Clinical Case Database / Category: Clinical Care

Osteomyelitis

Publication details

Nikolaos Gougoulias MD, PhD, Anil Khanna, Nicola Maffulli
Foundation Years Journal, volume 3, issue 8, p.36 (123Doc Education, London, October 2010)

Abstract

A 42-year-old man was presented to the A&E department with a temperature of 39°C, feeling unwell. Heart rate was 110bpm, blood pressure 100/60mmHg, respiratory rate 24 breaths/minute, oxygen saturation on room air 90%. He had no chest pain, or abnormal neurological findings. Chest auscultation and ECG were normal. He smoked 20 cigarettes/day, and his past medical history was unremarkable. He sustained an open fracture of his left tibia and fibula 8 months previously. This was managed with an ankle spanning external fixation, and open reduction internal fixation of the fibula. The external fixator was removed 4 weeks before presentation at the A&E, and the patient was mobilising with a removable ankle brace. He had pain in his distal tibia and a pus discharging sinus (Figure 1) had developed in the last few days. Radiographs of his left tibia were requested (Figure 2). What is your assessment? How should this patient be managed?

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Authors

Nikolaos Gougoulias MD, PhD

CCT Orthopaedics
Clinical Fellow Royal Surrey and Frimley Park Hospitals

Anil Khanna

Anil Khanna
Registrar in Orthopaedics
University Hospital North Staffordshire
Umile Giuseppe Longo
Registrar in Orthopaedics
Campus Biomedico University
Rome

Nicola Maffulli

Nicola Maffulli
Professor of Sports and Exercise Medicine and Surgery
Consultant Trauma and Orthopaedic Surgeon
Centre for Sports and Exercise Medicine
Queen Mary University of London
Barts and the London School of Medicine
Mile End Hospital
275 Bancroft Road
London E1 4DG
n.maffulli@qmul.ac.uk

References

1. Cierny G, Mader JT, Pennick JJ. A clinical staging system for adult osteomyelitis. Contemp Orthop, 1985, 10:17–37.
2. Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. J Am Acad Orthop Surg, 2005, 13(6):417–427.
3. Parsons B, Strauss E. Surgical management of chronic osteomyelitis. Am J Surgery, 2004, 188:57–66.
4. Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop Rel Res, 1992, 280:143–152.
5. Williams MO. Long-term cost comparison of major limb salvage using Ilizarov's method versus amputation. Clin Orthop Relat Res, 1994, 301:156–158.
6. Bosse MJ, McCarthy ML, Jones AL, Webb LX, Sims LH, Sanders RW, MacKenzie EJ and the Lower Extremity Assessment Project (LEAP) Study Group. The insensate foot following severe lower extremity trauma. An indication for amputation? J Bone Joint Surg Am, 2005, 87A:2601–2608.
7. MacKenzie EJ, Bosse MJ, Castillo RC, Smith DG, Webb LX, Kellam JF, Burgess AR, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, Travison TG, McCarthy ML. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg, 2004, 86:1636–1645.
8. Zalavras CG, Patzakis MJ, Thordarson DB, Shah S, Sherman R, Holtom P. Infected Fractures of the Distal Tibial Metaphysis and Plafond. CORR, 2004, 427:57–62.
9. Zalavras CG, Patzakis MJ, Holtom P. Local Antibiotic Therapy in the Treatment of Open Fractures and Osteomyelitis. Clin Orthop, 2004, 427:86–93.
10. Zalavras CG, Marcus RE, Levin LS, Patzakis MJ. Management of open fractures and subsequent complications. J Bone Joint Surg Am, 2007, 89A:884–895.
11. Baumaeister M, Germann G. Soft tissue coverage of the extremely traumatised foot and ankle. Foot Ankle Clinics, 2001, 6:867–903.
12. Beals RK, Bryant RE. The Treatment of Chronic Open Osteomyelitis of the Tibia in Adults. Clin Orthop Rel Res, 2005, 433:212–217.
13. Paley D, Maar DC. Ilizarov bone transport treatment for tibial defects. J Orthop Trauma, 2000, 14:76–85.
14. Keating JF, Simpson AHRW, Robinson CM. The management of fractures with bone loss. J Bone Joint Surg Br, 2005, 87B:2:142–150.
15. Levin LS. The reconstructive ladder — an orthoplastic approach. Orthop Clin North Am, 1993, 24:393–409.
16. Marsh JL, Prokuski L, Biermann JS. Chronic infected tibial nonunions with bone loss-conventional technique versus bone transport. Clin Orthop, 1994, 301:139–146.
17. Siegel HJ, Patzakis MJ, Holtom PD, et al. Limb salvage for chronic tibial osteomyelitis: an outcome study. J Trauma, 2000, 48:484–489.
18. Lew DP, Waldvogel FA. Osteomyelitis. Lancet, 2004, 364:369–379.
19. Hudson MC, Ramp WK, Nicholson NC, Williams AS, Nousiainen MT. Internalisation of Staphylococcus aureus by cultured osteoblasts. Microb Pathog, 1995, 19:409–419.
20. Costerton W, Veeh R, Shirtliff M, Pasmore M, Post C, Ehrlich G. The application of biofilm science to the study and control of chronic bacterial infections. J Clin Invest, 2003, 112:1466–1477.
21. Cierny G, Zorn EZ. Arthrodesis of the tibiotalar joint for sepsis. Foot Ankle Clin, 1996, 1:177–197.
22. Blaha JD, Calhoun JH, Nelson CL, et al. Comparison of the clinical efficacy and tolerance of gentamicin PMMA beads on surgical wire versus combined and systemic therapy for osteomyelitis. Clin Orthop, 1993, 295:8–12.
23. Tetsworth K, Cierny G III. Osteomyelitis debridement techniques. Clin Orthop Rel Res, 1999, 360:87–96.
24. Simpson AH, Deakin M, Latham JM. Chronic osteomyelitis. The effect of the extent of surgical resection on infection-free survival. J Bone Joint Surg Br, 2001, 83B:403–407.
25. Green S. Skeletal defects: a comparison of bone grafting and bone transport for segmental skeletal defects. Clin Orthop Rel Res, 1994, 301:111–117.
26. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. The influence of stability of fixation and soft-tissue preservation. Clin Orthop, 1989, 239:249–281.
27. Malizos KN, Zalavras CG, Soucacos PN, Beris AE, Urbaniak JR. Free vascularised fibular grafts for reconstruction of skeletal defects. J Am Acad Orthop Surg, 2004, 12(5):360–369.
28. Toolan BC. Current concepts review. Orthobiologics. Foot Ankle Int, 2006, 27(7):561–566.
29. Friedlaender GE, Perry CR, Cole JD, Cook SD, Cierny G, Muschler GF, Zych GA, Calhoun JH, LaForte AJ, Yin S. Osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions. J Bone Joint Surg Am, 2001, 83A Suppl 1(2):S151–158.
30. Masquelet AC, Beveridge J, Romana C, et al. The lateral supramalleolar flap. Plast Reconstr Surg, 1988, 81:74–81.
31. Gopal S, Majumder S, Batchelor AG, et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br, 2000, 82B:959–966.
32. Jupiter JB, Kour AK, Palumbo MD, et al. Limb reconstruction by free-tissue transfer combined with the Ilizarov method. Plast Reconstr Surg, 1991, 88:943–951.
33. Argenta LC, Morykwas MJ, Marks MW, DeFranzo AJ, Molnar JA, David LR. Vacuum-assisted closure: state of clinic art. Plast Reconstr Surg, 2006, 117(7 Suppl):127–142.
34. Herscovici D Jr, Sanders RW, Scaduto JM, Infante A, DiPasquale T. Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma, 2003, 17(10):683–688.

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