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ASK DR. H

September 16, 2008

Open fractures can lead to bacterial infection called osteomyelitis ASK DR. H MITCHELL HECHT

Q: My husband broke the two bones above his ankle. The doctor needed to stabilize the bones using a metal plate and screws. Two weeks later, he developed an infection of the bone, requiring intravenous antibiotics, reopening of the wound to clean it out, and removal of all the metal hardware. He’s been on antibiotics for two weeks now. How long will he need antibiotics? How did this happen?

A: Talk about a bad break! He developed the painful and nasty bone infection called “osteomyelitis.” The skin surface is full of bacteria. If your husband broke the tibia and fibula bones, there was likely an open fracture. Bacteria normally found on the skin surface can contaminate bone after it’s broken through the skin. Despite disinfecting the skin, the metal screws and plate may have been contaminated by bacteria when they were installed.

Osteomyelitis is tough to treat because outer bone tissue does not have the same rich blood supply that skin and soft tissue have. Diagnosis requires isolating the organism through wound or blood cultures, and then choosing an antibiotic that can effectively kill it. X-rays of the bone generally are not sufficiently sensitive to detect osteomyelitis unless it’s pretty severe. Bone scans, MRI, and CT scans are all helpful if osteomyelitis is suspected but not yet apparent.

High-dose intravenous antibiotics are used initially to achieve higher blood and tissue levels than oral antibiotics. The length of antibiotic treatment depends on the severity of infection and how well the patient is responding, but 4-6 weeks of intravenous antibiotics followed by oral antibiotics for another two months is typical. Once the infection has resolved, a new orthopedic prosthesis (e.g., knee or hip) may be implanted.

Q: I had a stroke five months ago. Can you please tell me what I can do to prevent a second stroke?

A: I will outline excellent, well-researched evidence-based recommendations on preventing a second stroke that come from the American Heart Association/American Stroke Association, endorsed by the American Academy of Neurology:

1) Hypertension: There’s a 30-40 percent reduced risk of stroke with blood pressure lowering. Normal blood pressure is 120/80 or less; benefit has been associated with an average reduction of 10 points on the systolic (upper) blood pressure and 5 points on the diastolic (lower) blood pressure. 2) Cholesterol: Whatever your cholesterol was prior to the stroke, it was too high – even if it was “normal.” Aggressive cholesterol lowering with a statin drug like Lipitor to get your LDL cholesterol level below 70 is advised by the SPARCL stroke prevention study.

3) Diabetes: Improving diabetic control to near-normal levels is recommended. A hemoglobin A1C level of below 6.5 percent is advised.

4) Smoking: Both first- and second-hand inhalation are risk factors for a future stroke.

5) Obesity: A waistline of less than 35 inches for a woman and 40 for a man is advised.

6) Antiplatelet therapy: Aspirin (81-325mg/day), Plavix and Aggrenox are all recommended as initial treatment for preventing a recurrent stroke. Coumadin is not recommended as an initial treatment.

Dr. Mitchell Hecht is a physician specializing in internal medicine. Send questions to him at: “Ask Dr. H,” P.O. Box 767787, Atlanta, GA 30076. Due to the large volume of mail received, personal replies are not possible. P. H., Cedar Lake, Ind. T.C., Huntsville, Ala.

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