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

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

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

5. History
Ancient
Pre-antibiotic
Modern

6. Pre-antibiotic

10. 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 :12

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

12. 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

13. 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).

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

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

23. One month
Five months

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

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

26. 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.

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

28. 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

29. 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.

30. 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

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