Prevalence of Osteomyelitis Osteomyelitis 10-15% mild infections - PowerPoint PPT Presentation

4/5/2014 Prevalence of Osteomyelitis � Osteomyelitis � 10-15% mild infections � 50% severe infections 1 ROLE OF SURGERY IN OSTEOMYELITIS Monara Dini, DPM Department of Orthopedic Surgery UCSF/SFGH Osteomyelitis Diagnosis Osteomyelitis Definitive Diagnosis � Probe to bone test (PTB) � Bone biopsy: � sensitivity 66%, specificity 85% 2 � Specimens obtained either percutaneously or at � ESR >70mm/h operation subjected to both histological and � sensitivity 28%, specificity 100% 3 microbiological analysis is the reference standard for bone infection 6,7 � Plain radiography � sensitivity 54%, specificity 68% 4 � Radionuclide bone scan � sensitivity 86%, specificity 50% 5 � MRI � sensitivity 90%, specificity 79% 4 1

4/5/2014 8 Antibiotics vs Surgery Exclusively Antibiotic-Based Treatment � Port of entry? � Recurrence? � Soft tissue infection vs osteomyelitis? Exclusively Antibiotic-Based Treatment IDSA Guidelines In summary all three of these studies have pitfalls. � 4 situations in which nonsurgical management of Although remission rates were high the studies: osteomyelitis might be considered 9 � lacked histpathological/microbiological � No applicable surgical target confirmation of OM � Irreparable vascular disease � lacked complete wound closure � Infection confined to forefoot � Involved primarily the forefoot � Surgical management carries excessive risk � Sharp debridement was performed when deemed necessary � remission does not indicate cure. 2

4/5/2014 Amputation as “Standard” Surgical 10 Diabetic Foot Surgery Classification 11, 12 Treatment Conservative Surgery as Treatment of Conclusion 12 Osteomyelitis � Antibiotic treatment achieves apparent remission � Combined approach of conservative surgery and antibiotics leads to lowest major amputation rates 3

4/5/2014 References References Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS,Karchmer AW, et al. Diagnosis and treatment of 9. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, et al. Diagnosis and treatment of 1. diabetic foot infections. Clin Infect Dis 2004;39:885-910. diabetic foot infections. Clin Infect Dis 2004;39:885-910 Armstrong DG, Lavery LA, Frykberg RG, Wu SC, Boulton AJ. Validation of a diabetic foot surgery 10. 2. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. JAMA classification. Int Wound J 2006;3:240-6. 1995; 273:721–3. 11. Karchmer AW, Gibbons GW. Foot infections in diabetes: evaluation and management. Curr Clin Top Infect Dis Kaleta JL, Fleischli JW, Reilly CH. The diagnosis of osteomyelitis in diabetes using erythrocyte sedimentation 3. 1994;14:1-22. rate: a pilot study. J Am Podiatr Med Assoc 2001; 91:445–50. Aragón-Sánchez FJ, Cabrera-Galvan JJ, Quintana-Marrero Y, Hernández-Herrero MJ, Lázaro-Martínez JL, 12. 4. Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for García-Morales E, et al. Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 osteomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis 2008; 47:519–27. patients with histopathological confirmation of bone involvement. Diabetologia 2008;51:1962-70. 5. Eckman MH, Greenfield S, Mackey WC, et al. Foot infections in diabetic patients. Decision and cost- Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al. Diabetic foot disorders. A 13. effectiveness analyses. JAMA 1995;273:712–20. clinical practice guideline (2006 revision). J Foot Ankle Surg 2006; 45(5 Suppl):S1-66. Sutton PR, Harley JD, Jacobson AF, Lipsky BA. Diagnosing osteomyelitis with percutaneous bone biopsy in 6. patients with diabetes and foot infections [abstract]. J Gen Intern Med 2000; 15(Suppl 2):6. 7. Jacobson AF, Harley JD, Lipsky BA, Pecoraro RE. Diagnosis of osteomyelitis in the presence of soft-tissue infection and radiologic evidence of osseous abnormalities: value of leukocyte scintigraphy. AJR Am J Roentgenol 1991; 157:807–12. 8. Aragon-Sanchez J. Treatment of diabetic foot osteomyelitis: a surgical critique: International J of Lower Extremity Wounds 2010; 9(1): 37-59. 4