Paul Holtom

Comparison of Anterior and Posterior Iliac Crest Bone Grafts in Terms of Harvest-Site Morbidity and Functional Outcomes

Background : Previous studies have demonstrated high complication rates after harvest of iliac crest bone grafts. This study was undertaken to compare the morbidity related to the harvest of anterior iliac crest bone graft with that related to the harvest of posterior iliac crest bone graft and to determine differences in functional outcome. Methods : The medical records of eighty-eight consecutive patients who had undergone a total of 108 iliac crest bone-grafting procedures for the treatment of chronic osteomyelitis from 1991 to 1998 were retrospectively reviewed. Demographic characteristics, the location of the harvest, the volume of bone graft that was harvested, the estimated blood loss, and postoperative complications were recorded. Fifty-eight patients completed a questionnaire pertaining to postoperative and residual pain, sensory disturbances, functional limitations, cosmetic appearance, and overall satisfaction with the bone-graft harvesting procedure. Results : Sixty-six anterior and forty-two posterior bone-graft harvest sites were evaluated at a minimum of two years after the operation. A major complication was associated with 8% (five) of the sixty-six anterior sites and 2% (one) of the forty-two posterior sites. The rates of minor complications were 15% (ten) and 0%, respectively. In the series as a whole, there were ten minor complications (9%) and six major complications (6%). The rates of both minor complications (p = 0.006) and all complications (p = 0.004) were significantly higher after the anterior harvest procedures than they were after the posterior procedures. The postoperative pain at the donor site was significantly more severe (p = 0.0016) and of significantly greater duration (p = 0.0017) after the anterior harvests. No patient reported functional limitations at the latest follow-up evaluation. Conclusions: In this series, the complication rate was lower than those previously reported by other investigators. Harvest of a posterior iliac crest bone graft was associated with a significantly lower risk of postoperative complications. On the basis of the results of this study, we recommend that iliac crest bone graft be harvested posteriorly whenever possible.

Periprosthetic total hip infection: outcomes using a staging system.

The outcomes of 50 consecutive patients with chronic periprosthetic total hip arthroplasty infections were evaluated based on a staging system developed at the authors’ institution. The staging system includes three categories: infection type (acute versus chronic), systemic host grade, and local extremity grade. The initial treatment plan was a two-stage resection followed by reimplantation if clinically indicated. Treatment was modified for each patient according to how the patient responded to initial debridement. The average followup was 23.2 months (range, 0–74 months). Of the 50 patients, 29 had reimplantation with a total hip arthroplasty (58%), 17 patients had permanent resections (34%), and four patients had amputations (8%). Five patients died (10%). Fifteen patients had muscle flap transfers into the hip for soft tissue coverage. Significant correlations were seen with the staging system and outcome parameters. Patients who were very medically ill were far more likely to die or have their leg amputated. Conversely, healthier patients were more likely to have successful reimplantation. A strong correlation was seen with a compromised local wound and the need for muscle flap transfer. Complication rates were strongly related to worsening medical condition and a worsening local wound. Based on these results, a staging system for periprosthetic infection is a useful tool that with additional refinement will provide more objective evaluation of treatment methods for periprosthetic hip infection in the future.

Early Mycological Treatment Failure in AIDS-Associated Cryptococcal Meningitis

Cryptococcal meningitis causes significant morbidity and mortality in persons with AIDS. Of 236 AIDS patients treated with amphotericin B plus flucytosine, 29 (12%) died within 2 weeks and 62 (26%) died before 10 weeks. Just 129 (55%) of 236 patients were alive with negative cerebrospinal fluid (CSF) cultures at 10 weeks. Multivariate analyses identified that titer of cryptococcal antigen in CSF, serum albumin level, and CD4 cell count, together with dose of amphotericin B, had the strongest joint association with failure to achieve negative CSF cultures by day 14. Among patients with similar CSF cryptococcal antigen titers, CD4 cell counts, and serum albumin levels, the odds of failure at week 10 for those without negative CSF cultures by day 14 was five times that for those with negative CSF cultures by day 14 (odds ratio, 5.0; 95% confidence interval, 2.2-10.9). Prognosis is dismal for patients with AIDS-related cryptococcal meningitis. Multivariate analyses identified three components that, along with initial treatment, have the strongest joint association with early outcome. Clearly, more effective initial therapy and patient management strategies that address immune function and nutritional status are needed to improve outcomes of this disease.

Tuberculous Meningitis in Patients With and Without Human Immunodeficiency Virus Infection

OBJECTIVE To characterize the symptoms, signs, laboratory findings, and outcome of culture-proven meningitis due to Mycobacterium tuberculosis in patients with and without human immunodeficiency virus (HIV) infection. DESIGN Retrospective chart review. SETTING Urban public general hospital in the United States. PATIENTS Fifteen patients with and 16 without HIV infection. MEASUREMENTS Demographics, symptoms, physical exam findings, serum sodium, complete blood cell count, CD4+ cell count, cerebrospinal fluid findings, imaging data, and in-hospital mortality. MAIN RESULTS Symptoms, signs, chest radiograph appearance, cerebrospinal fluid cell counts and chemistries, and mortality were similar in both groups (p = NS). Median CD4+ cell counts were lower in HIV-infected patients (median 99/mm3, range 7 to 251, versus 384/mm3, range 171 to 724 in those without HIV infection, p = 0.007). Intracerebral mass lesions were more common in the HIV-infected group (60% versus 14% in the uninfected group, p = 0.01), although the presence of a mass did not correlate with focal neurologic deficits, altered level of consciousness, or mortality. CONCLUSION With the exception of an increased incidence of intracerebral mass lesions in HIV-infected individuals, HIV infection appears to have little impact on the findings and in-hospital mortality of tuberculous meningitis.

2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults

These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention.

Prospective, Randomized, Double-blind Study Comparing Single-agent Antibiotic Therapy, Ciprofloxacin, to Combination Antibiotic Therapy in Open Fracture Wounds

OBJECTIVE The purpose of this study was to compare the efficacy of a single agent, ciprofloxacin, with that of combination antibiotic therapy consisting of cefamandole and gentamicin in all types of open fracture wounds. STUDY DESIGN A prospective double-blind randomized clinical trial. SETTING A Level 1 trauma center. PATIENTS One hundred ninety-five consecutive patients with 203 open fractures were enrolled over a twenty-month period. Twenty-nine fractures from low-velocity gunshot wounds were excluded, and three other patients were excluded because of protocol violations. Our final number of patients were 163, with 171 open fractures. MAIN OUTCOME MEASUREMENT The infection rates for Type I and Type II open fractures for both antibiotic groups were calculated. The infection rate of Type III open fractures for both antibiotic groups was also calculated. Chi-square analysis with Yates correction was used to assess statistical significance of two treatment groups. RESULTS The infection rate for Types I and II open fractures in the ciprofloxacin group was 5.8 percent and 6 percent for the cefamandole/gentamicin group (p = 1.000). The infection rate for Type III open fractures for the ciprofloxacin group was 31 percent (8 of 26) versus 7.7 percent (2 of 26) for the cefamandole/gentamicin group (p = 0.079). There were no statistically significant differences in infection rate between the group treated with ciprofloxacin and that treated with cefamandole/gentamicin for Types I and II open fracture wounds. However, there appeared to be a high failure rate for the ciprofloxacin Type III open fracture group, with patients being 5.33 times more likely to become infected than those in the combination therapy group. Although this difference was not statistically significant, possibly because of the small sample size, there was a definite trend toward statistical significance. CONCLUSION Single-agent antibiotic therapy with ciprofloxacin is effective in treatment of Type I and Type II open fracture wounds. However, on the basis of our results, we cannot recommend ciprofloxacin alone for Type III wounds. Possibly one can use fluoroquinolones in combination therapy, specifically as an alternate to an aminoglycoside.

Comparison of the results of bacterial cultures from multiple sites in chronic osteomyelitis of long bones. A prospective study.

We evaluated the results of aerobic, anaerobic, and fungal cultures of specimens that had been obtained from multiple sites in thirty patients who had traumatic osteomyelitis with a sinus track. In each patient, we obtained specimens of material from the sinus track; specimens of purulent fluid, of soft tissue, and of bone obtained from curettage; and specimens from the bed of the involved bone. More than one organism grew on culture of the specimens from twenty-one of the patients; more than three organisms, from those of eleven patients; and ten organisms, from those of two patients. The same organisms grew on culture of the specimens from every site in only fourteen (47 per cent) of the thirty patients. We recommend that specimens of material from the sinus track; specimens of purulent material, of soft tissue, and of bone obtained from curettage; and specimens from the bed of the involved bone be obtained for culture before the treatment of chronic osteomyelitis with a draining sinus, so that as many of the infecting organisms as possible will be identified.

Spinal epidural abscess: early clinical outcome in patients treated medically.

Treatment of spinal epidural abscess has been based on surgical debridement. Medical treatment with antibiotics has been proposed as an alternative, but data on its efficacy are limited. The purpose of this study was to determine the early clinical outcome of medical treatment. This is a retrospective review of 52 patients with a spinal epidural abscess who were treated at our institution. Medical treatment was selected if no systemic sepsis was present and the neurologic examination was normal or stable (radiculopathy or signs of partial cord compression present for more than 72 hours before admission without deterioration). Twenty-nine patients had medical treatment and 23 patients were treated surgically. Medical treatment resulted in good or excellent early neurologic outcome in 24 of 29 patients (83%) at a median followup of 2 months. Three patients (11%) had failed medical treatment and required surgery and one patient (3%) who had severe comorbidities died. Staphylococcus aureus was the most common infectious pathogen, isolated in 28 of 36 positive cultures (78%). Medical treatment is a viable alternative to surgery for selected patients with a spinal epidural abscess. However, close clinical followup is essential and surgical decompression should be done when neurologic deterioration or development of systemic sepsis is observed. Level of Evidence: Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Management of Chronic Deep Infection Following Rotator Cuff Repair

Background: Deep infection of the shoulder following rotator cuff repair is uncommon. There are few reports in the literature regarding the management of such infections. Methods: We retrospectively reviewed the charts of thirteen patients and recorded the demographic data, clinical and laboratory findings, risk factors, bacteriological findings, and results of surgical management. Results: The average age of the patients was 63.7 years. The interval between the rotator cuff repair and the referral because of infection averaged 9.7 months. An average of 2.4 procedures were performed prior to referral because of infection, and an average of 2.1 procedures were performed at our institution. All patients had pain on presentation, and most had a restricted range of motion. Most patients were afebrile and did not have an elevated white blood-cell count but did have an elevated erythrocyte sedimentation rate. The most common organisms were Staphylococcus epidermidis, Staphylococcus aureus, and Propionibacterium species. At an average of 3.1 years, all patients were free of infection. Using the Simple Shoulder Test, eight patients stated that the shoulder was comfortable with the arm at rest by the side, they could sleep comfortably, and they were able to perform activities below shoulder level. However, most patients had poor overhead function. Conclusions: Extensive soft-tissue loss or destruction is associated with a worse prognosis. Extensive débridement, often combined with a muscle transfer, and administration of the appropriate antibiotics controlled the infection, although most patients were left with a substantial deficit in overhead function of the shoulder.

Negative pressure dressings as an alternative technique for the treatment of infected wounds.

Coverage of wounds caused by infection and subsequent treatment often are variable because of the location of the wound and wound size. Although much research has been done to expand the indications of negative pressure wound treatment systems, little investigation has been done to quantify the reduction of wound size for vacuum-assisted closure treatment in the presence of infection. In this series, 14 patients who had wounds caused by infections were treated with the vacuum-assisted wound closure system. All wounds were greater than 20 cm2. The duration of treatment averaged 10 days (range, 2–27 days), and the initial wound size averaged 70 cm2 (range, 22.5–288 cm2). After the course of treatment, the final wound size averaged 39 cm2 (range, 10–147 cm2). The average wound size reduction was 43%. This method seems to enhance the rapidity of wound reduction, and because it is a closed system of treatment, it has the added benefit of minimizing exposure of staff and other patients to communicable diseases. Vacuum-assisted wound closure systems add another option in the care of musculoskeletal infections.