G19_Osteomyelitis.ppt

8/9/2019 G19_Osteomyelitis.ppt

1/120


2/120

'One (hould )s*eciall# Aoid (uch

Cases if One has a Res*ecta"le )+cuse,

for the !aora"le Chances are !e and

the Ris-s are Man#.


3/120


4/120

Fracture Management Goals

&. Osseous 1nion

2. Restore 6i7" !unction

8. Aoid Co7*lications


5/120

Osteomyelitis Results in:

&. Reduction in li7" function

2. 3s#chological % (ocial d#sfunction

8. ncreased cost


6/120

/ansen9s $ DsConcerning 3rolonged Ortho*aedic 3ro"le7s

Des*air

Diorce

Destitute

De*ression

Delinuenc#Default

Death

(igard ed /ansen, &$


7/120

Introduction< 8=0,000 long "one f+s>#r

< nfection ris- aries:

? #*e o*en ? &0>&,000 infections

? #*e o*en ? u* to 2=@


8/120

Gustilo Open Fx Class!"# $%: %''()*)# +''*

2@

$@

$@

+*(,*-

%,(,*-


9/120


10/120

.egati/e !iology o0 Open Fx

Conta7ination

Crushing

(tri**ing

Deasculariation

Co77inution


11/120

!lood "upplyRhinelander# CORR# +'$1


12/120

!lood "upplyRhinelander# CORR# +'$1

.ormal endosteal>7edullar# 2>88>4

internal e+ternal

Fracture *eriosteal>e+ternal 7aorit#

internal e+ternal

3eriosteal Blood (u**l# 7*ortant


13/120

Centripetal Flo2Rhinelander# CORR# +'$1


14/120

Initial 3mergent Treatment

d

Anti"iotics,

Reduce

(ta"ilie

Coer ound


15/120

4hy in0ection ris5 high6

nfection ris- E !racture t#*e Fsoft tissueG

O*en f+ H Conta7ination F$0@ c+ IG

O*en f+ H nfected f+ K hours


16/120

Cost nalysisnfection

? ncrease cost &L2&@>*t

? ncrease hos* sta# 8L=0@>*t

otal Cost ⇒ 7 %$+ million8yr


17/120


18/120

4hy destruction o0 9one

matrix6

3roteol#tic en#7es

/#*ere7ia

Osteoclasts


19/120

Do .ot Delay Tx & Dx


20/120


21/120

PathogenesisWaldvogel, 1971

&. /e7atogenous

2. Contiguous focus of infection

8. Direct inoculation


22/120

natomicClassi0ication

F!iern"#$a%er G &K=

I:I: II:II:

III:III: I:I:


23/120

Classi0ication !rea5(Do2n

. Medullar#)ndosteal nidus, 7in soft tissue inole7ent, (inus tract

. (u*erficial(urface of "one, usu 2P to soft tissue defect

. 6ocalied6ocalied seuestra, usu sinus tract,

1su sta"le s>* e+cision

. Diffuse3er7eatie *rocess, co7"ination of >>,

1su 1nsta"le s>* e+cision


24/120


25/120

Clinical "taging;Cierny(Mader# +'?,<

Anato7ic #*e

@ Clinical "tage

3h#siologic Class '(a&ple) *V B+ tiial osteo&"elitis - %i../se tiial lesion in a s"ste&icall" co&pro&ise% 0ost


26/120

Types o0 Pathophysiology

Acute>/e7atogenous

Chronic>onhe7atogenous


27/120


28/120

cute8=ematogenous

Progression o0 DA

< Cell death 2P to "acterial e+oto+ins

"acterial culture 7ediu7 orsens condition

∀ ascularit#, leu-oc#tosis, ede7a

3ressure >in rigid osseous container 3ain, selling, er#the7a

3otential for se*tic arthritis F-nee, hi*, shoulderG


29/120


30/120

Clinical Findings

;/aried<)r#the7a

(elling

(inus ract

Drainage

6i7*

!luctuence

one one

3ain3ain

endernessenderness

!eer !eer

/A/A ausea>o7iting ausea>o7iting


31/120

Clinical Findings

< Must hae high inde+ of sus*icion

< na**ro*riate use of A"+ ? o"scure (+

< Must o"tain D+ uic-l#

? f + started $2P:

< Decrease incidence of chronic osteo7#elitis

< Decrease destruction of "one


32/120

>a9oratory Data

Acute F $orre", BF, 2!N3, 1974G

↑ NBC F2=@ of ti7eG

? A"nor7al differential, 6eft (hift FL=@G ? Blood C+ ? =0@ *ositie

Chronic

? Mild ane7ia, N)(R, Creactie *rotein

? 3ossi"le leu-oc#tosis ith 6 shift

? Blood C+ ? usuall# negatie


33/120

Radiographs

)arl# ? usu negatie

Changes ? dela#ed F&02& da#sG


34/120


35/120

Radionucleotide Imaging

M c

L$a

&&&n NBC


36/120

''M Tc

< Action

? "inds to h#dro+#a*etite cr#stals

< Osteo"lastic actiit#

? De7ineralied "one

? 77ature collagen


37/120

''M Tc

< 8 3hase Bone (can

&. Radionucleotide angiogra7

2. 77ediate *ost inection "lood *ool

8. hree hour: ↓ soft tissue, urinar# e+cretion

< Diagnosis

? Cellulitis: ↑ 3hases & %2, no change 8

? Osteo7#elitis: ↑ 3hases & % 2, 0ocal )

< Results: 4@ sensitiit#, =@ s*ecificit#

? Rosent0al 1995, +c0a/wecker 1995


38/120

Cellulitis


39/120


40/120

''M Tc: False Positi/e

DM foot d>o

(e*tic arthritisnfla77ator# "one d

Adacent to *ressure sores


41/120

''M Tc

4 3hase Bone (can

< e deelo*7ent

< Action: ? Mature "one: u*ta-e sto*s at 4 hr

? 77ature oen "one: cont9d u*ta-e at 24 hr

< 3ro"le7: needs f>u i7aging at 24 hr Fco7*lianceG< 6/pta 1988, *srael 1987, +c0a/wecker 1995


42/120

B$Ga

< )+udation of in io la"eled seru7 *rotein

? ransferrin, ha*toglo"in, al"u7in

< Results

? K&@ sensitiit#, L@ s*ecificit# ? +c0a/wecker, 1995

< Co7"ination ith c ↑ sensitiit#, "ut ↓ s*ecificit#


43/120

+++In 4!C

< 1sed in co7"ination F+eaol%, 1989G

? n>c: KK@ accurate

? a>c: 8@ accurate

< 3re*aration *ro"le7

↑ rad dose to s*leen, &K24hr dela#

< (*ine FW0alen, +pine 1991G

? K8@ false negatie use MR


44/120

MRI

o radiation

ood soft tissue i7aging

7aging:

? & Dar-

? 2 Bright>Mi+ed


45/120


46/120

T+ 9right T% dar5


47/120

MRI

< Acute:

↓ 7arro fat

↑ granulation tissue /2O

< Chronic: thic-ened corte+

? 6o signal on all scans< Cellulitis: no 7arro changes


48/120

MRI Results Schauwecker, 1992

< (ensitiit# 2&00@

< (*ecificit# K&00@

< )+cellent for (*ine F $o%ic, R!N3, 198 G

? (ens L@, (*ec 2@, Accurac# 4@

< (oft tissue e+tension

< (inus tract for7ation

? Bright + fro7 s-in to "one


49/120

CT Imaging

7age cortical and cancellous "one

)aluate osseous adeuac# of de"ride7ent


50/120

spiration !iopsy

Acute

? ood, onl# &0&=@ false negatie

Chronic ? (inus tract c+: $L@ sens, K0@ s*ec

? $0@ ith + a/re/s % 'nterococc/s

? 80@ Pse/%o&onas

? Does not deter7ine correct A"+


51/120

cute8=ematogenous


52/120

Changing !acterial

Pathogens


53/120

Resistant Bacteriu7 ( 3"P3

) )nterococcus faecui7

( (ta*hlococcus aureusS Sle"siella *neu7oniae

A Acino"acter "au7annii

3 3seudo7onas aeruginosa) )ntero"acter aerogenes


54/120

M"" & MR"

< M((A Change to T lacta7

< MR(A reat U MC


55/120

ra7 egatie Rods ( "PIC3

( (erratia

3 3seudo7onas

ndole *ositie

C Citro"acter

) )ntero"acter


56/120

Gram

.egati/eRods


57/120

Proioni9acterium acnes

< A+illar# "acteria Fse"aceous glandsG< reated ith:

? &st: 3C or anco

? 2nd: Macrolides % !luorouinolones

< 6ong incu"ation ti7e

< Call la" ? culture 2 -s, gra7 *ositie rods

< )s*eciall# i7*ortant for shoulder:

? onunions ? nfections


58/120

Multilocus Polymerase Chain reaction &

3lectrospray IoniAation8Mass "pectrometry< Bacterial or fungal DA is a7*lified "#

*ol#7erase chain reaction and introduced

into a 7ass s*ectrosco*# "# electros*ra#ioniation

< he a7*lification *rocedure uses &L (

*ri7ers, and the *ri7ers can "e aried todetect fungi and anti"iotic resistance genes

Feg, 7ec AG.


59/120

Multilocus Polymerase Chain reaction &

3lectrospray IoniAation8Mass "pectrometry< Although culturing "acteria ta-es da#s,

a7*lif#ing DA ta-es hours

< Accurate, ra*id *ointofcare deices ould "e ideal for clinical use


60/120

Treatment Pre/entation

< Anti"iotics ? correct organis7

< De"ride7ent ? until ia"le tissue o"tained

< rrigation

< Nound care>coerage

< Osseous % soft tissue sta"ilit#

? !+ sta"ilit#

? Dead s*ace 7anage7ent


61/120

e Oral Agents: MR(A

V#o+>linaid *o>i W *lts

(#nercid i

In0ectious Disease Consult


62/120


63/120

Glycocalyx Eslime

Re7oe hardare, e+change for ne once infection under controlRe7oe hardare, e+change for ne once infection under control


64/120

Dead "pace Control


65/120

9x IM. Materials & Methods

Research: Retros*ectie Reie

i7e: 8 #ear *eriod, 2 #ear !>16ocation: 6eel & rau7a Center


66/120

Patientsge: )$ ;range +?(B$<

!e7urs FnH4G

Closed nH2

O*en nH2

i"ia FnH2KG

Closed nH2

O*en nH2L

: 4>2L

A: &2>2L

B: &0>2K

&0>2K o*en ti"ial f+ ith rotational or ! for coerage


67/120

nti9iotic .ail

Inserted /g ) mo ;range % day H %) mo<

2 "ags 3MMA

2.O g anco7#cin

2.4 g o"ra7#cin

82 !r Chest u"e

8.2 77 uide Nire


68/120

Incise & De9ride 4ound%D Nound

%D Canal

Rea7ers, ent /ole


69/120

Presentation

44 M44 M

4 "acteriu74 "acteriu7Coccidio7#cosisCoccidio7#cosis

2 *rior -non 'flare u*s52 *rior -non 'flare u*s5


70/120


71/120

Insert 9x IM.


72/120


73/120

3xample


74/120


75/120

In0ected Ti9ial .onunion

< 82 M

< 2 **d s7o-er

< MCA &K 7o, 2 *rior surgeries

< Draining ound

< 'o one to ta-e care of hi75

? ranslation o 7one#


76/120

Presentation


77/120

Options

< #*e BC

< 1nsta"le ith Osteo

< (7o-er, 7alnutrition< 6ocal o*en ound

< othing

< Reise ith *late

< Reise ith nail< Reise ith e+ fi+

< Reise ith liaro

< A7*utation

6ength I>


78/120


79/120

Dead "pace Management


80/120

"ta9iliAe .onunion"ta9iliAe .onunion


81/120

Co/erage o0 4ound


82/120

>engthening >eg


83/120

.oncompliance ( .onunion.oncompliance ( .onunion


84/120

Final H =ealed 2ith Gra0tingFinal H =ealed 2ith Gra0ting


85/120

In0ected Ti9ial .onunion

< 8K #o M

< (nuff to"acco

< & *int od-a>da#

< L 7o MCA ith B o*en ti"ia

#*e B(


86/120

Presentation


87/120

Initial Post opInitial Post op


88/120

) mo


89/120

3xchange IM. at 1 mo3xchange IM. at 1 mo


90/120

Final at +? moFinal at +? mo


91/120

3xample

< =4 #o Male

< 3osto*eratie Pse/%o&onas osteo7#elitis

< Refractor# to /N re7oal % Ancef

< /ealth#, nons7o-ing

< Ciern# A /ost

P0otos .ro& $ +wiontkowski


92/120


93/120

3 l + t B 5


94/120

3xample +# at B 25s

< Re7oal A"+ "eads

< Bone grafting

< 6ateral ar7 fla*< nfection eradication


95/120

3xample

< 4$ #o Male, s7o-er

< 3resentation 2 7onths s>* OR! closed *ro+i7alti"ia f+

< Draining ound

< )+*osed /N

< Ciern# BC /ost

< P0otos .ro& $ +wiontkowski

3 l


96/120

3xample

< De"ride7ent

< /N re7ains

< A"+ "eads

)+*osed *late


97/120

3xample

< astrocne7eus fla*, ((


98/120

3xample

< At L ee-s

< Re7oe A"+ "eads

< Bone grafting

< /ealed ound and fracture


99/120

3xample

< At = #o, ti"ial osteo7#elitis

< 3artiall# treated

< At L2 #o, *resentation to MD< Chronic draining ti"ial osteo7#elitis

< Ciern# BC /ost

< P0otos .ro& $ +wiontkowski


100/120


101/120

3xample


102/120

3xample

< A"+ "eads

< 6atissi7us !la*

< ((


103/120

3xample

< Re7oal A"+ "eads at L -s

< o "one graft ? lo de7and

*atient< D free at K #ears F$0 #oG


104/120


105/120

The Fate o0 Patients 2ith a


106/120

E"urprise Positi/e Culture

0ter .onunion "urgery

Olszewski D, Stucken C, Tornetta III P, Ricci W, Struebel

P, Jones C, Sietsema D


107/120

Results

< 1B* *atients

< T2o cohort grou*s

? '? cultures ;%+-< Esurprise positi/e

? )B% cultures ;$'-< negati/e

!acteria


108/120

Type of Bacteria Number

Coagulase-negative Staphylococcus 45

Methicillin-resistant S. Aureus !

"seu#omonas $

"roprionibacterium $

Methicillin-sensitive S. Aureus %Bacillus 4

"eptostreptococcus &

Staph species unspecifie# &

'nterococcus !

Strep viri#ans !

Clostri#ium !

'. coli( Staph epi#ermi#is( Beta hemolytic strep(

Serratia( Can#i#a an# Aspergillus

Positi/e Cultures


109/120

< K ith *ositie cultures

? 0 treated ith anti"iotics

< B H ? 2ee5 duration

< Culture speci0ic

? K *atients not treated

< EPresumed contaminant


110/120

Jnion 0ter Index

< Culture FIG H LL > 0 F$8@G

< Culture FG H 84$ > 8L2 FL@G

< 3 0.000&


111/120

In0ection 0ter Index

< Culture FIG H && > 0 F&2@G

< Culture FG H &= > 8L2 F4@G

< 3 0.000&

Final Outcome


112/120

< Culture FIG H KL > 0 F=.=@G ? 24 Additional *rocedures

? > &8 De"ride7ent onl#

? 4 > &8 ith & additional *rocedure ? 4 > 0 F4.=@G infected nonunion

? 2 BSA

< Culture FG H 8L2 > 8L2 F&00@G ? &= Additional *rocedures

< 3 0.000&


113/120


114/120

Culture "ositive CultureNegative

)eale# %&* +5.$*

,nfecte#Nonunion

&* 4*

A##itional"roce#ures

!%* 4*

nion atfinal follo-up

+&* //*

ll Patients


115/120

"ummary

< 2&@ of 4L0 'at ris-5 nonunions had

sur*rise *ositie culture

< (ta*h s*ecies< 0 of K treated ith anti"iotics

"ummary


116/120

y

< Culture *ositie

? $8@ nde+

? 8@ !inal< Culture negatie

? =.=@ nde+

? &00@ !inal


117/120


118/120

Conclusions

< 2&@ 'sur*rise5 *ositie cultures

< $4@ heal after initial inde+

*rocedure

< 2L@ reuired additional *rocedures


119/120

Recommendations

< Counsel *atients

< reat all *ositie cultures

< 3otentiall# offer tostage *rocedures ? 1n-non efficac#

? $@ ould "e unnecessar#


120/120

Conclusion

3reention

)arl# D+

)arl# +

(ta"ilie

Conert to 1nion A(A3

Documents

G19_Osteomyelitis.ppt