My Orthopaedic Surgeon

Wheeless' Textbook of Orthopaedics - necrotizing fascitits is any necrotizing soft tissue infection spreading along fascial planes, with or without overlying cellulitis; - also called Meleney ulcer, NF is severe manifestation of lymphangitis that progresses in a frightening manner within a few hours; - tissue necrosis develops rapidly behind advancing wall of inflammation that limits penetration by antibiotics; - desquamation followed by gangrene may be relentless; - clinical signs of pain, hyperyrexia, and chills are severe; - skin lesions are incised and drained or aspirated to obtain fluid for culture; - initial findings are localized pain and minimal swelling, often w/ no visible trauma or discoloration of the skin; - dermal induration and erythema eventually become evident; - eventually the patient has limited range of motion, chills, fever; - dx is confirmed when a probed can be passed laterally along fascial cleft in a open wound; - blistering of the epidermis is a late finding;

Wheeless' Textbook of Orthopaedics
Discussion:
- predisposing conditions:
- open fracture
- sickle cell anemia
- septic arthritis
- in children, distinguishing between metaphyseal osteomyelitis and septic arthritis can be problematic;
- diabetes (see osteomyelitis in the diabetic patient);
- classification:
- hematogenous osteomyelitis;
- cierny classification
- chronic osteomyelitis
- vertebral osteomyelitis
- characteristics based on age:
- osteomyelitis in infants
- osteomyelitis in children

Antimicrobial therapy for diabetic foot infections A practical approach Kevin W. Shea, MD VOL 106 / NO 1 / JULY 1999 / POSTGRADUATE MEDICINE CME learning objectives To identify factors that influence antibiotic selection in the treatment of diabetic foot infections To understand the microbiology of the infected diabetic foot To establish an effective antimicrobial regimen for empirical treatment of diabetic foot infections

Medical Microbiology Section 5. Introduction to Infectious Diseases 100. Bone, Joint, and Necrotizing Soft Tissue Infections Jon T. Mader Jason Calhoun General Concepts Sections include:- Introduction Necrotizing Soft Tissue Infections Crepitant Anaerobic Cellulitis Necrotizing Fasciitis Nonclostridial Myonecrosis Clostridial Myonecrosis Fungal Necrotizing Cellulitis Joint Infections Gonococcal Arthritis Nongonococcal Arthritis Diagnosis of Bacterial Arthritis Granulomatous Arthritis Bone Infections Hematogenous Osteomyelitis Contiguous-Focus Osteomyelitis Chronic Osteomyelitis Diagnosis of Bacterial Osteomyelitis Skeletal Tuberculosis Fungal Osteomyelitis References

From Applied Radiology Radiological Case of the Month Calcaneal Bone Osteomyelitis Posted 08/04/2004 Walter Silbert, MD; Maroun Karam, MD Case Summary A 51-year-old white man with a medical history significant for Type I diabetes mellitus and peripheral vascular disease necessitating multiple prior distal amputations presented with increasing right foot pain. He reported no recent trauma or corticosteroid therapy. Physical examination revealed prior transmetatarsal amputation and a large nonhealing ulcer that penetrated deeply to the lateral aspect of the ankle. In addition, erythema, warmth, and edema of the leg and foot were noted, leading to a strong clinical suspicion of osteomyelitis

From Neurosurgical Focus Cervical Osteomyelitis: A Brief Review Posted 01/21/2005 Bryan Barnes, M.D.; Joseph T. Alexander, M.D.; Charles L. Branch Jr., M.D. Abstract Object: The authors conducted a literature-based review of the etiology, diagnosis, and treatment of cervical vertebral osteomyelitis (CVO). Methods: A Medline (PubMed) search using the key words "cervical vertebral osteomyelitis" yielded 256 articles. These were further screened for relevance, yielding 15 articles. Each publication was reviewed, and several others not identified in the PubMed search were screened and included in the review according to relevance. Each article was identified as involving either the epidemiology/etiology, diagnosis, or treatment of CVO. Separate categories were created for case reports and general reviews. Conclusions: Cervical vertebral osteomyelitis has a spectrum of origins, which include spontaneous, postoperative, traumatic, and hematogenously spread causes. The majority of patients have medical risk factors and comorbidities that include diabetes, trauma, drug abuse, and infectious processes in extraspinal areas. The diagnosis of CVO can be accomplished in most cases by using plain x-ray films and computerized tomography scans. Nevertheless, preferential use of magnetic resonance imaging in cases in which there is a neurological deficit is helpful in identifying epidural compressive processes. Treatment for CVO can be successfully initiated with intravenous antibiotic therapy. Nevertheless, in cases in which there is a neurological deficit, spinal deformity and/or progressive lysis, or intractable pain, the earliest feasible surgical intervention with debridement and fusion is warranted.

Full text article Journal of Clinical Microbiology Sept 1995 p2382-2387

Poster. Weber et al, Aurora Health Care and Hyperbaric and Wound Care Associates, Milwaukee

Conservative Management of Diabetic Foot Ulcers Complicated by Osteomyelitis from Wounds 2002 NG Yadlapalli, MD, Anand Vaishnav, MD, and Peter Sheehan, MD Abstract Osteomyelitis of the diabetic foot remains a difficult clinical infection, often resulting in disability and amputation. Standard management consists of thorough removal of all infected bone in conjunction with antimicrobial therapy. This may have an untoward effect on foot mechanics and may increase risk of future ulcer events. In order to evaluate the efficacy of a more conservative approach, we retrospectively assessed the outcomes patients managed by an interdisciplinary team of comprehensive inpatient and outpatient care. Over a three-year period, 160 patients were identified by a discharge database with osteomyelitis; of these, 58 had outpatient follow-up records for at least 12 months. The treatment regimen consisted of conservative debridement or surgery, four to six weeks of empiric intravenous antibiotics, and biomechanical offloading of pressure impediments to wound healing. Initial procedures were debridement (34 patients), excision of bone (13 patients), toe or ray amputation (8 patients), and major amputation (3 patients). The mean duration of antibiotic therapy was 40.3 days. At twelve-months follow up, twelve patients (20.7%) failed treatment, with nine patients having persistent ulcers, and three patients requiring amputation. The remaining 46 patients healed (79.3%). Three patients had ulcer recurrence and 21 patients had new ulcer episodes in the follow-up observation period. In conclusion, an approach to osteomyelitis in the diabetic foot that is based on conservative surgical intervention, long-term empiric antibiotics, and interdisciplinary wound care and offloading may be a safe and effective alternative to amputation in selected patients.

From Applied Radiology Cryptococcal Osteomyelitis Posted 09/04/2003 Timothy C. Sloan, DVM, MD, Jason Hosey, MD Summary A 51-year-old man presented to the emergency department with chest pain radiating to the right shoulder. The pain had been present for several months but had become refractory to analgesics. Past medical history was remarkable for recently diagnosed diabetes mellitus with negative cardiac and gastrointestinal workups. Physical examination revealed the patient had a low-grade fever and pain localized over the midthoracic spine. A radiograph of the thoracic spine (Figure 1) prompted subsequent computed tomography (CT; Figure 2) and magnetic resonance (MR; Figure 3) examinations.

Diagnosis and Management of Adult Pyogenic Osteomyelitis of the Cervical Spine Posted 01/05/2005 Frank L. Acosta Jr., M.D.; Cynthia T. Chin, M.D.; Alfredo Quiñones-Hinojosa, M.D.; Christopher P. Ames, M.D.; Philip R. Weinstein, M.D.; Dean Chou, M.D Abstract Establishing the diagnosis of cervical osteomyelitis in a timely fashion is critical to prevent catastrophic neurological injury. In the modern imaging era, magnetic resonance imaging in particular has facilitated the diagnosis of cervical osteomyelitis, even before the onset of neurological signs or symptoms. Nevertheless, despite advancements in diagnosis, disagreement remains regarding appropriate surgical treatment. The role of instrumentation and type of graft material after cervical decompression remain controversial. The authors describe the epidemiological features, pathogenesis, and diagnostic evaluation, and the surgical and nonsurgical interventions that can be used to treat osteomyelitis of the cervical spine. They also review the current debate about the role of instrumentation in preventing spinal deformity after surgical decompression for cervical osteomyelitis. Based on this review, the authors conclude that nonsurgical therapy is appropriate if neurological signs or symptoms, instability, deformity, or spinal cord compression are absent. Surgical decompression, debridement, stabilization, and deformity correction are the goals once the decision to perform surgery has been made. The roles of autogenous graft, instrumentation, and allograft have not been clearly delineated with Class I data, but the authors believe that spinal stability and decompression override creating an environment that can be completely sterilized by antibiotic drugs. (full text) Sections - Abstract and Introduction Epidemiology and Etiology Microbiology Pathogenesis Clinical Presentation Management Protocols Prognosis Conclusions Figures Tables References

Editorial Paediatrics and Child Health May/June 2001, Volume 6, Number 5 Flesh-eating disease: A note on necrotizing fasciitis H Dele Davies MD MSc, Child Health Research Unit, Alberta Children’s Hospital and Departments of Pediatrics, Microbiology and Infectious Diseases and Community Health Sciences, University of Calgary, Calgary, Alberta There has been much media attention in the past few years to the condition dubbed ‘flesh-eating disease’, which refers, primarily, to a form of invasive group A beta hemolytic streptococcal (GABHS) infection that leads to fascia and muscle necrosis. In 1999, the Canadian Paediatric Society issued a statement on the state of knowledge and management of children, and close contacts of persons with all-invasive GABHS disease (1). The present note is intended to deal specifically with necrotizing fasciitis (NF) by providing an update on the limited current state of knowledge, diagnosis and management. Surveillance to establish actual national rates and epidemiology of NF through the Canadian Paediatric Society is proposed.

From Emerging Infectious Diseases Multidrug-Resistant Acinetobacter Extremity Infections in Soldiers Posted 08/11/2005 Kepler A. Davis; Kimberly A. Moran; C. Kenneth McAllister; Paula J. Gray Abstract War wound infection and osteomyelitis caused by multidrug-resistant (MDR) Acinetobacter species have been prevalent during the 2003–2005 military operations in Iraq. Twenty-three soldiers wounded in Iraq and subsequently admitted to our facility from March 2003 to May 2004 had wound cultures positive for Acinetobacter calcoaceticus-baumannii complex. Eighteen had osteomyelitis, 2 burn infection, and 3 deep wound infection. Primary therapy for these infections was directed antimicrobial agents for an average of 6 weeks. All soldiers initially improved, regardless of the specific type of therapy. Patients were followed up to 23 months after completing therapy, and none had recurrent infection with Acinetobacter species. Despite the drug resistance that infecting organisms demonstrated in this series, a regimen of carefully selected extended antimicrobial-drug therapy appears effective for osteomyelitis caused by MDR Acinetobacter spp.

Research Focus Musculoskeletal Manifestations of HIV Infection from The AIDS Reader ® Posted 03/25/2003 Ann-Marie Plate, MD, Brian A. Boyle, MD Introduction Musculoskeletal disorders are relatively common during the course of HIV infection, although they are more prevalent in the late stages of disease. These disorders cause a significant amount of morbidity, and occasionally mortality, in HIV-infected patients, and some chronic musculoskeletal disorders may cause a significant decrease in the patient's quality of life. This column will focus on the most common musculoskeletal disorders HIV clinicians are likely to encounter and will provide a review of the most recent literature on each disorder. The spectrum of musculoskeletal disorders in HIV-infected patients ranges from myopathies and arthralgias to rheumatic disorders such as Reiter syndrome and psoriatic arthritis. Infection and septic arthritis are also common entities. The prevalence of inflammatory musculoskeletal manifestations remains uncertain; however, studies indicate that the prevalence of these disorders may be influenced by the risk factors responsible for HIV infection: patients who use injection drugs or have hemophilia are more susceptible to septic arthritis and osteomyelitis, whereas Reiter syndrome is more common among homosexual HIV-infected patients. Contents - Introduction Myopathies Inflammatory Arthropathies Infections Neoplastic Condition References

BMJ 2005;330:830-833 (9 April), doi:10.1136/bmj.330.7495.830 Clinical review Necrotising fasciitis Saiidy Hasham, research registrar in plastic surgery1, Paolo Matteucci, specialist registrar in plastic surgery1, Paul R W Stanley, consultant plastic surgeon1, Nick B Hart, consultant plastic surgeon1 1 Department of Plastic Reconstructive and Hand Surgery, Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ Correspondence to: S Hasham saiidyhasham@hotmail.com Necrotising fasciitis is a rare but life threatening condition that requires immediate action, but uncertainties still hamper prompt diagnosis and treatment