Date: Wed, 16 Apr 2003 00:49:25 +0000

From: Jeff Richmond

This is a pleasant 23 year old 375lb+ schizophrenic male with a seizure disorder, non-smoker, who had an open tibia fracture in December 2002, complicated by infection and treated(apparently) by multiple debridements (organism unknown). He is not sure specifically where this was done other than "Down south," which on Long Island means west of the Hudson River. He currently resides in an automobile parked near the hospital, where he was admitted last week because of fevers to 103f and a "warm leg" with no other apparent source. He was placed on ancef by the medical service, who admitted him without xrays and only today called an ortho consult.

Wounds are well healed. There are no signs of drainage, and the medial skin graft looks good. He is bearing full weight without pain.

What next for this unreliable guy? How long does he need to be off antibiotics to insure a reliable culture? Should I remove the nail now and ream the canal, or should he be suppressed to allow for further consolidation of the fracture, follwed by I&D/ROH? Does anyone have any experience with resorbable (ie osteoset) antibiotic beads in the medullary canal?

Thanks.

Jeff Richmond
North Shore University Hospital
Manhasset, New York

Date: Tue, 15 Apr 2003 20:12:08 -0500

From: Andrew H. Schmidt

Jeff,

We see cases like this several times a year - always tough to know what to do. I'd recommend getting oblique x-rays and measuring ESR and CRP levels. Based on the xrays that you provided, and his lack of pain, I'd suggest that you could go ahead and remove the rod and ream the canal. Obviously, you'd send a lot of cultures, and I'd give him Vanco to cover MRSA or coag-neg staph. Regarding beads, I usually use PMMA beads and remove them (with a second reaming) after a couple weeks. We used the Osteoset beads for a while, but I didn't like the way that they handled. If you think that he needed continued protection, you could replace the nail at that time. In cases of gross infection and an ununited fracture, I have put some beads inside the second nail. If he seems solidly united, removing the nail and reaming often works, including a 6 weeks course of antibiotic therapy.

Andy Schmidt

Andrew H. Schmidt, M.D.
Faculty, Hennepin County Medical Center
Assoc. Professor, Univ. of Minnesota
Minneapolis, MN

Date: Wed, 16 Apr 2003 06:34:11 -0500

From: Adam J. Starr, M.D.

Hi Dr. Richmond.

The plain films appear to show a healed fracture, but the broken proximal locking screw raises the specter of a nonunion. The pain free weight-bearing's a good sign. Maybe he broke the locking screw months ago and went on to unite?

At this point, I'd get a ESR and CRP to use as baseline measures. Then take him to the OR and remove the nail, ream the canal, and assess the union. If it's still wobbly, I'd place an external fixator frame.

I would take cultures and a biopsy of the reamings and some bone from the canal. I'd start him on vancomycin first, and tailor my antibiotic coverage according to what the cultures grew.

Also, I would get an Infectious Disease consult. Bruce Ziran makes a great case for building a relationship with the ID folks at your hospital. Two minds are better than one, and the ID doctors have a lot to offer as far as strategies to fight infection. I've had some good luck here in Dallas working with our ID people - they're usually happy to help. Since we all have these kinds of cases, it seems sensible to get to know the infectious disease MD's.

The osteoset beads work great. I mix in vancomycin and tobramycin powder and use the little molds that come with the osteoset to make round beads.

They handle fine. The trick is to allow them time to set up. Ordinarily, osteoset sets up in about 3 minutes, but if you mix in the antibiotic powder it takes more like 30 minutes. So, start mixing the beads as soon as you start the case.

If you use the beads before they set up fully they'll dissolve in the blood in the wound. Very frustrating. Be sure to wait until they get hard as rocks.

The nicest thing about the beads is that as they dissolve they elute ALL the antibiotic inside, not just the antibiotic on the outer 1mm of the bead, the way PMMA beads do. Plus, you don't have to go back in after them.

To get them in the canal, I stick a drill sleeve from the IM nail set into the top of the canal and roll the beads down into it. You can use a guide wire as a plunger to shove them into the canal. Use fluoro to make sure you get the beads down near the fracture.

Good luck,

Adam Starr
Dallas, Texas

Date: Wed, 16 Apr 2003 09:54:06 -0700

From: Johh Ruth

His radiographs certainly look as though the fracture may be infected. It also may be united. Since there is a titanium rod in place, I would recommend an MRI to look for soft tissue abscesses adjacent to the fracture that may require open drainage. Then removal of the rod with reaming plus/minus intramedullary antibiotic beads (would require later removal). Hopefully the fracture is stable because external fixation in this patient would be a disaster. If the fracture is not stable then I would favor rod removal, reaming and intramedullary antibiotic beads. The beads would require removal or exchange after 3 weeks to minimize difficulty in removal. After at least 6 weeks of IV antibiotics I would ream again and place a new IM rod. He would likely need long term suppressive antibiotics with hopes the fracture will heal and the new rod removed and the infection cleared. Obviously this type of protracted treatment will be extremely difficult to complete in this patient. The planned treatment should minimize the problems encountered by the next poor orthopaedic surgeon whose doorstep he lands on.

Date: Thu, 17 Apr 2003 00:36:34 +0600

From: Alexander Chelnokov

Hello Jeff,

Wednesday, April 16, 2003, 6:49:25 AM, you wrote:

JR> admitted last week because of fevers to 103f and a "warm leg" with no other apparent source. He was placed on ancef by the medical service, who admitted

Recently i nailed both tibiae of a 44 yrs old male after bilateral segmental fractures, left was open grade I with some contusion around the lower fracture. The surgery was performed in 2 weeks after the injury. A month later he readmitted with high fever and strong pain medially to tibial tuberosity not connected to any surgical wound, redness and swelling below the knee. I/v vancomycin and oral ciprofloxacin were administered for 10 days. All signs except local pain disappeared, WBC/ESR went to normal.

Today is 3 months after the surgery, he came for xray/check - still on crutches, despite painless full WB of the right leg. No clinical signs of infection. The pain in the left leg migrated to lateral side of the distal tibia(?!). I dynamized both nails by removal of distal screws. The upper one from the left tibia appeared to have local resorption. I am a bit nervous about what to expect, and recommended him one more week course of oral ciprofloxacin. Any other idea? THX in advance.

Best regards,

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

Date: Wed, 16 Apr 2003 22:54:48 EDT

From: Aobonedoc

I have used the osteoset beads with antibiotics three times. They drain for several months, in my experience (as I was told the first time).

Sincerely and respectively,

M. Bryan Neal, MD
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
Arlington Heights, Illinois 60005

Date: Thu, 17 Apr 2003 09:34:59 -0500

From: Adam J. Starr, M.D.

I've used osteoset beads impregnated with vancomycin and tobramycin about a hundred times - maybe more - and I don't think I've ever had them drain.

PMMA beads seem to cause a lot of local inflammation, and they get surrounded by exudative fluid quickly. My bead pouches always seem to fill up with "bead juice". The osteoset beads don't do that.

Adam Starr
Dallas, Texas

Date: Sun, 20 Apr 2003 11:37:00 -0400

From: David Goetz

We would ream and brush the canal, then irrigate drawing the fluid out the distal screw holes. Our preference is a cement rod with antibiotic, it offers some local antibiotic elution [not as much surface area as osteoset beads] but the best "dead space" control. Currently, about a dozen cases under retrospective review.

David R. Goetz MD
Medical Director, Orthopaedic Trauma

Date: Mon, 21 Apr 2003 08:32:51 -0400

From: James Carr

I think if its healed, and you pull the nail, clean the canal, and appropriate abx, his chances of healing are good. I like to irrigate with 60 cc catheter tip syringes, and get a nice flow of fluid thru the canal from top to bottom. You can pressurize them by sticking the catheter tip in the distal screw holes. Jim Carr

James B. Carr, MD
Palmetto Health Orthopedics