The “Septic” Patient – Psychological, Social and Economic Consequences:  Behind X-rays, beneath scars (view of the patient).

     My X-rays and scars literally show my life-story. What they show is a destroyed right hip bone due to osteomyelitis at the early age of 4 days and, 18 years later, a length difference between my legs of approximately 6 inches.  What the x-rays do not show is me: the fragile infant who became a little girl, turned into a teenager, and eventually grew into a woman; a woman who, throughout this process, was forced to set her personal hopes and dreams aside in order to be (the) patient.  

     Why is it that when you get sick you simultaneously seem to vanish as a person?  It feels like your individuality becomes second to your medical status.  Moreover, you are expected to stick to the rules of your role to serve the system.  Once a patient, you are trapped and challenged by the obstacles of a life that is no longer in your hands.  Lying in a hospital bed, childlike and deprived of your gender, often not even capable of choosing when to act according to your personal needs….. you just never know when to feel safe within yourself.  Exposure, shame, and pain become a daily routine, as your handicap is put into the spotlight of men, without any space left for privacy.  This vicious circle can lead into self abandonment and depression. You break under the pressure of getting healthy and your self-imposed control.  Dependency on strangers, adapting to hospital rules, waking up in a changed body after surgery and losing your self-worth are some of the consequences you have to face along the way.  Pain is not the problem; your soul, adapting to the changes that are made on your body, is.

     Take a closer look at the bravely smiling patients, who are sitting in your offices, scheduling their next surgeries without hesitation, because they finally want to get well. The system has to be individually adapted  for all parties. It is teamwork after all.  As for me, I stood up for myself,  got to be part of my surgical team and am now, 28 years later, living  my freedom, the “normal” life, so to say. I am safe, for now.      E. Luger: osteomyelitis surviver; Vienna, Austria.  (paper S10.KL1 presented at the 28^th Scientific Meeting of the European Bone and Joint Infection Society/EBJIS/, Palais Niederösterreich, Vienna /Austria -  September 17-19, 2009.

DIABETIC FOOT INFECTIONS: where do I start?

Q: “I have a foot distortion and suffer from osteomyelitis of my fourth toe along with chronic skin ulcer. My fifth toe has been amputated due to osteomyelitis. What do you suggest?”

A: Most complaints involving ulcerations and bone infections of the foot come associated with varying degrees of diabetic neuropathy (decreased, protective sensation), making self-diagnosis difficult in the early stages of disease when treatment can prevent serious problems. Once bone infection is established, there are some general principles to care: 1) Team up with healthcare providers that specialize in conditions of the foot and ankle and understand diabetic foot care:   http://www.aofas.org/Scripts/4Disapi.dll/4DCGI/directory/person.html?Action=AOFAS&AOFAS_Activity=Directory&MenuKey=123&Time=31517&SessionID=4496z95o789l0livsy59jqp2trt2whs6fu4t6bq0oz58470mqx5p87×0pl0h5z0m ; 2) The organisms that cause osteomyelitis and soft tissue infections in the foot are unique and require specific antimicrobial therapy.   Treatment of these infections is best done in conjunction with an internist with specialializing in infectious diseases;  3) Try to improve your health to optimize your chances of healing, once treated: stop the use of all nicotine products; maintain tight blood sugar control; lose weight if you are over weight (take the load off): http://orthoinfo.aaos.org/topic.cfm?topic=A00148 . 4) Get thoroughly educated in the appropriate selection of foot wear.  Injury from poor-fitting shoes is one of the leading causes of ulcerations, pressure sores and osteomyelitis of the heel, toes and fore-foot.  Shoes that are matched to the anatomic profile of your feet will: a) shield the areas of on-going injury/infection; b) protect from further injury; c) prevent ‘wear conditions’ in your other foot while you are in treatment.  http://www.aofas.org/scripts/4disapi.dll/4DCGI/cms/review.html?Action=CMS_Document&DocID=77.     GC 9/15/09

TREATMENT OF OSTEOMYELITS; RIGHT FEMUR

Thanks,Doc.                                                                                                                           After the accident, my life was shattered by the reality of how what you think is important can always be replaced by your need to survive.   It seemed foolish to reflect on “why me”, when what was important was really “what’s next?”    You treated my  infection and healed me,  in the process (Featured Case #4).   Because of what you were able to accomplish, “what’s next” now includes building  my world, not saving it.                                                                                                            I am now able to plan for the future without worrying when my next flare-up (infection) will show or how I might be an amputee before the year was out.   My original doctors told me I would never run again.  Others told me I would have to fight the infection (osteomyelitis)  forever.  My life was put on hold ……. until I met you.   In one visit, you told me what it would take to get rid of the infection and how we would do it (the treatment protocol).  Then, we put that plan into action.                                                                                                     Today, I am able to live my life without limitation, moving beyond the pain and the uncertain-ty, the surgeries and the medicated means of life I lived for so very long.   Please, never forget the good you do for all your patients by helping them become people again.  I know I never will.

In appreciation,  Steven C. Berry /Asheville, NC                                                           ————

The Biology of Surgical Site Infection

Surgical site infection (SSI) is the third most common type of nosocomial (hospital acquired) infection, accounting for 38% of all infections in the 27 million patients who undergo surgery in the United States each year.  Following orthopaedic surgery, an SSI could be called a peri-prosthetic total joint infections, infected total joint, infected non-unions, infected fracture, osteomyelitis,  ”rejected” hardware, chronic wound drainage,  bone infection following an osteotomy, pin-tract infection, bone abscess, etc.    These infections are associated with substantial morbidity, mortality, and expense. Critical bacterial burden is by far the most significant of the many factors that influence surgical wound healing and determine the potential for infection and its incidence.

Unacceptable surgical site infection (SSI) rates still occur, despite the best efforts of infection prevention practitioners and improvements in surgical technique, antibiotic prophylaxis, methods of instrument sterilization, and “clean” operating room practices.  Bacteria can still gain access to a surgical wound from several sources. Endogenous contamination arises from: the patient’s skin or nares; the gastrointestinal, genitourinary, bronchial, or sinusoidal tracts; a concomitant remote-site infection (an infection existing somewhere else in the body).  Exogenous contamination comes from airborne or ‘transient pathogens’ transferred from instruments, implants, or personnel.   Most SSIs are caused by ‘commensal organisms’ from the patient’s skin or ‘transient organisms’ disseminated from health care personnel or surgical instruments.  Normal resident skin flora inhabit even the deepest layers of the dermis and are difficult to remove; these commensal organisms include Staphylococcus, diphtheroid, Pseudomonas, and Propionibacterium species.   Transient organisms are not consistently present but are easily exchanged between individuals: 30% of the contamin-ants are airborne and 70% transferred through instruments, personel or other contact surfaces. 

Although microorganisms gain access to all surgical wounds, only a small percentage of surgical patients develop a clinical infection (post-operative infection).  The take home point: the presence of micro-organisms in a wound is less important than the level of bacterial growth recorded during the first hours or days after surgery.  Whether an infection develops depends on the number and virulence of the bacteria present, the status or viability of the wound, presence or absence of a surgical implant, and the ability of host defenses to eliminate invading pathogens.  GC  9/04/09

OSTEOMYELITIS IN MY BIG TOE: DIABETES; VANCOMYCIN

Submitted questions via the “Quick Contact – Osteomyelitis.com” form at: http://www.osteomyelitis.com/html/about.html

Greeting: I was informed this morning that I have osteomyelitis in the bottom of my big toe and they want to put a PICC line in by 1:30pm today and start giving me Vancomycin. I am very concerned about the effect this medication will have on my kidneys and hearing. I am sixty and they claim I have diabetes; but I am very healthy and eat well. Please let me know how you feel about this approach, and what would you do if you were me.  My doctor told me that if I don’t have the procedure done today the infection could spread to my foot and lead to an amputation of my foot;  she also said it could get into my bloodstream and destroy my kidneys… is all this true?

Dr. Cierny’s reply:  Yes —- I agree that pathogen-specific antibiotics will, indeed, help to control the spread of infection, particularly in patients with a compromise in wound-healing (like even mild, diabetics).  There is, however, no reason to be exposed to the added risks of a PICC line and being exposed to the toxicity of the antibiotic, Vancomycin, unless cultures from your infection have grown a resistant Staphylococcus (MRSA or MRSE) or an Enterococcus species. If you have a sensitive Staphylococcus organism causing the infection, it will be better not to treat it with Vancomycin; other drugs are both more effective and less risky. 

If you have had the wound (and osteomyelitis) for more than 4 weeks, it is likely the infection has already gone beyond at point that can still be cured with the use of antibiotics, alone.   Please ask your present doctor (infectious disease specialist?) to refer you to an orthopaedic surgeon who specializes in foot and ankle surgery and do it sooner, rather than later.  See also, HOW TO MANAGE CHRONIC MEDULLARY OSTEOMYELITIS in this blog to get a feel for why infections become refractory to antibiotic treatment.      GC    9/03/09

The following case was submitted via the “Quick Contact – Osteomyelitis.com” form:http://www.osteomyelitis.com/html/osteomyelitis.html – 9/01/09: I am a 53 year male with intra-meddulary osteomyelitis (I had acute osteomyelitis when I was a child). Now I may have heavy pain in the area for a couple of days per year (worst in night). The rest of the time, the pain is low but always there. I am fully mobile, cycle, jog and ski. QUESTIONS: Q1: will the infection gradually spread to the rest of the bone and destroy it? Q2: Should I treat the osteomyelitis now, or wait until the pain gets worse or more continuous?  Q3: will the intra-medullary osteomyelitis gradually develop into another type of osteomyelitis?

Dr. Cierny’s Response:  Chronic, type I osteomyelitis (with a remote, hematogenous source) is unpredictable in two ways: 1) when it becomes symptomatic; 2)when and if it re-activates to acutely require treatment(fever, illness, pain, drainage).  In either situation, the cause will be due to the release of a few ‘active’ bacteria (planktonic organisms) from a majorly dormant colony(sessile organisms).  Chronic bone infections do not usually spread throughout the bone, or to other bones, particularly when dormant.  The infection will, however, never spontaneously go away.

This is a biofilm disease where the bacteria are permanently attached to surfaces inside the bone where the old ‘scars’ have remained all these years. As a result, the infection will always be due to the very same bacteria that caused the original episode back in your youth.  The reason for this is that the bacteria, while within their biofilm cocoon (called a slime), are immune to both antibiotics and host defenses (your immune system).  They are vulnerable only when ‘active’ and free-floating, outside the slime.  Over 90% of the bacterial colony is, at any one time, dormant (sessile).  So, antibiotic treatment, alone, is rarely(if ever) curative. Today, there is no cure other than with surgical excision of the entire biofilm burden.  This is, essentially, a physical removal of the non-viable core of bone and dead marrow housing the attached colony. 

Parallel visual:  The visual is likened to a rock geode that has been broken open to reveal the inside: the outside of the geode looks like a regular rock (the bone looks on the outside);  But, when the geode is broken open, it is hollow and there is an inside layer of crystals (likened to a biofilm colony inside the bone) that is intimately attached throughout the inner cavity of the rock (making it a geode). It is very difficult to remove the crystal lining from the rock, itself.

Fortunately, the surgical removal of the attached, biofilm colony can usually be accomplished without injuring the residual bone or disabling the patient. Within the last year, we have treated two such cases (right femurs); both men remained full-weight-bearing and active throughout treatment.  The treatment protocol requires at least two surgical interventions: one to remove the biofilm and its surface attachments; one to reconstruct the window we make in the bone to visualize and remove the disease. We recommend crutches for about two weeks post-op.  The success rate after one treatment attempt is 98% for healthy patients and 90% in patients with health problems.  If re-treatment is necessary, the overall success rates are 99% and 94%, respectively ( treatment outcomes ).

I cannot tell you when to have the surgery.  Nor can I tell you if you will ever require surgical treatment.  I can, however, tell you that most reconstruction surgeons will not operate you for an elective surgery (rotator cuff repair, artificial joint replacement, ACL repair, cosmetic surgery) when there is an on-going site of infection somewhere else in your body (ie; your osteomyelitis).   This is because such remote sites of infection have, histori-cally been proven to increase the risk of elective, clean, surgical procedures.  However,  the most impelling reason to pursue ealy  surgical treatment of your osteomyelitis is to avoid every having a fracture through that femur.    If this happens, the fracture will get infected (100%) and treatment will be very (VERY) difficult, indeed.     GC / 9/02/09