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A 41-year-old male sustained the open injury shown in Figures A and B after a motor vehicle accident. He was treated with a tibial intramedullary nail (IMN). The patient presents to your clinic 12 months from his surgery with persistent pain at the fracture site. Figures C-E are the most recent imaging findings. His ESR and CRP are elevated. The decision is made to proceed with irrigation and debridement and nail exchange for a polymethylmethacrylate (PMMA) with vancomycin and tobramycin impregnated IMN. The peak antibiotic elution from an antibiotic-impregnated IMN is expected to occur at what time from surgery?
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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.
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