Osteocutaneous-flap-related osteomyelitis following mandibular reconstruction: a cohort study of an emerging and complex bone infection

Clément Javaux; Clémentine Daveau; Clotilde Bettinger; Mathieu Daurade; Céline Dupieux-Chabert; Fabien Craighero; Carine Fuchsmann; Philippe Céruse; Arnaud Gleizal; Nicolas Sigaux; Tristan Ferry; Florent Valour; The Lyon Bji Study Group

doi:10.5194/jbji-7-127-2022

Osteocutaneous-flap-related osteomyelitis following mandibular reconstruction: a cohort study of an emerging and complex bone infection

J Bone Jt Infect. 2022 Jun 10;7(3):127-136. doi: 10.5194/jbji-7-127-2022. eCollection 2022.

Authors

Clément Javaux^{1

2}, Clémentine Daveau³, Clotilde Bettinger⁴, Mathieu Daurade⁵, Céline Dupieux-Chabert^{2

6

7}, Fabien Craighero⁸, Carine Fuchsmann³, Philippe Céruse³, Arnaud Gleizal⁵, Nicolas Sigaux⁹, Tristan Ferry^{1

2

7}, Florent Valour^{1

2

7}, The Lyon Bji Study Group¹⁰

Affiliations

¹ Department of Infectious Diseases, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, 69004, France.
² Regional Reference Center for the Management of Complex Bone and Joint Infections, Hospices Civils de Lyon, Lyon, 69004, France.
³ Department of Otolaryngology Surgery, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, 69004, France.
⁴ Department of Anesthesiology, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, 69004, France.
⁵ Department of Oral and Maxillofacial Surgery, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, 69004, France.
⁶ Laboratory of Bacteriology, Institute of Infectious Agents, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, 69004, France.
⁷ Centre International de Recherche en Infectiologie (CIRI), Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Lyon, 69007, France.
⁸ Department of Radiology, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, 69004, France.
⁹ Department of Oral and Maxillofacial Surgery, Groupement Hospitalier Sud, Hospices Civils de Lyon, Pierre-Bénite, 69310, France.
¹⁰ A full list of authors appears at the end of the paper.

Abstract

Osteocutaneous flap (OCF) mandible reconstruction is at high risk for surgical site infection. This study aimed to describe diagnosis, management, and outcome of OCF-related osteomyelitis. All patients managed at our institution for an OCF-related osteomyelitis following mandible reconstruction were included in a retrospective cohort study (2012-2019). Microbiology was described according to gold-standard surgical samples, considering all virulent pathogens, and potential contaminants if present on at least two samples. Determinants of treatment failure were assessed by logistic regression and Kaplan-Meier curve analysis. The 48 included patients (median age 60.5 (IQR, 52.4-66.6) years) benefited from OCF mandible reconstruction mostly for carcinoma ( $n = 27 / 48$ ; 56.3 %) or osteoradionecrosis ( $n = 12 / 48$ ; 25.0 %). OCF-related osteomyelitis was mostly early ( $\leq 3$ months post-surgery; $n = 43 / 48$ ; 89.6 %), presenting with local inflammation ( $n = 28 / 47$ ; 59.6 %), nonunion (wound dehiscence) or sinus tract ( $n = 28 / 47$ ; 59.6 %), and/or bone or device exposure ( $n = 21 / 47$ ; 44.7 %). Main implicated pathogens were Enterobacteriaceae ( $n = 25 / 41$ ; 61.0 %), streptococci ( $n = 22 / 41$ ; 53.7 %), Staphylococcus aureus ( $n = 10 / 41$ ; 24.4 %), enterococci ( $n = 9 / 41$ ; 22.0 %), non-fermenting Gram-negative bacilli ( $n = 8 / 41$ ; 19.5 %), and anaerobes ( $n = 8 / 41$ ; 19.5 %). Thirty-nine patients (81.3 %) benefited from surgery, consisting of debridement with implant retention (DAIR) in $25 / 39$ (64.1 %) cases, associated with 93 (IQR, 64-128) days of antimicrobial therapy. After a follow-up of 18 (IQR, 11-31) months, $24 / 48$ (50.0 %) treatment failures were observed. Determinants of treatment outcomes were DAIR (OR, 3.333; 95 % CI, 1.020-10.898) and an early infectious disease specialist referral (OR, 0.236 if $\leq 2$ weeks; 95 % CI, 0.062-0.933). OCF-related osteomyelitis following mandibular reconstruction represents difficult-to-treat infections. Our results advocate for a multidisciplinary management, including an early infectious-disease-specialist referral to manage the antimicrobial therapy driven by complex microbiological documentation.