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A 34-year-old man is involved in a motor vehicle accident and sustains an open tibia fracture and is treated with intramedullary nailing. For the next 4 years, he continues to have pain and persistent discharge from a sinus over his shin. He ambulates with crutches and refrains from putting weight on the extremity. The clinical appearance and radiographs are seen in Figures A and B. Wound culture reveals methicillin-resistant Staphylococcus aureus (MRSA). What is the next step in treatment?
Retention of tibial nail, lifelong intravenous antibiotic suppression
Debridement and lavage, exchange nailing using a larger diameter nail, intravenous antibiotics for 6 weeks.
Debridement and lavage, excision of sinus tract, implant removal, intravenous antibiotics for 6 weeks.
Debridement and lavage, addition of ring fixator, intravenous antibiotics for 6 weeks.
Debridement and lavage, excision of sinus tract, exchange nailing using antibiotic impregnated-cement nail, intravenous antibiotics for 6 weeks.
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A 33-year-old motorcyclist is involved in a motor vehicle accident and sustains a Grade III open fracture of his tibia that is treated surgically. Over the next 35 years, he undergoes multiple debridements for a persistently draining wound. Over the last year, he has noticed "tissue growing out of the wound" and a malodorous smell. A photograph of the wound and a recent radiograph are seen in Figure A. A biopsy of the mass is shown in Figures B, and C. What is the most likely pathologic process?
Squamous cell carcinoma
Basal cell carcinoma
A 34-year-old man sustained a gunshot wound to the knee 18 months ago and was treated with bullet removal and a 10 day course of oral antibiotics. He now complains of 12 months duration of pain in the thigh and recent ulceration and drainage of the skin near the site of his gunshot wound. Physical exam is notable for a draining sinus tract, erythema and tenderness of the mid-thigh. He is afebrile. An MRI image of this patient is shown in Figure A. Which of the following is the most appropriate management?
Two week course of oral cephalosporin
Core needle bone culture followed by intravenous antibiotics
Surgical debridement, culture, and intravenous antibiotics
Core needle biopsy, chest CT scan, and bone scan
Neoadjuvant chemotherapy and wide resection followed by adjuvant chemotherapy
A 45-year-old homeless hemophiliac male presents with chronic tibial osteomyelitis. Which of the following factors has been shown to predict a better prognosis?
Use of external fixation
Infection with Methicillin-resistant Staphylococcus aureus
Contralateral lower extremity amputation
HPI - s/p open arthrotomy of septic knee 2 years ago. Now returns with recurrent effusion (3-6 months per his report) and chronic pain. Knee aspirate returns frank pus (MRSA).
What would you do with this?
HPI - Open wound 35 days ago , left untreated.
Immediately , blind antibiotic therapy was started ( Augmentin 1gr X 2 + Clindamycin 300mg X 2 ) per os.
Before deciding treatment, what other imaging would you obtain
HPI - 37 years male from Somalia, war injury after explosion in Somalia 2010 lead to open femur fracture. The patient was treated conservatively. Referred to our clinic may 2012 because of draining sinus from his distal lateral femur. He underwent an operation at that time.
Now presents again to our clinic fall 2 weeks before, swelling, tenderness distal femur medial. CRP 180, ESR 140
How would you treat this patient?