Working in collaboration with local, national, and international facilities, the orthopedic medicine and surgery specialists at REOrthopaedics, Inc., in San Diego have spearheaded numerous scientific investigations that have led to practical treatment solutions bringing immediate benefits to patients and families throughout the world.

In The News

Publications, Scientific Meetings and Important Events Pertaining to our Los Angeles Area Orthopedic Doctors

Dr. George Cierny and Dr. Doreen DiPasquale have over 60 years of experience in the field of orthopedic surgery. Treating hundreds of patients each year, our Los Angeles area orthopedic doctors are among the few in the world specializing in the evaluation and treatment of orthopedic infections.

The orthopedic specialists at our REOrthopaedics Inc. location are among the select few making their own headway in the field of orthopedic surgery, offering new treatment protocols and methods to help patients suffering from orthopedic disorders. Here we present several of our most recent and/or pertinent publications and newsletters, as well as information pertaining to events of interest to colleagues in the field.

Scientific Papers
Orthopedic Meetings/Seminars
Flyer for REOrthopaedics, Inc. 2010
Newsletter, fall 2011

The orthopedic doctors at our Southern California practice, near Los Angeles, have exceptional knowledge and experience with chronic bone disorders and infections, including, but not limited to osteomyelitis, bone and soft tissue tumors, non-unions, wound healing disturbances, prosthetic infections, limb lengthening, and correction of bone deformities. Treatment is determined on an individual basis and is commonly dependent on a variety of factors such as age, extent of the injury, pre-existing conditions/diseases, and others. Your individual problem will be diagnosed and treated accordingly.

Scientific Papers

The experienced orthopedic surgeons at our San Diego practice, Dr. George Cierny and Dr. Doreen DiPasquale, have produced several publications on orthopedic disorders, including significant findings, treatment options, and other topics that have made headway in the field of orthopedic medicine. Click on a link below to view each paper.

Procedure-related reduction of risk of infection
In this chapter from the American Academy of Orthopaedic Surgeons’ Orthopaedic Knowledge Update: Musculoskeletal Infection (2009), Dr. Cierny discusses how caregivers can decrease the risk of surgical site infections (SSI) by: limiting patient exposure to exogenous and endogenous pathogens; maintaining a vital, resilient wound; and working to prevent, accommodate, and minimize systemic factors affecting the overall immunity of the host.
Primary vs Delay Soft Tissue Coverage for Severe Open Tibia Fractures This was Dr. Cierny's thesis paper when a resident surgeon at Parkland Hospital in Dallas, Texas 1975-1979. It became a classic, addressing, for the first time (in English), the issue of early vs late soft tissue coverage in patients suffering a significant soft tissue loss following Grade IIIB (Gustillo) open tibial fractures. This paper, published years before the discovery of microbial biofilms, initiated the clinical pathway toward all modern-day open-fracture treatment protocols and has more than 1000 references in the world's medical literature.

Infection Following Open Fracture
The monograph “Complications in Orthopaedics: Open Fractures”, published in 2010 by the American Academy of Orthopaedic Surgeons, discusses the prevention and management of complications following open injuries to bone by the most respected clinicians in the field. Dr. Cierny presents his classification /treatment algorithm, which is one of the principal advances in the management of post-traumatic osteomyelitis.
If You Have Diabetes, A Joint Replacement or Arthritis… You Are At Risk For A Bone Infection
A ‘plain talk’, 2009 interview with Drs. Cierny and DiPasquale in their San Diego office, discussing the causes, symptoms, diagnosis and incidence of bone infection (osteomyelitis) in both the general and ‘at risk’ population.
Segmental Osseous Defects:comparing conventional and Ilizarov methodologies
Dr. Cierny’s classic article from 1994 was the first American study to clinically compare and contrast conventional methods of bone reconstruction to the then-controversial methods described and refined by Professor Gabriel Ilizarov, an orthopaedic surgeon from Kurgan, Siberia.
Limb Lengthening For Bone Loss Due To Infection In this recent chapter-update, Drs. Cierny and DiPasquale present their 2011 treatment algorithm for internal bone lengthening (ie; bone transport), including outcomes for 137 consecutive case studies treated 1988-2004 prior to their move to the Musculoskeletal Sepsis Center / San Diego, California.
The Classic: A Clinical Staging System for Adult Osteomyelitis
Here, Dr. Cierny and his colleagues discuss their internationally recognized classification system that is based on anatomic and physiologic factors affecting patient selection, treatment options and long-term outcomes.
The Diagnosis and Treatment of Musculoskeletal Infections
An editorial written by George Cierny III, MD, where he discusses the concerns of a ‘global medical community’ regarding the diagnosis and treatment of bone and soft tissue infections.
Infected Tibial Nonunions - The Evolution of Change
Dr. Cierny discusses the treatment of infected, tibial fracture-nonunions (Type IV osteomyelitis, 1981-1995), spanning two eras of treatment innovations including limb and bone lengthening, staged treatment protocols and antibiotic depots (beads).
In Vitro and In Vivo Evaluation of Antibiotic Diffusion From Antibiotic-Impregnated Polymethylmethacrylate Beads
This article was written by Dr. George Cierny and his colleagues, specialists in orthopedic medicine and surgery. The article discusses the elution characteristics of various antibiotics from the hand-made, acrylic, antibiotic beads used in the treatment and management of patients with chronic osteomyelitis.
Osteomyelitis: Debridement Techniques
Dr. Cierny and his colleague discuss the techniques used by musculoskeletal infection surgeons to surgically treat bone and soft tissue infections with emphasis on creating a live, clean, manageable wound.
Osteomyelitis and Related Topics
Literature abstracted by Dr. Cierny covering topics related to: osteomyelitis, treatment of osteomyelitis, bone infection and non-unions; wound healing; peri-prosthetic infections (PPI), bone lengthening, surgical site infections (SSI) and biofilms.
G. Cierny III, MD: 75TH Annual Meeting of the American Academy of Orthopedic Surgeons; (San Francisco, CA, March, 2008) - G. Cierny III, MD: 28TH Scientific Meeting of the European Bone and Joint Infection Society; (Vienna, Austria, September, 2009)
Periprosthetic Total Joint Infections - Staging, Treatment, and Outcomes
Drs. Cierny and DiPasquale, experts in musculoskeletal pathology, conduct a study of patients suffering from infections involving prosthetic, total joint arthoplasties (TJA). The two surgeons report their treatment protocols, long-term outcomes and the staging systems used to compare and contrast various patient cohorts. Dr. Cierny and Dr. DiPasquale discuss treatment options and the process of patient selection.
Treatment of Chronic Infection
Dr. George Cierny, III and Dr. Doreen DiPasquale share their experience treating severe, debilitating infections of the musculoskeletal system in a Symposium sponsored by the U.S. Department of Defense on War Wounds . This publication discusses the chronologic development of today’s treatment modalities including antibiotic beads and spacers, limb-salvage protocols, methods of bone restoration and amputation.
Treatment via Antibiotic Beads
Dr. Cierny discusses the advantages of using antibiotic beads in the management of bone infection, presents an illustrative case study, and demonstrates the process of creating the “hand-made” product.
Surgical Treatment of Osteomyelitis; In this Supplement on Wound Healing published in J Plast. Recon. Surg, 2011; 127(1S): 190-204, Dr. Cierny presents the 2010 treatment algorithm used in San Diego for all types of osteomyelitis as well as outcomes and a method analysis for the 2207 patients treated 1981-2007.

Orthopedic Meetings/Seminars

Dr. Cierny is course coordinator and author of the president's letter for the Musculoskeletal Infection Society. View their flyer for the upcoming scientific meeting in San Diego.

Musculoskeletal Infection Society of North America meeting: 2009

European Bone and Joint Infection Society Meeting: 2009

Sharp HealthCare Orthopaedic

Trauma and Fracture Care Conference

La Jolla, CA - January 14-15, 2012: “The Sharp Experience” – An annual conference sponsored by San Diego’s Sharp Memorial Hospital and the entire Sharp HealthCare Network to benefit our entire medical community with news of emerging innovative techniques for treating orthopaedic trauma and infection. Local and nationally recognized speakers will discuss the newest techniques in fracture care, negative pressure wound healing, management of large bone defects and the prevention of orthopaedic infection (infected fractures, chronic osteomyelitis, infected non-unions). George Cierny III, MD from Sharp’s Musculoskeletal Sepsis Center will present: “New Techniques in Decreasing Post-Trauma Osteomyelitis” 11:45am 1/14/2011. The educational objectives will include:

The added value of Stimulan over OsteoSet when delivering local antibiotics
Correlating Staphylococcal nasal carrier status to surgical outcomes
How hemodynamic optimization enhances wound perfusion
When to use NPAC (negative-pressure assisted closure)

In addition, the conference will cover deliberation son surgical techniques not yet in textbooks, clarification of on- and off-label use, and balancing technology and economic realities.

SURGICAL GRAND ROUNDS: Dept. Orthopaedic Surgery, Standford University - January 25, 2012.

Treatment of Chronic osteomyelitis: Methods To Decrease Both Surgical Morbidity and The Role of Systemic Antibiotics. Head of Orthopaedic Trauma at Stanford University School of Medicine, Dr. David Lowenberg, has invited Dr. Cierny to present his current approach to patient selection and options management when managing chronic musculoskeletal infections. Discussed will be the 2012 San Diego Algorithym wherein 'high risk' patients are matched with 'low risk' surgical procedures to decrease surgical morbidity, increase success rates and limit the need for long-term antibiotic treatment.

Flyer and Office Card for REOrthopaedics, Inc.

View and print out the business card for REOrthopaedics, Inc.

View and print out the flyer for our San Diego area practice.

View our fall 2011 REOrthopaedics Newsletter discussing our case of the month (TKA peri-prosthetic infection with extensor loss, 2006-2011 patient demographics and 16s bacterial DNa pyrosequencing in the analysis of biopsy specimens from patients with orthopaedic infections. In just 5 years, the Sepsis Center at Sharp Memorial Hospital in San Diego, CA logged its 500^th referral on August 18, 2011 with patients coming from 40 of our 50 States and 14 foreign nations. As expected, type IV osteomyelitis lesions (infected non-unions and peri-prosthetic infections) and complex reconstructions accounted for75% of all patients seen and treated – see www.osteomyelitis.com for more details and click “YOUR TREATMENT OUTCOMES” to research each treatment option.

In 2010, a Musculoskeletal Foundation grant introduced real-time microbial rDNA pyrosequencing to the SepsisCenter. With this technology, we can now document the ‘true’ microbial diversity in osteomyelitis and implant-related infections, detect all known pathogens and do so with nearly 100% sensitivity and specificity. Clinically, this may mean no more “culture negative” infections, even in the face of concurrent antimicrobial therapies. A table in the newsletter documents sensitivities and methods used to culture and identify wound pathogens in a SMH 2010/2011 series of non-unions and peri-prosthetic infections.

Clincial Abstract: MSIS-NA 21st Annual Meeting: Rochester, MN

TITLE: Osteomyelitis Treatment Algorithms Based on rDNA Profiling: are we there yet? BACKGROUND: Acknowledging that molecular technologies are now capable of detecting 100% of the microorganisms present in a chronic wound, we retrospectively asked if and how our initial experience with PCR pyrosequencing had influenced care. STUDY QUESTION: Has rDNA pyrosequencing changed our approach to the treatment of chronic osteomyelitis? METHODS: We present an 'incidence-of-occurrence' microbiogram based on the numbers /types of pathogens isolated from a randomly selected subset of 200 cases of chronic osteomyelitis spanning over two decades of patient care. In one of our 2010 protocols, tissue samples prospectively underwent c/s / histological processing plus a molecular assessment using quantitative bacterial tag-encoded FLX 16s rDNA amplicon pyrosequencing . Patient selection, Treatment options and clinical outcomes were then correlated to each diagnostic method. RESULTS: Staphylococcal species were the most commonly isolated pathogens in all treatment cohorts. PCR pyrosequencing revealed: 1) increased numbers of microbes than c/s; 2) an increased incidence of anaerobes, GM- rods and previously unknown pathogens; 3) 'pathogens' in all specimens with "no growth" cultures; 4) 11% 'false positive' and 11% 'false negative' analyses and 4) influenced the selection of treatment options in 16% of the cases evaluated. DISCUSSION: The acquisition /processing of specimens and the interpretation of 16s rDNA pyrosequences are a new set of clinical tools being used at our Osteomyelitis Treatment Center in San Diego. Processing this wealth of newknowledge remains a work-in-progress. There are still sampling errors, errors of omission /commission, diagnostic delays and, most importantly, therapeutic dilemmas relating to the management of unexpectedly large numbers of diverse and even previously 'unknown' microorganisms profiled in chronic wounds. CONCLUSIONS: Qualitative diagnostic criteria must still play a significant role in the diagnosis and treatment of musculoskeletal infection. Cierny G, DiPaqsquale, D - REOrthopaedics Inc. - San Diego, CA

CURRENT RESEARCH ACTIVITIES:

`COLLECTION OF RESIDUAL TISSUE SPECIMENS FOR FEASIBILITY AND ANALYTICAL STUDIES IN SUPPORT OF ORTHOPAEDIC iNFECTONS`

( March 2012 - to - present )

sponsor: Ibis Biosciences, Inc

2251 Faraday Avenue

Carlsbad, CA 92008

Investigator: REO Orthopaedics, Inc.

7910 Frost St. Suite 120

San Diego, CA 92123

Background and Rationale:

Orthopedic infections are common and can occur in at least one percent of all orthopedic operations; post-operative infections are one of the most common and devastating complications facing orthopedic patients. Without prompt and accurate treatment, orthopedic infections become chronic. Adverse patient outcomes can be catastrophic and impact on health care costs.

Early diagnosis and appropriate antibiotic therapy and/or surgical intervention will successfully resolve most orthopedic infections. Although blood-based tests, such as C-reactive protein levels and cell counts, can suggest the presence of infection, they cannot identify a specific micro-organism. To develop an accurate antibiotic or anti-microbial treatment regimen, physicians generally rely on microbiology culture and antibiotic sensitivity studies with tissue and/or fluid as the sample(s). Although this “culture” technology remains the closest to a gold standard(test) for diagnosing infection, antibiotics are, nevertheless, prescribed and surgical debridement often performed on an empiric basis when cultures come up “no growth” even though an infection is clinically eminent. Indeed, the most difficult aspect of treatment is often an inability to obtain a rapid, accurate identification of the specific organism(s) involved in colonizing and infecting wounds. Simply stated, an alarming number of micro-organisms are not capable of growth when using standard laboratory methods. As a result, the percentage of cases in which traditional culture and sensitivity tests are sufficient for physicians to develop an accurate and thorough treatment plan are reported as low as 55% .

Recent advances in the diagnosis and treatment of orthopedic infections are beginning to move from basic research to clinical reality. Ibis Biosciences, a subsidiary of Abbott Molecular, has developed high-throughput, cost-effective technology that uses PCR amplification and mass spectroscopy to detect and identify micro-organisms present in a biological specimen. The technology was initially developed with the U.S. government for epidemiological surveillance and forensics. The technology may be applicable to the rapid and accurate identification of infectious agents underlying an orthopedic infection and could serve as the basis for a novel molecular diagnostic kit for orthopedic infections. However, the technical feasibility of developing the advance surveillance technology for identification of infectious agents in an orthopedic or other tissue or fluid specimen has not been established.

Purpose of this study:

The primary purpose of this tissue specimen collection protocol is to collect de-identified, residual tissue and/or fluid specimens from patients thought to harbor orthopedic or other relevant infections and who are receiving standard-of-care interventions that require removal of tissue and will generate residual tissue. The specimens, and a corresponding de-identified microbiology laboratory report, will be analyzed at Ibis Biosciences to determine and establish the feasibility of adapting the Ibis technology for use in the orthopedic setting. The data also may be used to evaluate feasibility for other indications, such as chronic infections. Once feasibility is established, these specimens may be used for analytical studies.

Specimen Type and Number of Specimens:

Tissue and/or fluid (typically synovial fluid and/or pus) specimens will be collected from patients suspected or known to harbor an orthopedic or other infection, typically a chronic infection (for example, bedsore or foot ulcer), and who require physical intervention such as standard-of-care treatment. It is anticipated that the physician, as part of standard-of-care intervention for the patient's underlying medical condition, will remove infected fluid or infected tissue during the intervention. A portion of the tissue is typically sent to the microbiology laboratory for routine culture and antibiotic susceptibility testing; the remaining residual tissue is then disposed of follow routine hospital or facility procedures.

In some cases, such as amputation or biopsy, the standard-of-care intervention may generate residual tissue that is uninfected but relevant for feasibility and analytical studies. This residual, uninfected tissue will be collected when available.

In an optimal setting, it is anticipated that approximately 500-600 specimens will be required to generate 450 unique and usable specimens, the minimum sample size anticipated to fully establish assay feasibility and to perform analytical studies. In the event of unforeseen complications in the feasibility program, the maximum sample size is anticipated to be 1000 specimens. In each and every case, it is only residual tissue (left over after diagnosis or medical evaluation unrelated to collection for this project) that will be collected. In no case will tissue be collected solely for this project.

Informed Consent:

This program involves the collection or study of existing pathological or diagnostic specimens and all information will be recorded in such a manner that subjects cannot be identified, either directly or through identifiers linked to the subjects. In no case will tissue be collected solely for this project. Thus, there is no plan to collect written informed consent from the donor.

Sample Collection and Handling:

tissue samples: After tissue has been taken for pathological or diagnostic purposes or other medical procedure, a piece of the residual tissue, anticipated to be not larger than 5 cm³, will be placed into a sterile specimen container and capped. The physician will note, in writing, the site (e.g., knee, foot, hip) from which the specimen was collected. The tube will be placed at 4°C for not longer than 48hr or at - 20°C for longer term storage. All personnel will follow universal precautions as well as any and all local standard policies and procedures in effect at each site or location for handling unfixed human tissue and fluid specimens.

fluid samples: After fluid has been taken or removed for pathological, diagnostic or other medical procedure, a portion of the residual fluid, anticipated to be not greater than 10 mL, will be placed into a sterile tube and capped. The physician will note (in writing on the outside of the tube) the anatomic site (e.g., knee, foot, hip) from which the fluid was collected. The tube will be placed at 4°C for not longer than 48hr or at -20°C for longer term storage. All personnel will follow universal precautions as well as any and all local standard policies and procedures in effect at each site or location for handling unfixed human tissue and fluid specimens.

Tissue Sample Processing and Storage:

The tissue or fluid sample will not be further processed at the site. Approximately one to two times per week, samples will be shipped on cold packs or dry ice for analysis in feasibility and analytical studies.

Data Available With Samples:

The only data to be provided with a tissue or fluid specimen is a general notation of the anatomic site from which the specimen was collected (e.g., knee, foot, hip), general information about type of procedure from which the specimen was collected (e.g. infected total joint revision, trauma case) and a de-identified copy of the microbiology laboratory report performed on the specimen (when applicable).

Patient Privacy and Confidentiality:

Under no circumstance will a link be intentionally established or maintained between the tissue specimen or microbiology report and any identifying information.

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From Mexico to Los Angeles and beyond, the orthopedic doctors at our Southern California practice serve patients from throughout the continent. To contact our office fill out our comprehensive contact form.

FEATURED CASES

At REOrthopaedics, Inc., located in San Diego, not far from Los Angeles, our specialists have helped thousands of patients suffering from orthopedic disorders. Below is one such case of a patient treated by the orthopedic doctors at our Southern California practice.