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





 Type III




 Type IV









Group 2





 Type III





 Type IV










* 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)