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Acute staphylococcal hind foot osteomyelitis in a healthy adult: A case report
Foot and Ankle Surgery 18 (2012) e12–e15
Contents lists available at SciVerse ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Acute staphylococcal hind foot osteomyelitis in a healthy adult: A case report Olusegun Aiyenuro FRCSEd (Tr&Orth)*, Sajid Shariff FRCS (Tr&Orth) Department of Orthopaedics, Medway Foundation NHS Trust, Gillingham, Kent, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 February 2011 Received in revised form 19 September 2011 Accepted 6 October 2011
Introduction: Acute osteomyelitis of the hind foot is uncommon in a normal immunocompetent adult. Case presentation: We present a previously healthy 52year old caucasian male who developed painful swelling of his ankle/hindfoot following closed soft tissue football injury. He had no antecedent systemic symptoms. Magnetic resonance imaging and bone scan imaging, followed by surgical decompression and bone biopsy confirmed a diagnosis of Staphylococcus aureus hind foot osteomyelitis. He underwent triple fusion after debridement and had suppressive antibiotics. His pain and swelling resolved at 6 weeks postoperation and CT confirmed fusion at 6 months. His inflammatory markers normalised over the course of 7 months. After 18 months, he remained asymptomatic without any evidence of recurrence. Conclusion: This case represents an unusual and important variation of presentation of acute osteomyelitis in a healthy adult. It can be easily overlooked when a normal patient presents with pain and functional impairment after a closed soft tissue trauma, but a high index of suspicion is paramount because virulent organisms can infect immunologically normal patients. ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hind foot Osteomyelitis Immunocompetent Staphylococcus aureus
1. Introduction Acute osteomyelitis of the hind foot is uncommon in a normal immunocompetent adult. We present a previously healthy 52 year old caucasian man who developed osteomyelitis of his hind foot following a simple closed soft tissue injury. 2. Case report A previously healthy 52-year-old caucasian man presented to our emergency department with a day history of severe, constant pain and swelling localised to the left ankle following soft tissue football injury. He was unable to bear weight but had no antecedent systemic symptoms. He had sustained a closed soft tissue injury to the same ankle in the preceding week playing cricket, but this resolved with simple analgesic treatment. A physical examination revealed a warm localised and erythematous swelling on the dorsum of the left foot, lateral ankle and hind foot. His ankle and hind foot movements were painful and restricted but neurovascular examination was normal. Our patient’s inflammatory markers were raised (white cell count at 13.3 109 cells/L [neutrophils = 10.72] C-reactive protein
* Corresponding author. Tel.: +44 7903120782. E-mail address: [email protected] (O. Aiyenuro).
at 32 mg/L and erythrocyte sedimentation rate at 36 mm/h), while his autoimmune antibody titres and blood cultures were normal. Initial radiographs were unremarkable (Fig. 1). Magnetic resonance imaging (MRI) of his hindfoot demonstrated an increased signal intensity in the talus, and subtalar joint on the T2 images. There was soft tissue oedema around the ankle with a small joint effusion (Fig. 2). Gallium scan confirmed infection, while NM White cell Fab Leukoscan was strongly positive for infection with tracer accumulation in the hind foot and ankle at 2 and 24 h (Fig. 3). CT scan revealed destruction of the talonavicular and calcaneocuboid joints with subtalar joint involvement (Fig. 4). We commenced treatment with oral fucidin 500 mg tds and trimethoprim 200 mg bd based on the advice of the microbiologist. A left hind foot debridement was performed. Operative findings were of widespread indurated soft tissues and hind foot joint destruction by infection. Infected contents of the sinus tarsi were removed and sent for microbiology and bone biopsies sent for histopathology and culture. Intra operative biopsy gram stain revealed pus cells but no organism. The culture grew Staphylococcus aureus sensitive to flucloxacillin and fusidic acid. Histopathology revealed bone necrosis and extensive inflammation of marrow spaces. Postoperatively, our patient’s pain improved and the hind foot swelling reduced. 8 days later, we performed a left ankle exploration, and hind foot debridement washout and triple fusion with cancellous screws (Fig. 5).
1268-7731/$ – see front matter ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2011.10.002
O. Aiyenuro, S. Shariff / Foot and Ankle Surgery 18 (2012) e12–e15
e13
Fig. 1. Initial plain radiographs were unremarkable.
He was discharged 4 days after his triple fusion. Pain and swelling resolved at 6 weeks postoperative and CT scan confirmed fusion at 6 months (Fig. 6). His inflammatory markers normalised over the course of 7 months. He was on suppressive antibiotics – trimethoprim and rifampicin for 5 months after triple fusion. He returned to work as a self employed carpenter with ankle dorsiflexion of 108, and plantar flexion of 308. A prominent calcaneal screw head was removed at 14 months and he has remained asymptomatic with no evidence of recurrence.
3. Discussion Osteomyelitis of the hindfoot can occur by direct inoculation from an open injury or surgical intervention; through local spread from an adjacent infected ulcer or by haematogenous spread commonly in children [2,8].
Fig. 2. Magnetic resonance imaging of the hindfoot demonstrated an increased signal intensity in the talus, and subtalar joint on the T2 images.
But in adults, haematogenous osteomyelitis is prevalent in those who are predisposed to bacteraemia from Intravenous drug abuse, percutaneous medical devices, indwelling catheters, dialysis. Immunocompromise is a risk factor in Diabetes Mellitus, chronic granulommatous infection or sickle cell disease [1,8,9]. There is a predilection for the vertebrae, sternoclavicular and sacroiliac joints in contrast to long bone involvement in children [10]. Acute haematogenous osteomyelitis localised in the hindfoot is a rarity, there may be little or no systemic features [2], and initial diagnosis of cellulitis and/or trauma may delay definitive diagnosis and treatment as in our patient. The most common infecting organisms is Staphylococcus aureus, although pseudomonas aeruginosa has been identified in puncture wounds and in patients on haemodialysis. Salmonella
Fig. 3. Bone scan was strongly positive for infection with tracer accumulation in the hind foot and ankle at 2 and 24 h.
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O. Aiyenuro, S. Shariff / Foot and Ankle Surgery 18 (2012) e12–e15
Fig. 6. CT scan confirmed fusion at 6 months.
Fig. 4. CT scan revealed destruction of the talonavicular and calcaneocuboid joints with subtalar joint involvement.
is common in sickle cell disease whereas staphylococcus epidermis and pseudomonas are prevalent in IV drug abusers [9]. The aetiology is polymicrobial in posttraumatic infection particularly in immune deficient patients [14]. Some unusual organisms such as mycobacterium tuberculosis, kingella kingae have been reported [9,11] and Community Acquired MRSA seems to be an emerging problem in both adult and paediatric populations [4,6,7,12]. The unique characteristics of the hind foot with a limited soft tissue envelope providing tenuous vascular perfusion combined with virulent organism invasion and impaired antibiotic penetration makes the treatment of acute osteomyelitis a challenge for the foot and ankle surgeon [13]. Malizo et al. have proposed a treatment protocol based on host, local and infection parameters [14]. Initial empirical antibiotic and analgesic treatment may cause diagnostic difficulties due to apparent improvement in patient’s condition [9]. Surgical treatment include adequate debridement and antibiotic loaded bone cement bead pouch for local antibiotic delivery [14,15].
Wong et al. reported on 2 cases of gentamicin resistance after gentamicin-PMMA beads implantation presumably due to adherence and survival of staphylococcal epidermidis which may cause treatment failure or disease recurrence [13]. Bone and soft tissue defects are managed using the ‘‘reconstructive ladder’’ protocol depending on local and host factors. Our patient presented acutely, he was type A – immunocompetent individual. Initial debridement of his hindfoot was radical to viable bleeding margins, and this was followed by culture guided intravenous antibiotic therapy. He had a second exploration, debridement and washout resulting in viable bleeding wound margins without significant soft tissue or bone defects and we proceeded to triple fusion after satisfactory joint preparation. Spontaneous hind foot osteomyelitis in a healthy adult is a unique presentation after a closed soft tissue injury [4,6]. Presumably, the modified warm and moist environment of the shod feet may encourage transition of colonising Staphylococcus aureus into a virulent invading organism which survives in the intracellular milleu in altered small-colony variants, SCVs, capable of multiplication and spread into the deeper bone and joint structures [3,5,7]. 4. Conclusion This case represents an unusual and important variation of presentation of acute osteomyelitis in a healthy adult. Definitive diagnosis may be missed or delayed because the associated pain and functional impairment closely mimicks a sprain or cellulitis. In addition, virulent Staphylococcus aureus organisms can infect immune competent hosts. Therefore, a high index of suspicion coupled with relevant and prompt laboratory and imaging modalities are paramount to achieving a satisfactory outcome. Conflict of interest statement The authors report they have no pecuniary or other conflicting interest from this report. References
Fig. 5. Triple fusion with cancellous screws.
[1] Altman. Practical statistics for medical research, vol. 1. 1999. p. 409–19. [2] Antoniou D, Conner AN. Osteomyelitis of the calcaneus and talus. JBJS Am 1974;56A(2):338–45. [3] Bassler. Curr Opin Microbiol 1999;2:582–7.
O. Aiyenuro, S. Shariff / Foot and Ankle Surgery 18 (2012) e12–e15 [4] Eady EA, Cove JH. Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus aureus—an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis 2003;16: 103–24. [5] Holden. Trends Microbiol 2000;8:101–4. [6] Kazakova SV, Hageman JC, Matava M, Srinivasan A, Phelan L, Garfinkel B, et al. A clone of methicillin-resistant Staphylococcus aureus among professional football players. N Engl J Med 2005;352:468–75. [7] Kluytmans J, vanBelkum A, Verburgh H. Nasal carriage of staphylococcus aureus: epidemiology, underlying mechanisms and associated risks. Clin Microbiol Rev 1997;10:505–20. [8] Mader JT, Shirtliff M, Calhoun JH. Staging and staging application in osteomyelitis. Clin Infect Dis 1997;25:1303–9. [9] Lee MC, Tashjian RZ, Eberson CP. Calcaneus osteomyelitis from communityacquired MRSA. Foot Ankle Int 2007;28(2):276–80.
e15
[10] Gordon RJ, Lowy FD. Bacterial infections in drug users. N Engl J Med 2005; 353(18):1945. [11] Yagupsky P, Howard CB, Einhorn M, Dagan R. KingellaKingae osteomyelitis of the calcaneus in young children. Pediatr Infect Dis J 1993;12:540–1. [12] Markus HS. Haematogenous osteomyelitis in the adult: a clinical and epidemiological study. Q J Med 1989;71(266):521–7. [13] Wong MWN, Hui M. Development of gentamicin resistance after gentamicinPMMA beads for treatment of foot osteomyelitis: report of two cases. Foot Ankle Int 2005;26(12):1093–5. [14] Malizos KN, Gougoulias NE, Dailana ZH, Varitimidis S, Bargiotas K, Paridis D. Ankle and foot osteomyelitis; treatment protocol and clinical results Injury. Int J Care Injured 2010;41:285–93. [15] Dalman-Coll A, Morales-Montoya A, Ronda-Rivero F, Comellas-Alabern JF. Post-traumatic osteomyelitis of the calcaneus: results of treatment. Rev Ortop Traumatol 2006;50:378–81.
Contents lists available at SciVerse ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Acute staphylococcal hind foot osteomyelitis in a healthy adult: A case report Olusegun Aiyenuro FRCSEd (Tr&Orth)*, Sajid Shariff FRCS (Tr&Orth) Department of Orthopaedics, Medway Foundation NHS Trust, Gillingham, Kent, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 February 2011 Received in revised form 19 September 2011 Accepted 6 October 2011
Introduction: Acute osteomyelitis of the hind foot is uncommon in a normal immunocompetent adult. Case presentation: We present a previously healthy 52year old caucasian male who developed painful swelling of his ankle/hindfoot following closed soft tissue football injury. He had no antecedent systemic symptoms. Magnetic resonance imaging and bone scan imaging, followed by surgical decompression and bone biopsy confirmed a diagnosis of Staphylococcus aureus hind foot osteomyelitis. He underwent triple fusion after debridement and had suppressive antibiotics. His pain and swelling resolved at 6 weeks postoperation and CT confirmed fusion at 6 months. His inflammatory markers normalised over the course of 7 months. After 18 months, he remained asymptomatic without any evidence of recurrence. Conclusion: This case represents an unusual and important variation of presentation of acute osteomyelitis in a healthy adult. It can be easily overlooked when a normal patient presents with pain and functional impairment after a closed soft tissue trauma, but a high index of suspicion is paramount because virulent organisms can infect immunologically normal patients. ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hind foot Osteomyelitis Immunocompetent Staphylococcus aureus
1. Introduction Acute osteomyelitis of the hind foot is uncommon in a normal immunocompetent adult. We present a previously healthy 52 year old caucasian man who developed osteomyelitis of his hind foot following a simple closed soft tissue injury. 2. Case report A previously healthy 52-year-old caucasian man presented to our emergency department with a day history of severe, constant pain and swelling localised to the left ankle following soft tissue football injury. He was unable to bear weight but had no antecedent systemic symptoms. He had sustained a closed soft tissue injury to the same ankle in the preceding week playing cricket, but this resolved with simple analgesic treatment. A physical examination revealed a warm localised and erythematous swelling on the dorsum of the left foot, lateral ankle and hind foot. His ankle and hind foot movements were painful and restricted but neurovascular examination was normal. Our patient’s inflammatory markers were raised (white cell count at 13.3 109 cells/L [neutrophils = 10.72] C-reactive protein
* Corresponding author. Tel.: +44 7903120782. E-mail address: [email protected] (O. Aiyenuro).
at 32 mg/L and erythrocyte sedimentation rate at 36 mm/h), while his autoimmune antibody titres and blood cultures were normal. Initial radiographs were unremarkable (Fig. 1). Magnetic resonance imaging (MRI) of his hindfoot demonstrated an increased signal intensity in the talus, and subtalar joint on the T2 images. There was soft tissue oedema around the ankle with a small joint effusion (Fig. 2). Gallium scan confirmed infection, while NM White cell Fab Leukoscan was strongly positive for infection with tracer accumulation in the hind foot and ankle at 2 and 24 h (Fig. 3). CT scan revealed destruction of the talonavicular and calcaneocuboid joints with subtalar joint involvement (Fig. 4). We commenced treatment with oral fucidin 500 mg tds and trimethoprim 200 mg bd based on the advice of the microbiologist. A left hind foot debridement was performed. Operative findings were of widespread indurated soft tissues and hind foot joint destruction by infection. Infected contents of the sinus tarsi were removed and sent for microbiology and bone biopsies sent for histopathology and culture. Intra operative biopsy gram stain revealed pus cells but no organism. The culture grew Staphylococcus aureus sensitive to flucloxacillin and fusidic acid. Histopathology revealed bone necrosis and extensive inflammation of marrow spaces. Postoperatively, our patient’s pain improved and the hind foot swelling reduced. 8 days later, we performed a left ankle exploration, and hind foot debridement washout and triple fusion with cancellous screws (Fig. 5).
1268-7731/$ – see front matter ß 2011 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2011.10.002
O. Aiyenuro, S. Shariff / Foot and Ankle Surgery 18 (2012) e12–e15
e13
Fig. 1. Initial plain radiographs were unremarkable.
He was discharged 4 days after his triple fusion. Pain and swelling resolved at 6 weeks postoperative and CT scan confirmed fusion at 6 months (Fig. 6). His inflammatory markers normalised over the course of 7 months. He was on suppressive antibiotics – trimethoprim and rifampicin for 5 months after triple fusion. He returned to work as a self employed carpenter with ankle dorsiflexion of 108, and plantar flexion of 308. A prominent calcaneal screw head was removed at 14 months and he has remained asymptomatic with no evidence of recurrence.
3. Discussion Osteomyelitis of the hindfoot can occur by direct inoculation from an open injury or surgical intervention; through local spread from an adjacent infected ulcer or by haematogenous spread commonly in children [2,8].
Fig. 2. Magnetic resonance imaging of the hindfoot demonstrated an increased signal intensity in the talus, and subtalar joint on the T2 images.
But in adults, haematogenous osteomyelitis is prevalent in those who are predisposed to bacteraemia from Intravenous drug abuse, percutaneous medical devices, indwelling catheters, dialysis. Immunocompromise is a risk factor in Diabetes Mellitus, chronic granulommatous infection or sickle cell disease [1,8,9]. There is a predilection for the vertebrae, sternoclavicular and sacroiliac joints in contrast to long bone involvement in children [10]. Acute haematogenous osteomyelitis localised in the hindfoot is a rarity, there may be little or no systemic features [2], and initial diagnosis of cellulitis and/or trauma may delay definitive diagnosis and treatment as in our patient. The most common infecting organisms is Staphylococcus aureus, although pseudomonas aeruginosa has been identified in puncture wounds and in patients on haemodialysis. Salmonella
Fig. 3. Bone scan was strongly positive for infection with tracer accumulation in the hind foot and ankle at 2 and 24 h.
e14
O. Aiyenuro, S. Shariff / Foot and Ankle Surgery 18 (2012) e12–e15
Fig. 6. CT scan confirmed fusion at 6 months.
Fig. 4. CT scan revealed destruction of the talonavicular and calcaneocuboid joints with subtalar joint involvement.
is common in sickle cell disease whereas staphylococcus epidermis and pseudomonas are prevalent in IV drug abusers [9]. The aetiology is polymicrobial in posttraumatic infection particularly in immune deficient patients [14]. Some unusual organisms such as mycobacterium tuberculosis, kingella kingae have been reported [9,11] and Community Acquired MRSA seems to be an emerging problem in both adult and paediatric populations [4,6,7,12]. The unique characteristics of the hind foot with a limited soft tissue envelope providing tenuous vascular perfusion combined with virulent organism invasion and impaired antibiotic penetration makes the treatment of acute osteomyelitis a challenge for the foot and ankle surgeon [13]. Malizo et al. have proposed a treatment protocol based on host, local and infection parameters [14]. Initial empirical antibiotic and analgesic treatment may cause diagnostic difficulties due to apparent improvement in patient’s condition [9]. Surgical treatment include adequate debridement and antibiotic loaded bone cement bead pouch for local antibiotic delivery [14,15].
Wong et al. reported on 2 cases of gentamicin resistance after gentamicin-PMMA beads implantation presumably due to adherence and survival of staphylococcal epidermidis which may cause treatment failure or disease recurrence [13]. Bone and soft tissue defects are managed using the ‘‘reconstructive ladder’’ protocol depending on local and host factors. Our patient presented acutely, he was type A – immunocompetent individual. Initial debridement of his hindfoot was radical to viable bleeding margins, and this was followed by culture guided intravenous antibiotic therapy. He had a second exploration, debridement and washout resulting in viable bleeding wound margins without significant soft tissue or bone defects and we proceeded to triple fusion after satisfactory joint preparation. Spontaneous hind foot osteomyelitis in a healthy adult is a unique presentation after a closed soft tissue injury [4,6]. Presumably, the modified warm and moist environment of the shod feet may encourage transition of colonising Staphylococcus aureus into a virulent invading organism which survives in the intracellular milleu in altered small-colony variants, SCVs, capable of multiplication and spread into the deeper bone and joint structures [3,5,7]. 4. Conclusion This case represents an unusual and important variation of presentation of acute osteomyelitis in a healthy adult. Definitive diagnosis may be missed or delayed because the associated pain and functional impairment closely mimicks a sprain or cellulitis. In addition, virulent Staphylococcus aureus organisms can infect immune competent hosts. Therefore, a high index of suspicion coupled with relevant and prompt laboratory and imaging modalities are paramount to achieving a satisfactory outcome. Conflict of interest statement The authors report they have no pecuniary or other conflicting interest from this report. References
Fig. 5. Triple fusion with cancellous screws.
[1] Altman. Practical statistics for medical research, vol. 1. 1999. p. 409–19. [2] Antoniou D, Conner AN. Osteomyelitis of the calcaneus and talus. JBJS Am 1974;56A(2):338–45. [3] Bassler. Curr Opin Microbiol 1999;2:582–7.
O. Aiyenuro, S. Shariff / Foot and Ankle Surgery 18 (2012) e12–e15 [4] Eady EA, Cove JH. Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus aureus—an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis 2003;16: 103–24. [5] Holden. Trends Microbiol 2000;8:101–4. [6] Kazakova SV, Hageman JC, Matava M, Srinivasan A, Phelan L, Garfinkel B, et al. A clone of methicillin-resistant Staphylococcus aureus among professional football players. N Engl J Med 2005;352:468–75. [7] Kluytmans J, vanBelkum A, Verburgh H. Nasal carriage of staphylococcus aureus: epidemiology, underlying mechanisms and associated risks. Clin Microbiol Rev 1997;10:505–20. [8] Mader JT, Shirtliff M, Calhoun JH. Staging and staging application in osteomyelitis. Clin Infect Dis 1997;25:1303–9. [9] Lee MC, Tashjian RZ, Eberson CP. Calcaneus osteomyelitis from communityacquired MRSA. Foot Ankle Int 2007;28(2):276–80.
e15
[10] Gordon RJ, Lowy FD. Bacterial infections in drug users. N Engl J Med 2005; 353(18):1945. [11] Yagupsky P, Howard CB, Einhorn M, Dagan R. KingellaKingae osteomyelitis of the calcaneus in young children. Pediatr Infect Dis J 1993;12:540–1. [12] Markus HS. Haematogenous osteomyelitis in the adult: a clinical and epidemiological study. Q J Med 1989;71(266):521–7. [13] Wong MWN, Hui M. Development of gentamicin resistance after gentamicinPMMA beads for treatment of foot osteomyelitis: report of two cases. Foot Ankle Int 2005;26(12):1093–5. [14] Malizos KN, Gougoulias NE, Dailana ZH, Varitimidis S, Bargiotas K, Paridis D. Ankle and foot osteomyelitis; treatment protocol and clinical results Injury. Int J Care Injured 2010;41:285–93. [15] Dalman-Coll A, Morales-Montoya A, Ronda-Rivero F, Comellas-Alabern JF. Post-traumatic osteomyelitis of the calcaneus: results of treatment. Rev Ortop Traumatol 2006;50:378–81.