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.

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.