INFECTED NON-UNION ,TIBIA:  George Cierny III, MD    REOrthopaedics, CA.

Dear Dr. Cierny,

I just wanted to let you know that I finally ran my marathon!  At age 49, getting back in shape was a struggle but, I ran and finished the Atlanta ING in 2007 clocking in a total of 26 miles. 

   Thank you so much for your hard work and perfectionist attitude.  My leg NEVER hurt me throughout my training.  It truly was a miracle.   Everyone who knew be during the early stages of my recovery from the accident was amazed I could walk, never mind run.  I’m so grateful my husband perused finding the best doctor for me and,  that some how, we found you. 

    I just wanted to let you know how much of an impact you make in the lives of your patients.  You cured my osteomyelitis and restored the lifestyle that I so need and enjoy.    I am truly grateful that you, Dr. Cierny, were my doctor.  To thank you does not begin to express my gratitude.         Sincerely and best wishes,    Joanne Marcone / Atlanta, GA

     In the summer of 2002, I was hit by a motorcycle while in Florence, Italy (with my husband, I might add).   I fractured my right tibia and was operated while still in Italy.  But, once back in the States, my bone just would not heal.   After two years and two additional surgeries, I still had non-union and a short, crooked leg.

     Very fortunately, I found Dr. George Cierny in the spring of 2005.  I had immediate confidence in him.  He operated both the bones in my leg and then used an Ilizarov external frame to mold them into length, position and alignment …..  After 7 months, my bone had healed:  I got back 1 1/3” in length and my leg was (and is) almost back to the way it was before the accident.  I have been walking a mile a day for 3+ years, go to the gym every day, lift weights and swim laps.   I am even back to playing golf.

     Dr. Cierny made a great difference in my life when I, myself, had given up.  He truly saved my leg.  I thank him every day in my prayers for what he did.   Carla Foreman /Roswell, GA

Osteomyelitis, Great Toe: 

“Dear Dr. Cierny, I wanted to share with you a goal I have been working towards ever since your cured the osteomyelitis in my big toe at your treatment center in San Diego.  Once my cast came off and I had the “go ahead” to exercise,  I took up weight training rather than go back to running, like I enjoyed before the infection.  

           On October 10, 2009, exactly one year (to the day) after my osteomyelitis surgery,  I  competed in the bikini division of the NPC Bodybuilding, Figure and Bikini Championships.  I placed 2nd in the bikini masters category and 3rd in the bikini class B category.   I had no trouble with the training, the competition (routines)  or even the perfunctory high heels.   It has been an enjoyable journey ……  

Thanks for all you do.    My toe is just beautiful!    

      Sincerely, T.J /Pleasanton, CA

G. Cierny, MD:  Tobacco abuse and Hyperbaric Oxygen treatments when treating osteomyelitis (”bone infection”) and/or  peri-prosthetic total joint infections.   Thank you for your questions.  I worked with Jon T Mader, MD in Galveston, TX 1980-1985 and also ran the HBO Treatment Centers at Crawford Long and St. Josephs Hospitals, in Atlanta, 1986 – 2003.   In cases where I completely removed all the tissues compromised by disease /infection at the time of the debridement surgery, we saw no benefit to outcomes in a randomized trial of patients (both A-hosts and B-hosts) treated for osteomyelitis, 1981-1988 (No=188).   It was only when residual disease (or ischemia) was retained that pre- and post-operative HBO had its place in reducing both failures and complications (ie; radiation necrosis, peripheral vascular disease, etc).   This study was presented and recorded at Dick Clarke’s HBO course, South Carolina (Cierny.Mader; 1989) .    

So far as tobacco use:  I have  come the conclusion that patient education is the best approach to take with patients who require treatment for infection.  I let them know the down side of continued tobacco use during treatment and tell both the patient and their support(family) that continued use may lead to consequences that they, alone, will have to bare: added expense, disability, surgery, and the possible need for ablation, for failure.  They (b-hosts) are quoted a 20-30% increase in failure and complication rates. 

When looking at bone transport and regenerate formation using the methods of Professor Gabriel Ilizarov, we found smokers had a 30% increase in disability time and time-to-union compared to non-smokers. We also observed that all of the patients suffering a regenerate failure (new bone growth) were smokers.   Those patients who did manage to quit smoking throughout treatment had results equal to non-smokers (Smokers Suffer Impaired Bone Healing. SCIENCE NEWS, Vol. 141, February 29, 1992).   Similarly, if you look at our outcomes when treating peri-prosthetic total joint infections (total hip, total knee, total shoulder), at two years,  B-hosts with < 3 major co-morbidities had a 90-93% success rate compared to 97% success for A-hosts and 66% success for those patients with > 3 co-morbidities.   However, 17% of those with <3 co-morbidities underwent a 3-stage or a second 2-stage protocol to achieve a successful outcome.  

When faced with a truly elective surgery, I try not to ever operate a patient with a reversible compromise to healing before that compromise is either eliminated or optimized (smoking, mal-nutrition, radiation necrosis, diabetes, etc).   However, when faced with an infection, treatment is often not elective. Historically speaking (our experience 1983 -2007: 2207 patients),  less than 40% of those who say they will quit at the time of presentation never do, when chemiclly screen-tested throughout treatment.  So, my policy with these patients is as follows:  “Here are the choices; here is the science; here are the anticipated outcomes if you do not refrain from tobacco use during treatment.  Let me know how you want to proceed.”     GCIII 10/16/09

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