Fluorescence-Guided Surgical Debridement of Chronic Osteomyelitis Utilizing Doxycycline Bone Labeling

A Technical Trick Revived

Garrhett G. Via, MD; David A. Brueggeman, MD; Grant M. Slack, BS; James M. Danias, DO; Jennifer L. Jerele, MD


Curr Orthop Pract. 2021;32(5):518-521. 

In This Article

Surgical Technique

The concept of fluorescence-guided resection within the realm of orthopaedic surgery is relatively straightforward and simple to apply. Initially, tetracycline (i.e., doxycycline) must be administered preoperatively to allow enough time for the metabolite to be incorporated into live bone. In the practice of the present authors, administration of doxycycline can range from an intravenous formulation of 100 mg delivered only in preoperative holding, to a multi-week regimen in an oral formulation of 100 mg to be taken as an outpatient twice daily. The authors have noted minimal variation in the level of fluorescence with different dosing schedules, although a longer preoperative administration window is preferred because of the theoretical advantage of increased time for bony uptake and metabolism.

At the time of surgical resection, a surgeon must carry out dissection in the usual manner based upon the region of operative pertinence. Typically, an initial debridement of obviously necrotic or osteomyelitic bone and collection of cultures are performed. Once this is carried out to a reasonable extent, it is the preference of the senior author to have the operating theater lights shut off. A nonsterile team member then operates an ordinary blacklight apparatus to illuminate adequately the surgical field. In areas of bone that are actively metabolizing the doxycycline, a greenish fluorescence will be noted. This intensity of fluorescence will be in stark contrast to any areas of bone that remain nonviable. Those areas lacking fluorescent intensity are then debrided more completely to the satisfaction of the attending surgeon. Assessing for fluorescence can be performed prior to the initial debridement if there is any ambiguity about which areas of bone may be viable.

Additional operative interventions such as open reduction internal fixation, intramedullary nailing, placement of antibiotic-laden cement beads or placing antibiotic-impregnated cement into a bone defect to stage for an additional procedure (ie, Masquelet), can then be carried out as indicated in the given clinical scenario. Given the complex nature of these infections, consultation by an infectious disease specialty team is recommended and utilized by the authors in most instances for establishing inpatient and outpatient antibiotic regimens.