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The Iowa Orthopaedic Journal 2024Periprosthetic joint infection (PJI) in revision arthroplasty presents as a challenging complication that is difficult to manage. Debridement, antibiotics, and implant...
BACKGROUND
Periprosthetic joint infection (PJI) in revision arthroplasty presents as a challenging complication that is difficult to manage. Debridement, antibiotics, and implant retention (DAIR) is a recognized treatment option, although few studies have investigated success rates in addition to eventual amputation rates for failed cases.
METHODS
A retrospective review of 365 DAIR cases was performed at a single institution from 2008-2020. Patient records were thoroughly reviewed for inclusion and exclusion criteria by multiple members of the research team, discovering 45 cases met criteria for the study cohort. Demographic information, medical history, culture data, and surgical history, were recorded. DAIR's overall survivorship was evaluated with a Kaplan-Meier (KM) survival curve. Additional KM curves were constructed to compare acute postoperative versus acute hematogenous infections as well as DAIR survivorship relative to infecting organism.
RESULTS
DAIR's success rate in revision TKA was 77% at 0.5 years, 56% at 2 years and 46% at 5 years. No significant difference was noted in survivorship when comparing acute postoperative and acute hematogenous cases at 5 years (29 vs 51%, P=0.64). No significance differences in survivorship were noted according to infecting organism (P =0.30). Median follow up duration was significantly lower in the failed DAIR cohort with a median time of 0.5 years in comparison to 1.7 years for the successful DAIR group (P =0.012). There were 20 DAIR cases that failed, 10 of which resulted in eventual amputation.
CONCLUSION
DAIR's success rate for managing acute PJI in revision arthroplasty cases was 46% at 5 years. Of the 20 failed DAIR cases, 10 resulted in eventual amputation. DAIRs utility in managing these complicated PJI cases in the setting of revision arthroplasty is concerning with low success rates and high rates of amputation in failed cases. .
Topics: Humans; Prosthesis-Related Infections; Arthroplasty, Replacement, Knee; Retrospective Studies; Debridement; Male; Female; Reoperation; Anti-Bacterial Agents; Aged; Middle Aged; Aged, 80 and over; Knee Prosthesis; Treatment Outcome
PubMed: 38919369
DOI: No ID Found -
The Iowa Orthopaedic Journal 2024Septic arthritis is an orthopedic emergency. Diagnosis is difficult in patients with concomitant crystalline arthropathy (gout or pseudogout). The symptomatology of...
BACKGROUND
Septic arthritis is an orthopedic emergency. Diagnosis is difficult in patients with concomitant crystalline arthropathy (gout or pseudogout). The symptomatology of crystal arthritis mimics septic arthritis, clouding clinical diagnosis. Arthrocentesis and synovial fluid analysis are the standard diagnostic tests for both pathologies. Crystals on microscopy are diagnostic of crystal arthritis, however their presence does not rule out septic arthritis. Septic arthritis is diagnosed by positive microbiology culture. Though septic arthritis is associated with elevated synovial total nucleated count (TNC), TNC elevations can also occur with gout. The literature suggests that a TNC count of > 50,000 cells in a crystal-positive joint should raise suspicion for concurrent septic arthritis, however data is limited. Further diagnostic indicators are needed to help clinicians promptly identify crystal positive septic arthritis as the treatments and prognoses are different.
METHODS
Patients were retrospectively identified who had arthrocentesis of a native joint positive for monosodium urate (MSU) and/or (CPPD) crystals. Laboratory data was collected including synovial fluid cultures, total nucleated cell count (TNC), percent polymorphic neutrophils (%PMN), and crystal analysis; and serum CRP, ESR, and white blood cell count (WBC). Statistical analysis performed using Spearman correlation, Univariate-Fischer's exact and Wilcoxon tests, and multivariate analysis.
RESULTS
442 joints identified with positive CPPD and/or MSU crystals, 31% female, 69% male. Of 442 aspirates, 58 had positive cultures. Patients were more likely to have positive cultures if synovial TNC > 50,000 (odds ratio 7.7), CRP > 10 mg/dL (OR 3.2), PMN > 90% (OR 2.17), and if the patient was female (OR 1.9), all were statistically significant with p < 0.05. There were 55 patients who underwent irrigation and debridement based on clinical suspicion or a positive gram stain, 37 of these ultimately had a positive culture (67%), the remaining 18 had negative cultures.
CONCLUSION
Results are consistent with the literature, a TNC > 50,000 warrants a high suspicion for concurrent septic arthritis and should prompt providers to critically evaluate other patient laboratory data. Results further suggests that a patient with positive crystals, synovial TNC > 50,000 cells, PMN > 90%, and serum CRP > 10mg/dL is at high risk for having a concurrent septic arthritis and may warrant urgent irrigation and debridement and antibiotic therapy. This data serves as a supporting to develop an infection risk calculator for crystal positive septic arthritis. .
Topics: Humans; Arthritis, Infectious; Female; Male; Retrospective Studies; Synovial Fluid; Aged; Middle Aged; Crystal Arthropathies; Arthrocentesis; Uric Acid; Adult; Aged, 80 and over
PubMed: 38919362
DOI: No ID Found -
The Permanente Journal Jun 2024Wrist (TB) complex osteomyelitis is rare, with polymicrobial TB osteomyelitis even more uncommon. The authors describe an unusual case of polymicrobial TB wrist...
Wrist (TB) complex osteomyelitis is rare, with polymicrobial TB osteomyelitis even more uncommon. The authors describe an unusual case of polymicrobial TB wrist osteomyelitis. The case patient presented with a 2.5-year history of 2 insidiously growing nodules on his wrist. He underwent debridement, and tissue cultures grew methicillin-resistant , , and, later, TB complex. He was started on vancomycin, rifampin, isoniazid, pyrazinamide, and ethambutol with improvement in symptoms. This case emphasizes the importance of a broad differential and thorough workup for atypical presentations of osteomyelitis. Diagnosis of uncommon etiologies is essential for definitive treatment.
PubMed: 38919054
DOI: 10.7812/TPP/24.025 -
International Journal of Surgery Case... Jun 2024Fournier's gangrene (FG) in neonates is less common than in adults, but this case can lead to a poor prognosis. FG is a disease of the genital, perianal, and perineal...
INTRODUCTION
Fournier's gangrene (FG) in neonates is less common than in adults, but this case can lead to a poor prognosis. FG is a disease of the genital, perianal, and perineal areas characterized by necrotizing infections. Here, we report a case of a 24-day-old male infant diagnosed with Fournier's gangrene involving the scrotum.
CASE PRESENTATION
The patient presented with scrotal swelling, fever, erythema, and insect bites on the penile tip that had gradually extended to the proximal area and bilateral scrotum. On physical examination, indurated grayish and blackish-brown scrotal skin with sharp distinction from the surrounding normal skin, erythema, purulence, ulceration, and necrotic tissue were observed. Abdominal X-ray and scrotal ultrasonography revealed gaseous distension of the scrotal region, free fluid on bilateral testes, and enlargement of bilateral testicles. Immediate surgical debridement, along with broad-spectrum antibiotics, was initiated, and a microbiological culture identified the presence of Pseudomonas aeruginosa. The patient demonstrated the completed healing of the surgical wound after thirty days of surgical intervention.
DISCUSSION
Fournier's gangrene in neonates is a sporadic case. Our patient presented with multiple predisposing factors, including insect bites and poor hygiene, underscoring the need for heightened clinical suspicion in vulnerable populations. Prompt recognition and intervention are critical, given the rapid progression of FG.
CONCLUSION
This case underscores the importance of timely diagnosis and early initiation of surgical and medical interventions in neonatal Fournier's gangrene, particularly in cases involving the scrotum.
PubMed: 38917701
DOI: 10.1016/j.ijscr.2024.109861 -
Infection and Drug Resistance 2024Periprosthetic joint infection (PJI) is a catastrophic complication following joint replacement surgery, posing significant challenges to orthopedic surgeons. Due to the... (Review)
Review
Periprosthetic joint infection (PJI) is a catastrophic complication following joint replacement surgery, posing significant challenges to orthopedic surgeons. Due to the lack of a definitive diagnostic gold standard, timely treatment initiation is problematic, resulting in substantial economic burdens on patients and society. In this review, we thoroughly analyze the complexities of PJI and emphasize the importance of accurate diagnosis and effective treatment. The article specifically focuses on the advancements in diagnostic techniques, ranging from traditional pathogen culture to advanced molecular diagnostics, and discusses their role in enhancing diagnostic accuracy. Additionally, we review the latest surgical management strategies, including everything from debridement to revision surgeries. Our summary aims to provide practical information for the diagnosis and treatment of PJI and encourages further research to improve diagnostic accuracy and treatment outcomes.
PubMed: 38912221
DOI: 10.2147/IDR.S457644 -
Clinical Medicine Insights. Case Reports 2024Tuberculosis (TB) is one of the most prevalent infectious diseases globally, often presenting with nonspecific symptoms that can obscure diagnosis, especially when it...
INTRODUCTION
Tuberculosis (TB) is one of the most prevalent infectious diseases globally, often presenting with nonspecific symptoms that can obscure diagnosis, especially when it manifests in uncommon sites such as osteoarticular tuberculosis (OA-TB).
CASE PRESENTATION
We report a rare case of a 9-year-old male diagnosed with right knee tuberculosis after enduring severe symptoms for several months. Despite multiple negative biopsies and aspirates during initial debridement surgeries, a biopsy taken 6 months later confirmed the presence of (MTB). The patient was subsequently treated with debridement and anti-tubercular therapy.
CONCLUSION
This case underscores the critical need to consider tuberculosis in patients presenting with chronic bone pain to avoid misdiagnosis, particularly in the developing world. The atypical presentation of osteoarticular tuberculosis in this young patient emphasizes the need for healthcare professionals to recognize subtle symptoms. Advanced imaging studies like MRI and microbiological evaluations, including site biopsies, are essential for accurate diagnosis. Increased awareness and collaborative research are crucial to improving the understanding and management of pediatric osteoarticular tuberculosis and extrapulmonary tuberculosis.
PubMed: 38911938
DOI: 10.1177/11795476241263683 -
JPRAS Open Sep 2024Breast reconstruction following mastectomy is a critical component of breast cancer treatment, aimed at improving patient quality of life. However, the management is...
BACKGROUND
Breast reconstruction following mastectomy is a critical component of breast cancer treatment, aimed at improving patient quality of life. However, the management is fraught with potential complications, including skin necrosis and wound dehiscence, which can significantly impact clinical outcomes.
CASE PRESENTATION
We report a unique case of a patient, 5 years post-breast reconstruction following mastectomy and radiation therapy, who developed severe skin necrosis and wound dehiscence due to a brown recluse spider bite on the reconstructed breast. The complication necessitated the debridement of skin, removal of the implant, and further reconstruction with a latissimus flap.
DISCUSSION
The case underscores the unusual etiology of spider bite-induced necrosis in breast reconstruction and highlights the challenges and strategic considerations in managing such complications. Upon presentation, the patient's affected breast area showed signs of extensive necrosis and wound dehiscence, directly attributed to the cytotoxic effects of the brown recluse spider's venom. The venom's pathophysiology involves a complex cascade, leading to local and systemic effects. The local effects, marked by dermonecrosis, com- promised skin integrity in this instance. Systemic effects, not observed in this patient but potentially severe, can include hemolysis, coagulopathy, and acute renal failure, highlighting the seriousness of brown recluse spider bites.
CONCLUSION
In conclusion, this case illustrates the complexities of managing breast reconstruction post-mastectomy complications, particularly those caused by external factors such as brown recluse spider bites. It highlights the need for meticulous attention to unusual etiologies of necrosis and dehiscence, demonstrating the importance of adaptable surgical strategies and a thorough understanding of venom pathophysiology in ensuring successful patient outcomes.
PubMed: 38911670
DOI: 10.1016/j.jpra.2024.05.008 -
Annals of Surgery Open : Perspectives... Jun 2024Western armies have relied on surgical field manuals to help physicians deal with unfamiliar combat medical conditions from the Napoleonic wars to the present day, but...
Western armies have relied on surgical field manuals to help physicians deal with unfamiliar combat medical conditions from the Napoleonic wars to the present day, but there has been little discussion of whether these handbooks have been used or improved outcomes. Recent research shows that the Union Army's American Civil War (1861-1865) surgical case fatality rates improved as the war progressed, much like the US Army's experience in later wars, and were generally superior to comparable European results. These positive Civil War outcomes have been attributed to field experience, adoption of best practices, and enhanced communication, without consideration of New York surgeon Stephen Smith's widely-used . The Army of the Potomac added Smith's pocket-sized to its supply table in 1862. Northern medical journals applauded it, and Smith's contemporaries documented its wide use. Smith's handbook explained and demonstrated surgical techniques that were adopted as the war progressed, such as the use of general anesthesia and limb-sparing resection (debridement) of gunshot wounds. It offered pithy, well-documented advice from recognized experts along with numerous illustrations, which allowed untrained physicians to visualize anatomical relationships and see contemporary best practices in a way that no other wartime publication provided, making it an exemplar of a mass-media surgical improvement change agent.
PubMed: 38911650
DOI: 10.1097/AS9.0000000000000419 -
Urology Case Reports Jul 2024Penile strangulation secondary to utilization of a constrictive ring is a rare urologic emergency that requires urgent decompression to prevent prolonged vascular...
Penile strangulation secondary to utilization of a constrictive ring is a rare urologic emergency that requires urgent decompression to prevent prolonged vascular obstruction resulting in necrosis and gangrene. Current literature is mainly comprised of case presentations that focus on management in the acute setting via removal of the ring. Herein, we describe surgical management of a patient who presents in delayed fashion after self-removal of the constrictive ring. We discuss our penectomy-sparing technique of debridement and split thickness skin graft.
PubMed: 38911466
DOI: 10.1016/j.eucr.2024.102762 -
Journal of Orthopaedic Case Reports Jun 2024Cryptococccus neoformans is a fungus which typically presents in immunocompromised hosts, commonly presenting as meningoencephalitis. There have been very few documented...
INTRODUCTION
Cryptococccus neoformans is a fungus which typically presents in immunocompromised hosts, commonly presenting as meningoencephalitis. There have been very few documented incidents of intramuscular manifestations of this pathogen.
CASE REPORT
We report on a case of a 45-year-old caucasian male with disseminated Cryptococcus neoformans who developed cryptococcal intramuscular abscesses of all extremities and osteomyelitis of the left upper limb. Clinical treatment and surgical debridement of the forearm was performed. Persistent infection resulted in a left humeral amputation and ultimately the patient's death. This is one of the few documented intramuscular abscesses of Cryptococcus neoformans.
CONCLUSION
Orthopedic manifestations of cryptococcal infections are rare; however, awareness and prompt diagnosis may improve outcomes.
PubMed: 38910993
DOI: 10.13107/jocr.2024.v14.i06.4488