Treatment of osteomyelitis

For all patients with 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 involving specialists in chemotherapy, traumatology, purulent surgery, plastic surgeons and, if necessary, other consulting physicians.

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

Surgical treatment of osteomyelitis

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

• radical surgical treatment;
• carrying out stable osteosynthesis;
• replacement of bone cavities with well-vascularized tissues;
• providing full replacement of soft tissue defects. Surgical treatment of the purulent focus. Its purpose is to remove
• nonviable and infected tissue, including necrotic areas of bone. Bone is treated until the bone begins to bleed (the "blood dew" symptom). The necrotic segment of bone can be easily identified, but great skill is required to identify nonviable bone and infected material in the medullary canal. Biopsy is repeated for culture and cytologic evaluation at the first and all subsequent treatments.

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

• sequestrectomy - an operation in which the fistula tracts are excised along with the free sequestra located in them;
• sequester necrectomy - removal of bone sequesters with resection of altered bone walls;
• trepanation of a long bone with sequestrectomy - provides optimal access to sequestra located in the medullary canal; performed in case of mosaic bone lesions, especially in case of hematogenous osteomyelitis;
• osteoplastic trepanation of a long bone with sequester necrectomy and restoration of the medullary canal - indicated for intraosseous location of a purulent-necrotic focus;
• bone resection - marginal resection is performed in case of marginal destruction of bone tissue; terminal and segmental - in case of damage to a long bone over more than half its circumference or in case of a combination of osteomyelitis and pseudoarthrosis.

Even when all necrotic tissue has been adequately removed, the remaining tissue must still be considered contaminated. The main surgical intervention, sequester necrectomy, can only be considered a conditionally radical operation. To increase the effectiveness of surgical treatment, physical methods of wound treatment are used, such as a pulsating stream of antiseptic and antibiotic solutions, vacuuming, low-frequency ultrasound exposure through solutions of antibiotics and proteolytic enzymes.

Surgical intervention for osteomyelitis is usually completed by flow-aspiration 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 of decisive importance in the treatment of osteomyelitis. If there is no confidence in the radicality of surgical treatment, tamponade of the wound is advisable.

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

After surgery, the patient with osteomyelitis is prescribed bed rest and an elevated position of the limb for 2 weeks. Immediately after surgery, anticoagulant treatment is prescribed (sodium heparin, fraxiparin, clexane), which is continued for 7-14 days. Then the treatment is continued with disaggregants. If necessary, antibiotics are prescribed for up to 6 weeks after the last surgical treatment. During the treatment, antibacterial therapy can be changed depending on the results of cultures and other clinical data. After surgery, monthly X-ray control is performed to assess the formation of bone regenerates and fracture fusion.

Immobilization methods

Treatment of patients with persistent, difficult to treat chronic osteomyelitis in the presence of nonunions and tissue defects has always been a difficult problem for clinicians. External osteosynthesis is the safest and most universal method of fixation in the treatment of patients with this form of the disease. In case of hematogenous osteomyelitis, it is advisable to wear various orthoses for a long time with subsequent gentle operations.

External osteosynthesis

External osteosynthesis for substitution of segmental bone defects in osteomyelitis is a continuation of the development of the method of dosed transosseous compression-distraction osteosynthesis proposed by G.A. Ilizarov for substitution of segmental defects of long bones. This method is based on the principle of distraction osteogenesis, which results in reproduction of the patient's own bone with restoration of its anatomy and function. A vascularized bone graft is formed by semi-closed subperiosteal osteotomy of the longest of the remaining bone fragments, followed by gradual stretching until the bone defect is filled. Blood supply to the osteotomized fragment is maintained by the periosteum and soft tissues, similar to a graft on a permanent pedicle. In the early postoperative period, the non-free vascularized bone graft is dosed (1 mm/day) and moved into the defect of the long bone. In the case of uncomplicated course of the distraction process, a full-fledged bone regenerate is formed in the resulting diastasis between the bone fragments, repeating in its cross-section the anatomical shape of the long bone in the osteotomy area with subsequent formation of the cortical layer and the medullary canal. It should be noted that when performing osteotomy in the proximal metaepiphysis, aa. nutriciae are also involved in the blood supply of the osteotomized fragment in most cases.

This method of replacing a defect in long bones differs from all others in that it does not require the use of transplants, foreign bodies or any complex flaps. The soft tissue defect is gradually replaced by the patient's own tissues surrounding the wound, the wound is closed with related skin, and the bone defect is filled with bone regenerate. At the same time, good blood supply and innervation of the tissues are maintained, which contributes to their resistance to purulent infection. In 96% of cases of treatment of post-traumatic osteomyelitis of long bones, this type of reconstructive surgery allows for the restoration of the anatomical and functional integrity of the affected limb.

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Replacement of soft tissue defects

Adequate closure of soft tissue defects around the bones is a prerequisite for the treatment of osteomyelitis. In case of extensive damage and soft tissue defects, the wound is closed with local tissues if possible. The following plastic methods exist:

• free skin flap;
• with a flap on a temporary feeding leg (Italian method);
• Filatov's migrating stalked flap;
• flap on a permanent feeding vascular pedicle.

Small defects of soft tissue can be closed with a split skin flap. This method is simple, flexible and reliable. At the same time, it has some disadvantages: due to the lack of the flaps' own blood supply, in the long term, connective tissue develops with the formation of coarse, easily damaged scars, which often ulcerate. Epidermal transplantation should especially not be performed on exposed bone, exposed muscles and tendons, since subsequent wrinkling and inflexibility of the transplant may result in severe secondary functional disorders in the form of stiffness and contractures.

A full-thickness skin flap does not have the above-mentioned disadvantages of an epidermal flap. It is more resistant to trauma and is more mobile. But a significant disadvantage of such a flap is its significantly lower ability to take root due to its thickness. Skin flaps taken together with subcutaneous fat rarely take root, so their widespread use should be considered unjustified.

Wound plastic surgery with Filatov stem has a number of disadvantages: the duration of migration stages, the forced position of the patient, a decrease in the elasticity of the skin of the stem, the cessation of the secretory function of the skin, a decrease in the blood flow rate in the stem with the development of its ischemia. In plastic surgery with a stem 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, since rough scars remain in open areas. At present, this method is practically not used to replace extensive defects of soft tissues.

In the presence of deep soft tissue defects or an incomplete soft tissue membrane, local skin-muscle or muscle flaps on a permanent pedicle from adjacent areas can be transferred into the defect. Depending on the location of the lesion, various muscles are used: mm. gracilis, biceps femoris, tensor fasciae latae, rectus femoris, vastus medialis, vastus lateralis, gastrocnemius, soleus, extensor digitorum longus.

This method is not feasible in muscle-deprived areas, especially in the distal part of the leg and foot. In such situations, the method of transdermomyoplasty on a temporary pedicle was used. The negative side of this tactic is a long-term forced position and limitation of the patient's movements until the transferred flap heals. The muscle flap on the pedicle performs a drainage function, prevents the accumulation of wound exudate in the bone cavity and, ultimately, the elimination of the purulent cavity.

Currently, flaps with an axial blood supply type are more 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; an exception is flaps where large feeding vessels pass through the pedicle, in which case the flap can be long and narrow. They are suitable for both free plastic surgery and plastic surgery of wounds on a feeding vascular pedicle. These include: thorocodorsal musculocutaneous flap (with displacement av thorocodorsalis), scapular fasciocutaneous flap (av circumflexa scapula), latissimus dorsi flap (av thorocodorsalis), inguinal fasciocutaneous flap (av epigastrica inferior), saphenous fasciocutaneous flap (av saphenus), radial flap from the anterior surface of the forearm with septal vessels (av radialis), lateral shoulder flap (av collaterialis humeri posterior).

Free vascularized flap is suitable for immediate closure of exposed bones, tendons and nerves. Due to the good blood supply of the flap, the local infectious process is quickly suppressed. In addition, the vascularized tissue flap is less susceptible to sclerosis, more elastic and suitable for closing extensive defects in the joint area.

Free graft transplantation using microvascular technology is used only in specialized hospitals with the appropriate equipment and qualified specialists. According to most authors, it should not be forgotten that microsurgical plastic surgery is a complex, lengthy and extremely labor-intensive operation associated with a high risk of ischemic flap necrosis as a result of thrombosis of microanastomoses. The use of an island flap is always preferable to free flap plastic surgery, since there is no need to impose vascular anastomoses. Therefore, the vast majority of surgeons use free flap transplantation only in cases where the use of simpler methods is not possible.

Plastic surgery of bone defects

Adequate surgical treatment may leave a large defect in the bone, called a "dead area". The lack of blood supply creates conditions for subsequent infection. Treatment in the presence of a dead area formed after treatment is aimed at stopping the inflammation and maintaining the integrity of the affected segment. The goal of treatment is to replace dead bone and scar tissue with well-vascularized tissue. Free non-vascularized bone grafting is contraindicated for the treatment of osteomyelitis. When transplanting the periosteum, it must be borne in mind that only its deepest, so-called cambial, or osteogenic layer, which is directly adjacent to the bone, has bone-forming properties. This layer is easily separated only in children; in adults, it is closely associated with the bone and cannot be peeled off. Therefore, when taking a periosteal graft from an adult, it is a mistake to simply peel it off with a knife, because only the superficial layer gets into the preparation.

Local soft tissue flaps on a pedicle or free flaps have long been used to fill the dead area. In contrast to fasciocutaneous and muscle flaps, the number of vascularized bone grafts used today is much smaller. They are usually formed from the fibula or ilium. Free transplantation of vascularized bone graft from the iliac crest on the superficial circumflex iliac vessels was first performed by J. Teilar et al. in 1975. The use of a free vascularized fragment of the iliac crest is technically simpler than the use of a fibula graft, however, closure of the donor site 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, radius, metatarsal bones, and scapula is limited due to the insufficient size and low quality of bone tissue for transfer, limited possibilities for including skin and muscles in the flap, and complications at the donor site.

The first surgical treatment of chronic osteomyelitis of the femur using a free transplant of a vascularized flap of the greater omentum for the purpose of tamponade of osteomyelitic cavities was performed by Japanese microsurgeons in 1976. In 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 techniques 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. Dreezman first published his materials on the replacement of bone cavities with gypsum containing 5% carbolic acid, many proposals have appeared for filling bone cavities with various fillings. Meanwhile, a large number of filling rejections and relapses of osteomyelitis forced a reconsideration of views on the use of this method. The method of filling bone cavities was recognized as pathogenetically unfounded and ineffective, and with the introduction of muscle plastic surgery, it lost its significance.

However, the idea of creating a universal, easy-to-use and non-invasive material similar to the structure of bone tissue remains tempting. New prospects for solving the problem of replacing the residual bone cavity after a radical sanitizing operation are opened by the use of modern biocomposite biodegradable materials. Such implants serve as a framework designed for the growth of primary vessels and osteoblasts from the bone bed into the defect area. Osteoconductors gradually undergo biological degradation and are replaced by newly formed bone. A representative of this class of agents, the drug "Kollapan", consists of hydroxyapatite, collagen and various immobilized antimicrobial agents. Experimental studies have proven that full-fledged bone tissue is subsequently formed on the surface of "Kollapan" granules implanted into the bone cavity without the formation of connective tissue layers between the granules and bone trabeculae. Immobilization of antibacterial agents on hydroxyapatite granules helps suppress infection. In the USA, crushed allogenic cancellous bone and calcium sulfate - "Osteoset" - are officially approved for clinical use. In addition, it is noted that two more drugs have significant potential for clinical use - collagen sponge and polylactide-polyglycolide (PLA-PGA).

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Choosing a treatment method for osteomyelitis

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

A number of authors believe that in medullary osteomyelitis, the operation of choice has become a modification of the Wir method (1892) - osteoplastic trepanation of a long bone. This operation allows for wide access to the lesion and a full sequester necrectomy, restoring the patency of the bone marrow canal. This intervention is considered plastic, since it does not result in tissue defects and does not disrupt the integrity of the bone.

In the treatment of cavitary forms of chronic osteomyelitis of the femur and tibia, we have proposed a new modification of osteoplastic trepanation - the "sac-bag" operation. The essence of the method is that a vascularized "bone flap" on a nourishing soft tissue pedicle is formed from the wall of a long bone. In this case, a skin-muscle-bone flap is created on the femur, and a skin-bone flap on the tibia. To do this, a longitudinal osteotomy of 15-30 cm in length is made over the lesion using an electric saw. One wall is cut completely, the opposite one - by 2/3 of the thickness. The ends of the cut are extended in the transverse direction by 1-1.5 cm. The result is an osteotomy in the form of the letter "C". Several osteotomes are inserted into the bone cut, which act as levers to move the bone flap aside, opening up wide access to the medullary canal or bone cavity. The bone resembles an open valise. Sequester necrectomy is performed before the "blood dew" symptom appears, with mandatory biopsy for bacteriological and morphological examination. When the medullary canal is obliterated with a burr, it is drilled until patency is restored (Fig. 36-3). Access to the femur is along the outer and antero-outer surface of the thigh, and to the tibia - along the antero-inner surface of the shin. In this case, a less traumatic arcuate incision of the skin is made over the lesion. The muscles are stratified, not cut.

The risk of circulatory disorders in the bone requires careful handling of the periosteum. Therefore, the latter is dissected with a scalpel along the line of the proposed osteotomy, without peeling it off the bone. To drain the medullary canal, two holes 3-4 mm in diameter are drilled with an electric drill above and below the bone valve. A through perforated tube is passed through them, the ends of which are brought out onto the skin through separate incisions. Depending on the clinical situation, the drainage tube in the medullary canal can be for 2-4 weeks. Then the vascularized soft tissue-bone valve is returned to its previous position - the "bag" is closed. The valve is fixed by suturing the soft tissues.

On the hip, soft tissues are drained with a second through perforated tube, which, if the course is favorable, is removed on the 2nd-3rd day after the operation. In cases of severe inflammation and in case of doubts about the radicality of surgical treatment, the wound is tamponed. The wound is closed delayed (after 7-10 days) after repeated surgical treatment. The sutures are removed on the 10th-14th day. Such an operation allows for a full sequester necrectomy and restoration of the bone marrow canal without creating a defect in healthy tissue. Antibacterial treatment is mandatory after the operation. Depending on the clinical situation, its duration is 2-4 weeks.

Intraosseous reaming, given its simple technical execution, may also have a right to exist as an alternative to complex and traumatic methods, even if they give better results.

In superficial osteomyelitis (type II), the main emphasis is on soft tissue closure after surgical treatment. Depending on the location and size of the defect, this may be accomplished using local tissues or may require free soft tissue grafting. In chronic osteomyelitis, muscle flaps are more indicated, as they are more resistant to purulent infection. Treatment of superficial osteomyelitis requires significant experience with complex soft tissue repositioning. Ischemic soft tissues are excised, and the exposed bone surface is removed tangentially (decortication) until the "blood dew" symptom appears. Plastic surgery with a pedicle flap or a freely displaced 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 an inflammatory process in the bone marrow cavity. Most damage in limited osteomyelitis is post-traumatic. Surgical treatment for this type of osteomyelitis usually includes sequestrectomy, medullary decompression, excision of scar tissue and superficial decortication. Preventive fixation is necessary in case of a risk of fracture after extensive bone treatment.

Muscle grafting plays an important role in the treatment of this form of osteomyelitis, along with surgical treatment and antibacterial therapy. Numerous clinical studies have proven the effectiveness of local muscle flaps on a vascular pedicle and transplantation of tissue complexes using microvascular technology to replace bone cavities in osteomyelitis. Radical surgical treatment and the correct choice of flap, the size of which would allow replacing the bone cavity without forming a "dead" space, are recognized as decisive conditions for successful grafting. In the treatment of chronic recurrent osteomyelitis of the extremities, especially when the process is localized in the distal metaphysis with a pronounced cicatricial process in the soft tissues, the greater omentum continues to be used. Possessing high resistance to purulent infection and plasticity, flaps from the greater omentum can fill large irregularly shaped bone cavities, where local skin and muscle grafting cannot be used. A limiting factor for using the greater omentum may be the development of various complications in the donor area - abdominal pain, hernias 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 the bone marrow cavity in the inflammatory process. All infected fractures are classified as this type of osteomyelitis. Diffuse osteomyelitis is often characterized by segmental bone lesions. The bone in this type is biomechanically unstable before and after surgical treatment. The risk of complications from the wound and bone (nonunion and pathological fractures) increases significantly. 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 amputation. The use of methods of transplanting blood-supplied flaps, the introduction of devices for external fixation, the use of controlled gradual distraction according to G.A. Ilizarov, the use of modern implants for filling bone cavities and adequate antibacterial treatment have created conditions for more complete surgical treatment. This has led to a significant improvement in treatment results in more than 90% of cases.

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Antibacterial treatment of osteomyelitis

Antibacterial treatment has been an obligatory component of complex treatment of osteomyelitis for over 60 years. Antibacterial therapy of osteomyelitis, which is etiotropic in nature, is selected based on 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 broad-spectrum drugs, taking into account the species composition (aerobes, anaerobes) and sensitivity of the microflora. Along with this, today most leading specialists are convinced that in chronic osteomyelitis, the use of antibiotics is ineffective without surgical treatment. Infected bone fragments deprived of blood supply are inaccessible to the action of drugs and become an excellent nutrient medium for pathogenic microflora. At the same time, the concentration of drugs in the blood serum can sometimes reach levels that are unsafe for the patient. Long-term persistence of a purulent focus, unsystematic use of antibacterial drugs inevitably leads to selection in the osteomyelitic focus of hospital flora resistant to traditionally used groups of antibiotics, to the development of dysbacteriosis and fungal infection up to its generalization. Studies have shown that patients with chronic osteomyelitis do not have immune disorders, therefore immune drugs (interferon alpha-2, immunoglobulins) are prescribed only to patients with septic manifestations.

Ideally, the use of antibacterial drugs should be based on the results of a comprehensive bacteriological study of the bone obtained during biopsy or surgical treatment. In patients with fistulous osteomyelitis in the absence of pronounced manifestations of the purulent process and intoxication without surgical treatment, antibacterial therapy is inappropriate. However, if there is an acute clinical situation (open fractures with extensive damage to soft tissues, acute hematogenous osteomyelitis), antibacterial treatment should not be delayed pending biopsy data. In such situations, the drug is selected empirically based on the localization and severity of the infection, which microorganisms are presumed to be pathogens, and their most likely sensitivity to antimicrobial agents. Taking into account the data on activity against the main pathogens of surgical infection, organotropism and safety of antibiotics, at present, along with traditional drugs (carbenicillin, gentamicin, lincomycin, etc.), new groups are prescribed - fluoroquinolones, carbapenems and glycopeptides.

Good prospects for complicated osteomyelitis appeared with the introduction of drugs from the fluoroquinolone group into medical practice, as they have good organotropy to bones and soft tissues. Oral treatment with fluoroquinolones for gram-negative infections is widely used in adult patients with osteomyelitis. Fluoroquinolones can be successfully used for long courses of step therapy (intravenously-orally). 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. Third-generation quinolones (levofloxacin, gatifloxacin) are active against streptococci, but have minimal effect on anaerobes.

At present, extensive experience has been accumulated in the use of cephalosporins in the complex treatment of patients with acute and chronic osteomyelitis. Most researchers prefer ceftriaxone, a third-generation cephalosporin resistant to beta-lactamases, with a broad spectrum of action, acting 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 its antibacterial concentration to be maintained with a single administration during the day. Among the existing drugs for the treatment of patients with osteomyelitis and extensive purulent lesions of soft tissues when associations of anaerobic and aerobic microorganisms are detected in the wound, the use of cephalosporins of the III (cefotaxime, ceftriaxone) and IV (cefepime) generations, carbapenems (imipenem + cilastatin), as well as clindamycin in combination with netilmicin, ciprofloxacin or dioxidine is effective.

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

Although the optimal duration of antibacterial therapy for osteomyelitis has not yet been clearly defined, most specialists use drugs for 4-6 weeks. This is due to the fact that bone tissue revascularization occurs 4 weeks after surgical treatment. However, it should be noted that failures do not depend on the duration of antibacterial treatment, but are mainly due to the emergence of resistant strains or inadequate surgical treatment. In some cases, when surgical treatment is not feasible, such as infection around orthopedic implants, longer courses of suppressive antibiotic therapy are administered. Ideal drugs for this should have good bioaccumulation, low toxicity, and good organotropy to bone tissue. For this purpose, rifampicin is used in combination with other antibiotics, fusidic acid, ofloxacin, and co-trimoxazole. Suppressive treatment is carried out for up to 6 months. If relapse occurs after stopping therapy, a new long-term suppressive antibiotic regimen is started.

Currently, intra-arterial and endolymphatic administration of antibiotics for osteomyelitis has been abandoned. There is a tendency to increase the use of oral and topical dosage forms. According to the results of many clinical trials, high efficiency has been proven when used orally of clindamycin, rifampin, co-trimoxazole, and fluoroquinolones. Thus, clindamycin, which is active against most gram-positive bacteria, is used orally after initial (1-2 weeks) intravenous treatment.

To prevent the development of fungal infection, along with antibacterial drugs, nystatin, ketoconazole or fluconazole are prescribed in each case. To maintain normal intestinal ecology, it is necessary to include monocomponent (bifidumbacterin, lactobacterin, baktisporin, baktisuptil), polycomponent (bifilong, acylact, acinol. linex, biosporin) and combined (bifidumbacterin forte, bifiliz) probiotics in the complex treatment.

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

• water-soluble antiseptic ointments - levosin, 10% ointment with mafenide, 5% dioxidine ointment, dioxykol, streptonitol, quinifuril, 1% iodopyrone ointment (povidone-iodine ointment), protogentin and lavendula ointments;
• antiseptics - 1% iodopyrone solution (povidone-iodine), 0.01% mira-mystin solution, 1% dioxidine solution, 0.2% polyhexanide solution;
• foaming aerosols - amitrozole, dioxizole;
• wound dressings: gentacicol, algipor, algimaf.

Treatment of patients with osteomyelitis requires the use of not only new antibacterial drugs, but also alternative routes of administration. The use of various bioimplants for the delivery of antibiotics directly to the bone is promising. Depending on the clinical situation, these prolonged-release drugs can be used as an alternative to systemic antibiotic therapy or as a supplement to it. Bioimplants have advantages over systemic antibacterial therapy, in which the penetration of the drug into the poorly blood-supplied bone at the site of inflammation is difficult. These drugs are capable of creating a high concentration of the drug in bone tissue for a long time (up to 2 weeks) without the unwanted side effect of the systemic drug on the entire body. To date, the most common carriers of antibiotics with proven effectiveness are non-biodegradable (PMMA cement and Septopal) and biodegradable (gentacicol, kollapan, crushed allogenic cancellous bone, Osteoset) implants. These drugs are approximately the same in terms of antimicrobial activity. The main advantage of biodegradable implants is the lack of need to remove the antibiotic carriers after the release of the drugs is complete.

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