Prevalence of Osteomyelitis Osteomyelitis 10-15% mild infections - - PowerPoint PPT Presentation

4/5/2014 1

ROLE OF SURGERY IN OSTEOMYELITIS

Monara Dini, DPM Department of Orthopedic Surgery UCSF/SFGH

Prevalence of Osteomyelitis

Osteomyelitis 10-15% mild infections 50% severe infections 1

Osteomyelitis Diagnosis

Probe to bone test (PTB) sensitivity 66%, specificity 85% 2 ESR >70mm/h sensitivity 28%, specificity 100% 3 Plain radiography sensitivity 54%, specificity 68% 4 Radionuclide bone scan sensitivity 86%, specificity 50% 5 MRI sensitivity 90%, specificity 79% 4

Osteomyelitis Definitive Diagnosis

Bone biopsy: Specimens obtained either percutaneously or at

• peration subjected to both histological and

microbiological analysis is the reference standard for bone infection 6,7

4/5/2014 2

Antibiotics vs Surgery

Port of entry? Recurrence? Soft tissue infection vs osteomyelitis?

Exclusively Antibiotic-Based Treatment

8

Exclusively Antibiotic-Based Treatment

In summary all three of these studies have pitfalls. Although remission rates were high the studies:

lacked histpathological/microbiological

confirmation of OM

lacked complete wound closure Involved primarily the forefoot Sharp debridement was performed when deemed

necessary

remission does not indicate cure.

IDSA Guidelines

4 situations in which nonsurgical management of

• steomyelitis might be considered 9

No applicable surgical target Irreparable vascular disease Infection confined to forefoot Surgical management carries excessive risk

4/5/2014 3

Diabetic Foot Surgery Classification

10

Amputation as “Standard” Surgical Treatment

11, 12

Conservative Surgery as Treatment of Osteomyelitis

12

Conclusion

Antibiotic treatment achieves apparent remission Combined approach of conservative surgery and

antibiotics leads to lowest major amputation rates

4/5/2014 4

References

1.

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004;39:885-910

2.

Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. JAMA 1995; 273:721–3.

3.

Kaleta JL, Fleischli JW, Reilly CH. The diagnosis of osteomyelitis in diabetes using erythrocyte sedimentation rate: a pilot study. J Am Podiatr Med Assoc 2001; 91:445–50.

4.

Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for

• steomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis 2008; 47:519–27.

5.

Eckman MH, Greenfield S, Mackey WC, et al. Foot infections in diabetic patients. Decision and cost- effectiveness analyses. JAMA 1995;273:712–20.

6.

Sutton PR, Harley JD, Jacobson AF, Lipsky BA. Diagnosing osteomyelitis with percutaneous bone biopsy in patients with diabetes and foot infections [abstract]. J Gen Intern Med 2000; 15(Suppl 2):6.

7.

Jacobson AF, Harley JD, Lipsky BA, Pecoraro RE. Diagnosis of osteomyelitis in the presence of soft-tissue infection and radiologic evidence of osseous abnormalities: value of leukocyte scintigraphy. AJR Am J Roentgenol 1991; 157:807–12.

8.

Aragon-Sanchez J. Treatment of diabetic foot osteomyelitis: a surgical critique: International J of Lower Extremity Wounds 2010; 9(1): 37-59.

References

9.

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS,Karchmer AW, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004;39:885-910.

10.

Armstrong DG, Lavery LA, Frykberg RG, Wu SC, Boulton AJ. Validation of a diabetic foot surgery

• classification. Int Wound J 2006;3:240-6.

11.

Karchmer AW, Gibbons GW. Foot infections in diabetes: evaluation and management. Curr Clin Top Infect Dis 1994;14:1-22.

12.

Aragón-Sánchez FJ, Cabrera-Galvan JJ, Quintana-Marrero Y, Hernández-Herrero MJ, Lázaro-Martínez JL, García-Morales E, et al. Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement. Diabetologia 2008;51:1962-70.

13.

Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg 2006; 45(5 Suppl):S1-66.