Description: OTA 2002 - Session 2 Session II - Post-Traumatic Reconstruction Fri., 10/11/02 Post Traumatic Reconstruction, Paper #12, 3:25 PM The Impact of a Dedicated Skeletal Infectious Disease Specialist in
the Treatment of Chronic and Post-Traumatic Skeletal Infections Bruce H. Ziran, MD ; N. Rao, MD; Joon Y. Lee, MD; Ronald
A. Hall, MD; University of Pittsburgh, Department of Orthopaedics, Pittsburgh,
Pennsylvania, USA Purpose: The collaboration of an infectious disease specialist
with the orthopaedic surgeon should theoretically provide a more comprehensive
approach to the treatment of osteomyelitis. At our institution, the surgeon
who treated most of the skeletal infections initially began without dedicated
support from the infectious disease department. This was followed by the
introduction of an infectious disease specialist who was dedicated to the
treatment of skeletal infections. We evaluated the impact of such a collaboration
to establish whether there was any benefit from the team approach. We hypothesized
that successful ablation or suppression of skeletal infections is improved
with use of such a dedicated team. Methods: A consecutive cohort of 70 patients with known skeletal
infections was treated. The protocol consisted of staging, debridement and
resection, and antibiotic therapy, followed by reconstruction in all cases.
All patients had tech/ind scans, MRI when possible, ESR/CRP, and clinical
evaluation for staging. A tumor type resection (bleeding bone/soft tissue)
was performed followed by the use of antibiotic bead spacers. After antibiotic
therapy, reconstruction was performed. Inclusion criteria were all chronic
or posttraumatic Cierny-Mader type III and IV infections. The treatment
for patients was either suppression or attempted ablation. Patients were
evaluated clinically, radiographically, and with laboratory values of ESR/CRP.
Ablation was defined as the normalization of laboratory parameters, clinical
and radiographic absence of infection, and a salvaged limb. In the cases
of suppression, continued antibiotic usage was considered necessary and
did not define a failed result. Failure was the persistence or re-emergence
of infection. Primary amputations were not included, but amputations after
attempted ablation/suppression were considered failures. Statistical analysis
was performed using chi square analysis and logistic regression. For the
first time period (group I), the antibiotic management was handled by the
consulting staff on call for infectious diseases. In the second time period
(group 2), a dedicated infectious disease specialist co-managed the patients
with a more intense approach to antibiotic regimens and postoperative management.
The orthopaedic and infectious disease team saw patients together in the
office. Results: We identified 70 patients with posttraumatic osteomyelitis.
The skeletal sites in group I included humerus, 3; radius, 2; pelvis, 5;
femur,12; tibia, 19; calcaneus, 2; and in group II, humerus,1; radius, 1;
pelvis, 5; femur, 5; tibia, 12; and calcaneus, 3. There were 43 patients
in group I (non-team) and 27 patients in group II (orthopaedic and infectious
disease team). There was no change in the surgical protocol or technique,
and the most noteworthy difference was a more refined and prolonged antibiotic
regimen. Oral antibiotics were administered for between 3 and 16 months
during the healing of the reconstructive phase of treatment to minimize
occult seeding of implants and grafts during the revascularization of the
reconstructed elements. There were 18 of 43 (42%) successful treatments
in group I compared with 21 of 27 (78%) in group II ( P <0.003).
Stratification was then done by infection type and host class. Of type III
cases, there were 13 of 23 (56%) successes in group I and 9 of 10 (90%)
in group II ( P <0.065). For type IV cases, there were 5 of 20 (25%)
successes in group I and 12 of 17 (71%) in group II ( P <0.003).
When stratified by host class B-local hosts, there were 11 of 22 (50%) successes
in group I and 12 of 15 (80%) successes in group II (**). For type B-systemic/local
hosts, there were 3 of 13 (23%) successes in group I and 6 of 8 (75%) successes
in group II (**). For C hosts, there were 4 of 8 (50%) successes in group
I and 3 of 4 (75%) successes in group II (**). Of the 25 patients with failed
treatment in group I, 7 went on to either amputation or chronic suppression.
The 18 remaining treatment failures had evidence of ongoing and active osteomyelitis
and were subsequently treated by the dedicated orthopaedic/infectious disease
team separately. Fourteen of these 18 patients went on to successful treatment.
Of the six failed treatments in group II, two had amputation, three have
ongoing treatment for an aseptic nonunion, and one is chronically suppressed. Discussion: Our results offer an interesting insight into the
management of difficult skeletal infections. The main paradigm shift was
a more involved and dedicated infectious disease specialist. Multi-drug
regimens were implemented that were synergistic and of longer duration of
treatment, based on surgical, clinical, laboratory, and radiographic information.
The impact of the team approach was especially noted with more severe infections
(type IV) and with compromised hosts (B-sys/loc). Although, more expensive
in terms of antibiotic usage, the savings in cost may be realized by the
efficacy of treatment (fewer hospitalizations, less lost time from work,
fewer surgical procedures, etc.). We recognize that the existing literature
recommends the need for shorter duration of antibiotic treatment, but we
have not been able to duplicate successful results with such a regimen.
Furthermore, the patients we treated often had more extensive and established
infections, requiring greater resections and more extensive reconstructions.
On the basis of our findings, we believe that the team approach to skeletal
infections facilitates care for both the patients and the providers. Further
study is warranted. Group 1 B-local B-sys/local C Type III 11/14 2/7 0/2 13/23* Type IV 0/8 1/6 4/6 5/20** 11/22 3/13 4/8 18/43*** Group 2 B-local B-sys/local C Type III 4/5 4/4 1/1 9/10* Type IV 8/10 2/4 2/3 12/17** 12/15 6/8 3/4 21/27*** * Type III: Group I vs. group II, P <0.065, odds ratio 6.92 (0.89, 54.0) ** Type IV: Group I vs. group II, P <0.006, odds ratio 7.2 (1.75, 29.62) *** Overall: Group I vs. group II, P <0.003, odds ratio 4.86 (1.68, 14.03)
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