Infections in foot and ankle surgery – where are we now? Dr Matthew Hope Orthopaedic Surgeon – Foot and Ankle

Disclosures Chairman QLD RACS Trauma Committee Member of Surgical Advisory Committee, QH Research at PAH and Jamieson Trauma Institute No conflicts of interests

Summary – foot and ankle infection History Who is at risk? Principles New technologies Case examples

History Ancient Pre-antibiotic Modern

Pre-antibiotic

Who is at risk? Diabetes Vascular disease Trauma S Kuys et. al. What are the key conditions associated with lower limb amputations in a major Australian teaching hospital? Journal of Foot and Ankle Research 2012 5:12

Musculoskeletal infection in children CM. Parry et. al. The Epidemiology of Pediatric Bone and Joint Infections in Cambodia, 2007–11 Journal of Tropical Pediatrics, 59 - 1, 2013

Principles Host factors – immunocompromised, IV drug use Bacteriology – ideal - deep samples, off antibiotics Vascularity Surgery Remove dead, devitalised infected tissue Anti-biotic coverage Reconstruct or amputate

New technologies – team approach Diagnosis - PCR - Kingella kingae Imaging - MRI - CT- PET Wound Care - dressings / ointments - negative pressure therapy Anti-microbial - local - systemic Reconstruction Amputation blue =septic arthritis, light blue = osteomyelitis, orange = endocarditis, yellow = bacteraemia, grey = unknown source We recommend the use of a K. kingae PCR in all children under 4 years of age with a possible osteoarticular infection. T. Walls. Kingella kingae carriage in New Zealand Journal of Paediatrics and Child Health (2016).

New technologies – team approach Diagnosis - PCR - Kingella kingae Imaging - MRI - PET - CT Wound Care - dressings / ointments - negative pressure therapy Anti-microbial - local - systemic Reconstruction Amputation

New technologies – team approach Diagnosis - PCR - Kingella kingae Imaging - MRI - PET - CT Wound Care - dressings / ointments - negative pressure therapy Anti-microbial - local - systemic Reconstruction Amputation

New technologies – team approach Diagnosis - PCR - Kingella kingae Imaging - MRI - PET - CT Wound Care - dressings / ointments - negative pressure therapy Anti-microbial - local - systemic Reconstruction Amputation

New technologies – team approach Diagnosis - PCR - Kingella kingae Imaging - MRI - PET - CT Wound Care - dressings / ointments - negative pressure therapy Anti-microbial - local - systemic Reconstruction Amputation

New technologies – team approach Diagnosis - PCR - Kingella kingae Imaging - MRI - PET - CT Wound Care - dressings / ointments - negative pressure therapy Anti-microbial - local - systemic Reconstruction Amputation

Case 1. 45yr male fall from ladder Open ankle fracture. ORIF ankle Case 1. 45yr male fall from ladder Open ankle fracture. ORIF ankle. Persisting infection.

Micro: Polymicrobial including E Micro: Polymicrobial including E.cloacae, Aeromonas hydrophlia, Serratia marcescens, E.coli, Strep agalactiae. Staph hominis scant (?significance)

One month Five months

Case 2. 55 yr male. Diabetic. Medial ankle cellulitis and ulcer Case 2. 55 yr male. Diabetic. Medial ankle cellulitis and ulcer. Recent MSSA sepsis and ICU admission.

bone scan and WC labelled scan consistent with OM, septic arthritis

bone scan and WC labelled scan consistent with OM, septic arthritis - debridement, bone biopsy and joint aspirate - ulcer tissue GPC, GNB, Pseudomonas aeruginosa. Bone and joint aspirate cultures negative.

Off-antibiotics, ulcer has healed Patient is well But….Ankle continues to deteriorate In cast for - Charcot Arthropathy

Case 3. 12 year old with distal leg pain, + ve blood culture and 1 x pyrexia. CRP = 30 MRI appearances raise the possibility of fasciitis extending from the level of the left distal tibia diaphysis, to the level of the medial tibial epiphysis. No current features to suggest osteomyelitis. No collection or abscess

The appearance is consistent with severe osteomyelitis of the distal left tibial metaphysis. Abnormal areas of avid enhancement and non-enhancement of the distal tibial metaphysis, with central nonenhancement likely representing bone necrosis +/- abscess.

Foot and ankle - Infection Advances in all areas of diagnosis and management. Team approach Diabetic patients remain the largest risk group prevention Surgical principles Deep tissue biopsy and adequate debridement Reconstruction options Consider amputation and rehabilitation

Infections in foot and ankle surgery – where are we now? Dr Matthew Hope Orthopaedic Surgeon – Foot and Ankle