Ken’s Osteomyelitis Story: Osteomyelitis treatment at Sharp Memorial Hospital, San Diego, CA……What began as a nagging pain in Ken Johnson’s upper leg and buttocks region evolved into a long and painful battle that diminished his quality of life. Everyday activities, and even a trip to Italy, were plagued by chronic discomfort. Eventually, the pain escalated to the point that the seasoned financial advisor was unable to make it through a day on the job. Consequently, he had to miss nine consecutive months of work. 

 “It consumed my life,” said  Ken. “I didn’t think I would  ever get better. No one could  figure out what was going  on.”

 After initially being told that  arthritis was the culprit, Ken  was diagnosed with  osteomyelitis: a chronic inflammation of the bone or bone marrow. His entire hip was infected, and in April of 2008 he underwent surgery to have it removed. Unfortunately, removing the hip did not eliminate the problem; persistent infection, pain and impaired leg function remained and he began suffering from 100 to 102 degree fevers on a daily basis.

“To be sick every single day was exhausting. Nothing seemed to help.“ Ken regained a sense of hope after seeking treatment from Sharp-affiliated orthopedic surgeons Drs. George Cierny and Doreen DiPasquale.

“They evoke a sense of confidence, are very good at what they do and, after reading the first MRI, were able to see where the infection was hiding; deep within my pelvis bone,” said Ken.

Drs. Cierny and DiPasquale are among a handful of physicians worldwide who specialize in the treatment of orthopedic infections. Utilizing state-of-the-art diagnostics, they located the source of infection and performed the surgery necessary to save Ken’s leg at Sharp Memorial Hospital in July of 2008.

Ken says his wife knew the surgery was a success even before he woke up. “She noticed, even though I was asleep, that the pained look on my face was gone.”

In addition to removing the source of the infection, Drs. Cierny and DiPasquale restored Ken’s hip motion and leg length using an antibiotic infused prosthesis to treat the infection locally. After relying on crutches, a walker or wheelchair to get around for months, he was once again able to walk unassisted.

Three months later, once the infection had cleared up, Ken underwent a total hip replacement surgery at Sharp Memorial Hospital, which further escalated his recovery. “From that point on, I just got better and better,” he said. “I went back to work full-time at the end of January 2009.”

A year and a half after undergoing hip replacement surgery, Ken is not only back at work — he has reclaimed the quality of life he knows and loves. He’s back to golfing, riding motorcycles and playing the drums. He remains infection-free.

Meet Eric Wickre (the original, Alaskan Viking Cowboy), treated at our center December 2008 for Stage IA osteomyelitis of his left tibia, a con-sequence of an open fracture suffered in 1981.   His (and others’) entire medical case portfolio will be posted  at http://www.osteomyelitis.com/html/news.html#featured-case .  After successful treatment at our treatment center in  San Diego, Eric is now back to his rough-and-ready cowboy ways, having just been selected to be one of 1000 motorcyclists from around the globe to compete in The Hoka Hey Motorcycle Challenge —– also known as the “Iditarod of Harley Davidson, 2010”.

CLICK TO ENLARGE

The Challenge is a grueling, 7,000 mile race from Key West, FL to the Kenai Peninsula, Alaska where “winner takes all” …one half million dollarsin Alaskan gold!  It starts June 20th and ends in Homer, AK on July 4th.  The secret route will initially head 1,000 miles into Mississippi. There, riders will get a map for the next leg of the ride: traveling the back roads, highways and byways; enduring hail storms, heat waves and scorpions; sleeping along side their bikes every night for the entire journey.

Join us as we follow Eric’s epic journey through the Americas on  OSTEOMYELITIS  BLOG.                                           Good luck, Eric!!

George Cierny, MD; REOrthopaedics in San Diego

In acute pediatric osteomyelitis  and osteomyelitis of the spine (verbetral osteomyelitis; sacroiliitis) in all ages,  surgery is not always necessary to affect cure.  In other forms of acute osteomyelitis  (infection following open fracture; surgical site infections following trauma or reconstructive surgery) and nearly all forms of the chronic disease, treatment will have to combine various aspects of surgery (with antibiotics) to result in cure .
The treatment of a refractory (chronic) osteomyelitis is governed by its pathophysiolgy —– it is a ‘biofilm disease’.    Unlike the mobile (planktonic), environmentally sensitive microbes found in an acute infection, chronic wound pathogens are sessile and resilient, transformed into colony-forming units by environmental triggers (quorum-sensing) and the successful attachment to ‘unprotected’ surfaces within the wound (inert materials; non-viable tissues or organisms, etc.).    Thereafter, individual cells become colony-forming units that mature (2-4 weeks) to secrete and maintain a mucopolysaccharide “slime” that protects them from host defenses and the penetration of most antimicrobial agents .   To cure this biofilm infection, a LIVE, CLEAN WOUND is paramount: the biofilm-colony its attachment surfaces must be completely excised.

The type of surgery will depend on the duration of the infection (acute or chronic), the contents of the wound (extent of necrosis; substrate surfaces), the anatomic site, the health and well-being (impairment) of the host, and the experience of the healthcare team.

However, surgery, as a form of treatment, is not available to everyone. Patients who are very ill may not be able to endure the extensive surgery and recovery. In these cases, doctors may use antibiotics for long periods in an attempt to suppress (rather than cure) the infection.  Then, if the infection persists and, again, threatens the patient’s well-being, lesser morbid procedures, such as amputation of all or part of an infected limb, may be necessary.  

Surgical treatment options  – Drain the infected area: Opening up the area around the infected bone allows the surgeon to drain any pus or fluid that has accumulated in response to the infection.  This is usually applied in the acute setting to decrease strain on host defenses and amplify the effects of antibiotics.  Remove the attached, biofilm-colony:  In a procedure called debridement, the surgeon removes the diseased bone and tissue. In some cases, foreign objects, such as surgical plates or screws, used in previous surgeries, may also be removed. Restore the bone and soft-tissue envelope: Your surgeon may fill any empty space left by the debridement procedure with a piece of bone or other tissue, such as skin or muscle, from another part of your body. Sometimes temporary fillers containing antibiotics (antibiotic depots) are placed in the space until the infection is cured and the patient is healthy enough to undergo a definitive reconstruction. Bone grafts and tissue flaps help the body recruit new blood vessels into the site and form new bone.  Protect against instability: Immediately following debridement, the surgeon may use an external fixatation device (external fixator) to hold and protect the bone from further injury.  This method limits the amount of implanted, foreign material (metal) in the still-contaminated wound by attaching thin wires or pins (that pass through the limb) to a frame positioned around the limb (outside the skin).  The fixator can be the only method used throughout treatment or, after a course of local antibiotic therapy, replaced with internal methods of fixation such as metal plates, rods or screws.

IF YOU HAVE DIABETES, A JOINT REPLACEMENT OR ARTHRITIS…. YOU’RE AT INCREASED  RISK FOR A BONE INFECTION?  George Cierny, MD, and Doreen DiPasquale, MD; *BottomLine Health, 2010; Vol 24(3), pp9-11

* Bottom Line/Health interviewed George Cierny, MD, and Doreen DiPasquale, MD, physician-partners at REOrthopaedics in San Diego.  Dr. Cierny is an international lecturer in orthopedic surgery who has published more than 100 scien­tific papers and/or book chapters in the field of musculoskeletal pathology and infection. Dr.Di­Pasquale, an orthopedic-trauma surgeon, is former resi­dency program director at George Washington University in Washington, DC, and National Na­val Medical Center in Bethesda, Maryland.

—————- When most people think of bone problems, broken bones and osteoporosis (re­duced bone density and strength) come to mind. But our bones also can be the site of infections that can sometimes go unrecognized for months or even years. This is especially the case if the only symptoms of bone infection (a condition known as osteo­myelitis) are ones that are commonly mis­taken for common health problems, such as ordinary back pain or fa­tigue. What you need to know…

ARE YOU AT RISK? Older adults (age 70 and older), people with diabetes or arthritis and anyone with a weakened immune sys­tem (due to chronic disease, such as cancer, for example) are among those at greatest risk for osteo­myelitis.   Anyone who has an artificial joint (such as a total hip replacement or total knee replacement) or metal implants attached to a bone also is at increased risk for osteomyelitis and should discuss the use of anti­biotics before any type of surgery, including routine dental and oral surgery. Bacteria in the mouth can enter the bloodstream and cause a bone infection.

TYPES OF BONE INFECTIONS: Before the advent of joint-­replacement surgery, most bone in­fections were caused by injuries that expose the bone to bacteria in the en­vironment (such as those caused by a car accident) or a broken bone…or an infection elsewhere in the body, such as pneumonia or a urinary tract infection, that spreads to the bone through the bloodstream. Now: About half the cases of osteo­myelitis are complications of surgery in which large metal implants are used to stabilize or replace bones and joints (such as in the hip or knee).   

Osteomyelitis is divided into three main categories, depending on the origin of the infection… Blood-born osteomyelitis occurs when bacteria that originate else­where in the body migrate to and in­fect bone. People with osteoarthritis or rheumatoid arthritis are prone to blood-borne infections in their af­fected joints due to injury to cells in the lining of the joints that normally prevent bacteria from entering the bloodstream. Contiguous-focus osteomyelitis oc­curs when organisms— usually bacte­ria, but at times fungal species —infect bone tissue. These cases usually occur in people with diabetes, who will often de­velop pressure sores on the soles of their feet or ­buttocks due to poor cir­culation and impaired immunity.   Post-traumatic osteomyelitis: Trau­ma or surgery to a bone and/or sur­rounding tissue can open the area to bacteria and other microbes. The use of prosthetic joints, surgical screws, pins or plates also makes it easier for bacteria to enter and in­fect the bone.  Important: any of the three types of bone infections described above can lead to chronic osteomyelitis, an initially low-grade infection that can persist for months or even years with few or no symptoms. Eventu­ally it gets severe enough to liter­ally destroy bone. Left untreated, the affected bone may have to be amputated.

DIFFICULT TO DIAGNOSE – When osteomyelitis first develops (acute osteomyelitis), the symptoms —such as pain, swelling and tender­ness—are usually the same as those caused by other infections. If the initial infection is subtle (low-grade) or doesn’t resolve completely with treatment, it can result in chronic osteomyelitis. In this case, you may have no symptoms or symp-toms that are not specific.  For example, some one who has had surgery might blame discomfort on delayed recovery, not realizing what they have a bone infection.  A surprising finding: When we stud­ied the histories of more than 2,000 osteomyelitis patients, we found that most of those with chronic infections had relatively little pain from the in­fection itself. About 28% of those who required surgery for infection had normal white blood cell counts—suggesting that, over time, the body adjusts to lingering infections.  If a doctor suspects that you may have osteomyelitis because of chron­ic pain…swelling…possibly fever…fatigue…or other symptoms, he/she will usually order special laboratory tests that detect the formation of an­tibodies and/or cellular signaling compounds. If the results indicate the presence of infection, he/she may then order an X-ray, a magnetic reso­nance imaging (MRI) scan or a nuclear scan(bone scan). These and other imaging tests can readily detect damaged­ bone tissue and re­veal the presence of infection.

BEST TREATMENT OPTIONS   About 60% to 70% of people with acute osteomyelitis can be cured with antibiotics (or anti­fungal agents, if a fungal infection is present) if treat­ment begins early enough to prevent the infection from becoming chronic. In these cases, patients exhibit symp­toms…test positive for infection…and readily respond to drug treatments. Most patients can be cured with a four- to six-week course of antibiotics. Fungal infections are more resistant to treatment—antifungal drugs may be needed for several months.

For chronic osteomyelitis, surgical debridement (the removal of dam­aged tissue and bone using such in­struments as a scalpel, dental burrs and/or chisels) usually is necessary. Reasons: dam­aged bone can lose its blood supply, die and remain in the body without living cells or circu­lation. Such “dead bone” is invulnerable to the effects of antibiotics and provides safe haven to organisms attached to its surface.  To address this, the surgeon, after debridement, may insert a slow-release antibiotic depot (antibiotic beads) that release antibiotic for up to a month. This approach can increase drug concentrations up to 100 times more than oral antibiotic therapy and help to eliminate the sequestered microorganisms.   Using these and other innovations, the REOrthopaedics  center in Southern California now posts an overall success rate of 95%.    Nevertheless,  up to 6% of patients who are otherwise healthy may require a second or even a third operation to completely cure the infec­tion;  and, iIn patients suffering from diabetes or oth­er disorders affecting wound healing (compromised hosts) , the percentage may be as high as 25%.    To improve your chances of a full recovery from chronic osteomyeli­tis following treatment: eat well, maintain healthy blood sugar levels, stay active after treat­ment (to promote blood circulation, prevent blood clots and help main­tain an appetite) and don’t use to­bacco products.

_{Copyright © 2009 by Boardroom Inc., 281 Tresser Blvd., Stamford, Connecticut 06901-3229.                          www.BottomLineSecrets.com}

Review Article:  Warner M et al; Comparison of Vacuum-assisted Closure to the Antibiotic Bead Pouch for the Treatment of Blast Injury of the Extremity. ORTHOPEDICS, 2010; 33: pp77-87.

A retrospective study of 24 patients suffering blast injuries to the lower extremities.  Prior to closure, half were initially treated with VAC (vacuum assisted closure) and half with an antibiotic bead pouch. The same surgeons performed all surgeries. Findings: VAC-therapies produced more late Methicillin-resistant Staphylococcus aureus (MRSA) infections (30% vs 0%), more unanticipated returns to the operating room (4:12 vs 0:12), required more surgeries to affect closure (at ~12days vs ~8days)and cost ~$1,000 more /patient once a $23,000 investment was made to purchase a single, VAC machine (KCI; SanAntonio, TX).

 Dr. Cierny comments: Although several studies have suggested that VAC will decrease the need for free tissue transfer in like/like wounds following trauma^1,2, others found no significant difference in time to closure³, an increase the amount of S aureus in the wound bed,⁴ a statistically significant increase in colony count during use,⁵ and infection /nonunion rates similar to historical controls (suggesting no benefit to the use of VAC over conventional dressings.⁶   Hallock⁷ contended that VAC does not prolong the time allowed for successful definitive wound closure and Stewart and Keating⁸ found VAC not as good as early soft tissue coverage (for acute wounds).  Although Morris⁹ found weak evidence to suggest that negative pressure therapy is superior to saline dressings when healing chronic wounds, Stannard et al¹⁰ , in a prospective, randomized study of 62 open fractures, found patients treated with NPWT one-fifth as likely to develop an infection compared with patients randomized to controls treated with wet-to-dry dressings until closure.

The consensus:  NPWT is more comfortable /convenient for the patient and healthcare team, effectively decompressing (displacing)  the inevitable need (energy) for complex and sequential reconstructions.  Despite its controversies, the use of external fixation and NPWT in the treatment of blast injuries and gunshot wounds resulting in open fractures with severe soft tissue injuries has become the mainstay of damage control orthopaedics.    In our experience, however,  15%-20% of patients with refractory infections following long-term  NPWT protocols have had retained sponge-fragments (gossypiboma) discovered in their wounds at the time of debridement and all of these fragements grew ‘culture positive’ for the primary, wound pathogen(s).   For us, NPWT is extremely helpful in managing acute /peri-operative wounds.   However, we find it of limited value in the chronic-wound scenario unless the wound has first been rendered 100% live and is no longer in need of any further reconstruction (ie; bone grafts, tendon repairs, etc.).   GC  02/20/10 .

Bibliography (1-10): -1- 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. -2- Dedmond BT, Kortesis B, Punger K, et al. Sub-atmospheric pressure dressings in the temporary treatment of soft tissue injuries associated with type III open tibial shaft fractures in children. J Pediatr Orthop. 2006; 26(6):728-732. -3- Song DH, Wu LC, Lohman RF, Gottleib LJ, Franczyk MPT. Vacuum assisted closure for the treatment of sternal wounds: the bridge between débridement and definitive closure. Plast Reconstr Surg. 2003; 111(1):92-97. -4- Mouës CM, van den Bemd GJ, Heule F, Hovius SE. Comparing conventional gauze therapy to vacuum-assisted closure wound therapy: a prospective randomized trial. J Plast Reconstr Aesthet Surg. 2007; 60(6):672-681. -5- Weed T, Ratliff C, Drake DB. Quantifying bacterial bioburden during negative pressure wound therapy: does the wound VAC enhance bacterial clearance? Ann Plast Surg. 2004; 52(3):276-279.  -6-Dedmond BT, Kortesis B, Punger K, et al. The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures. J Orthop Trauma. 2007; 21(1):11-17.  -7- Hallock GG. To VAC or not to VAC? Ann Plast Surg. 2007; 59(4):473-474. -8- Stewart KJ, Wilson Y, Keating JF. Suction dressings are no substitute for flap cover in acute open fractures. Br J Plast Surg. 2001; 54(7):652-653. -9- Morris GS, Brueilly KE, Hanzelka H. Negative pressure wound therapy achieved by vacuum-assisted closure: Evaluating the assumptions. Ostomy Wound Manage. 2007; 53(1):52-57. -10- Stannard JP, Wolgas DA, Stewart R, et al; Negative Pressure wound therapy after severe open fractures: a rospecive randomized study.  J. Orthop. Trauma, 2009; 23(8): 552-557.

The article:  What is Osteomyelomyelitis? What Causes Osteomyelitis?” in Medical News Today: 10 Feb 2010-0:00PST

Dr. Cierny comments:

TYPES OF OSTEOMYELITIS: ‘Acute’,’ sub-acute’ and ‘chronic’ are time-related terms that parallel the fundamental principles and mechanisms  inherent to wound colonization by microorganisms.  Early in the course of infection, microorganisms are mobile (plankonic) and vulnerable to antibiotics and host defenses.   If the fracture is live and stable, the infection may resolve following adequate wound decompression, antimicrobials and the elimination of dead space (the acute wound).  After 2-3 weeks,  reactions between surface macromolecules begin forming at pathogen-substrate interfaces (sub-acute), resulting in a resilient “microzone’ of attachment in 4-6weeks that is precursor to a microbial-based, mucopolysaccharide “slime” that encompasses the entire colony.   Within the bio-slime (biofilm) microbial nutrition and growth are enhanced, protected from host defenses and the penetration /effects of antimicrobials.  The result is a profound compromise to the host: wound healing and fracture repair are impaired due to toxins produced by the pathogens and the by-products of host efforts to unsuccessfully destroy the biofilm colony. Curative treatment of such a biofilm-infection (chronic /refractory) requires both anti-microbial therapy and surgical removal of the entire biofilm burden.

WHAT ARE THE SIGNS AND SYMPTOMS OF OSTEOMYELITIS? See: http://www.osteomyelitis.com/html/osteomyelitis.html

WHAT ARE THE RISK FACTORS FOR OSTEOMYELITIS? Open fractures create “the perfect storm” for infection to complicate injury:  the initial wound is contaminated and injury to soft tissues potentiates an on going exposure to pathogens; surgical implants and dead bone fragments grant ‘safe-haven’ to proliferating microbes; ischemia, dead space and foreign bodies impede local immunity and the delivery of antibiotics; shock, injury and pre-existing health conditions compromise the host response.   The goals of treatment are three-fold: timely intervention; creation/maintenance of a clean, manageable wound; adequate and durable fracture fixation.

Surgical Site Infections (infection following elective surgery) are more common in compromised hosts,( ), long procedures (SSI) and operations where in a large surgical implant is used (substrat surfaces; see above).  OSTEOMYELITIS: CIERNY/MADER HOST STATUS  OSTEOMYELITIS: CIERNY/MADER CLASSIFICATION SYSTEM 

DIAGNOSIS OF OSTEOMYELITIS:   MALNUTRITION;   WHAT BLOOD TESTS ARE USED TO DIAGNOSE OSTEOMYELITIS?    DO POSITIVE CULTURES ALWAYS MEAN A BONE INFECTION IS PRESENT?   WHEN DO I NEED A NUCLEAR SCAN?

TYPES OF BONE INFECTIONS:   There are really only three etiologic categories of bone infection, not five:  hematogenous (blood-born) osteomyelitis;  contiguous-focus osteomyelitis;  and post-traumatic osteomyelitis.  Osteomyelitis due to vascular insufficiency is a form of contiguous focus infection since the lack of oxygen leads to breakdown of the integument (skin), ulceration and eventual exposure ( and contamination) of the underlying bone (a contiguous focus).  Ischemic compromise can  occur in patients with peripheral vascular disease, disruption of major bood vessels, diabetes (foot ulcers) and patients developing bed (decubitus) ulcers.

The categorization of bone infection into etiologic types,  however, does not help with establishing a treatment strategy or prognosis.  To do this, the chronology (see above), patient’s health and anatomic localization of the infection (in the bone itself) must be brought together into a staging system similar to those used for various forms of cancer.    For example, vertebral osteomyelitis is a regional localization of infection (the spine) as opposed to an anatomic localization (configuration) of the disease in the spinal bone (s) itself.  Spine infections occur following: blood-born contamination (hematogenous) to the marrow part of the bone or to the disc between the vertebral bodies;  as a contiguous focus infection (sacral decubitus ulcers); or following trauma (ie; post-operative, surgical site infections ).   Treatment will depend on the etiology, the timing (acute, subacute, chronic) and the extent to which the infection involves the bone (on the surface, in the marrow, fracture with instability, etc.).  That is why the CIERNY/MADER Clinical Staging System (1985)  is now accepted internationally as the gold standard for classifying bone infection in adults (all types, all etiologies, all locations) as it articulates the natural history of the disease with treatment and outcomes.

Contents: 1) Management of Bone Loss; 2) Common Decision-Making Errors in Limb Salvage; 3) Chrnic Neuropathic Pain Following Open Fractures; 4) Management of Soft-Tissue Loss After Trauma; 5) Malunions and Nonunions in the Lower Exdtremity; 7) Infection Following Open Fracture – George Cierny III, MD  pp71- 87.  In Complications in Orthopaedics: Open Fractures; Levin, L.S. (ed).   AAOS monograph Series; Amer. Acad. Orthop Surg, Rosemont, IL, 2010.  Here, Dr. Cierny presents his classification systems and treatment algorithms which are among  the principal advances in the management of infection following open fractures – osteomyelitis with micro-necrosis; osteomyelitis with macro-necrosis; fixation strategies; chronic_infection; staged treatment options.

Request:   Dr. Cierny,  my 17 year old son suffered  a motorcycle accident and developed osteomyelitis five  months after an open compound fx of his tibia. His surgeon removed about three inches of his bone and packed the wound with antibiotic “beads”.   Now they want to perform a bone graft from his hip to his tibia.   I am concerned and wondering if his doctors are up to date on the latest techniques.   I want to avoid amputation.   Any advice or help would be appreciated.    01/01/10; Atascadero, CA

Response:   A type IIIB open fracture (Gustillo Classification) of the tibia with resultant infection and segmental osseous defect represents a formidable challenge in terms of restoring skeletal continuity and the ultimate achievement of a better functional result compared with that after successful amputation and prosthetic fitting. The extensive nature of the problem, the complexity of the reconstructive procedures that are needed and the fact that independent walking will usually not be possible for eighteen months or more, make this one of our most formidable challenges.  Cierny, G; Infected Tibia1 Nonunions (1981-1995) The Evolution of Change. CORR, 1999; 360: 97-105.

A defect of ~3 inches (7.5cm) is usually refractory to iliac crest bone grafting, alone.  The decision to reconstruct such a lesion should be based not only on the ability to control infection but also on the surgeon’s ability (experience, knowledge), the duration of treatment, and the extent of disability to be anticipated.  May, Jupiter, Weiland and Byrd; Clinical Classification of Post-traumatic Tibial Osteomyelitis. JBJS, 1989;71:1422-1428.

Similarly, the best method of skeletal reconstruction is based on the availability of local and donor bone, defect length, condition of the soft tissues and patient age and health.  See:  TREATMENT RESULTS.

If you would send me a few photographs of his wounds (distant and close up) and a few, recent x-rays, I will generate a treatment plan with options and prognoses.  GCIII; 01-01-10

What constitutes an Internet Consult?   For no fee, the physicians at REOrthpaedics will do all they can to help you and your family both understand your condition and receive appropriate care.  In the process, we may ask you questions about your health, previous/current care and current status (i.e.; weight-bearing capacity, wound healing and current disabilities).  If you can send your clinical photographs and plain x-rays over the Internet (as jpeg files), we will be happy to review and comment on them, as well.  If, however, your medical condition proves too complex to comfortably manage on the Internet, a formal consultation may be necessary and a $200 fee generated.  For this, we will offer an opinion based on a detailed review of medical records, pathology slides, x-rays and/or discs of other, radiographic studies (MRI scans, CT scans, bone scans, etc).  If, on completion, we feel our services will not help you, the $200 will be returned, in full.

In accordance with laws stipulating we practice medicine only in states in which we are licensed, no prescriptions or treatment will be offered until you are seen in San Diego, as a patient.  If we do, indeed, provide your care and offer definitive treatment, REOrthopaedics will reimburse your airfare for the initial office visit.   In most instances, it will be necessary to see a patient before insurance coverage can be pre-certified and surgery scheduled in the operating room; for those patients coming from countries outside the United States, special arrangements are made in lew of same.   

Our curriculum vitae and scientific work are posted on the Internet for review.  We are experts with over 30 years of experience in the fields of musculoskeletal infection, musculoskeletal oncology, deformity correction and complex orthopaedic reconstructions.  As such, our opinions are  meant not to set community “standards of care” but, rather, as a source of evidence-based information to help patients and providers make wise choices.  GC  11/23/09

Patient Selection: The treatment of adult, chronic osteomyelitis is directed by the careful consideration of anatomic, physiologic and socioeconomic parameters: the site and extent of involvement, the degree of functional impairment caused by disease, the condition of the host, physician experience and institutional resources.         ( CLICK ON IMAGE TO ENLARGE )

  The complex interplay of these factors will  determine treatment to be palliative or curative, simple or complex, limb-sparing or ablative.