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Average 3.8 of 68 Ratings
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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The patient has chronic osteomyelitis and an infected nonunion complicating previous IM nailing of an open tibia fracture. Successful treatment requires debridement, removal of the existing tibial nail, placement of an antibiotic-impregnated rod and IV antibiotics. Sinus tract excision and biopsy is important to exclude malignant transformation (Marjolin's ulcer).
Intramedullary infection is a recognized complication of IM nailing, especially in the setting of an open fracture. When the fracture fails to unite prior to deep infection treatment options include: nail removal and antibiotic exchange nailing, nail removal, intramedullary debridement and uniplanar external fixation, or nail removal and resection of the infected segment with circular frame application and bone transport.
Paley et al. first described the treatment of intramedullary infection with antibiotic-impregnated cement nails in 6 femora, 2 tibiae and 1 humerus. There was no recurrence of infection. The antibiotic-impregnated cement nail fills the canal dead space while locally eluting high concentrations of antibiotics (for up to 36 wk), and is easy to remove.
Qiang et al. described antibiotic-cement rod placement in 19 patients (5 femora, 14 tibiae). There was no recurrence of infection. 11 cases went on to union, 6 cases achieved partial union, 1 case had nonunion and 1 went on to amputation.
Riel et al. described the method of creating a PMMA-coated nail. They advocate this method because it provides limited axial and bending stability (but no rotational stability).
McGrory et al. described 53 patients with malignancy complicating chronic osteomyelitis. 50 patients had squamous cell carcinoma. Most had mixed infections, predominantly Staph and Strep.
Figure A shows a poor soft tissue envelope with a draining sinus consistent with chronic osteomyelitis. Figure B is an AP radiograph showing fluffy callus formation, lack of bony bridging and interlocking screw back out. Combined with the clinical picture this would be consistent with deep infection. Illustration A shows the steps of making an antibiotic-impregnated cement rod using a 3 mm guidewire, chest tube and cement gun. Illustration B is a lateral radiograph of a cement rod in the tibia.
Answer 1: Tibial nail removal is paramount as the implant is likely seeded and infection will not be eradicated as long as foreign material is present.
Answer 2: While exchange nailing provides mechanical support for the nonunion, immediate nailing risks reinfection. Sinus tract biopsy is important to exclude malignant transformation.
Answer 3: The tibial nail is stabilizing an infected nonunion. Following its removal, some other form of stabilization must be substituted. Sinus tract biopsy is important to exclude malignant transformation.
Answer 4: The addition of an external fixator does not detract from the fact that the foreign body (nail) is left behind.
Paley D, Herzenberg JE.
J Orthop Trauma. 2002 Nov-Dec;16(10):723-9. PMID: 12439196 (Link to Abstract)
Paley, JOT 2002
Qiang Z, Jun PZ, Jie XJ, Hang L, Bing LJ, Cai LF.
Arch Orthop Trauma Surg. 2007 Dec;127(10):945-51. Epub 2007 Mar 27. PMID: 17387498 (Link to Abstract)
Qiang, AOTS 2007
Riel RU, Gladden PB.
Am J Orthop (Belle Mead NJ). 2010 Jan;39(1):18-21. PMID: 20305835 (Link to Abstract)
Riel, AJO 2010
McGrory JE, Pritchard DJ, Unni KK, Ilstrup D, Rowland CM.
Clin Orthop Relat Res. 1999 May;(362):181-9. PMID: 10335297 (Link to Abstract)
McGrory, CORR 1999
Please rate question.
Average 4.0 of 17 Ratings
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 Marjolin's ulcer is a malignant tumor (Figure A) that develops around chronic osteomyelitis. The increasing size and foul smell suggest malignant change. These tumors are most commonly squamous cell carcinoma (90%). Figures B and C confirm the diagnosis of squamous cell carcinoma.
Marjolin's ulcers can arise in the setting of burns, venous and decubitus ulcers, vaccination, snake bites and hidradenitis suppurativa. They usually involve the lower extremities. While squamous-cell carcinoma is most common, a small percentage of cases are basal-cell carcinoma, melanoma and sarcoma.
Copcu et al. examined 31 Marjolin's ulcers arising at burn sites. 58% were on the extremities, and had an average time lag of 19 years. Four of 31 cases had regional lymph node spread. They also drew attention to the fact that Marjolin's ulcers are more aggressive, with higher rates of metastasis, recurrence and fatality than other types of skin cancer.
Pandey et al. reviewed the literature on Marjolin's ulcers in chronic bone infections and found that the treatment of choice was still amputation (90% of cases). The challenges faced by the surgeon considering a more conservative approach include: wide resection of cancer for cure, resection of infected bone and soft tissue, preservation of limb function, and reconstruction.
Figure A shows the appearance of a fungating soft tissue tumor, together with a radiograph of chronic osteomyelitis. Figure B (low power) shows the transition between normal epithelium (left) and squamous cell carcinoma (right), which is infiltrating downward. Figures C is a high power image of SCC. Illustration A shows basal cell carcinoma (Answer 3) with a cleft (red arrow) separating basaloid cells (green arrow) from the stroma. Illustration B shows melanoma with asymmetric proliferation of nests of melanocytes (red arrow), descending into the dermis (Answer 4).
Answer 1: While there is underlying chronic osteomyelitis, the more concerning disease process is malignant transformation into squamous cell carcinoma (Marjolin's ulcer)
Answer 3: There is no evidence of basal-cell carcinoma.
Answer 4: There is no evidence of melanoma.
Answer 5: There is no evidence of sarcoma.
Copcu E, Aktas A, Sisman N, Oztan Y
Clin. Exp. Dermatol.. 2003 Mar;28(2):138-41. PMID: 12653697 (Link to Abstract)
Pandey M, Kumar P, Khanna AK.
J Wound Care. 2009 Dec;18(12):504-6. PMID: 20081575 (Link to Abstract)
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
The clinical presentation and radiographs are consistent with chronic osteomyelitis. The MRI shows chronic changes of the distal femur with intraarticular (knee) extension. Chronic osteomyelitis is notable for a sequestrum, which is necrotic bone that has become avascular and no longer connected to the normal bone via the Haversian canal system. Involucrum refers to the new bone forming around the sequestrum. Often the involucrum will form a sinus tract allowing the sequestrum to drain into the soft tissues. Illustration A is a diagram of chronic osteomyelitis depicting the sequestrum (E), Involucrum (C), and sinus tract (D). In contrast to acute osteomyelitis, chronic osteomyelitis is often not eradicated with intravenous antibiotics alone. All necrotic bone (including the sequestrum) must be resected as it serves as a nidus for infection. Antibiotics should be guided off culture sampling of the infection.
In the referenced article by Parsons and Strauss, the management of chronic osteomyelitis is reviewed.
Parsons B, Strauss E.
Am J Surg. 2004 Jul;188(1A Suppl):57-66. PMID: 15223504 (Link to Abstract)
Average 4.0 of 29 Ratings
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
Success in the treatment of chronic tibial osteomyelitis is dependant on various factors including patient factors (immunocompetency of patient, nutritional status), injury factors (severity of injury as demonstrated by segmental bone loss), and infection factors (the extent and location of infection – metaphyseal infections heal better than mid-diaphyseal infections).
Cierny’s article states that factors affecting prognosis and treatment include: residual foreign materials and/or ischemic and necrotic tissues, host compromise, inappropriate antibiotic coverage, and the lack of patient cooperation or desire.
The second referenced article by Cierny reviews the significant increase in success over the last 20 years in treating infected tibial nonunions, due to pharmacological and technological advances. He reports an increase in limb salvage from 78% to 93% with modern protocols.
Answer 1: Polymicrobial infection portends a worse prognosis than a single organism.
Answer 2: External fixation has not been shown to improve outcomes in chronic osteomyelitis.
Answer 3: MRSA infections are a risk factor for poor outcomes.
Answer 5: Contralateral extremity amputation increases the risk of poor outcomes.
Cierny G 3rd, Mader JT, Penninck JJ.
Clin Orthop Relat Res. 2003 Sep;(414):7-24. PMID: 12966271 (Link to Abstract)
Cierny, CORR 2003
Cierny G 3rd.
Clin Orthop Relat Res. 1999 Mar;(360):97-105. PMID: 10101314 (Link to Abstract)
Cierny, CORR 1999
Average 2.0 of 46 Ratings
HPI - Swelling and pain right thigh - Spontaneous onset, gradually progressive over 03 months. Pain thigh is mild, activity related. No fever/ night pain/ recent trauma / puncture injury. Able to walk full weight bearing.
Likely diagnosis on clincal presentation and plain radiographs
HPI - 55 yo male farmer 14 months s/p ORIF ankle with subsequent infection at 3 months. Outside surgeon removed hardware and patient underwent 8 surgical debridements through old direct medial and lateral incisions. IV abx treatment has continued for last 11 months at time of presentation. He has drainage from medial wound. 1 month prior previous surgeon performed biopsy to confirm osteomyelitis. Previous cultures reveal MRSA osteomyelitis. Patient wishes to keep leg.
MRI/Bone Scan: Reveal focal edema/increased signal within 2 cm of tibiotalar joint.
CT: Reveals nonunion fibula
What management strategy would you offer?
HPI - Continuos secretion through a medial fistula on his tibia for the last 2 years
What is the best approach?
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?
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 - 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?