Michelle’s Osteomyelitis Story: from http://www.sharp.com/ortho/michelle-osteomyelitis-story.cfm

For most cancer patients, hearing the words “cancer free” signifies victory — the end of a long and painful battle. Unfortunately, that wasn’t the case for 62-year-old Michelle Ashwell.  In 2005, Michelle had a malignant tumor removed from her left leg, just above the knee. “I made it through the cancer, and at first, it seemed like everything was going to be OK,” she said. “However, the treatment that followed actually prevented my recovery from moving forward.”  The radiation therapy Michelle underwent after having the tumor removed set in motion a series of debilitating complications. The  radiation treatments, which were only intended for the soft tissues surrounding the tumor site, extended deeper into the bone. As a result, the tissue deep within her wound pulled away from the bone and would not heal. This complication required Michelle to undergo a second surgery, which was intended to repair and heal the wound.

Unfortunately, the second surgery did not produce the desired outcome; and on top of that, the wound became infected. Michelle had developed osteomyelitis, which is an infection of the bone or bone marrow. The infection prevented the open wound in her leg from healing and severely limited the motion in her knee.  “It was very discouraging,” said Michelle. “I went through many different kinds of surgeries and none of them helped.”

After being advised to consider amputation, and preparing herself for the possibility that this course of action was the only way to eliminate the infection, Michelle was referred to Sharp-affiliated orthopedic surgeons Drs. George Cierny and Doreen DiPasquale.

Following a preliminary consultation and exam, Dr. Cierny told Michelle he was confident that he could save her leg. “When I heard him say that, part of me was wondering if it was too good to be true.”  Subsequent surgeries performed under Dr. Cierny’s direction included placement of antibiotic-impregnated beads into the wound and stabilization of the upper leg bone via a bone-plate and screws to prevent fracture. Finally, a flap of living tissue from Michelle’s abdomen was transplanted onto the wound. Unlike previous surgeries in which a similar procedure had been performed, the new living flap was, this time, attached to blood vessels outside the area treated with radiation.  Following this multidisciplinary treatment plan and continuous physical therapy, Michelle emerged infection free in January 2008.  

She is especially grateful for the fact that she has since regained full motion in her knee.  “I love taking care of my one-year-old grandson, Brayden,” said Michelle. “He just started walking, and he’s fast!”  At the height of her medical complications, Michelle struggled to keep up with her favorite pastimes, which include gardening. Following recovery, she has been able to return to and even grow some of those activities. She recently relandscaped her entire backyard, a symbol of her personal growth and passion for life.  Today, Michelle remains cancer- and infection-free.

 6/22/2010:   The Hoka Hey Challenge (race) is on! 

Eric made it to the first check point in 25^th place.   He remains salty (the heat!) and unscathed, despite a 4-bike accident along the way.   They’re now in Mississippi, heading north —– hopefully out of that brutal heat.   GC

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!!

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

Case presentation for Dr. Cierny:   52 yo diabetic woman with recent history of pancreatitis and MRSA sepsis (3 months prior to her presentation) presented to ER in early July with several week history of progressive knee pain, left worse than right (ESR in the 70s, WBC 15).  ED staff aspirated the left knee sent fluid for cell count(65,000 WBCs) started antibiotics and we took her to OR for arthroscopic lavage, both knees (right knee with similar effusion).  Pt placed on Vancomycin, was up walking POD 3 and went home on Vanco post op day4. . Intra op cultures all negative.

She came back 3 weeks later with large effusions and pain.  Taken back to OR for open I and D, synovectomies. Started on clinda and high-dose vanco but failed to clear the synovial aspirate. Repeat I and D done several days later. Again, all cultures negative (including AFB, fungus).  Tigecycline added by ID.  Again, no improvement and at the next wash out, pus was noted coming from the femur, suggesting a juxta-articular osteomyeltis.  Cortical window made to debride a bone infection: the medullary canal was irrigated; antibiotic cement beads were placed to treat the dead space.  Repeat I & D done in 4 days and the beads were exchanged.

She came back in less than one week with purulant fluid draining from both knees and drain sites.  Xrays were consistent with osteomyelitis of the distal femurs with periosteal elevation/bone formation.  The patient was taken back to the OR and the femurs reamed abnd lavaged; antibiotic rods were positioned.  Antibiotics were then changed to Daptomycin, Ciprofloxacin and Flagyl.  All cultures remained negative.   

Rheumatology recommended trial of steroids on the chance this is a “post infectious inflammatory arthropathy.”  She was started on Prednisone 60mg, quickly improved but the left knee continued to drain.  She was taken back for another I and D.  The knee appeared less inflamed and the femoral canals appeared clean.  She is now home on antibiotics and steroids. Could this not be infection?   Thanks!

Answer:   I have never been confronted by such a scenario but do have rules of thumb for a clinical course that defies reason: 1) Define the status of the host.  In this case: normoglycemia? mal-nutrition? impaired cellular immuno-competence? Remote site infection? ; and 2)  Establish the anatomic extent of disease: MRI, bone scans, whole-body PET/CT scan.   Your rheumatology colleagues were savvy in recommending systemic steroids.  It is interesting tonote that Pyoderma gangrenosum and acne (PAPA) syndrome is an autosomal dominant auto-inflammatory disease associated with multiple, sterile, ‘purulent’ joint effusions.  I refer you to the following readings:    Anakinra for flares of pyogenic arthritis in PAPA syndrome – http://rheumatology.oxfordjournals.org/cgi/content/full/44/3/406-a ; MRI Findings of Septic Arthritis and Associated Osteomyelitis in Adults – http://www.ajronline.org/cgi/reprint/182/1/119.pdf ; Hematogenous Septic Ankle Arthritis – http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2384014 .

Regarding a refractory, joint sepsis (pyoarthrosis) – no problem in leaving a joint open to drainage.  Indeed, this was our routine when treating high volumes of Gonorrheal arthritis back in the 70’s … In the knee, a through-and-through  penrose drain was often looped across the joint line (medial to lateral) and tied anteriorly (as an earring loops the earlobe) .   GCIII