Fibular osteomyelitis

[CutsWithFury]

I have several patients right now with fibular osteomyelitis that were dumped on me by ortho (ankle fracture ORIF complications) and two from wound care where chronic wounds were over the fibula for months and resulted in contiguous spread. Lab work up demonstrates elevated inflammatory markers. Advanced imaging workup usually includes CT/bone scan (if hardware present) and MRI (if hardware is not present).

What are people doing for these?

My go to is to excise the fibula and/or remove hardware and fuse ankle.

Anybody else staging?

Any other approaches (i.e. ex fix) or considerations?

Anybody just doing long term IV ABx and HBOT to eradicate the bone infection?

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[DYK343]

This first: long term IV ABx and HBOT to eradicate the bone infection

This second: excise the fibula and/or remove hardware and fuse ankle. (Stage it)

This third: BKA

 

[PeaJay]

Remove distal fibula, take clearance fragment, pack with antibiotic beads(do not use absorbable), take cultures (tissue samples not swabs), excise wound and close on drain. Pull drain and IV Abx as needed. Let the soft tissue envelope calm down and return to put a retrograde nail.

 

[CutsWithFury]

Remove distal fibula, take clearance fragment, pack with antibiotic beads(do not use absorbable), take cultures (tissue samples not swabs), excise wound and close on drain. Pull drain and IV Abx as needed. Let the soft tissue envelope calm down and return to put a retrograde nail.

What’s your incision placement if you are already went lateral to remove fibula? Anterior I’m Guessing. Are you prepping the STJ?

 

[PeaJay]

I use a direct lateral biasing anterior or posterior based off wounding that needs to be excised. If you do a damn thorough clean out with the fibular resection the area should come back negative on post cleanup cultures. The addition of the antibiotics and beads renders area sterile. Give the tissue time to rest and you can enter through the same incision. Both ankle and stj can be prepped through the incision.

 

[PeaJay]

I use nails for ttc fusions and thus flip the jig and run hardware from lateral or is you feel like going real off label grab some femoral plates and place it laterally

 

[ExperiencedDPM]

Hmm. Take a long needed vacation for the upcoming week and push the patient back to the Ortho who dumped it on you. No matter what you do, this case will end up in a lawsuit.

I learned many years ago that trying to be the super hero didn’t always work out so well. I never abandoned a patient, but I also didn’t look for potential problems.

I always resented when ortho or vascular dumped on me. I never turned down a referral, but resented dumps.

I was on staff at a major university teaching hospital. I had a great rapport with a nationally known vascular surgeon and his entire group, with the exception of one old fart partner.

We would often get consulted on the same cases. This one doc would always try beating me to the consult and when I walked in the patient room, he was already there with the consent form for the amputation, etc. And he would say “while you’re here the nails on the other foot are long and could use a trim”

His partners and the vascular fellow would never do that and would always ask me first if our group wanted the case.

I was rounding one day and the old fart doc pulled me aside and said he’s got a patient scheduled today for a TMA but he just got called in to repair an aneurysm and that would be a prolonged case. He asked if I could do him a favor and do the TMA.

THAT was a dump since he used to only consult me for nails. I DID take the case and when I answered him I said “Just realize I’m not doing you the favor, I’m doing the patient a favor, since I do a nicer TMA than you”. The vascular fellow was standing there and almost peed himself.

Later that week, the head of vascular came up to me and told me he was proud of how I handled the issue.

 

[msuDPM]

Hmm. Take a long needed vacation for the upcoming week and push the patient back to the Ortho who dumped it on you. No matter what you do, this case will end up in a lawsuit.

I learned many years ago that trying to be the super hero didn’t always work out so well. I never abandoned a patient, but I also didn’t look for potential problems.

I always resented when ortho or vascular dumped on me. I never turned down a referral, but resented dumps.

I was on staff at a major university teaching hospital. I had a great rapport with a nationally known vascular surgeon and his entire group, with the exception of one old fart partner.

We would often get consulted on the same cases. This one doc would always try beating me to the consult and when I walked in the patient room, he was already there with the consent form for the amputation, etc. And he would say “while you’re here the nails on the other foot are long and could use a trim”

His partners and the vascular fellow would never do that and would always ask me first if our group wanted the case.

I was rounding one day and the old fart doc pulled me aside and said he’s got a patient scheduled today for a TMA but he just got called in to repair an aneurysm and that would be a prolonged case. He asked if I could do him a favor and do the TMA.

THAT was a dump since he used to only consult me for nails. I DID take the case and when I answered him I said “Just realize I’m not doing you the favor, I’m doing the patient a favor, since I do a nicer TMA than you”. The vascular fellow was standing there and almost peed himself.

Later that week, the head of vascular came up to me and told me he was proud of how I handled the issue.

Cool story?

 

[ExperiencedDPM]

Cool story?

True story.

 

[GreenHousePub]

True story.

Yeah right when I hear "it was an ORIF that turned into fibular osteomyelitis" that rings my "oh **** my notes are going to be used for legal purposes" alarm bells.

Personally, I'd do IV abx, wound care as long as possible. Once it calms down, refer back to original surgeon or someone else. An ORIF gone wrong patient is a lot different than a negligent diabetic. Last thing I need is an expert witness claiming that with more IV abx it would've just healed, instead of resecting the fibula. Or the ankle fusion turning into OM and then a BKA.

 

[DYK343]

Personally, I'd do IV abx, wound care as long as possible. Once it calms down, refer back to original surgeon or someone else. An ORIF gone wrong patient is a lot different than a negligent diabetic. Last thing I need is an expert witness claiming that with more IV abx it would've just healed, instead of resecting the fibula. Or the ankle fusion turning into OM and then a BKA.

I am 100% for cutting the bone out when infected. I believe we can sequester but not cure osteomyelitis with long term antibitoics. The osteomyelitis is still there despite "clinical cure". It is just in hiding. Long term antibiotics may fail from the start, or "cure" the infection only to stay in hiding for many years to come... but it will eventually resurface.

In residency we cut out the infected bone everytime. Thats how I trained. I now practice in an area where that is not necessarily the standard of care. Many of the providers here consult ID for long term antibiotics prior to major limb amputation. Practicing in the norm for my region I do have a few "cured" cases of osteomyelitis.

But as I originally stated and as greenhousepub just stated, I would not run to staged fusion with fibular resection as a primary treatment for fibular osteomyelits. It will eventually progress to that and we all know that. But in the ever hungry legal world we live in I would start with an infectious disease consult. I acknowledge that it is a waste of health care dollars to keep yourself from litigation.

 

[dtrack22]

I am disappointed that there has been discussion about post-op fibula ORIF patients with hardware in place and diagnosed OM...and not one person has asked if the fractures are healed and if the hardware is stable, prior to discussing thoughts on treatment.

 

[CutsWithFury]

I am disappointed that there has been discussion about post-op fibula ORIF patients with hardware in place and diagnosed OM...and not one person has asked if the fractures are healed and if the hardware is stable, prior to discussing thoughts on treatment.

Both cases I am dealing with no showed no lucency around the hardware or screws. Fractures healed as well. This was seen on CT

Side note...

One of the infected ankle fractures I am dealing with now had an Arthrex tightrope for syndesmosis fixation. Bacteria tracked right through the fiber wire and infected the tibia which was confirmed with bone biopsy. Something to think about.

 

[air bud]

Both cases I am dealing with no showed no lucency around the hardware or screws. Fractures healed as well. This was seen on CT

Side note...

One of the infected ankle fractures I am dealing with now had an Arthrex tightrope for syndesmosis fixation. Bacteria tracked right through the fiber wire and infected the tibia which was confirmed with bone biopsy. Something to think about.

How would that be different vs a syndesmostic screw?

 

[CutsWithFury]

How would that be different vs a syndesmostic screw?

Prob no difference but it would probably be harder for the infection to track that far into the tibia. I could be wrong.

But after looking at the tight rope intraoperatively and seeing the crap on the fiberwire it’s I feel it’s a lot easier for infection to track through the drill hole into the tibia

 

[PeaJay]

I am disappointed that there has been discussion about post-op fibula ORIF patients with hardware in place and diagnosed OM...and not one person has asked if the fractures are healed and if the hardware is stable, prior to discussing thoughts on treatment.

This is the iv antibiotic option. In my mind there are two options. The first is removal of hardware coring out screw holes. Temp fixation should be placed if needed. Then holes may be filled with antibiotic cement or left open. Antibiotics from there. The second is the resection of bone in a staged fashion.

In my neck of the woods, infected tissue goes in a bucket. That is by agreement of Ortho/podiatry/gen surg/vasc/id.

 

[air bud]

I am a cut it out kind of guy too. Don't rely on IV and never used HBO before. Not like HBO exists in my neck of the woods.....unless I tell them to go hang out at the top of the mountain