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.

 “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.

Since no one study is able to definitively confirm the presence of absence of infection, cross-sectional imaging modalities such as CT and MR scanning are now considered the gold standard in diagnosing osteomyelitis, giving excellent anatomic delineation of the infected area and the surrounding soft tissue envelope.   In our protocols, all methods of used, selectively: (7) plain radiographs  to reveal internal hardware, axial alignment, fracture patterns and instability; nuclear scans  to correlate  cellular activity with radiographic change and assess for  poly-osseous disease;  CT scans to delineate sequestra, cloacae, bone volumes, and the extent of fracture healing (union vs non-union);  MRI and PET/CT scans to define the zone of injury/inflammation, disclose skip-lesions and highlight necrotic foci.   

Bibliography:  (1) Haas DW, McAndrew MP. Bacterial osteomyelitis in adults: evolving considerations in diagnosis and treatment. Am J Med, l996; 101:550-561.  (2)  Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy.   Semin Plast Surg, 2009 May; 23(2):80-9.  (3) Termaat MF, Raijmakers PG, Scholtein HJ et al. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systemic review and meta-analysis. J Bone Joint Surg Am, 2005; 87:2464-2471.  (4) Mahnken AH, Bucker A, Adam G, Gunther RW. MRI of osteomyelitis: sensitivity and specificity of STIR sequences in comparison with contrast-enhanced T1 spin echo sequences. RöFo, 2000; 172” 1016-1019.  (5) Littenerg B, Mushlin AL. Technetium bone scanning in the diagnosis of osteomyelitis: a meta-analysis of test performance. J Gen Intern Med, l992; 7:158-163.  (6) Cierny III, G., Pennick, JJ, Mader, JT, A Clinical Staging System for Adult Osteomyelitis, J. Clinical Orthopaedics and Related Research, Number 414, pp 7-24, September 2003 .  (7)  Cierny G, DiPasquale D. Adult Osteomyelitis. Chapter 16 in Orthopaedic Knowledge Update : Musculoskeletal Infection. Amer. Acad. Orthop. Surg, Rosemont, IL, 2009. pp 135-155.

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

Dr. Cierny’s comments:  this article describes the epidemiology and early management of hematogenous vertebral osteomyelitis (anatomic types I and IV) in 70 patients over a 2-year period at Barnes Hospital in Missouri (a retrospective, cohort review).  A microbiological diagnosis was made in only two-thirds the cases.  S. aureus was the most common causative organism.

Results – The mean age was 59.7 years with 54% male. Predisposing factors included: B-hosts with diabetes (43%) or renal insufficiency (24%); in the 30 days prior to admission, an indwelling catheter (30%), bacteremia (19%) or skin/soft tissue infection (17%).  Back pain was the most common symptom (87%), followed by weakness (56%) and fever (46%); seven patients presented with paraplegia.  48% had a normal WBC but 95-98% had either an elevated ESR or CRP. 

The lumbar spine was the most common anatomic location (47%): thoracic (29%); cervical (24%).  Among the 46 (66%) patients with a microbiological diagnosis, the most common organisms were MSSA (33%) and MRSA (22%).  Among the 44 (63%) patients who had a diagnostic biopsy, open biopsy was more likely to result in pathogen recovery [14 (93%) of 15 with open biopsy vs. 14 (48%) of 29 with needle biopsy; p=0.003].   Surgery was required during the initial hospitalization in 23% of patients: decompression laminectomy 14%), laminectomy /fusion (7%) and corporectomy (1%).  Treatment outcomes were not included.  

Stone Step Alaska; the HOKA HEY finish

Well folks, it’s about a month to the start of the Hoka Hey challenge and our main man, Eric, is now back in Anchorage after spending last week driving the 1000 miles downrange from the finish line (pictured at left) ;  burying 6 gallon gas cans every 170 miles all along the way and marking them with a GPS coordinate kilometer marker and land mark notation….WHEW!!!  No surprise, he’s working in his Super Duty 351M w/ C6 trans Bronc………., a true thoroughbred, guaranteed to pass up everything on the road but the gas pump. According to Eric, it has “studs on mains,heads, roller cam , roller rockers, MSD ignition,400plus hp, Kevlar bands in trans. Shift kit custom ground camshaft …. you name it. “.

He’s seen grizzlies, porcupine caribou, Alaskan cowgirls, a whole lot of beauty and more to come ……. the Challenge is just a month away.    Hoka Hey, Eric !

 Dr. George Cierny is an orthopaedic surgeon .  He has 36 years as a doctor and is based out of REOrthopaedics located at 7910 Frost Street; Ste 120, San Diego, CA.   Dr. Cierny is affilitated with a 4-star hospital, has received a fellowship, and attended a 4-star medical school.  Dr. George Cierny has additional knowledge and expertise in areas of bone transplantation, bone marrow inflammation (osteomyelitis), fracture fixation, tibial fractures, musculoskeletal tumors, un-united fractures and Methods of Ilizarov.  He has 126 research publications.   His overall average patient rating is four out of four stars, with an overall rating of “Excellent”.  You may also find the doctor’s name written as Dr. George Cierny III, MD.

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!!

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.

I.  Hand Hygiene:  Before the past decade, the major method of decontamination of the hands was the use of soap and water. The limitations of this procedure included the time it took to do, the number of sinks and the location of sinks in the hospital defined the optimal adherence to policy, and repeat use of detergents can be very irritating to the skin.

In 2002, the Centers for Disease Control and Prevention [CDC] through the Healthcare and Infection Control Practices Advisory Committee firmly established alcohol-based hand rubs at the center of hand hygiene practices, recommending them for routine decontamination of hands in all clinical situations except when the hands are visibly soiled.    Application of the rub takes seconds, the compounds are non-irritating and the dispensers are small, inexpensive and accessible wherever needed.  By 2008 84% of all US hospitals surveyed indicated that they had adopted alcohol-based hand rub and number of studies have shown dramatic increases in adherence to hand hygiene.  - Mody L, et al; Adoption of Alcohol-Based Handrub by United States Hospitals: a National Survey. Infect Control Hosp Epidemiol., 2008; 29:1177-1180.

II. Central Line catheter infections:  In the 2000s, there were 2 separate reports of large collaborative regional demonstration projects that focused on improved implementation of existing recommendations to prevent central line-associated blood stream infections (CLABSI) among patients in intensive care units (ICUs), first in southwestern Pennsylvania (2005) and then in Michigan (2006). Both studies demonstrated ~70% reductions in CLABSI rates across a wide variety of facility and ICU types, suggesting that the preventable fraction of these infections was perhaps much larger than we had originally thought.  The protocol was a 5-step process:  1) hand hygiene by the person inserting the device.  2) maximal barrier precautions.  3) chlorhexidine gluconate for antisepsis applied to the site of the insertion.  4) avoidance of femoral central line insertion.  5) removal of the central line as soon as possible /when no longer needed.

The results of these 2 studies have changed expectations of CLABSI prevention programs. The earlier single-center reports were viewed by many as somehow aberrant, the result of special circumstances and/or resources that could exist only in those particular, reporting facilities. These regional studies demonstrated that better implementation of existing recommendations can have a major impact across a wide spectrum of hospital settings —– dramatic success was possible, and not just under special circumstances.

III. DECOLONIZATION OF PATIENTS: Another innovative advance is the role of “source control” in preventing infection, particularly with the use of chlorhexidine bathing of patients. Based on data suggesting that colonization of a patient’s skin is an important source of spread for epidemiologic imported bacteria, it was hypothesized that daily bathing with a skin antiseptic (chlorhexidine gluconate) would decrease the burden of the patient’s skin contamination, indirectly decrease contamination in the environment, decrease transmission by healthcare worker, and play a role in decreased transmission of resistant pathogens and the incidence of both surgical site infections and CLABSI.  Today, data strongly suggest that daily chlorhexidine bathing can significantly reduce contamination of the patient’s skin, the environment, and healthcare workers’ hands, and an impact on methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) acquisition has been documented.  - Barta R, Cooper BS, Whitely C, Patel AK, Wyncoll D, Edgeworth JD.  Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant Staphylococcus aureus in an intensive care unit. Clin Infect Dis. 2010;50:210-217.

Discussion: One area of controversy is the role of active surveillance, or what the value is of actively screening patients for MRSA.  . Most of the studies done in the past were typically small, single-institution studies, and often with quasi-experimental, pre- vs post- design. The results from those studies leave the conclusions open to interpretation and raise the issues of potential confounding or bias. With that said, even more rigorously done, recent studies have come to different conclusions.   Clearly, more work needs to be done.  - Harbarth S, Fankhauser C, Schrenzel J, et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA. 2008;299:1149-1157. CONCLUSION: A universal, rapid MRSA admission screening strategy did not reduce nosocomial MRSA infection in a surgical department with endemic MRSA prevalence but relatively low rates of MRSA infection. – Robicsek A, Beaumont JL, Paule SM, et al. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008;148:409-418.  CONCLUSION: The introduction of universal admission surveillance for MRSA was associated with a large reduction in MRSA disease during admission and 30 days after discharge.

IV. Catheter-Associated Urinary Tract Infections:  Wald and colleagues  looked at catheter-associated UTIs [urinary tract infections] — morbidity and mortality associated with the device.  There is good evidence that getting the catheter out by postoperative day 2 makes a real difference. – Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data. Arch Surg. 2008;143:551-557.