long-acting drugs can be used as an alternative to systemic antibiotic therapy, and as an addition to it. Bioimplants have advantages over systemic antibacterial therapy, in which penetration of the drug is difficult in a poorly blood supply bone in the inflammatory focus. These drugs for a long time (up to 2 weeks) are able to create a high concentration of the drug in the bone tissue without undesirable side-effects of the drug on the whole organism. To date, the most common antibiotics with proven efficacy have been recognized as non-biodegradable (PMMA cement and "Septopal") and biodegradable (gentacil, collapan, crushed allogeneic spongy bone, "Osteoset") implants. For antimicrobial activity, these drugs are approximately the same. The main advantage of biodegradable implants is the absence of the need to remove antibiotic carriers after the release of drugs.

[18], [19], [20], [21], [22],