My Orthopaedic Surgeon

Extremity Necrotizing Soft Tissue Infections AAOS Poster Board Number: P422 2005 Theodore Miclau, MD San Francisco CA (n) Christian Ogilvie, MD Merion Station PA (n) -------------------------------------------------------------------------------- This large series without treatment delays shows lower mortality than abdominal infections and demonstrates characteristic findings associated with mortality. Necrotizing soft tissue infections (NSTIs) are potentially fatal infections that often involve the extrmities. The purpose of our study was to determine the mortality rate of extremity NSTIs, and then identify patient characteristics, diagnostic signs, and treatment factors associated with mortality. We performend a retrospective analysisof 150 consecutive cases of extremity NSTIs treated at San Francisco General Hospital. We included cases that involved the extremities, including the hip and shoulder girdles. We recorded information on possible cofactors, treatment, physical findings, radiography, and laboratory findings at presentation. The data was compared statistically between survivors and nonsurvivors. The overall mortality rate was 9.3%. No cofactor predicted increased mortality. Physical exam also revealed common but not predictive findings. Laboratory results indicated that nonsurvivors showed signs of organ dysfunction. Nonsurvivors did not have delays intreatment relative to survivors. Univariate analysis noted increased risk (p<0.05) for mortality with hypotension, hypothermia, low leucocyte count, low bicarbonate levels, elevated BUN, creatinine, AST and potassium levels, and Clostridium species in the wound culture. This is the largest presented series of extremity NSTIs and perhaps the only NSTI study of this size without significant delays in treatment. Extremity NSTIs have a significant mortality rate but less than abdominal NSTIs. Orthopaedic surgeons should become familiar with the manifestations of serious NSTIs and provide timely treatment for such cases.

Identifying and treating Necrotizing Fasciitis. AAOS Paper No: 033 Wednesday, March 22, 2006 Shaul Beyth, MD Jerusalem Israel (n) Allon E Moses, MD Jerusalem Israel (n) Meir Liebergall, MD Jerusalem Israel (n) Amos Peyser, MD Jerusalem Israel (n) Signs and symptoms of necrotizing faciitis are misleading resulting in delayed diagnosis therefore a high index of suspicion is mandatory. Surgical treatment of potentially fatal necrotizing fasciitis (NF) is often delayed due to late diagnosis. Identifying distinguishing characteristics may improve management of this medical emergency. A retrospective analysis of 68 patients with NF between 1990 and 2004. Our study focused on 28 (34%) patients with limb involvement. We review cases from initial medical encounter to resolution, especially focusing on clinical signs and symptoms, time to diagnosis, treatment and outcome. Age ranged from 1-83 years (average 53.6), 68% were males, 80% had underlying diseases (44% diabetes). Only 25% presented with fever, 25% had hypotention. The most prominent finding (84% of patients) was severe pain. 72% had skin erythema and only one patient had palpable crepitus. Only 25% were correctly diagnosed at initial presentation, leading to delayed surgical treatment (64% beyond 24 hours, 40% beyond 48 hours). Streptococci were isolated in 40% and polymicrobial infection was noted in 28%. Only 3 cultures grew anaerobic bacteria, air was noted in the radiographs of 6 patients. Hospitalization averaged 32.4 days; amputation rate was 12%, as was multi-organ failure. Mortality was 32%. In our 28 patients with limb NF, we found that patients' signs and symptoms are misleading and result in delayed diagnosis. Many of our patients had underlying diseases predisposing to infection. Severe, sometimes excruciating pain, disproportionate to the initial objective findings seems to be a clue to diagnosis. A high index of suspicion in patients with limb infection and severe pain is mandatory for early diagnosis and treatment.

Infected ischemic diabetic foot: one more attempt to improve microcirculation V.T.Krivikhin, R.M.Parhimovich, D.V.Krivikhin, O.S.Troitskaja District hospital, Vidnoje, Moscow Region and Moscow Regional Res.Clinical Institute Surgical revascularization is often impossible in ischemic diabetic foot (DF) because of dis-tal form of occlusions and comorbidity. The medication to improve microcirculation often does not work. Besides, restricted facilities of some hospitals we have to consider. Aim was to revise known surgical technology ‘revascularising osteotrepanation’ (ROT) and adopt it for use as an additional way of improving the DF microcirculation in cases, when angioplasty or another revascularization methods are impossible. Material and methods. Two matched group of type 2 diabetes mellitus (DM) patients (mean DM duration was 10 years) with infected necrotizing forefoot lesions including ac-ral necroses or toe(s) gangrene (grade 3-4 after Wagner)were treated in local hospital. Con-trol group consisted of 25 patients aged 50-72 years (mean 64), 9 males. ROT-group in-cluded 12 patients (4 males) aged 49- 73 years (mean 65). Doppler ultrasonography, laser Doppler fluxmetry and transcutaneous oxygen pressure (TopO2) measurement were used. Ischemia signs predominated in all patients (TopO2 was<35 mm Hg), but neuropathic signs were too. Multiple stenosis or occlusions were in all patients. Standard care including de-bridements and management of infection, diabetes, rheology was given to all patients. Be-cause of uncontrolled ischemia and infection transmetatarsal amputation had to be made in both group and simultaneously ROT was performed in the ROT-group. The essence of ROT is formation of 10-14 holes (d= 6 mm) in tibia and 2-3 in femur to stimulate angio-genesis. Autodermic grafting was made to all patients after stump wound was prepared. Results. Wound cleansing and granulation in ROT-group accelerated and mean time of stump preparation for grafting shortened to 46 days; in control group it lasted 77 days. In two patients of ROT-group the stump wound healed by secondary tension without grafting. Microcirculation index increased significantly to 25th day after operation. Pain relief was more pronounced in ROT-group. Above-knee amputation had to be made in 3 control pa-tients and in 1 – from ROT-group. These 3 control patients died because uncontrolled in-fection and co- morbidity. ROT operations and postoperative period were without compli-cation. The amputated limb of ROT- patient was examined; it was revealed that the made by ROT holes was filled with tissue rich in vessels which spread along periosteum. Conclusion. Our preliminary experience may be useful in some “hopeless” DF cases. The method is not expensive, shorten time of hospitalization and deserve further study

Necrotizing Soft-Tissue Infections Roger A. Fontes, Jr, MD, Christian M. Ogilvie, MD and Theodore Miclau, MD J Am Acad Orthop Surg, Vol 8, No 3, May/June 2000, 151-158. © 2000 Necrotizing fasciitis is a rare and often fatal soft-tissue infection involving the superficial fascial layers of the extremities, abdomen, or perineum. Necrotizing fasciitis typically begins with trauma; however, the inciting event may be as seemingly innocuous as a simple contusion, minor burn, or insect bite. Differentiating necrotizing infections from common soft-tissue infections, such as cellulitis and impetigo, is both challenging and critically important. A high degree of suspicion may be the most important aid in early diagnosis. Prompt diagnosis is imperative because necrotizing infections typically spread rapidly and can result in multiple-organ failure, adult respiratory distress syndrome, and death. Although group A Streptococcus is the most common bacterial isolate, a polymicrobial infection with a variety of Gram-positive, Gram-negative, aerobic, and anaerobic bacteria is more common. Orthopaedic surgeons are often the first physicians to evaluate patients with such infections and therefore need to be familiar with this potentially devastating disease and its management. Prompt diagnosis, immediate administration of broad-spectrum antibiotic coverage, and emergent aggressive surgical debridement of all compromised tissues are critical to reduce the morbidity and mortality of these rapidly progressing infections.