George Cierny

A clinical staging system for adult osteomyelitis.

INTRODUCTIONJon Terry Mader (Fig 1) was born on March 21, 1944 in Madison, WI. He earned his BA and MD degrees at Wabash College at Indiana University in 1966 and 1970, respectively. He trained in Internal Medicine at the University of Texas Medical Branch in Galveston, TX and made his career there

In vitro and in vivo evaluation of antibiotic diffusion from antibiotic-impregnated polymethylmethacrylate beads

The elution of antibiotics from antibiotic-impregnated polymethylmethacrylate (PMMA) beads was measured in mongrel dogs. The antibiotics, used in mixture with Simplex cement, included cefazolin (Ancef; 4.5 g/40 g cement powder), ciprofloxacin (Cipro; 6 g/40 g powder), clindamycin (Cleocin; 6 g/40 g powder), ticarcillin (Ticar; 12 g/40 g powder), tobramycin (Nebcin; 9.8 g/40 g powder), and vancomycin (Vancocin; 4 g/40 g powder). After a pneumatic drill was used to dredge a trough in the tibia, five beads were implanted. During the next 28 days, seroma samples and serum samples were taken for antibiotic measurements. On Day 28, the dogs were killed, beads removed, and the seroma, serum, bone, and granulation tissue sampled. The results of the study showed that clindamycin, vancomycin, and tobramycin exhibited good elution characteristics and had consistently high levels in bone and granulation tissue.

Adult chronic osteomyelitis.

Distinctions between hematogenous, traumatic, and contiguous forms of chronic osteomyelitis are noted, and treatment discussed on the basis of the literature and of protocols of the adult osteomyelitis service at the University of Texas Medical Branch.

Osteomyelitis debridement techniques.

Debridement of chronic osteomyelitis can be technically demanding and difficult. The surgical principles that govern treatment of osteomyelitis involve an atraumatic approach and complete removal of all devitalized tissue and foreign material. Despite recent advances in medical science, the quality of surgical debridement remains the most critical factor in the successful management of chronic orthopaedic infections. Important areas discussed include thorough preoperative evaluation, the surgical philosophy, soft tissue aspects, bone considerations, and dead space management.

Infected tibial nonunions (1981-1995). The evolution of change.

Between 1981 and 1995, 150 consecutive cases of middiaphyseal, infected nonunions of the tibia were treated prospectively on the authors osteomyelitis service. Thirty-nine (78%) of the 49 patients seen between 1981 and 1986 and 94 (93%) of the 101 patients seen 1986 through 1994 underwent successful salvage protocols with a minimum followup of 5 years. The difference in outcomes seen in the two groups eloquently reflects the emergence of specific pharmaceutic, technical, and biologic advances earmarking these two, distinct eras of care.

Evaluation of biodegradable ampicillin anhydrate microcapsules for local treatment of experimental staphylococcal osteomyelitis

Successful treatment of chronic osteomyelitis requires sustained high concentrations of antibiotics locally within the infected bone. The efficacy of biodegradable (poly-DL-lactide-co-glycolide) microspheres containing 30.7% ampicillin anhydrate for the local treatment of experimental staphylococcal osteomyelitis was evaluated in rabbits. In the initial experiment, antibiotic therapy was initiated immediately following injection of Staphylococcus aureus into the proximal tibial metaphysis. A single intramedullary injection of microencapsulated ampicillin (100 mg) prevented osteomyelitis in all seven animals tested and was as effective as a two-week course of parenteral ampicillin administration. When antibiotic therapy was delayed for seven days, osteomyelitis developed in four of eight animals treated locally with microencapsulated ampicillin and in six of eight animals that received parenteral ampicillin therapy. When antibiotic therapy was delayed for seven days and was preceded by debridement, all ten animals treated locally with microencapsulated ampicillin had sterile bone cultures. In contrast, seven of ten animals treated locally with unencapsulated ampicillin powder developed osteomyelitis. Biodegradable antibiotic-loaded microspheres may be of clinical benefit for the local treatment of chronic osteomyelitis.

Inpatient and outpatient use of the Hickman catheter for adults with osteomyelitis

One hundred five Hickman catheters were inserted in 96 patients with a diagnosis of osteomyelitis. There were 78 men and 18 women with a mean age of 36.4 years. The catheters were present for a total of 6903 days with a mean of 66.4 days. Sixty-five percent of the catheters were used for outpatient as well as inpatient antibiotic therapy. The mean duration of outpatient antibiotic therapy was 30 days. Nine patients had more than one catheter inserted. The overall complication rate was 20% (21/105 catheters). The infectious complication rate was 11/ 105 (10.5%) or 0.16/100 catheter days. The non-infectious complication rate was 10/105 (9.5%) or 0.14/100 days. The catheter had to be removed prematurely before the completion of antibiotic therapy in only five of the 105 (4.8%) catheter insertions. The Hickman catheter is a safe and effective intravenous access device for long-term antibiotic therapy in patients with osteomyelitis. Inpatient management and intravenous antibiotic therapy are facilitated by a stable and long-term access to the venous circulation. The simplicity of the device also enables it to be used in the outpatient setting, reducing the time of hospitalization and the costs of treatment.

Delayed local treatment of rabbit tibial fractures with biodegradable cefazolin microspheres.

The prevention of infection is a primary objective in the treatment of open fractures. The objective of this study was to compare the efficacy of biodegradable, poly (DL-lactide-co-glycolide) cefazolin microspheres and free cefazolin powder in Staphylococcus aureus contaminated rabbit tibial fractures when treatment was delayed for 2 hours. Fractures were produced in the tibia of rabbits, inoculated with Staphylococcus aureus, and 2 hours later treated by either direct local application of cefazolin microspheres or an equivalent dose of free cefazolin powder. Control animals did not receive antibiotic therapy. The fractures then were stabilized with a bone plate, and the animals were observed for 8 weeks. Local antibiotic therapy with biodegradable cefazolin microspheres prevented the establishment of infection in all animals, and cultures of the tibiae were sterile in all cases. In contrast, clinical evidence of infection developed in 50% of the rabbits that had been treated with free cefazolin powder and 71% of the control animals. Staphylococcus aureus was recovered from the tibiae of 75% and 100% of these animals, respectively. The results of this study suggest that local antibiotic therapy with biodegradable, controlled release cefazolin microspheres may be useful for the management of open fractures in humans, even when treatment is delayed for several hours after bacterial contamination.

Pseudoallescheria boydii soft tissue abscess

Pseudoallescheria boydii, a fungus often isolated from soil, commonly causes a mycetoma. Successful treatment involves resection of the infected area and appropriate antifungal chemotherapy. In vitro sensitivity of P. boydii to miconazole is usually demonstrated, but resistance to amphotericin B and 5-fluorocytosine is often observed. Limited data are available on the treatment of this infection with ketoconazole. An usual case of nontraumatic P. boydii soft tissue infection without draining sinus tracts occurred in a 50-year-old woman. Nontraumatic P. boydii soft tissue infection was diagnosed by cytologic preparation and fungal cultures of the aspirate. The patient was successfully treated with en bloc resection for four months of oral ketoconazole.

Bacterial osteomyelitis: Adjunctive hyperbaric oxygen therapy

Mechanistically, hyperbaric oxygen (HBO) appears useful for the treatment of osteomyelitis. HBO increases the oxygen tension in infected tissue, including bone. An adequate oxygen tension is necessary for oxygen-dependent killing of organisms by polymorphonuclear leukocytes, and for fibroblast activity leading to angiogenesis and wound healing. In addition, HBO augments the killing of Pseudomonas aeruginosa by the aminoglycoside tobramycin. At the University of Texas Medical Branch in Galveston, adjunctive HBO is used for Cierny-Mader stage 3B and 4B osteomyelitis.