- Infections Abstracts (4)
- Abstracts from the literature and proceedings relating to Orhtopaedic Infections
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Wheeless' Textbook of Orthopaedics
- necrotizing fascitits is any necrotizing soft tissue infection spreading along fascial planes, with or without overlying cellulitis;
- also called Meleney ulcer, NF is severe manifestation of lymphangitis that progresses in a frightening manner within a few hours;
- tissue necrosis develops rapidly behind advancing wall of inflammation that limits penetration by antibiotics;
- desquamation followed by gangrene may be relentless;
- clinical signs of pain, hyperyrexia, and chills are severe;
- skin lesions are incised and drained or aspirated to obtain fluid for culture;
- initial findings are localized pain and minimal swelling, often w/ no visible trauma or discoloration of the skin;
- dermal induration and erythema eventually become evident;
- eventually the patient has limited range of motion, chills, fever;
- dx is confirmed when a probed can be passed laterally along fascial cleft in a open wound;
- blistering of the epidermis is a late finding;
Wheeless' Textbook of Orthopaedics
- predisposing conditions:
- open fracture
- sickle cell anemia
- septic arthritis
- in children, distinguishing between metaphyseal osteomyelitis and septic arthritis can be problematic;
- diabetes (see osteomyelitis in the diabetic patient);
- hematogenous osteomyelitis;
- cierny classification
- chronic osteomyelitis
- vertebral osteomyelitis
- characteristics based on age:
- osteomyelitis in infants
- osteomyelitis in children
Antimicrobial therapy for diabetic foot infections
A practical approach
Kevin W. Shea, MD
VOL 106 / NO 1 / JULY 1999 / POSTGRADUATE MEDICINE
CME learning objectives
To identify factors that influence antibiotic selection in the treatment of diabetic foot infections
To understand the microbiology of the infected diabetic foot
To establish an effective antimicrobial regimen for empirical treatment of diabetic foot infections
Medical Microbiology Section 5. Introduction to Infectious Diseases
100. Bone, Joint, and Necrotizing Soft Tissue Infections
Jon T. Mader
Necrotizing Soft Tissue Infections
Crepitant Anaerobic Cellulitis
Fungal Necrotizing Cellulitis
Diagnosis of Bacterial Arthritis
Diagnosis of Bacterial Osteomyelitis
From Applied Radiology
Radiological Case of the Month
Calcaneal Bone Osteomyelitis
Walter Silbert, MD; Maroun Karam, MD
A 51-year-old white man with a medical history significant for Type I diabetes mellitus and peripheral vascular disease necessitating multiple prior distal amputations presented with increasing right foot pain. He reported no recent trauma or corticosteroid therapy. Physical examination revealed prior transmetatarsal amputation and a large nonhealing ulcer that penetrated deeply to the lateral aspect of the ankle. In addition, erythema, warmth, and edema of the leg and foot were noted, leading to a strong clinical suspicion of osteomyelitis
From Neurosurgical Focus
Cervical Osteomyelitis: A Brief Review
Bryan Barnes, M.D.; Joseph T. Alexander, M.D.; Charles L. Branch Jr., M.D.
Object: The authors conducted a literature-based review of the etiology, diagnosis, and treatment of cervical vertebral osteomyelitis (CVO).
Methods: A Medline (PubMed) search using the key words "cervical vertebral osteomyelitis" yielded 256 articles. These were further screened for relevance, yielding 15 articles. Each publication was reviewed, and several others not identified in the PubMed search were screened and included in the review according to relevance. Each article was identified as involving either the epidemiology/etiology, diagnosis, or treatment of CVO. Separate categories were created for case reports and general reviews.
Conclusions: Cervical vertebral osteomyelitis has a spectrum of origins, which include spontaneous, postoperative, traumatic, and hematogenously spread causes. The majority of patients have medical risk factors and comorbidities that include diabetes, trauma, drug abuse, and infectious processes in extraspinal areas. The diagnosis of CVO can be accomplished in most cases by using plain x-ray films and computerized tomography scans. Nevertheless, preferential use of magnetic resonance imaging in cases in which there is a neurological deficit is helpful in identifying epidural compressive processes. Treatment for CVO can be successfully initiated with intravenous antibiotic therapy. Nevertheless, in cases in which there is a neurological deficit, spinal deformity and/or progressive lysis, or intractable pain, the earliest feasible surgical intervention with debridement and fusion is warranted.
Conservative Management of Diabetic Foot Ulcers Complicated by Osteomyelitis
from Wounds 2002
NG Yadlapalli, MD, Anand Vaishnav, MD, and Peter Sheehan, MD
Osteomyelitis of the diabetic foot remains a difficult clinical infection, often resulting in disability and amputation. Standard management consists of thorough removal of all infected bone in conjunction with antimicrobial therapy. This may have an untoward effect on foot mechanics and may increase risk of future ulcer events. In order to evaluate the efficacy of a more conservative approach, we retrospectively assessed the outcomes patients managed by an interdisciplinary team of comprehensive inpatient and outpatient care. Over a three-year period, 160 patients were identified by a discharge database with osteomyelitis; of these, 58 had outpatient follow-up records for at least 12 months. The treatment regimen consisted of conservative debridement or surgery, four to six weeks of empiric intravenous antibiotics, and biomechanical offloading of pressure impediments to wound healing. Initial procedures were debridement (34 patients), excision of bone (13 patients), toe or ray amputation (8 patients), and major amputation (3 patients). The mean duration of antibiotic therapy was 40.3 days. At twelve-months follow up, twelve patients (20.7%) failed treatment, with nine patients having persistent ulcers, and three patients requiring amputation. The remaining 46 patients healed (79.3%). Three patients had ulcer recurrence and 21 patients had new ulcer episodes in the follow-up observation period. In conclusion, an approach to osteomyelitis in the diabetic foot that is based on conservative surgical intervention, long-term empiric antibiotics, and interdisciplinary wound care and offloading may be a safe and effective alternative to amputation in selected patients.
Read 1 Review
From Applied Radiology
Timothy C. Sloan, DVM, MD, Jason Hosey, MD
A 51-year-old man presented to the emergency department with chest pain radiating to the right shoulder. The pain had been present for several months but had become refractory to analgesics. Past medical history was remarkable for recently diagnosed diabetes mellitus with negative cardiac and gastrointestinal workups. Physical examination revealed the patient had a low-grade fever and pain localized over the midthoracic spine. A radiograph of the thoracic spine (Figure 1) prompted subsequent computed tomography (CT; Figure 2) and magnetic resonance (MR; Figure 3) examinations.
Diagnosis and Management of Adult Pyogenic Osteomyelitis of the Cervical Spine
Frank L. Acosta Jr., M.D.; Cynthia T. Chin, M.D.; Alfredo Quiñones-Hinojosa, M.D.; Christopher P. Ames, M.D.; Philip R. Weinstein, M.D.; Dean Chou, M.D
Establishing the diagnosis of cervical osteomyelitis in a timely fashion is critical to prevent catastrophic neurological injury. In the modern imaging era, magnetic resonance imaging in particular has facilitated the diagnosis of cervical osteomyelitis, even before the onset of neurological signs or symptoms. Nevertheless, despite advancements in diagnosis, disagreement remains regarding appropriate surgical treatment. The role of instrumentation and type of graft material after cervical decompression remain controversial. The authors describe the epidemiological features, pathogenesis, and diagnostic evaluation, and the surgical and nonsurgical interventions that can be used to treat osteomyelitis of the cervical spine. They also review the current debate about the role of instrumentation in preventing spinal deformity after surgical decompression for cervical osteomyelitis. Based on this review, the authors conclude that nonsurgical therapy is appropriate if neurological signs or symptoms, instability, deformity, or spinal cord compression are absent. Surgical decompression, debridement, stabilization, and deformity correction are the goals once the decision to perform surgery has been made. The roles of autogenous graft, instrumentation, and allograft have not been clearly delineated with Class I data, but the authors believe that spinal stability and decompression override creating an environment that can be completely sterilized by antibiotic drugs.
Abstract and Introduction
Epidemiology and Etiology
Editorial Paediatrics and Child Health
May/June 2001, Volume 6, Number 5
Flesh-eating disease: A note on necrotizing fasciitis
H Dele Davies MD MSc, Child Health Research Unit, Alberta Children’s Hospital and Departments of Pediatrics, Microbiology and Infectious Diseases and Community Health Sciences, University of Calgary, Calgary, Alberta
There has been much media attention in the past few years to the condition dubbed ‘flesh-eating disease’, which refers, primarily, to a form of invasive group A beta hemolytic streptococcal (GABHS) infection that leads to fascia and muscle necrosis. In 1999, the Canadian Paediatric Society issued a statement on the state of knowledge and management of children, and close contacts of persons with all-invasive GABHS disease (1). The present note is intended to deal specifically with necrotizing fasciitis (NF) by providing an update on the limited current state of knowledge, diagnosis and management. Surveillance to establish actual national rates and epidemiology of NF through the Canadian Paediatric Society is proposed.
Necrotizing soft-tissue infections encompass a wide variety of clinical syndromes resulting from introduction of various pathogens into injured or devitalized tissue. The extent of microbial involvement in such tissue may range from simple contamination, which results in self-limited bacterial proliferation with few, if any, clinical symptoms to overt and progressive local tissue necrosis, which, if untreated, may lead to septicemia and death. Early differentiation among these infections is not always possible, as there are overlapping classification criteria.
This chapter will provide an overview of necrotizing soft-tissue infections in the upper extremity focusing on gas gangrene, or clostridial myonecrosis, and necrotizing fasciitis to facilitate early diagnosis and optimal management of these lethal diseases.
Authors - Waldo E. Floyd III, M.D. Betsy N. Perry, MD
Mercer University School of Medicine
Emory University School of Medicine
Macon, GA 31201
Currents: Fall 2002, Volume 3, Number 4
Hyperbaric oxygen therapy enhances tissue healing
Zlatko Anguelov (in collaboration with Eric Greensmith, M.D.)
History: Compressed air has been used as a therapeutic tool since medieval times with variable success and without any knowledge of what may cause its beneficial effect on disease. In the mid-1950s hyperbaric oxygen (HBO) came into use in the U.S. and the Netherlands, especially for conducting surgical operations under pressure. Clinicians noted that patients were less cyanotic after anesthesia in a hyperbaric chamber and since, nitrous oxide became a powerful anesthetic when administered under increased pressure. HBO use declined in the early 1970s because of lack of serious research on the mechanisms of action and appropriate indications. In this country a revival of the field occurred in the late 1970s when the Undersea Medical Society became involved in clinical hyperbarics, and a textbook on HBO therapy was published.
University of Iowa
Hyperbaric Oxygen Therapy In Necrotizing Fasciitis: Panacea, Useful Adjunct, or Nostrum?
J. Jeffrey Brown, MD
"...hyperbaric oxygen has drawn a dramatic line between those who do not have a hyperbaric chamber and are skeptic, and those who do have one and believe." TK Hunt(1)
The overall mortality rate of patients with necrotizing fasciitis approaches 40%.(2) Hollabough et al.(3) have reported their experiences with the use of adjunctive hyperbaric oxygen therapy (HBO) and reduced the mortality rates in patients with Fournier's gangrene from 42% (5/12) in those who did not receive HBO to 7% (1/14) in those treated with HBO. While it might seem that the surgical community would embrace a treatment modality that promised such a dramatic benefit, the fact is that skepticism seems to be the prevailing sentiment in most major surgical texts and review articles. Namely, that until the results of prospective randomized trials are reported the use of HBO in necrotizing soft tissue infections must be considered only potentially useful. Unfortunately, Hollabaugh's study does not meet these rigid criteria.
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