Osteomyelitis of the Foot and Ankle: Medical and Surgical Management

343 Pages·2015·37.55 MB·English

by  Troy J. Boffeli (eds.)

Troy J. Boff eli
Editor
Osteomyelitis of
the Foot and Ankle
Medical and
Surgical Management
123
Osteomyelitis of the Foot and Ankle

Troy J. Boffeli
Editor
Osteomyelitis of the Foot
and Ankle
Medical and Surgical Management
Editor
Troy J. Boffeli, DPM, FACFAS
Regions Hospital/HealthPartners
Institute for Education and Research
St. Paul , MN , USA
ISBN 978-3-319-18925-3 ISBN 978-3-319-18926-0 (eBook)
DOI 10.1007/978-3-319-18926-0
Library of Congress Control Number: 2015943592
Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2015
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Pref ace
The onset of osteomyelitis in the foot or ankle is frequently the turning point where an other-
wise stable wound, injury, or elective surgery becomes a serious medical condition. While
largely associated with diabetic foot wounds, osteomyelitis also has a major impact on the
outcome of decubitus ulcers, puncture wounds, septic arthritis, open fractures, and gangrene.
A chronic wound can remain stable for months or even years without much more than topical
treatment or occasional antibiotics for cellulitis. It is the onset of deep infection of the under-
lying bone and joint structures that frequently leads to hospitalization, emergency surgery,
and amputation.
Lower extremity osteomyelitis is a daily occurrence in most hospitals around the world, yet
there are limited resources to guide treatment of an individual patient. Evidence-based guide-
lines to help the surgeon determine what or when to amputate are lacking. Meaningful evi-
dence is challenging due to highly variable patient presentation, including wound location,
extent of osteomyelitis, vascular status, and associated deformities. This book was written to
provide specifi c treatment protocols which can be individualized to a particular patient’s con-
dition after consideration of the entire clinical picture. The chapters are organized based on
anatomic location of the wound and infection, allowing clinicians easy access to relevant treat-
ment options.
This is a how-to book focusing on a variety of challenging and controversial situations
related to the treatment of patients with osteomyelitis of the foot and ankle.
• How to diagnose osteomyelitis early in the course of disease without unnecessary tests or
harmful biopsy procedures is covered in the early chapters.
• How to avoid excessive cost and side effects associated with antibiotics for conditions that
are better treated surgically is carefully considered for various clinical presentations.
• How to minimize the risk of recurring wounds and infection yet preserve optimal foot func-
tion after surgery is a major focus of surgical treatment guidelines.
• H ow to incorporate advanced techniques like fl ap surgery, minimally invasive procedures,
or local delivery of antibiotics is addressed using case examples that highlight alternative
surgical approaches.
Our attempt to answer these challenging questions is the foundation of this book. Whether
a seasoned foot and ankle surgeon looking for a new approach or a vascular surgeon searching
for late-night guidance, the reader is likely to gain new insights. The effectiveness of shared
decision-making between the patient, surgeon, infectious disease specialist, radiologist, and
hospitalist or primary provider is largely dependent on knowledge of treatment options. This
book is intended to provide the entire care team with practical guidelines to treat both chronic
wounds with low-grade bone infection and acute limb-threatening infections.
The image-heavy format of this text is of real value, providing a unique look into the treat-
ment protocols discussed. Rather than vague recommendations to “resect to viable, bleeding
bone,” pictures are used to fully describe the methods presented. To that end, treatment proto-
cols for nearly every ulcer location or bone of the foot and ankle are laid out in a step-by-step
pictorial format.
v
vi Preface
T he reader might notice that there is no chapter on the defi nitive surgical treatment for dia-
betic foot infection. The surgeon should forget about the quest for defi nitive treatment and
focus instead on planning ahead for future foot function and revision options should recurrent
problems develop. This approach represents a philosophical shift away from radical resection
and toward biomechanically sound methods that make foot function a priority. These methods
often employ minimal resection techniques combined with biopsy-directed medical treatment
in an effort to preserve structures of the foot and ankle which are important for gait. This con-
servative approach applies to ideal procedure selection, incision or fl ap design, extent of bone
resection, and level of amputation.
C ontributors were carefully selected based on expertise, background, and clinical focus.
Authors are both thought leaders and clinicians who deal with foot and ankle osteomyelitis on
a daily basis. The information contained here represents a number of major teaching institu-
tions with the community of interest represented by a multidisciplinary panel of experts.
St. Paul, MN, USA Troy J. Boffeli
Contents
1 Relevance of Osteomyelitis to Clinical Practice .................................................... 1
Caitlin S. Garwood and Paul J. Kim
2 Clinical and Laboratory Diagnosis......................................................................... 13
Emily A. Cook and Jill F. Ashcraft
3 Diagnostic Imaging of Osteomyelitis of the Foot and Ankle ................................ 27
Susan B. Truman
4 Bone Biopsy Techniques .......................................................................................... 39
Ryan R. Pfannenstein , Shelby B. Hyllengren , and Troy J. Boffeli
5 Pathologic Diagnosis of Osteomyelitis .................................................................... 49
Suzanne B. Keel
6 Medical Treatment Guidelines for Osteomyelitis of the Foot and Ankle ............ 55
Chris A. Manu , David B. Banach , Peter A. Blume , Bauer E. Sumpio ,
and Michael E. Edmonds
7 Acute Hematogenous Osteomyelitis of the Foot and Ankle in Children............. 67
Ralph J. Faville
8 Infected Nonunions and Infected Hardware ......................................................... 75
Jeremy J. Cook and Michael Sganga
9 Diagnosis and Management of the Septic Joint .................................................... 91
Troy J. Boffeli and Jonathan C. Thompson
10 Surgical Treatment Principles for Diabetic Wounds
Complicated by Osteomyelitis ................................................................................ 99
Lindsay Gates , Peter A. Blume , and Bauer E. Sumpio
11 Use of Antibiotic Beads and Antibiotic Spacers in Limb Salvage ....................... 113
Noah G. Oliver , Corey M. Fidler , and John S. Steinberg
12 Management and Prevention of Postamputation
Heterotopic Ossification .......................................................................................... 127
Troy J. Boffeli and Jonathan C. Thompson
13 Prevention of Osteomyelitis in Traumatic Injuries ............................................... 139
Rachel C. Collier and Jessica A. Tabatt
14 Osteomyelitis Associated with Charcot Arthropathy ........................................... 157
Laurence G. Rubin and Allen M. Jacobs
15 First Ray Osteomyelitis ........................................................................................... 167
Troy J. Boffeli , Shelby B. Hyllengren , and Matthew C. Peterson
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viii Contents
16 Osteomyelitis of the Central Toes ........................................................................... 197
Kyle W. Abben and Troy J. Boffeli
17 Central Metatarsal Osteomyelitis ........................................................................... 217
Troy J. Boffeli and J onathan C. Thompson
18 Fifth Ray Osteomyelitis ........................................................................................... 229
Troy J. Boffeli , Jessica A. Tabatt , and Kyle W. Abben
19 Transmetatarsal and Lisfranc Amputation ........................................................... 253
Troy J. Boffeli and B rett J. Waverly
20 Chopart’s Amputation for Osteomyelitis of the Midfoot ..................................... 283
Troy J. Boffeli and K evin J. Mahoney
21 Osteomyelitis of the Calcaneus ............................................................................... 297
Troy J. Boffeli and R achel C. Collier
22 Osteomyelitis of the Distal Fibula Associated
with Lateral Ankle Decubitus Ulceration .............................................................. 325
Ryan R. Pfannenstein , Kevin J. Mahoney , and Troy J. Boffeli
Index .................................................................................................................................. 339
Contributors
Kyle W. Abben , DPM, AACFAS Jamestown Regional Medical Center , Jamestown , ND ,
USA
J ill F . Ashcraft, D PM Harvard Medical School, Mount Auburn Hospital , Cambridge ,
MA , USA
David B. Banach , MD, MPH, MS Section of Infectious Diseases , Yale School of Medicine ,
Woodbridge , CT , USA
Peter A. Blume , DPM , FACFAS Yale New Haven Hospital , New Haven , CT , USA
Troy J. Boffeli , DPM, FACFAS R egions Hospital/HealthPartners Institute for Education and
Research , St. Paul , MN , USA
Rachel C. Collier , FACFAOM R egions Hospital/HealthPartners Institute for Education and
Research , St. Paul , MN , USA
Emily A. Cook , DPM, MPH, CPH, FACFAS Division of Podiatric Surgery, Department of
Surgery , Mount Auburn Hospital , Cambridge , MA , USA
Jeremy J. Cook , DPM, MPH, CPH, FACFAS D ivision of Podiatric Surgery, Department of
Surgery , Mount Auburn Hospital , Cambridge , MA , USA
Michael E. Edmonds, MD Diabetic Foot Clinic, Department of Diabetics, Kings College
Hospital , L ondon , UK
Professor of Surgery, Surgery Orthopedics and Rehabilitation Anesthesia, Yale New Haven
Hospital, New Haven, CT, USA
Ralph J. Faville, Jr, MD D epartment of Pediatric Infections Disease, Gillette Childrens
Specialty Healthcare , St. Paul , MN , USA
Corey M. Fidler , DPM MedStar Washington Hospital Center , W ashington , DC , USA
Caitlin S. Garwood , DPM D epartment of Plastic Surgery, Center for Wound Healing &
Hyperbaric Medicine , Georgetown University Hospital , Washington , DC , USA
Lindsay Gates , MD Yale New Haven Hospital , New Haven , CT , USA
Shelby B. Hyllengren , DPM Allina Health Cambridge Medical Center , Cambridge , MN ,
USA
Allen M. Jacobs , DPM, FACFAS St. Louis , MO , USA
Suzanne B. Keel , MD Department of Pathology , Regions Hospital , St. Paul , MN , USA
Paul J. Kim , DPM, MS, FACFAS Department of Plastic Surgery , Center for Wound Healing
& Hyperbaric Medicine, Georgetown University Hospital , Washington , DC , USA
Kevin J. Mahoney , DPM Regions Hospital/HealthPartners Institute for Education and
Research , St. Paul , MN , USA
ix