Bone Health

Author: Ahmad Bo-Eisa, MD, Chairman, Program Director, Department of Orthopedic Surgery, King Fahad Hospital, Saudi Arabia Coauthor(s): Sadek Al-Omran, MD, Consultant Of Pediatrics and Pediatric Nephrologist, Departments of Pediatrics and Pediatric Nephrology, Maternity and Children's Hospital-Al-Ahsa, Saudi Arabia; Abbas Al-Abbad, MD, Pediatric Nephrology Fellowship Program Director, Section of Pediatric Nephrology, Department of Pediatrics, Pediatrics, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia Osteomyelitis is a difficult-to-treat infection of bone and bone marrow. It is progressive and results in inflammatory destruction of the bone, bone necrosis, and new bone formation. Bacterial osteomyelitis causes substantial morbidity worldwide, despite continued progress toward understanding its pathophysiology and optimal management. The approach to osteomyelitis depends upon the route by which bacteria gained access to bone, bacterial virulence, local and systemic host immune factors, and patient age. While imaging studies and nonspecific blood tests may suggest the diagnosis, an invasive technique is generally required to identify the causative pathogens. Antibacterial regimen selection has been largely guided by knowledge of the relative activities and pharmacokinetics of individual drugs, supported by data from animal models. Definitive therapy often requires a combined medical and surgical approach. Newer microvascular and distraction osteogenesis techniques and the use of laser Doppler allow more complete surgical resection of infected material while maintaining function. Despite recent advances, aggressive medical and surgical therapy fails in many patients with osteomyelitis. More accurate diagnostic methods, better ways to assess and monitor the effectiveness of therapy, and novel approaches to eradicate sequestered bacteria are needed.

OTA Trauma & Fracture Care Residency Core Curriculum Lectures Clifford Jones 2004

Rapidly progressive necrotising fasciitis following a stonefish sting: report of two cases Journal of Orthopaedic Surgery 2006; 14(1): 67-70 (full text

The role and effectiveness of adjunctive hyperbaric oxygen therapy in the management of musculoskeletal disorders. Wang J, Li F, Calhoun JH, Mader JT Department of Orthopaedics and Rehabilitation, University of Texas Medical Branch, Galveston, TX 77555-1115, USA. The management of musculoskeletal disorders is an increasing challenge to clinicians. Successful treatment relies on a wide range of multidisciplinary interventions. Adjunctive hyperbaric oxygen (HBO) therapy has been used as an orthopaedic treatment for several decades. Positive outcomes have been reported by many authors for orthopaedic infections, wound healing, delayed union and non-union of fractures, acute traumatic ischemia of the extremities, compromised grafts, and burn injuries. Severe side effects have also been reported with this therapy. To aid in the use of HBO therapy in orthopaedics, we reviewed 43 papers published in the past four decades and summarised the mechanisms, effectiveness, indications and contraindications, side effects, and cost impact of adjunctive hyperbaric oxygen therapy in the management of difficult musculoskeletal disorders. Adjunctive HBO therapy is an effective treatment modality for the management of some severe and refractory musculoskeletal problems. If appropriate candidates are carefully identified, hyperbaric oxygen is a limb- and sometimes life-saving therapy. HBO therapy significantly reduces the length of the patient's hospital stay, amputation rate, and wound care expenses. Thus, it is a cost-effective modality. A clinician must understand the side effects and risks of HBO treatment. Close monitoring throughout the treatment is warranted to minimise the risk to the patients. (full text available)

A case of Total Hip Arthroplasty infection with Staphylococcus aureus co-infected with Salmonella choleraesuis was treated with two-stage exchange and administration of vancomycin and ciprofloxacin. No signs of re-infection have appeared 14 months after surgery. Cases of Salmonella infection of hip prostheses are quite rare, with only a handful of reports in the literature.

Salmonella Osteomyelitis in an otherwise healthy adult male - successful management with conservative treatment: a case report

Salvage of Limb and Function in Necrotizing Fasciitis of the Hand: Role of Hyperbaric Oxygen Treatment and Free Muscle Flap Coverage
South Med J 95(2):255-257, 2002 James C. Yuen, MD, Zuliang Feng, MD Division of Plastic Surgery, Department of Surgery, University of Arkansas
Abstract We report a case of necrotizing fasciitis of the hand treated by urgent debridement followed by serial debridements, hyperbaric oxygen, and delayed free muscle flap coverage. After control of the infection, a major soft-tissue defect remained on the dorsum of the wrist and hand, exposing all extensor tendons. A rectus muscle free flap was used for wound coverage and salvage of the exposed tendons; the muscle flap was covered with a delayed skin graft. The patient regained satisfactory function with ability to extend all digits. This case emphasizes the importance of aggressive debridement and hyperbaric oxygen treatment and shows the valuable role of free muscle flap wound coverage for preservation of function in cases of necrotizing fasciitis of the hand. (more, full text)

Severe necrotising soft tissue infections in orthopaedic surgery Journal of Orthopaedic Surgery10(2):108–13 JC Theis, J Rietveld, T Danesh-Clough Department of Orthopaedic Surgery, Dunedin School of Medicine, PO Box 913, Dunedin, New Zealand PURPOSE. To review all cases of necrotising infection managed in the Department of Orthopaedic Surgery of Dunedin Hospital in New Zealand between 1989 and 1998. METHODS. Hospital records were analysed for predisposing factors, clinical features, diagnostic results, treatment strategies, and outcomes. RESULTS. 13 cases (9 males and 4 females) of necrotising infection were identified. The mean age was 48 years (range, 8–76 years). Presenting symptoms included painful swelling, erythema, and necrosis. Most patients had predisposing factors and had received nonsteroidal anti-inflammatory drugs before presentation. 12 patients underwent surgical debridement including a total of 4 amputations. Septic shock developed in 9 patients who required dialysis for renal failure. Four patients died. The most common organisms identified were group A beta-haemolytic streptococci. CONCLUSION. Severe necrotising infections require a high index of suspicion and rapid medical and surgical intervention to reduce the mortality and morbidity.

From Neurosurgical Focus Surgical Strategies for Vertebral Osteomyelitis and Epidural Abscess Posted 01/07/2005 Neurosurg Focus 17(6), 2004
Patrick C. Hsieh, M.D.; Robert J. Wienecke, M.D.; Brian A. O'Shaughnessy, M.D.; Tyler R. Koski, M.D.; Stephen L. Ondra, M.D. Abstract Pyogenic vertebral discitis and osteomyelitis (PVDO) has become an increasing problem for the spine surgeon. Despite recent advances in medical care and improved diagnostic neuroimaging, PVDO remains a major cause of illness and death in the elderly population. Infection of the spinal column often presents insidiously; however, if not treated appropriately and in a timely manner it can lead to severe neurological impairment, systemic septicemia, and progressive spinal deformity. In this paper the authors review the epidemiological and pathophysiological features and the clinical presentation of PVDO. Conventional medical therapy is described, with a particular focus on the methods of diagnosis. Surgical strategies for PVDO are then presented based on the literature and according to the practice of the senior author (S.L.O.), with an emphasis placed on structural considerations, implant selection, and techniques for augmenting vascular tissue to the site of infection.

Wheeless Textbook of Orthopaedics Discussion: - caused by non hemolytic Strep and hemolytic Staph aureus; - although staph alone may show up on culture, special attention may must be paid to isolating the microaerophilic Streptococceae; - necrotizing fascitis may occur, especially in diabetics; - any hand infection that does not respond to local drainage, wet dressings, and antibiotics should be suspected of having a symbiotic infection; - if special techniques are not used, the diagnosis of a symbiotic infection will be missed, and Staph aureus, Bacillus pyocyaneus, Proteus, and Enterococci will predominate on culture;

Wheeless' Textbook Synergistic Nonclostridial Anaerobic Myonecrosis - similar to gas gangrene - dishwater pus may be present; - Bacteroides and/or anaerobic streptococci may be present, together with aerobic or facultative grm neg. bacilli; Necrotizing Fasciitis: - serious infection that spreads rapidly along fascial planes and is commonly caused by Staphylococcus aureus or Streptococcus pyogenes; - anaerobes - especially clostridia and bacteroides can also be the cause;

Case Report Neurosurg Focus 17(6), 2004 Posted 01/18/2005 John W. German, M.D.; Susan M. Kellie, M.D.; Manjunath P. Pai, Pharm.Dc.; Paul T. Turner, M.D.
Scedosporium apiospermum is a rare cause of fungal vertebral osteomyelitis that may result in chronic infection requiring multiple surgical interventions and long-term medical therapy. This case is the seventh one reported in the literature and is the first to include salvage surgery of a previous major spinal reconstruction. This report is also the first to describe the use of the new antifungal agent voriconazole. In treating this case of chronic vertebral osteomyelitis, several principles are emphasized from both the surgical and medical perspectives. From a surgical perspective, the use of salvage surgery, temporary avoidance of spinal instrumentation, and an appropriate choice of graft materials are emphasized. From a medical perspective, confirmation of the diagnosis, the need for long-term antifungal therapy, the need for long-term patient compliance, and the use of the new antifungal agent voriconazole are emphasized. Application of these principles has led to an adequate 2-year outcome.