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

Discussion

To the best of the authors' knowledge, the topic of fluorescence-guided surgery has been absent in the major orthopaedic literature for nearly 20 yr. Most of the knowledge available in the literature is presented from the viewpoint of maxillofacial surgeons. Some of the discrepancy stems from which antibiotic to choose, as well as the duration for which it should be administered preoperatively. The literature suggests that surgeons around the world are choosing either tetracycline or doxycycline for antibiosis, with doxycycline being most common.[1,2,4,7–11,14,15] As for duration and dose, 1 to 2 wk preoperatively of twice daily 100 mg doxycycline administration should be sufficient.[8–11,14] One group routinely prescribed tetracycline 250 mg four times daily only 48 hr preoperatively, and another administered an intravenous form only 1 hr preoperatively.[1,15] Both groups reported visible fluorescence. However, the orthopaedic literature would argue that a longer duration is best, with extremes of up to 3 to 6 mo of twice daily doxycycline when case planning permits.[2]

The senior author of this manuscript prefers preoperative administration of twice daily 100 mg doxycycline for at least 1 mo combined with use of an ordinary blacklight as the intraoperative excitation source. As pointed out first by Dahners and Bos,[2] a longer duration seems to produce fluorescence that is brighter and extends deep to the periosteum. Furthermore, the use of an ordinary blacklight is cost-effective, readily attainable, and proven to be efficacious.[7] Of course, an obvious limitation is that this work is largely rooted in opinion. The authors hope that any curious surgeon merely gives this technical trick an opportunity to demonstrate its value as an adjunct to the treatment of chronic osteomyelitis. More formal trials to quantify fluorescence intensity objectively in the presence of doxycycline can follow once the topic gains a foothold in the orthopaedic literature.

In the opinion of the authors, fluorescence-guided surgical resection of necrotic or osteomyelitic bone utilizing doxycycline involves the art of medicine rather than an exact science. The described technique is used as an adjunct to treatment rather than an absolute guide to bone resection. Implementation of this technical trick is dictated by the discretion and experience of the attending surgeon and best practice regarding individual patient circumstances or surgical indications.

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