Date: Wed, 24 Dec 2003 06:11:14 -0600

Subject: Tibia - MRSA osteomyelitis

From: Obremskey, William T

This patient is a 40 year old woman who is five years status post an open tibia fracture. She has healed her tibia, but has developed a chronic osteomyelitis w/ MRSA. She has had several debridements. She's had labeling, with Tetracycline with the debridement ((Dahners JOT)) as well as reaming of her tibia and placement of local antibiotic beads to try and clear the osteomylelitis as well as systemic IV antibiotics. She appeared to heal but recently has had a recurrence with a small pinpoint drainage on the antermedial aspect of her tibia. A CT scan has not been helpful in identifying a nidus of persistent bony infection. She complains of pain that coincides w/ her fluctuating drainage. Any ideas?

William T Obremskey MD MPH
Vanderbilt University
Orthopedic Trauma Division
Nashville, TN 37232-3450

Bill Obremskey

Date: Wed, 24 Dec 2003 07:47:14 -0600

From: J. Tracy Watson, M.D.

Short of segemental resection.....I would again overream, and place antibiotic rod....to fill entire medullary canal dead space.....may not eradicate entirely at this point but will certainly supress.....

JTW

Date: Thu, 25 Dec 2003 11:28:33 -0000

From: Nuno Craveiro Lopes

Wide segmental resection as it was a tumor, acute compression and proximal lengthening as shown (for the femur) at http://www.geocities.com/craveiro01/brodie01.htm

Best regards,
Nuno Craveiro Lopes
Almada - PORTUGAL

Date: Thu, 25 Dec 2003 21:01:21 +0530

From: tigeorge

Dear Nuno,

Quite an impressive case report. However my worry is how do the vessels behave when acutely shortened ? Especially when the whole area has been chronically inflammed with residual fibrosis. I will be happy to know how many similar cases you have in your series and whether at any time you could not shorten due to compromise in distal vascularity.

SEASON GREETINGS.

DR T I GEORGE,
Head, Ortho Unit III,
Little Flower Hospital,
Angamaly, Kerala, India.

Date: Thu, 25 Dec 2003 21:36:04 -0000

From: Nuno Craveiro Lopes

Dear George,

On the tibia you can resect as much as 8-10 cm without any vascular impairment. What we do is to control vascular flow with a oximeter on the great toe on the post operative period and if measurements are lower than on the opposite great toe, we decompress it until ppO2 is normal and do continuous compression.

Best regards,
Nuno Craveiro Lopes
Almada - PORTUGAL