[ORT-L] femur infection - Orthopedics Forum


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[ORT-L] femur infection

william.obremskey at Vanderbilt
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Mar 24, 2008, 3:56 AM

Post #1 of 8 (1086 views)
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[ORT-L] femur infection	Can't Post

42 yo healthy married male school teacher w/ no risk factors presented
w/ increasing pain in thigh for 2 mos and finally unable to walk to
local ED. Noted to have increased labs and minimal bony reaction of
left femur w/ MRI consistent w/ abscess. He had I&D at local hospital
of thigh and "drilling" of later femur cortex. All intra op cultures
were negative, but one blood culture positive for MRSA. Patient
compliant w/ 6 weeks of IV Vanco and while partial wt bearing on
crutches had a femoral shaft fx and presented to me. Xrays and MR
images are in Powerpoint. I&D of entire femur done from lateral;
approach and canal reamed w/ RIA to 16 mm, ex fix placed . No gross
puss, but debrided reactive tissue around anterior and lateral femur.
All cultures neg for bacteria and fungus. Antibiotic cement placed
along lateral femur. Pt has had minimal systemic symptoms or local
reaction to impressive progression of infection. Now on Vanco and
Levaquinn. ID di not feel antifungals indicated.

Any thoughts or experience w/ similar situation?. Will remove ex fix at
approx 4 weeks and plan on later revision ORIF and bonegraft if cultures
from another debridement are negative and labs have returned to normal.

WTO

William T Obremskey MD MPH

Vanderbilt Orthopedic Trauma

Associate Professor Divsion of Orthopedic Trauma

Director of Orthopedic Trauma Research and Education

Suite 4200 Medical Center East - South Tower

Nashville, TN 37232-8774

615-936-0112- office

615-936-1566- fax

Attachments:

Healthy 42 yo male.ppt (1.23 MB)

fx77 at optonline
New User

Mar 24, 2008, 5:51 AM

Post #2 of 8 (1085 views)
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RE: [ORT-L] femur infection [In reply to]	Can't Post

Dr. Murray at MD Anderson gave a lecture once and said to Biopsy your pus
and Culture your tumors. Just to be sure it is OM

I had one such case which for all the world looked like and behaved like OM
and turned out to be lymphoma and led to a forequarter.

JMHO.

From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Obremskey, William T
Sent: Monday, March 24, 2008 6:57 AM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] femur infection

42 yo healthy married male school teacher w/ no risk factors presented w/
increasing pain in thigh for 2 mos and finally unable to walk to local ED.
Noted to have increased labs and minimal bony reaction of left femur w/ MRI
consistent w/ abscess. He had I&D at local hospital of thigh and "drilling"
of later femur cortex. All intra op cultures were negative, but one blood
culture positive for MRSA. Patient compliant w/ 6 weeks of IV Vanco and
while partial wt bearing on crutches had a femoral shaft fx and presented to
me. Xrays and MR images are in Powerpoint. I&D of entire femur done from
lateral; approach and canal reamed w/ RIA to 16 mm, ex fix placed . No
gross puss, but debrided reactive tissue around anterior and lateral femur.
All cultures neg for bacteria and fungus. Antibiotic cement placed along
lateral femur. Pt has had minimal systemic symptoms or local reaction to
impressive progression of infection. Now on Vanco and Levaquinn. ID di not
feel antifungals indicated.

Any thoughts or experience w/ similar situation?. Will remove ex fix at
approx 4 weeks and plan on later revision ORIF and bonegraft if cultures
from another debridement are negative and labs have returned to normal.

WTO

William T Obremskey MD MPH

Vanderbilt Orthopedic Trauma

Associate Professor Divsion of Orthopedic Trauma

Director of Orthopedic Trauma Research and Education

Suite 4200 Medical Center East - South Tower

Nashville, TN 37232-8774

615-936-0112- office

615-936-1566- fax

mmcandrew at siumed
New User

Mar 24, 2008, 6:49 AM

Post #3 of 8 (1085 views)
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Re: [ORT-L] femur infection [In reply to]	Can't Post

tough case, probably not as normal a host as his past history indicates
did you saucerize any of the shaft and see and sample the sequestrum?
reamed products make it difficult to get a sense of diaphyseal bone's
condition and involvement.
i would hesitate to internally fix until diaphyseal bone evolution
complete, complete dissolution or further sequestration. bone grafting
probably not necessary, involucrum seems to have bridged fx already.
outcome please
thanks

Obremskey, William T wrote:
>
> 42 yo healthy married male school teacher w/ no risk factors presented
> w/ increasing pain in thigh for 2 mos and finally unable to walk to
> local ED. Noted to have increased labs and minimal bony reaction of
> left femur w/ MRI consistent w/ abscess. He had I&D at local hospital
> of thigh and �drilling� of later femur cortex. All intra op cultures
> were negative, but one blood culture positive for MRSA. Patient
> compliant w/ 6 weeks of IV Vanco and while partial wt bearing on
> crutches had a femoral shaft fx and presented to me. Xrays and MR
> images are in Powerpoint. I&D of entire femur done from lateral;
> approach and canal reamed w/ RIA to 16 mm, ex fix placed . No gross
> puss, but debrided reactive tissue around anterior and lateral femur.
> All cultures neg for bacteria and fungus. Antibiotic cement placed
> along lateral femur. Pt has had minimal systemic symptoms or local
> reaction to impressive progression of infection. Now on Vanco and
> Levaquinn. ID di not feel antifungals indicated.
>
> Any thoughts or experience w/ similar situation?. Will remove ex fix
> at approx 4 weeks and plan on later revision ORIF and bonegraft if
> cultures from another debridement are negative and labs have returned
> to normal.
>
> WTO
>
> William T Obremskey MD MPH
>
> Vanderbilt Orthopedic Trauma
>
> Associate Professor Divsion of Orthopedic Trauma
>
> Director of Orthopedic Trauma Research and Education
>
> Suite 4200 Medical Center East - South Tower
>
> Nashville, TN 37232-8774
>
> 615-936-0112- office
>
> 615-936-1566- fax
>
---
[This E-mail scanned for viruses by Declude Virus]

nswolfso at usc
New User

Mar 24, 2008, 9:11 AM

Post #4 of 8 (1085 views)
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Re: [ORT-L] femur infection [In reply to]	Can't Post

Interesting case. We have this type of pathology every week.

I agree: look for underlying cause: tumor would be # 1. Hemathological, immunocompromized patient...

In this particular case systemic treatment is as important as local.

Systemic: need cultures of every possible type, including TB( including biopsy..). AB treatment according to the cultures.
Local:
I would not leave extramedully AB cement rod for too long. Ex fix is not stable for this femur. It will not work as a definite fixation. I would consider Circular frame even going through the shaft. To me it is all about stability.
Consider IM AB loaded cemented rod as supplement , for 4-6 weeks. to be removed later.

I would not ORIF with the bone graft, despite the fact that it will likely heal. Reason the same: MRSA to me is not good for bone graft with ORIF. Not for fracture healing , for the future possible problems

This femur is different. It is healing, I am just concerned it is going to heal with some "infected" callus.
Once again: the periosteal elevation is indicative to me to some hemathogenous, oncological process rather than simple osteo with abscess.

Would love to know the outcome.

Good luck

Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Keck School of Medicine
University of Southern California
nswolfso@usc.edu
(323) 226-7346 phone
http://www.usc.edu/medicine/orthopaedic_surgery

----- Original Message -----
From: "Obremskey, William T" <william.obremskey@Vanderbilt.Edu>
Date: Monday, March 24, 2008 4:11 am
Subject: [ORT-L] femur infection
To: ORT-L@www2.aaos.org

> 42 yo healthy married male school teacher w/ no risk factors presented
> w/ increasing pain in thigh for 2 mos and finally unable to walk to
> local ED. Noted to have increased labs and minimal bony reaction of
> left femur w/ MRI consistent w/ abscess. He had I&D at local hospital
> of thigh and "drilling" of later femur cortex. All intra op cultures
> were negative, but one blood culture positive for MRSA. Patient
> compliant w/ 6 weeks of IV Vanco and while partial wt bearing on
> crutches had a femoral shaft fx and presented to me. Xrays and MR
> images are in Powerpoint. I&D of entire femur done from lateral;
> approach and canal reamed w/ RIA to 16 mm, ex fix placed . No gross
> puss, but debrided reactive tissue around anterior and lateral femur.
> All cultures neg for bacteria and fungus. Antibiotic cement placed
> along lateral femur. Pt has had minimal systemic symptoms or local
> reaction to impressive progression of infection. Now on Vanco and
> Levaquinn. ID di not feel antifungals indicated.
>
> Any thoughts or experience w/ similar situation?. Will remove ex
> fix at
> approx 4 weeks and plan on later revision ORIF and bonegraft if
> culturesfrom another debridement are negative and labs have
> returned to normal.
>
>
>
> WTO
>
>
>
> William T Obremskey MD MPH
>
> Vanderbilt Orthopedic Trauma
>
> Associate Professor Divsion of Orthopedic Trauma
>
> Director of Orthopedic Trauma Research and Education
>
> Suite 4200 Medical Center East - South Tower
>
> Nashville, TN 37232-8774
>
> 615-936-0112- office
>
> 615-936-1566- fax
>
>
>
>
---
[This E-mail scanned for viruses by Declude Virus]

alex61 at gmail
New User

Mar 24, 2008, 10:53 AM

Post #5 of 8 (1085 views)
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Re: [ORT-L] femur infection [In reply to]	Can't Post

Dear colleagues

2008/3/24, Nikolaj Wolfson <nswolfso@usc.edu>:
>
> I would not leave extramedully AB cement rod for too long. Ex fix is not
> stable for this femur. It will not work as a definite fixation. I would
> consider Circular frame even going through the shaft. To me it is all about
> stability.
> Consider IM AB loaded cemented rod as supplement , for 4-6 weeks. to be
> removed later.
>

Or antibiotic cement coated locked nail can be used instead of external
fixator. Since the canal is reamed to 16 mm it can be made ex tempore rather
easily with 10 mm nail and appropriate silicone tube. And grafting could be
avoided.
The situation in general is very unclear though.

--
Best regards,
Alexander N. Chelnokov
Ural Scientific Research Institute
of Traumatology and Orthopaedics
7, Bankovsky str. Ekaterinburg 620014 Russia

william.obremskey at Vanderbilt
New User

Mar 24, 2008, 11:26 AM

Post #6 of 8 (1085 views)
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RE: [ORT-L] femur infection [In reply to]	Can't Post

Good thought. Have discussed case w/ our tumor MD and send biopsy at debridement and no concern for neoplasm.

WTO

________________________________

From: ORT-L-owner@www2.aaos.org on behalf of Bruce Meinhard
Sent: Mon 3/24/2008 5:51 AM
To: ORT-L@www2.aaos.org
Subject: RE: [ORT-L] femur infection

Dr. Murray at MD Anderson gave a lecture once and said to Biopsy your pus and Culture your tumors. Just to be sure it is OM

I had one such case which for all the world looked like and behaved like OM and turned out to be lymphoma and led to a forequarter.

JMHO.

From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf Of Obremskey, William T
Sent: Monday, March 24, 2008 6:57 AM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] femur infection

42 yo healthy married male school teacher w/ no risk factors presented w/ increasing pain in thigh for 2 mos and finally unable to walk to local ED. Noted to have increased labs and minimal bony reaction of left femur w/ MRI consistent w/ abscess. He had I&D at local hospital of thigh and "drilling" of later femur cortex. All intra op cultures were negative, but one blood culture positive for MRSA. Patient compliant w/ 6 weeks of IV Vanco and while partial wt bearing on crutches had a femoral shaft fx and presented to me. Xrays and MR images are in Powerpoint. I&D of entire femur done from lateral; approach and canal reamed w/ RIA to 16 mm, ex fix placed . No gross puss, but debrided reactive tissue around anterior and lateral femur. All cultures neg for bacteria and fungus. Antibiotic cement placed along lateral femur. Pt has had minimal systemic symptoms or local reaction to impressive progression of infection. Now on Vanco and Levaquinn. ID di not feel antifungals indicated.

Any thoughts or experience w/ similar situation?. Will remove ex fix at approx 4 weeks and plan on later revision ORIF and bonegraft if cultures from another debridement are negative and labs have returned to normal.

WTO

William T Obremskey MD MPH

Vanderbilt Orthopedic Trauma

Associate Professor Divsion of Orthopedic Trauma

Director of Orthopedic Trauma Research and Education

Suite 4200 Medical Center East - South Tower

Nashville, TN 37232-8774

615-936-0112- office

615-936-1566- fax

william.obremskey at Vanderbilt
New User

Mar 24, 2008, 11:39 AM

Post #7 of 8 (1085 views)
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RE: [ORT-L] femur infection [In reply to]	Can't Post

Thanks for your insight. I also was suspicious for immunocompromised cause, but ID has worked up HIV, drug use, etc. and all negative. He seems like a normal working middle class guy with no history of weird or multiple infections. He certainly progressed on IV antibiotics.
I had planned on putting antibiotic IMN intramedullary and no fixation as is commonly done in tibia IMN infection, but worried about long lever arm and fracture of cement and difficult cement nail extraction so I compromised with Ex fix and antibiotic nail next to bone.
Suugestions on definitive fixation w/ IMN or plate and risk of persistent infx? The biopsy of bone prior to fixation is a good idea as well.
Agree w/ Marc McAndrew that it appears to be trying to heal.

WTO

________________________________

From: ORT-L-owner@www2.aaos.org on behalf of Nikolaj Wolfson
Sent: Mon 3/24/2008 9:11 AM
To: ORT-L@www2.aaos.org
Subject: Re: [ORT-L] femur infection

Interesting case. We have this type of pathology every week.

I agree: look for underlying cause: tumor would be # 1. Hemathological, immunocompromized patient...

In this particular case systemic treatment is as important as local.

Systemic: need cultures of every possible type, including TB( including biopsy..). AB treatment according to the cultures.
Local:
I would not leave extramedully AB cement rod for too long. Ex fix is not stable for this femur. It will not work as a definite fixation. I would consider Circular frame even going through the shaft. To me it is all about stability.
Consider IM AB loaded cemented rod as supplement , for 4-6 weeks. to be removed later.

I would not ORIF with the bone graft, despite the fact that it will likely heal. Reason the same: MRSA to me is not good for bone graft with ORIF. Not for fracture healing , for the future possible problems

This femur is different. It is healing, I am just concerned it is going to heal with some "infected" callus.
Once again: the periosteal elevation is indicative to me to some hemathogenous, oncological process rather than simple osteo with abscess.

Would love to know the outcome.

Good luck

Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Keck School of Medicine
University of Southern California
nswolfso@usc.edu
(323) 226-7346 phone
http://www.usc.edu/medicine/orthopaedic_surgery

----- Original Message -----
From: "Obremskey, William T" <william.obremskey@Vanderbilt.Edu>
Date: Monday, March 24, 2008 4:11 am
Subject: [ORT-L] femur infection
To: ORT-L@www2.aaos.org

> 42 yo healthy married male school teacher w/ no risk factors presented
> w/ increasing pain in thigh for 2 mos and finally unable to walk to
> local ED. Noted to have increased labs and minimal bony reaction of
> left femur w/ MRI consistent w/ abscess. He had I&D at local hospital
> of thigh and "drilling" of later femur cortex. All intra op cultures
> were negative, but one blood culture positive for MRSA. Patient
> compliant w/ 6 weeks of IV Vanco and while partial wt bearing on
> crutches had a femoral shaft fx and presented to me. Xrays and MR
> images are in Powerpoint. I&D of entire femur done from lateral;
> approach and canal reamed w/ RIA to 16 mm, ex fix placed . No gross
> puss, but debrided reactive tissue around anterior and lateral femur.
> All cultures neg for bacteria and fungus. Antibiotic cement placed
> along lateral femur. Pt has had minimal systemic symptoms or local
> reaction to impressive progression of infection. Now on Vanco and
> Levaquinn. ID di not feel antifungals indicated.
>
> Any thoughts or experience w/ similar situation?. Will remove ex
> fix at
> approx 4 weeks and plan on later revision ORIF and bonegraft if
> culturesfrom another debridement are negative and labs have
> returned to normal.
>
>
>
> WTO
>
>
>
> William T Obremskey MD MPH
>
> Vanderbilt Orthopedic Trauma
>
> Associate Professor Divsion of Orthopedic Trauma
>
> Director of Orthopedic Trauma Research and Education
>
> Suite 4200 Medical Center East - South Tower
>
> Nashville, TN 37232-8774
>
> 615-936-0112- office
>
> 615-936-1566- fax
>
>
>
>
---
[This E-mail scanned for viruses by Declude Virus]

nswolfso at usc
New User

Mar 24, 2008, 12:01 PM

Post #8 of 8 (1085 views)
Shortcut

Re: RE: [ORT-L] femur infection [In reply to]	Can't Post

There must be some form of other than infection going on. Leukemia, MM, ??

Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Keck School of Medicine
University of Southern California
nswolfso@usc.edu
(323) 226-7346 phone
http://www.usc.edu/medicine/orthopaedic_surgery

----- Original Message -----
From: "Obremskey, William T" <william.obremskey@Vanderbilt.Edu>
Date: Monday, March 24, 2008 11:41 am
Subject: RE: [ORT-L] femur infection
To: ORT-L@www2.aaos.org

> Thanks for your insight. I also was suspicious for
> immunocompromised cause, but ID has worked up HIV, drug use, etc.
> and all negative. He seems like a normal working middle class guy
> with no history of weird or multiple infections. He certainly
> progressed on IV antibiotics.
> I had planned on putting antibiotic IMN intramedullary and no
> fixation as is commonly done in tibia IMN infection, but worried
> about long lever arm and fracture of cement and difficult cement
> nail extraction so I compromised with Ex fix and antibiotic nail
> next to bone.
> Suugestions on definitive fixation w/ IMN or plate and risk of
> persistent infx? The biopsy of bone prior to fixation is a good
> idea as well.
> Agree w/ Marc McAndrew that it appears to be trying to heal.
>
> WTO
>
> ________________________________
>
> From: ORT-L-owner@www2.aaos.org on behalf of Nikolaj Wolfson
> Sent: Mon 3/24/2008 9:11 AM
> To: ORT-L@www2.aaos.org
> Subject: Re: [ORT-L] femur infection
>
>
>
> Interesting case. We have this type of pathology every week.
>
> I agree: look for underlying cause: tumor would be # 1.
> Hemathological, immunocompromized patient...
>
> In this particular case systemic treatment is as important as local.
>
> Systemic: need cultures of every possible type, including TB(
> including biopsy..). AB treatment according to the cultures.
> Local:
> I would not leave extramedully AB cement rod for too long. Ex fix
> is not stable for this femur. It will not work as a definite
> fixation. I would consider Circular frame even going through the
> shaft. To me it is all about stability.
> Consider IM AB loaded cemented rod as supplement , for 4-6 weeks.
> to be removed later.
>
> I would not ORIF with the bone graft, despite the fact that it
> will likely heal. Reason the same: MRSA to me is not good for bone
> graft with ORIF. Not for fracture healing , for the future
> possible problems
>
> This femur is different. It is healing, I am just concerned it is
> going to heal with some "infected" callus.
> Once again: the periosteal elevation is indicative to me to some
> hemathogenous, oncological process rather than simple osteo with
> abscess.
> Would love to know the outcome.
>
> Good luck
>
> Nikolaj Wolfson, MD, FRCSC
> Assistant Professor of Orthopaedic Surgery
> Department of Orthopaedic Surgery
> Keck School of Medicine
> University of Southern California
> nswolfso@usc.edu
> (323) 226-7346 phone
> http://www.usc.edu/medicine/orthopaedic_surgery
>
>
> ----- Original Message -----
> From: "Obremskey, William T" <william.obremskey@Vanderbilt.Edu>
> Date: Monday, March 24, 2008 4:11 am
> Subject: [ORT-L] femur infection
> To: ORT-L@www2.aaos.org
>
> > 42 yo healthy married male school teacher w/ no risk factors
> presented> w/ increasing pain in thigh for 2 mos and finally
> unable to walk to
> > local ED. Noted to have increased labs and minimal bony
> reaction of
> > left femur w/ MRI consistent w/ abscess. He had I&D at local
> hospital> of thigh and "drilling" of later femur cortex. All
> intra op cultures
> > were negative, but one blood culture positive for MRSA. Patient
> > compliant w/ 6 weeks of IV Vanco and while partial wt bearing on
> > crutches had a femoral shaft fx and presented to me. Xrays and MR
> > images are in Powerpoint. I&D of entire femur done from lateral;
> > approach and canal reamed w/ RIA to 16 mm, ex fix placed . No gross
> > puss, but debrided reactive tissue around anterior and lateral
> femur.> All cultures neg for bacteria and fungus. Antibiotic
> cement placed
> > along lateral femur. Pt has had minimal systemic symptoms or local
> > reaction to impressive progression of infection. Now on Vanco and
> > Levaquinn. ID di not feel antifungals indicated.
> >
> > Any thoughts or experience w/ similar situation?. Will remove ex
> > fix at
> > approx 4 weeks and plan on later revision ORIF and bonegraft if
> > culturesfrom another debridement are negative and labs have
> > returned to normal.
> >
> >
> >
> > WTO
> >
> >
> >
> > William T Obremskey MD MPH
> >
> > Vanderbilt Orthopedic Trauma
> >
> > Associate Professor Divsion of Orthopedic Trauma
> >
> > Director of Orthopedic Trauma Research and Education
> >
> > Suite 4200 Medical Center East - South Tower
> >
> > Nashville, TN 37232-8774
> >
> > 615-936-0112- office
> >
> > 615-936-1566- fax
> >
> >
> >
> >
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
>
>
>
---
[This E-mail scanned for viruses by Declude Virus]

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