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

Disclosures

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

In This Article

Case Report

The attending surgeons of this report have been utilizing fluorescence-guided resection with preoperative doxycycline administration over the last several years since beginning their respective practices after fellowship training. They have used this stepwise, planned approach successfully to treat chronic osteomyelitis and achieve bony union in about a half-dozen patients. The assistance of their infectious disease colleagues and plastic surgeons has been critical to the success of these patients. Included are sample photographs taken intraoperatively that depict the bone fluorescence in a patient prescribed doxycycline preoperatively (Figure 1). As a control of sorts, intraoperative fluorescence was photographed in a patient undergoing procedures that were separate from osteomyelitic debridement without any preoperative doxycycline (Figure 2). Additionally, a photograph of fresh-frozen cadaveric bone is included to demonstrate the lack of fluorescence in dead bone (Figure 3).

Figure 1.

(A) Intraoperative fluorescence of a tibia before debridement (proximal is up, distal is down). (B) More complete fluorescence of the same tibia after completion of debridement.

Figure 2.

A viable tibia with intraoperative bone fluorescence. This patient had not received any preoperative doxycycline.

Figure 3.

Fresh-frozen cadaveric humerus with blacklight exposure. Notice that minimal to no fluorescence is exhibited by nonviable, dead bone.

Recently, a 30-year-old female patient of the senior author initially presented with a history of recurrent incision and drainage for skin abscesses to the axillae, groin, and right anterior leg. Vague right leg pain limited her activities and woke her from sleep for 6 mo. Advanced imaging demonstrated chronic osteomyelitis and an intramedullary tibial abscess. She was treated in two stages with irrigation and debridement, culture collection, gentamicin-vancomycin-coated intramedullary nailing, and gentamicin-vancomycin-impregnated cement at the tibial defect for a Masquelet procedure. The infectious disease team discharged her on intravenous daptomycin, and the senior author prescribed doxycycline. The patient returned 7 wk later for irrigation, debridement, and autogenous bone grafting with Reamer Irrigator Aspirator (RIA). Intraoperatively, debridement proceeded under black light until all exposed bone fluoresced. The infectious disease team discharged the patient on 6 mo of doxycycline. At her final follow-up just over 1 yr out from the Masquelet procedure, examination demonstrated good healing and full, painless range of motion without tenderness, erythema, warmth, or fluctuance. The patient had resumed all normal activities.

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