Counterpoint: Diabetic Foot Osteomyelitis Is A Surgical Disease Transcript PDF

PRESENT Podiatry Online CME & Conferences | Counterpoint: Diabetic Foot Osteomyelitis is a Surgical Disease 8/26/18, 9)49 PM
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Counterpoint: Diabetic Foot Osteomyelitis is a Surgical Disease

Guido LaPorta, DPM, MS
Guido LaPorta, DPM, FACFAS, MS discusses the diagnosis and treatment of osteomyelitis. Dr LaPorta
reviews tools and methods of diagnosis and the advantages and disadvantages of specific antibiotics used
with or without surgical intervention for treatment. He outlines literature and experience that support both
conservative and/or surgical interventions.
CME (Credits: 1)
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Guido LaPorta, DPM, MS

Director Podiatric Medical Education
Community Medical Center
Scranton, PA
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Lecture Transcript
biomedical
Gran: Diabeticdevice
footmanufacturers,
osteomyelitis isorindeed
other corporations whoseso
a surgical disease, products
Dr. Port or services are related to the subject
[Phonetic].
matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of
interest from making a presentation. It is merely intended that any potential conflict should be identified openly
Dr. Port: Thanks, Gran [Phonetic]. We’re actually going to have to reevaluate our friendship. First, I get to talk I
so
knowthatnothing
the listeners
about.may form their
Secondly, own
I have tojudgments about
counterpoint the presentation
Dr. Jeff with
Kirk [Phonetic]. the full
Thank you disclosure of the
very much. facts.
I guess
there’s
--- an old adage, “If all.” I’m going to come to it from a surgeon standpoint. Quite frankly, what I just heard
is very much youhas
own is a hammer,
nothing everything looks like a nail commonsensical to me and seems to be
to disclose.
Guido LaPorta
something that we should all consider. But I would suggest to you that medical treatment of osteomyelitis may
be a very effective alternative when one is talking about osteomyelitis in the digits and possibly even the
metatarsal heads. But I would also suggest that as one moves more proximal into the midfoot, talus, calcaneus,
even tibia, that that may not be a good alternative as a primary interdiction. It may be. The answer may lie in
what we diagnose as osteomyelitis and what type of osteomyelitis that we have. Suppose this patient comes
Gran: Diabetic
in, who’s had afoot osteomyelitis
diabetic is indeed
patient, who’s had aa surgical
previousdisease, so Dr.with
ankle fusion Portan[Phonetic].
intramedullary nail. The nail is now
migrating. It is toggling within the tibia. If you look closely enough around the margins of the nail, there’s a
Dr. Port: Thanks,
radiolucency Gran [Phonetic].
suggesting We’re
at the very leastactually going
loosening, to haveeven
possibly to reevaluate
infection. our friendship.
He arrives First,
at your I getwith
clinic to talk
thisI
know nothing
Ceretec white about. Secondly,
blood cell scan and I have to counterpoint
presents Dr. is
like this. This Jeff Kirk [Phonetic].
osteomyelitis in a Thank you
diabetic very much.
patient. I guess
What I’m trying
there’s
to point out is that, can it be treated medically? I think it depends on your definition of osteomyelitis and heard
an old adage, “If all.” I’m going to come to it from a surgeon standpoint. Quite frankly, what I just maybe
is verythe
even much you ownlocation
geographic is a hammer, everything
of what lookstreating.
in fact you’re like a nail commonsensical
In this particular case, to we
me elected
and seems to treat
not to be it
something that we should all consider. But I would suggest to you that medical treatment of osteomyelitis may
medically, at least medically alone. We elected to treat it with a combination of surgery and antibiotics. We use
be
theaantibiotics
very effective alternative
in one whennot
of two ways, onejust
is talking aboutbut
parenterally osteomyelitis
also locallyininthe
thedigits and
form of possiblybeads
antibiotic even the
and
metatarsal heads. But I would also suggest that as one moves more proximal into the midfoot, talus,
antibiotic nail. This patient had a nail. We removed it. You can see an antibiotic nail used in its place to treat calcaneus,
even tibia, thatosteomyelitis,
intramedullary that may not be a good beads
antibiotic alternative
over as a primary
a drain interdiction.
and this It maypatient,
is very difficult be. Thethis
answer
was may lie in
a 50-year-
what we diagnose
old. This was Ohanda as osteomyelitis and what
[Phonetic], I think type
I heard of osteomyelitis
before. that we have.
This was a 50-year-old Suppose
patient withthis patientalcoholic
diabetes, comes
in, who’s had a diabetic patient, who’s had a previous ankle fusion with an intramedullary nail. The nail is now
problem and certainly a very non-adherent patient. Yet, in this particular case, it took us seven months. But we
migrating. It iswhere
got to a point toggling
notwithin thewe
only did tibia. If youall
remove look closelybone
infected enough aroundable
but we’re thetomargins of the
affect the nail,
solid there’s
fusion, anda the
radiolucency suggesting
leg lengthening. at the
If you were veryme,
to ask least loosening,
could that bepossibly
achievedeven infection.
in this Hepatient
particular arrives pre-op,
at your Iclinic
would with this
have
Ceretec
basicallywhite blood
said no. cellabout
What scan the
andtype
presents like this. ThisWell,
of osteomyelitis? is osteomyelitis
Cierny-Mader in aclassification
diabetic patient.
tells What I’m trying
us a number of
to pointthat
things outwe
is that,
should canbeit familiar
be treated medically?
with. I think itthat
I would suggest depends on your
if we have definition even
a superficial, of osteomyelitis
a localized and maybe
even the geographic location of what in fact you’re treating. In this particular case, we elected not to treat it
osteomyelitis that medical treatment may in fact be very effective and should be tried first. But once it becomes
medically,
medullary orat once
least medically
it becomes alone. We elected
diffused, at least to
in treat it with setting,
my clinical a combination
I wouldofbesurgery andtoantibiotics.
expected attack thatWe use
the antibiotics in one of two ways, not just parenterally but also locally in the form of antibiotic beads and
antibiotic nail. This patient had a nail. We removed it. You can see an antibiotic nail used in its place to treat
intramedullary osteomyelitis, antibiotic beads over a drain and this is very difficult patient, this was a 50-year-
old. This was Ohanda [Phonetic], I think I heard before. This was a 50-year-old patient with diabetes, alcoholic
problem and certainly a very non-adherent patient. Yet, in this particular case, it took us seven months. But we
surgically and with antibiotics. The first thing that I would have to do as a clinician is make a diagnosis and I
can do that in any one of a number of ways. The gold standard, of course, is the bone biopsy which can be
done at the time of debridement.
[05:03]
But many times, we have to make a clinical decision prior to doing that. How many of you have had on service
when you’re co-managing a diabetic patient, have somebody order a triphasic bone scan to help you out? I’m
sure a number of you had, right? It basically is a totally useless test other than to tell you that something is
wrong, okay. How do we make a diagnosis? What are things we have to be familiar with? Well, we can do it
clinically. We can do it with lab analysis. We can do it with microbiology, pathology and imaging modalities.
How about our bone biopsy? Is there a difference between histology and microbiology? The literature would
surgically
suggest thatandit with antibiotics.
pretty much gives Theyou
first thing
the samethat I wouldofhave
amount to information.
useful do as a clinician
If youislook
makeat athe
diagnosis and I
pathology,
can do thathas
pathology in any one of a of
a sensitivity number
about of75%ways.
andThe gold standard,
specificity or 42% of course,
with is thepredictive
a positive bone biopsy
value which can
of 77, a be
done at the
negative time of value
predictive debridement.
of 39. Its reliability is about 33%. Well, why would that be? Well, it depends on how
your lab handles the pathology. The only really good studies about pathologic benefit or in periprosthetic
[05:03]
infections, there are very few studies in the patient population we’re talking about. But one of the things you
But
can many times,
go down we your
is ask havepathologist
to make a clinical decision
what their prior
criteria to diagnosing
is for doing that. infections.
How many Are of you
theyhave had for
looking on 5service
or 10
when
neutrophils per high power field? How about frozen sections? How do you feel about that? How many do I’m
you’re co-managing a diabetic patient, have somebody order a triphasic bone scan to help you out?
sure a number
frozen sectionsof atyou
the had,
time right? It basically Frozen
of debridement? is a totally useless
section has test other than of
the sensitivity to25
telltoyou
28%that something
but is of
a specificity
wrong, okay. ItHow
98 to 100%. has do we make
a positive a diagnosis?
predictive valueWhat are things
of 100% we have to
and a negative be familiar
predictive with?
value Well, we canbetween
of somewhere do it
clinically.
70 and 90%. We can do ittime
It adds withtolab analysis.
your operativeWeprocedure
can do it with
but microbiology, pathology
it gives you good and imaging
information. You may modalities.
want to
How about our bone biopsy? Is there a difference between histology and microbiology?
consider that with your bone biopsy to see if in fact you have done an adequate debridement. What about The literature would
suggest that it prettyWell,
imaging modalities? muchx-ray
givesandyouCT thescan
sameareamount of useful
pretty much information.
similar. They haveIf you look at the
a sensitivity pathology,
of 75, specificity of
pathology has a sensitivity of about 75% and specificity or 42% with a positive predictive
74. But it’s difficult and there is no differentiation between osteo versus Charcot. And that’s my toughest value of 77, a clinical
negative
problem whenpredictive value ofwith
I’m dealing 39. these
Its reliability
types ofis patients.
about 33%.MRIWell,
has why would thatofbe?
the sensitivity 90% Well,
anditadepends onofhow
specificity 82%.
your labbetter
They’re handles thebone
than pathology.
scans. The
Mostonly reallysay,
people good studies
if no about
Charcot pathologicbut
or hardware, benefit or in periprosthetic
my experience clinically is that
infections, there are very few studies in the patient population we’re talking about. But
the MRI is as good as the person reading it. Unless you have a musculoskeletally trained radiologist, one of the things
youyou
can
can
give confusing readings from your MRI. I’m going to get an MRI and say suggest bone scan based on the 10
go down is ask your pathologist what their criteria is for diagnosing infections. Are they looking for 5 or
neutrophils
results whereperyou
highgetpower field?
a bone scanHow
andabout
suggestfrozen
MRI.sections? How
Well, I think it’sdo you feel
difficult to about
rely onthat? Howtomany
one test makedo that
frozen sections at the time of debridement? Frozen section has the sensitivity of 25 to 28% but
particular diagnosis. In fact, I think MRIs tend to over read most things. How about nuclear medicine studies? a specificity of
98
As to 100%. It has
I mentioned a positive
before, predictive
the triphasic bone value
scanofis100% and
in fact, in amynegative
mind, apredictive valuewith
waste of time of somewhere between
respect to trying to
70 and 90%. It adds time to your operative procedure but it gives you good information. You may
differentiate between osteomyelitis especially in Charcot disease. All of our medical colleagues ordered this and want to
consider thatgood
it makes for with arguments
your bone biopsy
and foodto fights
see if in
andfact you have
things done
like that an adequate
in cafeteria. Butdebridement.
it gives us veryWhat
littleabout
imaging modalities?
information. Well, x-ray
The literature wouldand CT scan
suggest thatare pretty
indium much
has similar. They
a sensitivity of 79,have a sensitivity
specificity of 78.ofBut
75,anspecificity
interestingof
74. But it’s difficult
phenomena occursand
whenthere
youiscombine
no differentiation between
indium and/or osteo
Ceretec versus
with Charcot.
sulfur And that’s
colloid scans. mynotice
You’ll toughestthat clinical
it has
problem
an accuracy whenupI’m dealing
in the with
90s as farthese types
as being of patients.
able MRI has
to differentiate the from
osteo sensitivity of 90%
Charcot. The and a specificity
terminology is of 82%.
They’re better Ifthan
concordance. youbone
havescans. Most
a positive peopleand
Ceretec say,aifpositive
no Charcot
sulfurorcolloid,
hardware,
youbut my experience
probably clinically
do not have is that
an infection.
the
If in MRI
fact is
youashave
goodaas the person
positive reading
Ceretec and ait.negative
Unless you have
sulfur a musculoskeletally
colloid, you probably dotrained radiologist,
have an you can
osteomyelitis.
give confusing readings from your MRI. I’m going to get an MRI and say suggest bone scan based on the
results
[10:05] where you get a bone scan and suggest MRI. Well, I think it’s difficult to rely on one test to make that
particular diagnosis. In fact, I think MRIs tend to over read most things. How about nuclear medicine studies?
As I mentioned before, the triphasic bone scan is in fact, in my mind, a waste of time with respect to trying to
differentiate between osteomyelitis especially in Charcot disease. All of our medical colleagues ordered this and
it makes for good arguments and food fights and things like that in cafeteria. But it gives us very little
information. The literature would suggest that indium has a sensitivity of 79, specificity of 78. But an interesting
If you have a negative Ceretec, your job is done. You don’t have to go any further. Gallium is not used too much
anymore, it’s pretty much shown to be non-reliable. Of course, everybody is chomping it a bit to utilize PET
scans in order to make this particular diagnosis. Now, I noticed that some of the articles that were quoted
previously, I’m also going to quote. It’s observations made about antibiotic treatments. Senneville said there
was a 36% failure when treated non-operatively. Indecipherable] [10:43] said there was a 44% failure with deep
infection when treated non-operatively. Kowalski, 44% failure when surgical resection left a positive margin.
And 44% need a more proximal AMP when a positive margin was left behind. Therefore, I think there is good
evidence for the local use of antibiotic cement. Buchholz and Engelbrecht in ‘70 were the ones to show that if
you had high concentrations of antibiotic locally, that it would elute into the local tissues. Stevens agreed and
noted that there was a lack of systemic risks. It needs the antibiotic that you use, needs to be thermostable and
hydrophilic. Palacos itself, in antibiotic-impregnated PMMA was shown to be bioactive levels of above the
If you have
minimal a negative
inhibitory Ceretec, your
concentration at 80job is done.
days. You don’t
The typical have to that
antibiotics go any
thatfurther.
are usedGallium is not
are gent, usedvanco
tobra, too much
and
anymore, it’s pretty much shown to be non-reliable. Of course, everybody is chomping it a bit to utilize PET
cephalosporins. The dosage is debatable but most people would agree that you should not go above 8 grams
scans in order to make this particular diagnosis. Now, I noticed that some of the articles that were quoted
per 40 grams of PMMA. Setting properties will vary with humidity. The setting properties in northeastern
previously, I’m also going to quote. It’s observations made about antibiotic treatments. Senneville said there
Pennsylvania where I’m at are different than they would say be in Atlanta where Ciranni [Phonetic] practiced for
was
mucha of
36% his failure
career.when
How treated
about thenon-operatively. Indecipherable]
illusion characteristics? [10:43] is
Clindamycin said there was
definitely the abest.
44%Itfailure with deep
has high
infection when treated non-operatively.
seromic concentration Kowalski,
and granulation tissue and 44%
bone.failure
Tobrawhen surgical
and vanco areresection left a positive
both considered to be margin.
good.
And 44% need a more proximal AMP when a positive margin was left behind. Therefore, I think there is good
Tobra has high seroma and granulation tissue but poor bone. Vanco has poor seroma but high granulation
evidence for the local use of antibiotic cement. Buchholz and Engelbrecht in ‘70 were the ones to show that if
tissue and bone. But you noticed they’re used together a lot. There’s a reason for that. The reason is that the
you had high concentrations of antibiotic locally, that it would elute into the local tissues. Stevens agreed and
tobra elutes quicker. Because of that, studies have shown that as it elutes quicker, it makes the PMMA beads
noted that there
more porous andwas a lack
allows for of systemic
more elutionrisks.
of theIt vancomycin.
needs the antibiotic that you
You noticed in theuse, needsthat
studies to be thermostable
vanco eluted at aand
hydrophilic.
higher rate whenPalacos itself,
it was in antibiotic-impregnated
combined with tobra. One ofPMMA was shown
the reasons they’retoused
be bioactive
together levels of above
is for that the
particular
minimal inhibitory concentration at 80 days. The typical antibiotics that that are used are gent, tobra, vanco and
effect. It’s also been shown that if you add a soluble such as dextran to the beads that you can get a higher
cephalosporins. The dosage is debatable but most people would agree that you should not go above 8 grams
elution of antibiotics into the soft tissue. Because of the phenomena of intracellular Staph aureus which I have
per 40 grams of PMMA. Setting properties will vary with humidity. The setting properties in northeastern
become enamored with over the last half year, we are now routinely adding rifampin to the beads. But Warren
Pennsylvania
[Phonetic] toldwhere I’m atdo
me, “Why are different
that? Why than theygive
not just would say be
it orally andinhave
Atlanta where Ciranni
a potentially same[Phonetic]
effect when practiced
treatingfor
much
this?” of his career.
I think How aboutwe
that’s something theshould
illusionbecharacteristics? Clindamycin
paying more attention is definitely
to. There the best. with
is a phenomena It hasintracellular
high
seromic concentration and granulation tissue and bone. Tobra and vanco are both considered to be good.
Staph that Staph aureus can invade the osteoblast. As soon as it does, it becomes less effective and the
Tobra has high seroma and granulation tissue but poor bone. Vanco has poor seroma but high granulation
antibiotic can’t reach it. The osteoblast dies. It’s a double whammy, if you will. It’s protected from antibiotics to
tissue and bone. But you noticed they’re used together a lot. There’s a reason for that. The reason is that the
some extent. The osteoblast can’t function like an osteoblast. Consequently, I think it’s important you realize
tobra elutes
that and alsoquicker. Because
to realize that one ofof
that,
the studies have shown
medications that canthat as it elutes
effectively quicker,
address the itintracellular
makes the Staph
PMMAisbeads
more porous
rifampin. There andareallows
other for more
tricks. elution
You of the
can use vancomycin.
a RIA device. This Youis noticed
a reamer, in irrigator
the studies andthat vanco especially
aspirator, eluted at a
higher rate when it was combined with tobra. One of the reasons they’re used together is for that particular
when you’re dealing with tibial osteomyelitis.
effect. It’s also been shown that if you add a soluble such as dextran to the beads that you can get a higher
elution of antibiotics into the soft tissue. Because of the phenomena of intracellular Staph aureus which I have
[15:02]
become enamored with over the last half year, we are now routinely adding rifampin to the beads. But Warren
[Phonetic] told me,
You can irrigate the “Why
canal do that?
if the IM Why
nail isnot just give
infected. it orally
You and have
can ream to theaproximal
potentially same
tibia effect
so you canwhen treating
actually recruit
this?” I think that’s something we should be paying more attention to. There is a phenomena with intracellular
good bone graft and get autogenous bone graft. You can also use the concept of induced membranes, known
Staph that Staph aureus can invade the osteoblast. As soon as it does, it becomes less effective and the
as Masquelet technique. Membranes one to two millimeters thick or form, they’re rich with growth factors.
antibiotic can’t reach it. The osteoblast dies. It’s a double whammy, if you will. It’s protected from antibiotics to
some extent. The osteoblast can’t function like an osteoblast. Consequently, I think it’s important you realize
that and also to realize that one of the medications that can effectively address the intracellular Staph is
rifampin. There are other tricks. You can use a RIA device. This is a reamer, irrigator and aspirator, especially
when you’re dealing with tibial osteomyelitis.
What you do is place in an antibiotic spacer. That spacer needs to cover both ends of the bones. It’s removed
in about four to eight weeks. Instead of curetting that nice membrane out, you take advantage of the fact that it
is full of growth factors and you pack it with cancellous bone. There is a reported 8% failure rate, so this really
should be used only in defects that are within two to four centimeters. If you have a larger defect, the
Masquelet technique is proved to be ineffective. Let me answer the same question. Can medical treatment of
osteomyelitis be effective? My answer is yes, and no. I think it depends on the quality of the osteomyelitis, how
it affects the bone, and the geographic location. I would not hesitate to use medical treatment as the primary
approach in digital and metatarsal head osteomyelitis. I would be very hesitant to depend on it alone in more
proximal forms of osteomyelitis, specifically those which are diffused and/or intramedullary. The end. Thank
you.
What you do is place in an antibiotic spacer. That spacer needs to cover both ends of the bones. It’s removed
in about four to eight weeks. Instead of curetting that nice membrane out, you take advantage of the fact that it
is full of growth factors and you pack it with cancellous bone. There is a reported 8% failure rate, so this really
should be used only in defects that are within two to four centimeters. If you have a larger defect, the
Masquelet technique is proved to be ineffective. Let me answer the same question. Can medical treatment of
osteomyelitis be effective? My answer is yes, and no. I think it depends on the quality of the osteomyelitis, how
it affects the bone, and the geographic location. I would not hesitate to use medical treatment as the primary
approach in digital and metatarsal head osteomyelitis. I would be very hesitant to depend on it alone in more
proximal forms of osteomyelitis, specifically those which are diffused and/or intramedullary. The end. Thank
you.

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PRESENT Podiatry Online CME & Conferences | Counterpoint: Diabetic Foot Osteomyelitis is a Surgical Disease 8/26/18, 9)49 PM

Residency Education / Diabetic Foot

Counterpoint: Diabetic Foot Osteomyelitis is a Surgical Disease

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