Correlating chronic pelvic and hip pressure injuries and bilateral hip destruction due to osteomyelitis: a case series
1Yurkiewicz S, 2Shem K
1Stanford University, Redwood City, Ca- califo, U.S.; 2Santa Clara Valley Medical Center, San Jose, Ca- califo, U.S.
Introduction: Osteomyelitis is a serious and not infrequent complication after spinal cord injury (SCI). The incidence of osteomyelitis in individuals with SCI is estimated to be approximately 5%. The infection most commonly affects the hips, ischia, sacrum, and calcaneus. These sites are also common areas of pressure injuries (PI). In fact, osteomyelitis is thought to occur in approximately one third of individuals with stage IV PI. One study found that among individuals with SCI who had osteomyelitis, 88% were secondary to PI. If the process becomes chronic, extensive bone destruction may occur. We present a case series of five individuals with SCI with long-term non-healing wounds, four of whom had PI, who developed chronic pelvic and hip osteomyelitis and bilateral hip destruction.
Timeline: The poster will include photographs of the various stages of these PI over the course of approximately eight years, as well as CT and MRI images of infection and bony destruction. The cases include traumatic and non-traumatic complete SCI. Four of five individuals were African American. Two injuries were cervical and three were thoracic. Length of time since injury ranged from less than one year to 29 years. PI were ischial, sacral, and trochanteric. Co-morbidities included heterotopic ossification (five patients), type 2 diabetes (three), obesity (one), sickle cell trait (one), traumatic fracture of the femur (one), the presence of hardware (two), and the presence of retained bullet fragments (one).
Diagnostic: All five patients were hospitalized multiple times with sepsis; one had septic shock, two had abscesses, and one had septic arthritis. Four patients had CT or MRI findings consistent with osteomyelitis. Three patients had positive bone biopsies, and one had a negative bone biopsy. Bilateral hip destruction was noted in all five patients via plain film, CT, and MRI. Wounds included a stage 4 sacral PI (patient 1), a stage 4 left ischial PI (patient 2), bilateral stage 4 trochanteric PI and a stage 3 right perineum PI (patient 3), stage 4 bilateral ischial and left perineum PI (patient 4), and an open right hip wound (patient 5).
Therapeutic: All five patients received long-term IV antibiotics and aggressive local wound care. Two patients had abscesses drained, two had removal of femur hardware, and one had removal of a bullet fragment in the iliac bone. None were candidates for surgical musculocutaneous flap procedures.
Results: One patient passed away in 2017 for unknown reasons. The other four are followed closely by PM&R / Wound Clinic and by Infectious Disease. They continue to receive aggressive local wound care and do bed rest as possible.
Discussion: Osteomyelitis in individuals with SCI is sometimes called “transferred osteomyelitis” from PI. However, other predisposing factors in SCI, such as heterotopic ossification, vascular pathologies, the presence of foreign objects, and fractures have yet to be fully elucidated. Our exploration of comorbidities in individuals with PI draws attention to these possible risk factors for chronic pelvic and hip osteomyelitis. We found severe sequalae of PI, serving as a reminder of the importance of aggressive wound care and other interventions when skin issues are first noticed.
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