Please join Lucian G. Vlad, MD for this mini on-demand video utilizing mechanical disposable negative pressure in the management of Olecranon Bursitis – Chronic Osteomyelitis.
Hello, My wound care colleagues. We're here today to talk about my personal experience on patients treated for electoral bursitis and chronic osteomyelitis using a snap therapy system. Ah, this is some important information toe review tried to using this system. Uh, this is a list off my disclosures. Different companies that I work and I consult with as a brief introduction. I am assistant professor in the Department of Plastic and across six reconstructive surgery at Wake Forest Baptist. I am by training a family physician. I am practicing one care full time for the past 10 years and outpatient setting. So just briefly, uh, remind about electoral beside us. This is a condition that causes swelling and inflammation off the versa around the elbow. Most of times, the traumatic issue, uh, it makes it swell up like a golf ball. A lot of times, it's other inflammatory conditions, like gout, rheumatoid arthritis, because there's a lot of pain with extension and flexion. This is an uncommon condition. Toc in ah, outpatient one care clinic. A lot of times, you see elect number side is an orthopedic clinic or other surgery clinics. Um, chronic costume, a light us on the other hand is a very common situation that we deal in the wound care clinic. The frustrating part about this condition is we don't have good diagnosis test. We don't have, uh, toe confirm it that say we have it. We also don't have good diagnosis. Diagnosis as toe, Uh, say we don't have it, so Ah, a lot of times Chronic osteomyelitis. It ends up being, uh, nowhere. Land don't clearly have signs of infection. It doesn't allow the wounds to heal it. It persists. And we left toe just, uh, clinical progress and, uh, cereal X ray. So it can be a frustrating condition to deal with, not even to mention the variations in approach and treatment from different providers in different clinics. Uh, another very common condition. That we deal with this. A pressure injury. Most of times, we see pressure, injuries and patient have significant neurologic ability. Especially spine injury, significant physical decline, sacred issue. Um, a lot of times per syria. Hell, um, not not usually at election on, but pressure injuries and officers are very common condition. So our patient want to talk about today? It kind of hit the trifecta. He had a combination of all these issues. Uh, electric number side is that was, uh, not allowing thio be the hell, because the pressure injury and, uh, the, uh, superimposed chronic osteomyelitis 67 year old gentleman who presents to us. Approximately three weeks after he had a fall, he was seen by his primary care physician. He was through with some antibiotics, some anti inflammatories, and he developed a very small pinpoint 34 millimeters alteration over the tip of a election on along with the significant swelling. So he was referred to a bunker clinic to evaluate and treat a za background. He had diabetes that was very well controlled. They did have Parkinson disease, iron deficiency, anemia. He had asthma and the numerous previous steroid courses treatments because of his asthma Ortho static hypertension, history for depression, hypertension, Hyperloop anemia. It was very debilitated. I was mostly wheelchair bound, was ableto take a couple of steps to transfer from wheelchair to the exam table. But, um, he was leaning on his elbow a lot of times. So we're initial work up, including some elevation of inflammatory America's that Saturday was 32 a c r. P. With a little higher. 74 white count was touched up. 14 is anyone see? Did show. Ah, good diabetes control nutrition. Americans were friendly American album in 4.3 and the extra didn't have any erosions, But he didn't. We were able to see any extra this significant and Australian that he had. So with this presentation, we send the patient for, uh, surgery referral. We sending toe one of our plastic surgery colleagues to evaluate him, and hey was taken to the operating room for excision off the versa and ah, closure attempt. Unfortunately, this approach didn't work, So patient returned to us after two months. And during these two months, hey was following the plastic surgery clinic and he had some packing silver algae in aid, some wet to dry. But he's wound just becomes completely stalled. And I wasn't progressing well. The older cultures that he had when the excision was done or negative on he did have quite significantly confidential undermining. It was going a few centimeters in spite of the small opening that's visible on the surface. He didn't have exposed bone, but it was very fab. Roddick issue was no signs of regulation. He didn't seem to be infected. It wasn't painful at all. So, like we have noticed previously, he was just resting on his elbows very comfortably. So, uh, we were thinking we need to do some mawr advanced treatment because the usual treatments that he had pretty much failed and he's had this for almost three months. So who would consider negative pressure on therapy? This option, however negative fashion. One therapy back there has evolved a lot in the past few years, and machines are getting smaller, smaller on and portable. And, uh, this is how we end up to the snap, uh, negative pressure one therapy system that we decided to use for for our patients. Ah, this is a therapy that's become so small that is really went from portable toe wearable. A lot of times, patients can have this, uh, therapy on them without anything noticing this. In our experience, the biggest problem patients use negative pressure on therapy is the Balkan. Thank you. Patients feel like they're on a leash. Their mobility is significantly hindered. While with the snap system, it's very convenient is actually concealable. So we started going on on a wound back and we decided to repeat some, uh, started being on the steps system. Decided to repeat some work up a Z you can see on this X rays. The snap system is in place. However, the X rays do show some erosions. Um, new focal, bony defecting. A proximal dorsal electron on This is concerning for acute osteomyelitis. However, the white count is 12 is not elevated it all his CRP sample one at S R is a This is a presentation we see a lot of times with probably costume Mallory's if you haven't acute awesome Larry's You think the inflammatory marks a lot higher, but he's were like, basically normal. So when we thought patients are the following week, he actually couldn't tolerate the Snapchat. But you couldn't keep the suction on. He lost it right away. Guess what? He was leaning on it. So he's having the shearing effect that kinda like pulled it off. So knowing that we have bone erosions, uh, and the bonus affected decided toe to proceed with a little more aggressive the agreement in the clinic and right away we encounter bone in the agreement process and were able to get some samples to send them to be analyzed. So we started were to drive packing off this wound using deluded, epochal resolution for the next two weeks on. Then we also alternative would still the algae dressings. And we have done the agreements for a few weeks. The results of the work up that we have started returning to come back on the microbiology. He only grew Corinna bacterium. Um, a lot of times, this is a type of bacteria that you can ignore Aziz being, ah, noninfectious, uh, skin flora. However, finding it in the bone, we decided that we need to treat it. He is surgical pathology that we obtained separately from micro actually confirmed chronic inflammatory changes suggestive of chronic osteomyelitis. So the treatment which shows was like nestle it 600 twice a day for 42 days. Financial. It is an antibiotic that 5 10 years ago was contraindicated to be used for more than 17 days due to concern for bone marrow suppression. However, with close supervision, that is a risk that's amenable. The another consideration treating with like nestle, it is interference with serotonin uptake uptake inhibitor, so you can cause serotonin syndrome. And this was a case for our patients who was on treatment for depression. He actually had to stop some SS arise. He did not have a good time during those six weeks where he had to treat him with these antibiotics. Um, uh, One of the really good things that we decided to do for him is Thio referring to P. T. To get a custom elbow brace. So three weeks later, uh, here is how he looks like after the packing, the agreements and three weeks of antibiotics. Now we can see clearly proved the grander tissue in the wound bed is not as fabricas used to be and what I found that is very, very helpful to delineate and actually draw the edges off the undermining. So that makes it he's information to understand how deep the wound is and where it needs to be packed. And so this point, we decided, like maybe we should try the negative pressure on therapy system with the snap system again. So here he is, with the system applied. But what we decided to do different from the previous time, is to protect this, to allow to keep it in place by applying this custom brace, which doesn't allow that sharing motion when he was resting on his elbows. You can actually see how he's resting here on the edge of the chair. And he was doing that all the time without having his brace. And that was disrupting any wound. And I believe that's the pressure injury that was contributing to this and didn't allow all the previous attempts toe get the one hell. Three weeks into this therapy, we're seeing quite significant progress. The one is contracted, undermining a lot smaller, healthy, grander tissue. We continue with the agreements application of a snap therapy system. He This is his appearance of four weeks undermining completely closed on media side and nine weeks. He is completely healed. So in conclusion, uh, toe allow wounds to heal chronic wounds, we must address the path of physiology like with Venus leg ulcers. You must do compression with diabetic foot. Also, you must do uploading but pressure injury. You must do a floating. I feel like that was the key thing that we had to do for this situation. Addressed the offloading, the pressure re injury and in conjunction with the agreements with the antibiotics offering brace and the chair in the top. Negative pressure on therapy system has allowed us to have a successful outcomes. So thank you so much for watching this presentation. I hope that you find something useful and you can use in your practice. Onda. Wish you best of luck.
