Session XI - Reconstruction
Sun., 10/10/04 Reconstruction, Paper #67, 10:13 am
The Socio-economic Impact of Chronic Osteomyelitis: The Most Frequent Complication
Purpose: The physical, emotional, and social effects of chronic osteomyelitis significantly affect patient treatment outcome. Treatment algorithms for the four types of chronic osteomyelitis are well-known. However, the social complications of the disease are under-reported. Our objective was to identify the factors related to improvement of the psychologic and functional status of the patients and to establish a grading scale of the impact of the illness to help prevent or reverse this social deterioration in a timely fashion.
Methods: The medical records of 52 adult patients with a diagnosis of active chronic osteomyelitis of the lower extremity treated between 2000 and 2003 were reviewed. Although all patients lived in this country at the time of consultation, 24 sustained their original injuries in other countries. Twenty-four men and 12 women agreed to participate in the study. Each patient had at least 18 months of follow-up care at the time of interview. The average age was 41 (range, 19 to 66). All patients were interviewed by a physician and asked to provide information about their social and personal status and the way these were affected by the illness. All interviews were personalized with open-ended questions to avoid limiting the variety of their answers. All the material gathered was entered into an anonymous data-flow sheet and then categorized to facilitate further analysis. The main categories were 1) evidence of long-term complications, 2) length of treatment, 3) number of operations, 4) number and type of antibiotic treatments, 5) changes in employment or education, (6) changes in health insurance coverage, (7) change of marital status, 8) percentage of savings spent on treatment, 9) new onset of depression, and 10) new addictions. The patients were also asked to grade the above-mentioned categories into mild, moderate, and severe according to how their social environment was affected by the disease. All physical and local complications, such as nonunion, malunion, shortening, alteration of the axis of the extremity, and loss of range of motion were excluded from this evaluation.
Results: None of the 36 patients had local or systemic complication from the infection. The average length of illness was 13.5 years (range, 1 to 30). The average of number of operations was three (range, 1 to 12). It should be noted that 28 patients were offered amputation but none would agree to the procedure. The average number of suppressive antibiotic treatments was four. Thirty of the patients (80%) were employed at the onset of the illness and six were self-employed; 25 (83%) became unemployed. Thirty-one (80%) lost their health insurance; this included those patients who lost their insurance coverage when they became unemployed and those self-employed patients who could no longer pay their insurance premiums. Twenty-seven (75%) underwent a divorce or separation from their spouse or significant other. A majority of the patients had exhausted their savings to pay for their treatment. It was difficult to determine the total cost of each patient's care and what percentage of their savings was spent. However, at the time of interview, 25 (70%) had applied for or were receiving public assistance or disability. Eight patients (22%) had a diagnosis of and were treated for depression during their illness. Sixteen patients (48%) were on a tapering dose of narcotic pain medication and had become addicted during treatment, and two patients (5%) developed new addictions to pain medication. Patients revealed that unemployment or ability to work was the most significant factor for the long cascade of events which followed. Loss of medical coverage was considered the second most devastating factor relating to their treatment outcome. Loss of spouse or companion was ranked the third. Patients were then graded 1 through 4, depending on how many of these three variables (employment, health insurance coverage, and loss of spouse or companion) remained: grade 1, 5; grade 2, 2; grade 3, 2, and grade 4, 27. Progression from grade 1 to grade 4 occurred characteristically during the first and second years after the onset of osteomyelitis.
Conclusion: The most frequent complications of chronic osteomyelitis are in the social sphere rather than the clinical. Classification of the patients into one of the four categories may have a prognostic value and can help identify the resources needed to improve patient care. Grade 1 and 2 patients have most resources intact and have good potential for total cure. Grade 3 patients have fewer resources and are likely to have longer hospital stays. Grade 4 patients have almost no resources. This status can correlate with a more progressive type of osteomyelitis which requires more extensive surgical treatment and carries a higher risk of amputation as well as long admissions to state-funded hospitals. Failure to recognize the early impact of the disease may cause an inevitable progression in the grade of social impairment. This "social slide" can be prevented by early diagnosis and assessment of the patient's insurance, financial, and social resources. Procurement of additional insurance and maximization of social programs can help ensure adequate patient financial and emotional support throughout their treatment. Thus, early referral to specialized centers equipped to handle this type of illness may help control the progression of chronic osteomyelitis in a timely fashion.