Cervical necrotizing fasciitis caused by oral cavity infection: a case report considering therapeutic approach and its morphofunctional implications / Fascitis necrosante cervical causada por infección de la cavidad oral. Reporte de un caso considerando el abordaje terapéutico y sus implicaciones morfofuncionales

SUMMARY: Cervical necrotizing fasciitis (NF) is a rare complication of oral cavity infection with high morbi-mortality. Given its low prevalence, adequately reporting cases of NF, its therapeutic management, and associated morphofunctional modifications to the clinical and scientific community is pivotal. To that end, we herein describe a case of cervical NF in a 60-year-old patient with comorbidities and patient presented large, painful cervical swelling associated with a necrotic ulcer lesion in the anterior neck region. Intraoral examination indicated a periodontal abscess in the right mandibular area, while computed tomography indicated the lesion's extension from the right mandibular to the submandibular region. Following empirical intravenous antibiotic treatment, a broad surgical debridement was performed, and the foci of oral infection were removed. Debridement revealed communication between deep and superficial anatomical regions in the submandibular area, where we subsequently placed a Penrose drain. Biopsies showing acute inflammatory infiltrate associated with necrotic and hemorrhagic regions confirmed the diagnosis of NF. When an antibiogram revealed resistance to the empirical treatment, the antibiotic scheme was replaced with an adequate alternative. After a second debridement, we closed the defect with fascio-mucocutaneous advancement flaps with a lateral base while maintaining suction drainage. Having reacted positively, the patient was discharged 10 days after the operation. Despite an extensive morphofunctional change generated in the treated area, the patient showed no difficulties with breathing, phonation, swallowing, or mobilizing the area during control sessions. Altogether, this report contributes to the highly limited literature describing morphological aspects that can facilitate or delay the spread of infection or the morphofunctional disorders associated with the size and depth of surgical interventions for cervical NF, information that is relevant for the comprehensive, long-term prognosis of the treatment of NF.

La fascitis necrosante (FN) cervical es una rara complicación de una infección proveniente de la cavidad bucal asociada a una alta morbimortalidad. Por lo anterior, es fundamental informar a la comunidad clínica y científica los casos de FN, su manejo terapéutico y las modificaciones morfofuncionales asociadas. Se describe un caso de FN cervical en una paciente de 60 años quien presentó una gran tumefacción dolorosa asociada a una lesión ulcerosa necrótica en la región anterior del cuello. El examen intraoral mostró un absceso periodontal en el área mandibular derecha y la tomografía computarizada mostró la extensión de la lesión hacia la región submandibular. Tras el tratamiento antibiótico empírico, se realizó un desbridamiento quirúrgico extenso y se extirparon los focos de infección oral. El desbridamiento reveló comunicación entre las regiones anatómicas profundas y superficiales del área submandibular, donde se colocó un drenaje Penrose. Las biopsias mostraron un infiltrado inflamatorio agudo asociado con regiones necróticas y hemorrágicas, confirmando el diagnóstico de FN. El antibiograma reveló resistencia al tratamiento empírico, por lo que el esquema antibiótico se sustituyó. Tras un segundo desbridamiento, se cerró el defecto con colgajos de avance fascio-mucocutáneos de base lateral manteniendo drenaje aspirativo. El positivo progreso del paciente permitió su alta 10 días después. Aun cuando se generó una gran modificación morfofuncional en el área tratada, la paciente no presentó dificultades para respirar, hablar, deglutir o movilizar el área cervical intervenida durante las sesiones de control. Este informe contribuye a la limitada literatura que describe los aspectos morfológicos que pueden facilitar o retrasar la propagación de la FN y las consecuencias asociadas a los trastornos morfofuncionales provocadas por el tamaño y profundidad de las intervenciones quirúrgicas requeridas por la FN, información relevante para el pronóstico integral a largo plazo del tratamiento de la FN.

Debridement of axillary necrotizing fasciitis under anesthetic blocks of the serratus plane and supraclavicular brachial plexus: a case report

Abstract The regional techniques for axillary analgesia are well established. However, few studies have investigated surgical anesthesia. In this report, extensive debridement of axillary necrotizing fasciitis, including the posteromedial region of the right arm, performed under exclusive regional anesthesia in a patient with probable difficult airway is described. The procedure was accomplished under a Serratus Plane Block (SPB) and supraclavicular brachial plexus block, guided by ultrasound, and with venous sedation. We observed satisfactory anesthesia 15 minutes after the intervention, efficient intraoperative pain control and within the following 24 hours. Surgical axilla anesthesia is feasible with the described blocks.

Plastic and reconstruction surgery for non-healing wound after posterior spinal surgery / 北京大学学报(医学版)

OBJECTIVE@#To investigate the clinical significance of different plastic surgeries in the treatment of poor healing wound after posterior spinal internal fixation.@*METHODS@#In this study, 16 patients with poor incision healing after posterior spinal internal fixation were retrospectively included, and dif-ferent plastic surgery treatment plans were determined according to the wound characteristics and defect condition. The measures included debridement, vacuum sealing drainage (VSD), and different tissue flaps according to the location and extent of the defect.@*RESULTS@#A total of 16 patients meeting the criteria were included, of whom 3 were treated with debridement combined with VSD and wound suture directly, 6 were treated with debridement combined with Z-flap for wound repair, 1 was treated with bilateral sacrospinous muscle flap for dural defect repair combined with Z-flap for skin wound repair, 1 was treated with lectus dorsi flap for wound repair, 3 were treated with the fourth lumbar artery perforator flap for wound repair. The wound was repaired with local rotating flap in 1 case and gluteus maximus musculocutaneous flap in 1 case. Among the 16 patients, 7 cases were positive for wound culture, including 3 cases of Staphylococcus aureus, 1 case of Pseudomonas aeruginosa, 1 case of Staphylococcus epidermidis, 1 case of Escherichia coli, 1 case of Klebsiella pneumoniae, and the other 9 cases were negative. After surgery, there were 7 patients with different degrees of poor wound healing, including 3 patients undergoing dressing change, 2 patients undergoing secondary debridement and suture, 1 patient undergoing free scalp skin graft, and 1 patient undergoing local effusion suction treatment. All the above 7 patients were discharged from hospital after improvement, and the remaining 9 patients had good first-stage wound hea-ling after surgery. None of the 16 patients underwent internal fixation.@*CONCLUSION@#Multiple factors could lead to poor wound healing after posterior spinal internal fixation. Early intervention, thorough debridement, removal of necrotic/infected tissue, and selection of suitable skin flap for effective wound fil-ling and covering were important means to ensure wound healing after spinal surgery and reduce removal of internal fixation.

The short-term outcomes of non-contact low frequency ultrasonic debridement in treating periprosthetic joint infections:a prospective single-arm clinical study / 中华外科杂志

Objective: To evaluate the short-term outcomes of non-contact low-frequency ultrasonic debridement in treating periprosthetic joint infections(PJI). Methods: The clinical data of patients with PJI who met the eligibility criteria and were treated with non-contact low-frequency ultrasonic debridement from August 2021 to January 2022 at the Department of Orthopaedics,the First Affiliated Hospital of Xinjiang Medical University were prospectively analyzed. PJI was defined according to the modified Musculoskeletal Infection Society criteria in 2016. After mechanical debridement,an 8-mm handheld non-contact low-frequency ultrasound probe was used for ultrasonic debridement in the whole surgical area at a frequency of (25±5)kHz and power of 90% for 5 minutes. Each ultrasound lasted 10 seconds with 3-second intervals. The probe was repeatedly sonicated among all soft tissue,bone interface and metal prosthesis surface(patients underwent debridement,antibiotics and implant retention (DAIR)) in the surgical area. The femoral canal of the hip joint,the distal femoral canal and the posterior capsule of the knee were fully sonicated with a special right-angle probe. Before and after ultrasonic debridement,20 ml of liquid was extracted from each operation area and injected into aerobic and anaerobic culture bottles,respectively,for pathogen culture. Harris hip score and Hospital for Special Surgery (HSS) score were used to evaluate clinical function. Treatment failure was defined as the recurrence of infection in the same joint. The patients were routinely followed up in the outpatient clinic at 1,3,and 6 months postoperatively and then annually with a deadline of August 2022. The paired t-test,rank sum,Mann-Whitney U or χ2 test was used to compare the observed data,and rates among multiple groups were compared using the Bonferroni approach. Results: A total of 45 patients were included in the study,including 21 men and 24 women with age of (65.8±15.2)years(range: 20 to 80 years) and body mass index of (29.3±4.2)kg/m2(range: 20.2 to 38.5 kg/m2). Twenty-eight patients (18 hips and 10 knees) underwent one-stage revision,and 17 cases (5 hips and 12 knees) underwent DAIR. Three of the patients (6.7%) had recurrent infections during follow-up. There were no intraoperative complications related to ultrasonic debridement (neurovascular and muscle injury,poor wound healing and fat liquefaction). Seventeen patients who received DAIR were followed for a median(M(IQR)) of 9(3) months,and two relapsed 3 weeks and 3 months post-operation,respectively. In addition,28 patients who underwent one-stage revision were followed for a median of 9(2) months,and one of the patients (3.6%,1/28) had a recurrence 6 months post-operation. The culture-positive rate of preoperative aspiration was 47.6% (20/42). The data of intraoperative soft tissue culture was 86.7% (39/45). The culture-positive rate of wound liquid before ultrasonic debridement was 46.7% (21/45). And the culture-positive rate after ultrasonic debridement was (75.6% (34/45)). After sonication,the culture-positive rate of explanted prostheses was 88.9% (40/45). There was a significant difference in culture-positive rates among all five cultures (χ2=35.483,P<0.01). Further pairwise comparison showed that the culture-positive rate of wound liquid after ultrasonic debridement was higher than that before ultrasonic debridement (χ2=7.901,P=0.005) but was not significantly different from the positive rates of other cultures (all P>0.05). The median number of colonies 24 hours after ultrasonic debridement(2 240 (1 310) CFU/ml,range: 310 to 3 140 CFU/ml) was significantly higher than that before debridement(450 (550) CFU/ml,range: 10 to 910 CFU/ml) (U=43, P=0.017). The post-operative Harris ((78.6±4.2)points,range:70.5 to 85.3 points) and HSS scores((76.4±4.8)points,range: 68.5 to 84.3 points) were significantly higher than the preoperative scores((46.0±9.8)points,range: 27.5 to 64.3 points;and (45.5±10.3)points,range: 27.6 to 63.1 points) (t=-14.6,t=-12.7;both P<0.01). Conclusions: Non-contact low-frequency ultrasonic debridement can increase the culture-positive rate and lead to a favorable short-term outcome. In addition,no complications are associated with using this new technique to treat PJI.

Basic principles,methods and evaluation of minimally invasive treatment for infected pancreatic necrosis / 中华外科杂志

Infected pancreatic necrosis(IPN) is the main surgical indication of acute pancreatitis. Minimally invasive debridement has become the mainstream surgical strategy of IPN,and it is only preserved for IPN patients who are not response for adequate non-surgical treatment. Transluminal or retroperitoneal drainage is preferred,and appropriate debridement can be performed. At present,it is reported that video assisted transluminal,trans-abdominal and retroperitoneal approaches can effectively control IPN infection. However,in terms of reducing pancreatic leakage and other complications,surgical and endoscopic transgastric debridement may be the future direction in the treatment of IPN.

Surgical management of chronic osteomyelitis: Organisms, recurrence and treatment outcome / 中华创伤杂志(英文版)

PURPOSE@#The study aimed to identify the risk factors of recurrence in chronic osteomyelitis (COM) and to document the microbiological patterns pre- and intra-operatively and at recurrence, if any.@*METHODS@#We performed retrospective review on COM patients treated with surgical debridement and a 6-week course of antibiotics. The patients with symptoms of osteomyelitis for at least 6 weeks, present or past episodes of discharging sinus, documentation of bone sequestration in operative notes or preoperative images were included in the study. Patients with symptoms of osteomyelitis < 6 weeks, lack of history of discharging sinus or lack of evidence of sequestration in preoperative images or intraoperative notes were excluded. Logistic regression models were used to assess the impact of risk factors of recurrence. Cohen-Kappa scores were derived to see the concordance between pre-operative and intra-operative isolates and at recurrence.@*RESULTS@#Totally, 147 COM patients (115 males and 32 females, mean age (33 ± 19) years) were included in this study. Recurrence was noted in 28 patients (19.0%). Polymicrobial growth and extended spectrum beta-lactamase producing Enterobacteriaceae increased the chance of recurrence. Cierny-Mader stage-1, hematogenous aetiology and negative intraoperative culture reduced the chance of recurrence. Concordance between pre-operative and intra-operative cultures was 59.85% (Kappa score 0.526, p < 0.001) and between index surgery and at recurrence was 23.81% (Kappa score 0.155, p < 0.001). Lack of knowledge of causative organism preoperatively did not affect outcome. At mean follow-up (42 ± 15) months, all patients were apparently infection free for at least 1 year.@*CONCLUSION@#Polymicrobial growth and multi-drug resistant organisms increase the risk of recurrence in COM. Patients' age, gender, diabetes mellitus, previous failed treatment, duration of symptoms, haemoglobin, white cell count, C-reactive protein and erythrocyte sedimentation rate at presentation did not have any impact on the recurrence of infection. Pre-operative isolation of organism is of questionable value. Recurrences of infections do occur and are more of re-infections than relapses. Diligent isolation of organism must be attempted even in re-debridements. Even patients with recurrences do well with appropriate debridement and antibiotic therapy.

Evolution and progress of surgical intervention strategies for acute pancreatitis / 中华外科杂志

Acute pancreatitis is one of the common surgical acute abdominal diseases. Since people first recognized acute pancreatitis in the middle of the nineteenth century, a diversified minimally invasive treatment model with standardization has been formed today. According to the main line of surgical intervention of acute pancreatitis treatment,this period can be roughly divided into five stages:exploration stage, conservative treatment stage, pancreatectomy stage, debridement and drainage of the pancreatic necrotic tissue stage, and minimally invasive treatment as the first choice led by the multidisciplinary team mode stage. Throughout history, the evolution and progress of surgical intervention strategies for acute pancreatitis cannot be separated from the progress of science and technology, the update of treatment concepts and the further understanding of the pathogenesis. This article will summarize the surgical characteristics of acute pancreatitis treatment at each stage to explain the development of surgical treatment of acute pancreatitis,to help investigate the development of surgical treatment of acute pancreatitis in the future.

Transporte sobre clavo respetando la membrana de Masquelet en defectos segmentarios severos. Serie de casos / Distraction osteogenesis technique using an intramedullary nail and an external fixator in large bone defects

Introducción: El adecuado tratamiento de los defectos óseos se presenta como un desafío para el cirujano ortopedista, en cuanto a la dificultad en la restitución de un miembro alineado, sin discrepancia ni infección. Se han descrito múltiples técnicas para reconstruir estos defectos, como el injerto óseo autólogo o de banco, la técnica de membrana inducida, la osteogénesis por distracción y los cilindros de titanio trabecular, pero ninguna ha demostrado ser significativamente superior a otra. materiales y métodos: Entre 2018 y 2021, 10 pacientes con defectos óseos de la tibia fueron tratados mediante transporte óseo guiado con osteosíntesis endomedular. Se realizó un estudio retrospectivo descriptivo analizando la magnitud de los defectos, el tiempo de transporte, las complicaciones y cirugías adicionales durante el proceso, si hubo consolidación y las deformidades residuales. Al final del proceso, se midió el puntaje de la ASAMI (óseo y funcional). Resultados: La longitud promedio de los defectos tratados fue de 9,75 cm y el índice de fijación externa promedio, de 40,62 días/cm. El 50% tenía un puntaje de la ASAMI óseo bueno; el 10%, excelente y el 40%, pobre al final del proceso reconstructivo. El 20% tenía un puntaje de la ASAMI funcional excelente; el 30%, bueno y el 50%, pobre. Conclusiones: El uso de tutores externos guiados mediante osteosíntesis es un método fiable para tratar defectos óseos, al mismo tiempo que se trata la infección de manera local y sistémica, acortando los tiempos de tutor externo y, por lo tanto, de internación y reintervención. Nivel de Evidencia: IV

Introduction: The proper treatment of bone defects represents a challenge for the orthopedic surgeon given the difficulty in restoring limb alignment without discrepancy nor infections. Multiple techniques have been described for the reconstruction of these defects. These include bone grafting, whether autologous or from a bank, the induced membrane technique, distraction osteogenesis, and, recently, the use of trabecular titanium cylinders, but none has been shown to be significantly superior to another. materials and methods: Between 2018 and 2021, ten patients with tibial bone defects were treated by guided bone transport with intramedullary osteosynthesis. We carried out a descriptive retrospective study of this series, analyzing the magnitude of the defects, the transport time, the complications and additional surgeries that took place during the process, whether there was con-solidation, and the residual deformities. The bone and functional ASAMI scores were measured at the end of the process. Results: The average length of the treated defects was 9.75 cm and the average external fixation index was 40.62 d/cm. At the end of the reconstructive process, 50% of the patients presented a good bone ASAMI score, 10% presented an excellent score, and 40% had a poor score. Regarding the functional ASAMI score, 20% were excellent, 30% were good, and 50% were poor. Conclusion: The use of fixators guided by intramedullary nails constitutes a reliable method to treat bone defects that allows treating the infection locally and systemically, shortens the times of external fixation and hospitalization, and reduces the need for reinterventions. Level of Evidence: IV

Aspectos clínicos e epidemiológicos e aceitabilidade da terapia larval em pacientes com feridas crônicas / Clinical and epidemiological aspects and acceptability of larval therapy in patients with chronic wounds / Aspectos clínicos y epidemiológicos y aceptabilidad de la terapia larval en pacientes con heridas crónicas

Objetivo: avaliar o perfil epidemiológico e clínico de pacientes com feridas e a aceitabilidade à Terapia Larval (TL). Método: acompanhados 15 pacientes com feridas crônicas e registrados em fichas clínicas. Resultados: pacientes não conheciam a TL. Idades variaram (45 a 73), pretos (46,66%), brancos (26,66%) e pardos (20,00%), predominantemente mulheres (73,33%). Tinham ensino fundamental (53,33%), médio (20,00%) e superior (26,6%) completos. 60% residiam no RJ; Lesões, (idade média de 6 anos e área média de 9,4 cm²) no terço distal das pernas (53,00%) e nos pés (47,00%), com origem vascular (40,88%), úlceras por pressão (31,69%), diabéticas (16,66%) e infecciosa (10,77%). Pacientes apresentavam três (20,00%), duas (20,00%) ou uma lesão (60,00%), com necrose (80,00%), infecção (37,60%), granulação (50,30%), epitelização (15,00%), dor (54,0%) e dificuldade de locomoção (47,00%). Insuficiência venosa como antecedente patológico mais observado. A aceitabilidade para TL foi 93,33%. Conclusão: TL é alternativa para melhor qualidade de vida

Objectives: to evaluate the epidemiological and clinical profile of patients with wounds and acceptability to Larval Therapy (LT). Method: followed 15 patients with chronic wounds and recorded in clinical records. Results: patients didn't know LT. Ages varied (45 to 73 y.o.), were black (46.66%), white (26.66%) and yellow (20.00%), predominantly women (73.33%). They had Elementary (53.33%), High (20.00%) and Higher education (26.60%). 60% lived in Rio de Janeiro; Wounds (mean age of 6 years; mean area of 9.4 cm²) in the distal third of the legs (53.00%) and feet (47.00%), with vascular origin (40.88%), pressure (31.69%), diabetic (16.66%) and infectious ulcers (10.77%). Patients had three (20.00%), two (20.00%) or one wound (60.00%), with necrosis (80.00%), infection (37.60%), granulation (50.30%), epithelialization (15.00%), pain (54.00%) and locomotion difficulty (47.00%). Venous insufficiency as the most observed pathological antecedent. Acceptability for LT was 93.33%. Conclusion: LT is an alternative to better quality of life

Objetivos: evaluar el perfil epidemiológico y clínico de pacientes con heridas y aceptabilidad a Terapia Larvaria (TL). Método: seguimiento de 15 pacientes con heridas crónicas y registrados en historias clínicas. Resultados: pacientes no conocían TL. Edades variaron (45 a 73%), negros (46,66%), blancos (26,66%) y morenos (20,00%), predominantemente mujeres (73,33%). Habían completado la educación primaria (53,33%), media (20,00%) y superior (26,6%). 60% vivían en RJ; Lesiones (edad media de 6 años y superficie media de 9,4 cm²) en el tercio distal de las piernas (53,00%) y pies (47,00%), con origen vascular (40,88%), úlceras por presión (31,69%), diabéticas (16,66%) e infecciosas (10,77%). Pacientes presentaban tres (20,00%), dos (20,00%) o una lesión (60,00%), con necrosis (80,00%), infección (37,60%), granulación (50,30%), epitelización (15,00%), dolor (54,0%) y dificultad locomotiva (47,00%). Insuficiencia venosa como antecedente patológico más observado. Aceptabilidad para TL fue del 93,33%. Conclusión: TL es una alternativa a una mejor calidad de vida

Macroporous latex biomembrane from Hancornia speciosa modulates the inflammatory process and has a debridement effect on wound healing in rats

Purpose: The angiogenic, osteogenic and anti-inflammatory activity of latex of Hancornia speciosa has been evidenced and indicates pharmacological potential with great applicability in the health area, especially in the wound healing process. The present work aimed to compare the effects of the H. speciosa macroporous latex biomembrane with saline on wound healing. Methods: Forty-three Wistar rats were submitted to excisional wound induction procedure and divided into groups according to treatment: saline (G1), and macroporous biomembrane (G2). The animals were euthanized at three, seven, 14, and 21 days after injury induction (DAI), and three animals were used for the debridement test. Morphometric, macroscopic, and microscopic analyses of general pathological processes were performed. Results: The macroporous biomembrane minimized necrosis and inflammation during the inflammatory and proliferative phases of the healing process, confirmed by the lower intensity of the crust and the debridement effect. In addition, the wounds treated with the macroporous biomembrane presented greater contraction rates in all the experimental periods analyzed. Conclusions: The macroporous biomembrane presents angiogenic, anti-inflammatory and debridement effects, contributing to the healing process, and can be considered a potentially promising new biomaterial to be used as a dressing.

Diverticulitis perforada causante de fascitis necrotizante de miembro inferior / Perforated diverticulitis causing necrotizing fasciitis of the lower limb / Diverticulite perfurada causando fasceíte necrosante do membro inferior

Mujer de 59 años, con antecedentes de diverticulosis de colon, que acude por dolor en la región inguinal y en el miembro inferior izquierdo de dos meses de evolución. En una primera instancia, la paciente se presentó con clínica de sepsis y se objetivó un eritema en el miembro inferior izquierdo, asociado a celulitis y crepitación subcutánea. La TC mostraba una colección hidroaérea en psoas y retroperitoneal que asciende hasta la cavidad abdominal hallándose una diverticulitis perforada. El tratamiento quirúrgico se basó en el drenaje de la colección retroperitoneal y sigmoidectomía, seguido de una fasciotomía, desbridamiento y lavado del muslo. La perforación de un divertículo puede formar un absceso intraperitoneal desarrollando una peritonitis o un absceso retroperitoneal, derivando en una translocación bacteriana hacia la extremidad inferior, debido a la comunicación existente en el anillo crural, generando una fascitis necrotizante del miembro.

Micetoma por Nocardia asteroides / Nocardia Asteroids Mycetoma

Introducción: En 1860 Henry Van Carter introdujo la definición del micetoma y desde 1884 se reportan los primeros casos en África (Sudán, Senegal). Estas infecciones afectan la piel, el tejido celular subcutáneo y, en ocasiones, los músculos, los huesos, y pueden diseminarse por la cavidad torácica, la abdominal, y por otras regiones del cuerpo. Objetivo: Presentar un caso de micetoma por Nocardia asteroides con evolución desfavorable y tratamiento. Presentación del caso: Paciente masculino de 47 años de edad que sufrió hace 18 años un trauma en la rodilla izquierda con herida avulsiva y evolución desfavorable por infección. Diez años después presentó en el mismo sitio múltiples lesiones fistulosas con drenaje activo, secreción serohemática escasa y no fétida. En varias ocasiones fue llevado al salón de operaciones para realizarle debridamientos quirúrgicos y toillete y recibió múltiples tratamientos antibióticos y antifúngicos. Se concluyó el caso como un micetoma y se aisló una Nocardia asteroides. El paciente estuvo en desacuerdo con la amputación de la extremidad como tratamiento quirúrgico definitivo. Llegó a nuestro centro en octubre del 2020 con mal estado general y extensión severa del proceso infeccioso en toda la extremidad. Se planificó una hemipelvectomía como tratamiento definitivo, pero desafortunadamente el paciente falleció antes, debido a complicaciones generales. Conclusiones: Ante la aparición del micetoma es importante definir el alcance de la infección para determinar el tipo de tratamiento a utilizar, ya que bien empleado y de forma oportuna, puede salvar la vida al paciente sin dejar graves secuelas(AU)

Introduction: In 1860, Henry Van Carter introduced the definition of mycetoma and since 1884 the first cases have been reported in Africa (Sudan, Senegal). These infections affect the skin, the subcutaneous cellular tissue and, sometimes, the muscles, the bones, and it can spread throughout the thoracic cavity, the abdominal cavity, and other regions of the body. Objective: To report a case of mycetoma due to nocardia asteroides with unfavorable evolution and treatment. Case report: We report the case of a 47-year-old male patient who suffered a left knee trauma 18 years ago with an avulsive wound and unfavorable evolution due to infection. Ten years later, he presented, in the same site, multiple fistulous lesions with active drainage, scant serohematic, non-fetid secretion. On several occasions he was taken to the operating room for surgical debridement and toilette and he received multiple antibiotic and antifungal treatments. The case was concluded as a mycetoma. Nocardia asteroides was isolated. The patient disagreed with limb amputation as definitive surgical treatment. He came to our treatment center in October 2020 with poor general condition and severe extension of the infectious process throughout the limb. A hemipelvectomy was planned as definitive treatment, but unfortunately the patient deceased before due to general complications. Conclusions: Before the appearance of mycetoma, it is important to define the extent of the infection to determine the type of treatment to use, since it can save the patient's life if properly used and in a timely manner without leaving serious sequelae(AU)

Surgical Management of Infected Pancreatic Necrosis. Case Series in a Quaternary Care Hospital in Bogotá, Colombia, 2014-2021 / Manejo quirúrgico de la necrosis pancreática infectada. Serie de casos en un hospital de cuarto nivel en Bogotá, Colombia, 2014-2021

Abstract Introduction: Pancreatitis is a frequent pathology in our environment, mostly related to benign biliary pathology. It can progress to severe forms in 10-15 % of cases, where the pancreatic tissue becomes necrotic and forms large collections with risk of infection. We do not have epidemiological data about the incidence or management of this complication in Colombia. Aim: This study aims to study the prevalence of infected pancreatic necrosis and describe the cases identified in a quaternary care hospital between 2014 and 2021. Materials and methods: A cross-sectional observational study. We analyzed records of patients diagnosed with stage 2 pancreatitis. Those cases with infected pancreatic necrosis that underwent debridement plus laparoscopic and open surgical drainage at Hospital Universitario Mayor Méderi in Bogotá, Colombia, between January 2014 and January 2021 were studied. A convenience sampling was carried out without calculating the sample size. We collected the patients' demographic and clinical variables, performing a descriptive statistical analysis in Excel. Qualitative variables were described through absolute and relative frequencies, while quantitative ones were expressed through measures of central tendency and dispersion based on their distribution. Results: We analyzed 1020 episodes of pancreatitis, finding pancreatic necrosis in 30 patients, i.e., a period prevalence of 2.9 %. Of the patients, 83 % (n = 25) underwent open drainage, with 48 % (n = 12) mortality. About laparoscopic management, the reduction in postoperative organ failure was 40 % (n = 2), with a 30 % shorter hospital stay than the open drainage approach. Those patients with a level of procalcitonin (PCT) lower than 1.8 ng/mL had less mortality. Conclusions: The laparoscopic approach shows promising results regarding final morbidity and mortality.

Resumen Introducción: la pancreatitis es una patología frecuente en nuestro medio, mayormente relacionada con la patología biliar benigna. Esta puede progresar a formas severas en 10 %-15 % de los casos, en donde el tejido pancreático se necrosa y forma grandes colecciones, con riesgo de infección. En Colombia no conocemos los datos epidemiológicos acerca de la incidencia de este tipo de complicaciones, ni del manejo de las mismas. Objetivo: este estudio tiene como objetivo estudiar la prevalencia de la necrosis pancreática infectada y describir los casos identificados en un hospital de alto nivel de complejidad entre 2014 y 2021. Métodos: estudio observacional de corte transversal. Se analizaron los registros de pacientes diagnosticados con pancreatitis en segunda etapa. Se estudiaron aquellos casos que presentaron necrosis pancreática infectada y se sometieron a desbridamiento más drenaje quirúrgico por vía laparoscópica y abierta en el Hospital Universitario Mayor Méderi de Bogotá, Colombia, entre enero de 2014 y enero de 2021. Se realizó un muestreo por conveniencia, sin cálculo de tamaño de muestra. Se recolectaron variables demográficas y clínicas de los pacientes. Se realizó un análisis estadístico descriptivo de las variables obtenidas en Excel. Las variables cualitativas se describieron a través de frecuencias absolutas y relativas; mientras que las cuantitativas se expresaron mediante medidas de tendencia central y de dispersión en función de su distribución. Resultados: se analizaron 1020 episodios de pancreatitis y se evidenció necrosis pancreática en 30 pacientes, es decir, una prevalencia de período de 2,9 %. De los pacientes, 83 % (n = 25) se llevó a drenajes por vía abierta, con un 48 % (n = 12) de mortalidad. En relación con el manejo por vía laparoscópica, la reducción en la falla orgánica posoperatoria fue de 40 % (n = 2), con un 30 % menos de duración en la estancia hospitalaria, comparado con la vía abierta. Aquellos pacientes que presentaron un nivel de procalcitonina (PCT) menor de 1,8 ng/mL tuvieron menos mortalidad. Conclusiones: el abordaje laparoscópico muestra resultados prometedores en cuanto a la morbilidad y mortalidad final observada.

Clinical effects of en bloc resection and debridement combined with gluteus maximus muscle flap in the treatment of ischial tubercle pressure ulcer complicated with chronic osteomyelitis / 中华烧伤杂志

Objective: To investigate the clinical effects of en bloc resection and debridement combined with gluteus maximus muscle flap in the treatment of ischial tubercle pressure ulcer complicated with chronic osteomyelitis. Methods: A retrospective observational study was conducted. From May 2018 to February 2020, 8 patients with pressure ulcers on the ischial tuberosity combined with chronic osteomyelitis who met the inclusion criteria were admitted to Fuyang Minsheng Hospital, including 5 males and 3 females, aged 38-69 years, with unilateral lesions in 6 patients and bilateral lesions in 2 patients. According to the anatomical classification of Cierny-Mader osteomyelitis, there were 6 patients (7 sides) with focal type, and 2 patients (3 sides) with diffuse type. The wound areas were 3 cm×2 cm to 12 cm×9 cm on admission. The pressure ulcer and chronic osteomyelitis lesions were completely removed by en bloc resection and debridement. The chronic infectious lesions were transformed into sterile incisions like fresh wounds by one surgical procedure, and the gluteus maximus muscle flaps with areas of 10 cm×6 cm to 15 cm×9 cm were excised to transfer and fill the ineffective cavity. The wounds of 5 patients were sutured directly, and the wounds of 3 patients were closed by local flap transfer. The intraoperative blood loss volume and blood transfusion, and length of hospital stay of patients were recorded. The incision healing and flap survival of patients were observed after operation. The recurrence of pressure ulcer and osteomyelitis, the appearance of the affected area, and the secondary dysfunction and deformity of the muscle flap donor site of patients were observed during followed up. Results: The intraoperative blood loss volume of the 8 patients was 220 to 900 (430±150) mL; 5 patients received intraoperative blood transfusion, of which 2 patients received 3 U suspended red blood cells and 3 patients received 2 U suspended red blood cells. The length of hospital stay was 18 to 29 (23.5±2.0) d for the 8 patients. In this group of patients, the incisions of 7 patients healed, while in one case, the incision suture was torn off during turning over and healed after secondary suture. The flaps survived well in 3 patients who underwent local flap transfer. During the follow-up period of 6-20 months, no recurrence of pressure ulcer or osteomyelitis occurred in 8 patients, the affected part had skin with good texture, mild pigmentation, and no sinus tract formation, and no secondary dysfunction or deformity occurred in the donor site. Conclusions: The en bloc resection and debridement combined with gluteus maximus muscle flap has good clinical effects on ischial tubercle pressure ulcer complicated with chronic osteomyelitis. Neither pressure ulcer nor osteomyelitis recurs post operation. The skin texture and appearance of the affected area are good, and the donor site has no secondary dysfunction or deformity.

A case of high-temperature steel bar penetration injury from scrotum to buttocks / 中华烧伤杂志

On November 17, 2013, the Second Affiliated Hospital of Kunming Medical University admitted a 23-year-old male patient with a high-temperature steel bar penetration injury from scrotum to buttocks who was transferred from another hospital. Expanded debridement, suture, and drainage of the perineum, right thigh, and right hip were performed as soon as possible after admission. A sputum suction tube was used as the guide mark for expanded debridement during the operation to ensure the accuracy of the direction and scope of expanded debridement. The incision was treated with vacuum sealing drainage (VSD) and full drainage. On the 20th day after the operation (the 25th day after admission), the unhealed wound was transplanted with split-thickness skin graft from the right thigh, and the drainage of the operation area and dressing change were strengthened. On the 53rd day after injury, the patient was discharged after complete wound healing. This case suggests that VSD after early debridement is an effective means to treat high-temperature steel bar penetration injuries.

Laparoscopic transgastric necrosectomy in treatment of wall-off pancreatic necrosis / 中华外科杂志

Mini-invasive surgical or endoscopic step-up approach is the first choice of pancreatic necrosectomy for infected wall-off necrosis. Surgical debridement has the advantage of high efficiency,low cost and good accessibility,while the complication rate of pancreatic fistula and incision hernia after endoscopic necrosectomy is low.Laparoscopic transgastric necrosectomy(LTGN) can combine the advantages of surgical and endoscopic debridement,and may become one of the important methods for the surgical treatment of necrotizing pancreatitis in the future. This paper focuses on the technical advantages,surgical points,indications and application status of LTGN,so as to provide reference for the technical promotion.

Arthroscopic debridement combined with platelet-rich plasma injection for the treatment of Kellgren-Lawrence gradeⅠ-Ⅲ knee osteoarthritis / 中国骨伤

OBJECTIVE@#To explore clinical effect of arthroscopic debridement combined with platelet-rich plasma (PRP) injection for Kellgren-Lawrence(K-L) gradeⅠ-Ⅲ knee osteoarthritis (KOA) .@*METHODS@#Totally 117 patients with KOA who underwent arthroscopic debridement combined with injection from November 2015 to January 2019 were retrospectively analyzed. According to different injection drugs, the patients were divided into sodium hyaluronate group(group A) and PRP group(group B). In group A, there were 60 patients, including 27 males and 33 females, aged from 49 to 67 years old with an average age of (54.1±4.8) years old;12 patients with gradeⅠ, 23 patients with gradeⅡand 25 patients with grade Ⅲ according to K-L clssification, 2 ml(20 g) sodium hyaluronate was injected into knee joint after intraoperative, 1, 2, 3 weeks after operation for 4 times. In group B, there were 57 patients, including 25 males and 32 females, aged from 47 to 70 years old with an average of (55.8±5.0) years old, 10 patients with gradeⅠ, 20 patients with gradeⅡand 27 patients with grade Ⅲ according to K-L classification, injected 5 ml PRP at the same time. Postoperative complications was recorded between two groups. Postoperative visual analogue scale(VAS) and Lysholm score at 3, 6, 12 months were used to evaluate improvement of knee pain and joint function.@*RESULTS@#All patients were followed up for 12 to 19 months with an average of (14.1±1.6) months. There was no significant difference in postopertaive complications between group A and group B (P>0.05). Postoperative VAS score in group A at 3, 6, 12 months were 3.0±0.8, 2.0±0.8, 2.6±0.9 respectively, and 2.9±0.8, 1.9±0.7, 2.2±0.8 in group B respectively; and no differnece at 3 and 6 months after operation between two groups (P<0.05), while VAS score in group B was higher than group A at 12 months after operation(P<0.05). Postoperative Lysholm score in group A at 1, 6, 12 months (86.6±1.8, 93.1±2.0, 86.7±1.7) were lower than group B(88.9±1.9, 95.0±2.0, 89.0±1.9)(P<0.05).@*CONCLUSION@#Arthroscopic debridement combined with sodium hyaluronate or PRP injection for K-L gradeⅠ-Ⅲ KOA could effectively relieve pain and improve joint function with higher safety in short term, but the medium-long-term effect of PRP injection is stable.

Mixed bacterial-fungal infection following total hip arthroplasty: A case report / 中华创伤杂志(英文版)

Prosthetic infection is one of the severe postoperative complications of arthroplasty. Mixed bacterial-fungal prosthetic infection is rare but can be disastrous. This case was a 76-year-old female suffered from prosthetic infection following total hip replacement due to femoral neck fracture and underwent multiple debridements. The culture of periprosthetic tissue was bacteriologically sterile following the first debridement, while the Staphylococcus hominis was identified in the second debridement in the previous hospitalization where fungal infection had not been considered. Thus the pathogen spectrum of anti-infection therapy failed to contain fungus. Ultimately, the culture result of our sampled periprosthetic tissue during the third debridement was Candida albicans without bacterium in our hospital. The fungal prosthetic infection was successfully treated by a two-stage revision with antifungal drugs. Accurate diagnosis and standardized treatment is the key to the therapy of infection after hip arthroplasty, especially for mixed bacterial-fungal prosthetic infection.

Therapeutic strategies for chronic wound infection / 中华创伤杂志(英文版)

Chronic wounds have always been a tough fight in clinical practice, which can not only make patients suffer from pain physically and mentally but also impose a heavy burden on the society. More than one factor is relevant to each step of the development of chronic wounds. Along with the in-depth research, we have realized that figuring out the pathophysiological mechanism of chronic wounds is the foundation of treatment, while wound infection is the key point concerned. The cause of infection should be identified and prevented promptly once diagnosed. This paper mainly describes the mechanism, diagnosis and therapeutic strategies of chronic wound infection, and will put an emphasis on the principle of debridement.