Pre-operative Questions for Patients with Osteomyelitis During Rounding
The most critical pre-operative questions for patients with osteomyelitis should focus on identifying the extent of infection, potential complications, and factors that may impact surgical outcomes and mortality. 1, 2
Essential History Questions
Infection History
- Duration of symptoms (acute vs. chronic osteomyelitis)
- Previous antibiotic treatments and response
- History of draining sinus tracts or fistulae
- Previous surgical interventions for the same condition
- Recent fever, chills, or systemic symptoms
- Presence of nocturnal pain of moderate intensity 2
Risk Factors and Comorbidities
- Diabetes mellitus and glycemic control (HbA1c levels)
- Peripheral vascular disease or arterial insufficiency
- Immunocompromised status (HIV, chemotherapy, steroids)
- Smoking history and current status
- Alcohol consumption
- History of intravenous drug use
- Cardiovascular disease 3
- Previous trauma or surgery at the infection site 1
Wound Assessment
- Presence of ulcers overlying bony prominences
- Exposed bone in wound
- Ulcer area >2 cm²
- Erythematous and indurated "sausage toe" appearance (if applicable)
- Green discharge (potential Pseudomonas infection) 1, 2
Physical Examination Focus Points
Local Examination
- Extent of erythema, warmth, swelling
- Presence and characteristics of any discharge
- Probe-to-bone test results (positive test strongly suggests osteomyelitis) 1, 2
- Assessment of surrounding soft tissue involvement
- Neurovascular status of affected limb
- Joint mobility and stability assessment
Systemic Examination
- Vital signs (particularly temperature and heart rate)
- General appearance (toxic vs. non-toxic)
- Signs of sepsis or systemic inflammatory response syndrome
Diagnostic Workup Questions
Laboratory Studies
- Results of inflammatory markers (ESR >27 mm/h, CRP >0.93 mg/L) 2
- White blood cell count and differential
- Blood culture results (if obtained)
- Bone biopsy and culture results (if performed) 2
- Antibiotic susceptibility of cultured organisms 1
Imaging Studies
- Findings on plain radiographs (bone destruction, periosteal reaction)
- MRI results (extent of bone and soft tissue involvement) 1, 2
- CT findings (sequestrum, involucrum, sinus tracts) 2
- Nuclear medicine studies (if performed) 1
Pre-operative Planning Questions
Surgical Approach
- Extent of planned debridement
- Need for hardware removal or retention
- Anticipated bone defects requiring reconstruction
- Soft tissue coverage options
- Need for external fixation or stabilization 4
Antibiotic Management
- Current antibiotic regimen and duration
- Plan for intraoperative cultures
- Postoperative antibiotic strategy (parenteral followed by oral) 4
- Consideration for antibiotic-impregnated materials 5
Postoperative Planning Questions
Rehabilitation
- Weight-bearing status post-surgery
- Need for assistive devices
- Expected duration of recovery
- Functional limitations
Follow-up
- Plan for monitoring treatment response
- Schedule for follow-up imaging
- Duration of antibiotic therapy
- Signs and symptoms requiring urgent attention
Common Pitfalls to Avoid
- Failing to obtain appropriate cultures before starting antibiotics 2
- Relying solely on radiographs for early diagnosis (changes may not appear until 3-6 weeks) 2
- Misinterpreting bone scan results in patients with recent trauma or surgery 2
- Overlooking polymicrobial infections, which are associated with worse outcomes 4
- Underestimating the extent of soft tissue involvement requiring grafting or flap procedures 4
By systematically addressing these questions during pre-operative rounding, clinicians can better prepare for surgical intervention, optimize outcomes, and reduce the risk of complications in patients with osteomyelitis.