An aggressive course of pyoderma gangrenosum mimicking bacterial osteomyelitis after open reduction and internal fixation of a distal radius fracture with a titanium plate.

Pyoderma gangrenosum (PG) is a rare condition characterized by the development of aseptic, non-healing skin ulcers. Any skin trauma, such as a surgical incision, can trigger an outbreak of lesions. Our case and literature review show that a physician should consider PG in every event of a non-healing, aseptic wound after surgery. The treatment of PG requires collaboration within a multidisciplinary team and immunosuppressive therapy is the first line of treatment, while surgical interventions should be avoided in the active stage of PG.

Difficulties in identifying the bacterial species from the genus Clostridium in a case of injury-related osteitis.

Most Clostridium species are part of saprophytic microflora in humans and animals; however, some are well-known human pathogens. We presented the challenges in identifying the Clostridium species isolated from a patient with an infected open dislocation of the proximal interphalangeal joint of the fourth digit of the right hand. The clinical materials were intraoperative samples collected from a patient diagnosed with an injury-related infection, with soft tissue loss and tendon sheath involvement. The available biochemical, molecular, and genetic techniques were used in identifying the isolated bacteria. The isolated bacterium was shown to have low biochemical activity; hence, it was not definitively identified via biochemical tests Api 20A or Rapid 32A. Vitek 2 and mass spectrometry methods were equally inconclusive. Clostridium tetani infection was strongly suspected based on the bacterium's morphology and the appearance of its colonies on solid media. It was only via the 16S rRNA sequencing method, which is non-routine and unavailable in most clinical laboratories, that this pathogen was excluded. Despite appropriate pre-laboratory procedures, which are critical for obtaining reliable test results, the routine methods of anaerobic bacterium identification are not always useful in diagnostics. Diagnostic difficulties occur in the case of environment-derived bacteria of low or not fully understood biological activity, which are absent from databases of automatic bacterial identification systems.

Orthopedic infections caused by obligatory anaerobic Gram-negative rods: report of two cases.

Anaerobic bone and joint infections are uncommon, although the number of anaerobic infections is presumably underestimated because of difficulties with isolation and identification of obligate anaerobes. This study describes two cases of complicated Bacteroides fragilis peri-implant infection of the lumbar spine, infection of the hip and osteomyelitis. Bacteria were identified with the use of a mass spectrometer, VITEK MS system. Drug susceptibility was performed with the use of E-test. The EUCAST breakpoints were used for interpretation with B. fragilis ATCC 25285 as a control. In the two described cases clinical samples were collected for microbiological examination intraoperatively and simultaneously empirical treatment was applied. B. fragilis was isolated in monoculture or in a combination with other bacteria. The treatment was continued according to the susceptibility tests. In a case one clindamycin failure was observed and clindamycin resistance of the isolate was likely due to inadequate time of therapy. Difficulties in collecting an adequate samples and culturing anaerobic bacteria cause that not all infections are properly recognized. In a successful therapy, identification and determination of the susceptibility of the pathogen are essential as well as an appropriate surgical debridement.

Economic Analysis of 4221 Revisions Due to Periprosthetic Joint Infection in Poland.

BACKGROUND: Periprosthetic joint infection (PJI) is one of the most severe complications of total hip (THA) and total knee (TKA) arthroplasty. The aim of the study is to determine the number and type of hip and knee prosthesis revisions in Poland performed due to infection and reimbursement of the cost of septic revisions and to compare the costs of septic and aseptic revisions in Poland and other countries. MATERIAL AND METHODS: The data published for the period 2009-2013 by the National Health Fund (NHF) were analysed and the average cost of septic and aseptic revisions was calculated. RESULTS: In the years 2009-2013, a total of 260,030 hip and knee arthroplasties including 23,027 revisions (incl. 4,221 septic) were performed in Poland. In 2013, septic revisions accounted for 1.38% of all hip replacement procedures, 2.56% of all knee replacement procedures and 14.67% of all hip revisions and 30.23% of all knee revisions. In 2013, the difference between the average cost incurred by the hospital and the NHF refund for septic revision due to PJI was at least €238 and the cost-refund gap for the entire year was €219198. CONCLUSION: 1. The system of reporting periprostheticjoint infections currently in use in Poland does not adequately reflect the current classification of PJI and reimbursement for septic revision of joint prosthesis does not match the actual costs. 2. The Polish DRG system does not distinguish between early and late PJI and fails to acknowledge basic guidelines for infection treatment currently followed in Poland and worldwide. 3. According to the DRG system, patients requiring different treatment are placed in one category. 4. Until the year 2013, the less expensive treatment of early infections had been reimbursed on the same basis as the more costly two-stage revision procedures.

Comparison of Bone Preserving and Radical Surgical Treatment in 32 Cases of Calcaneal Osteomyelitis.

Introduction. Radical procedures like calcanectomy and amputation performed for calcaneal osteomyelitis are regarded as effective in eradication of infection even though potentially functionally disabling. Bone sparing procedures offer better functional result at the expense of potentially worse infection control. The aim of the study has been to assess the influence of the surgical radicalism as much as the extent of bone infection on the final outcome in the surgical therapy of chronic calcaneal osteomyelitis (CO). Material and method. 32 patients with chronic CO have comprised the group under study: 8 with superficial type, 12 localised type and 12 with diffuse type according to Cierny-Mader classification. The aim of the treatment was to heal infection, preserve the heel shape and achieve good skin coverage over the calcaneus. The therapy consisted of 9 debridement surgeries with or without flaps, 8 drilling-operations of the calcaneus with application of collagen-gentamicin-sponge in bore holes, 15 partial and 2 total calcanectomies, and 4 below-the knee amputations. Results. The healing of infection and wound has been achieved after 7 of 9 debridements, 6 of 8 drilling-operations, 13 of 15 partial and all total calcanectomies. Conclusion. Bone preserving operations in chronic calcaneal osteomyelitis provided inferior infection control (76,47% vs 88,24%) and worse patient satisfaction (88,24% vs 100%) and almost camparable ambulation (100% vs 93,33%). Drilling of the calcaneus with application of collagen sponge containing gentamicin performed in chronic diffuse calcaneal osteomyelitis seems to offer a viable alternative to partial or radical calcanectomy. LEVEL OF EVIDENCE: V.

Wear of acrylic cement (methylene-polymethacrylate) can manifest as extraosseous cement granuloma or false aneurysm of the popliteal artery after total knee arthroplasty.

Wear particles of acrylic cement, similar to other biomaterials, can cause periprosthetic osteolysis and formation of extraosseous cement granuloma (ECG). Expansive granuloma can manifest as a tumorous mass adjacent to the knee prosthesis, or it even can damage the popliteal artery and lead to false aneurysm formation. Suspicion of these two conditions requires a complex diagnostic approach and eventually revision of the endoprosthesis itself or reparation of the popliteal artery. Despite the beneficial fixative properties of acrylic cement (methylene-polymethacrylate), which are important for implantation of joint prostheses, the acrylic cement can also cause severe complications related to the wear process.

Open tibial fractures grade IIIC treated successfully with external fixation, negative-pressure wound therapy and recombinant human bone morphogenetic protein 7.

The aim of the therapy in open tibial fractures grade III was to cover the bone with soft tissue and achieve healed fracture without persistent infection. Open tibial fractures grade IIIC with massive soft tissue damage require combined orthopaedic, vascular and plastic-reconstructive procedures. Negative-pressure wound therapy (NPWT), used in two consecutive cases with open fracture grade IIIC of the tibia diaphysis, healed extensive soft tissue defect with exposure of the bone. NPWT eventually allowed for wound closure by split skin graft within 21-25 days. Ilizarov external fixator combined with application of recombinant human bone morphogenetic protein-7 at the site of delayed union enhanced definitive bone healing within 16-18 months.

Application of individually performed acrylic cement spacers containing 5% of antibiotic in two-stage revision of hip and knee prosthesis due to infection.

Deep infection of a joint endoprosthesis constitutes a threat to the stability of the implant and joint function. It requires a comprehensive and interdisciplinary approach, involving the joint revision and removal of the bacterial biofilm from all tissues, the endoprosthesis must be often removed and bone stock infection treated. The paper presents the author's experience with the use of acrylic cement spacers, custom-made during the surgery and containing low dose of an antibiotic supplemented with 5% of a selected, targeted antibiotic for the infection of hip and knee endoprostheses. 33 two-stage revisions of knee and hip joints with the use of a spacer were performed. They involved 24 knee joints and 9 hip joints. The infections were mostly caused by staphylococci MRSA (18) and MSSA (8), and in some cases Enterococci (4), Salmonella (1), Pseudomonas (1) and Acinetobacter (1). The infection was successfully treated in 31 out of 33 cases (93.93%), including 8 patients with the hip infection and 23 patients with the knee infection. The endoprosthesis was reimplanted in 30 cases: for 7 hips and 23 knees, in 3 remaining cases the endoprosthesis was not reimplanted. Mechanical complications due to the spacer occurred in 4 cases: 3 dislocations and 1 fracture (hip spacer). The patients with hip spacers were ambulatory with a partial weight bearing of the operated extremity and those with knee spacers were also ambulatory with a partial weight bearing, but the extremity was initially protected by an orthosis. The spacer enables to maintain a limb function, and making it by hand allows the addition of the specific bacteria targeted antibiotic thus increasing the likelihood of the effective antibacterial treatment.

[Application of negative-pressure wound therapy in complex therapy of open tibia fractures IIIB and IIIC with massive soft tissue loss]. / Zastosowanie opatrunków podcisnieniowych VAC w kompleksowym leczeniu otwartych zlaman IIIB i IIIC podudzia z masywnym ubytkiem tkanek miekkich.

Patients with high-grade open tibia fractures and massive soft tissue damage pose a demanding clinical challenge, requiring a complex inter-disciplinary approach and multiple orthopedic, vascular and plastic-reconstructive procedures. These types of fractures still have a 50% risk of loss, although amputation remains a treatment method of last resort. In our experience negative-pressure wound therapy (NPWT), used in the form of the vacuum assisted closure - VAC System (KCI, USA) improves healing of excessive soft tissue damage with exposure of the bone accompanying open fracture of the tibia. VAC seals the wound with a foam dressing and applies negative pressure to the wound bed. The removal of exudate and infectious material supports the cleaning of the wound. Together with the reduction of oedema and the increase in blood flow, this promotes formation of granulation tissue and eventually wound closure by split skin graft. Utilizing this method as part of a multi directional approach VAC System not only helps the patient to recover faster but also in some cases can replace microsurgical soft-tissue transfer and thus allows salvage of the leg in orthopaedic teams lacking advanced reconstructive experience.

Characterization of transcription within sdr region of Staphylococcus aureus.

Staphylococcus aureus is an opportunistic pathogen responsible for various infections in humans and animals. It causes localized and systemic infections, such as abscesses, impetigo, cellulitis, sepsis, endocarditis, bone infections, and meningitis. S. aureus virulence factors responsible for the initial contact with host cells (MSCRAMMs-microbial surface components recognizing adhesive matrix molecules) include three Sdr proteins. The presence of particular sdr genes is correlated with putative tissue specificity. The transcriptional organization of the sdr region remains unclear. We tested expression of the sdrC, sdrD, or sdrE genes in various in vitro conditions, as well as after contact with human blood. In this work, we present data suggesting a separation of the sdr region into three transcriptional units, based on their differential reactions to the environment. Differential reaction of the sdrD transcript to environmental conditions and blood suggests dissimilar functions of the sdr genes. SdrE has been previously proposed to play role in bone infections, whilst our results can indicate that sdrD plays a role in the interactions between the pathogen and human immune system, serum or specifically reacts to nutrients/other factors present in human blood.

[Septic loosing of hip and knee prosthesis]. / Septyczne obluzowania protez stawów biodrowego i kolanowego.

Loosening of an artificial joint is a common complication in orthopedic surgery. It is estimated that bacteriological implant contamination is responsible for its loosening in 2-5 percent of cases, and in most cases aseptic loosening takes place. Despite low percentage of positive microbiological studies, histopathological examinations and modern laboratory techniques, including PCR (Polymerase Chain Reaction) allow to diagnose the bacterial contamination of the loose implant to ca 70 percent. Those observations point out to the high coincidence of bacterial contamination with implant loosening strongly suggesting its influence on activation of the inflammatory process destabilizing an implant. But the question, why in those cases bacterial contamination does not lead to clinically obvious suppuration, remains unknown. The possibility to activate the immune system by the subcellular elements of the bacterial cells leading to persistent inflammation with granulation tissue formation is likely. Presented paper discusses the process of orthopedic prosthesis loosening, the role of bacterial contamination in it. and the newest techniques for their examination.

Application of clindamycin in therapy of orthopaedic infections with special regard to applicability in outpatients practice.

Background. There is presented the applicability of clindamycin alone or combined with chinolon group antibiotics in therapy of orthopaedic infections.
Material and methods. In the period 1998-2002 a group of 47 patients underwent therepy due to soft tisue infection within extremities (9 patients), osteomyelitis (30) and periprosthetic infection (8). In 21 cases there was acute (within 1 month) and in 26 cases chronic infection. Etiologicaf factors include: Staphylococcus aureus (35), Acinetobacter baumani, Corynebacterium parvum, Enterobacter cloacae, Enterococcus faecalis, Serratia liquaefaciae, Morganella Morgagni. According to complex therapy protocol - procedure in deep infections included antimicrobial therapy and surgical debridement with application of garamycin spongue.
Results. Goud results i.e. permanent infection control was achiewed in 18 cases. Acceptable results i.e. temporary infection healing was achiewed in 16 cases. Poor result i.e. insatisfactory infection control was stated in 13 cases.
Conclusions. Clinical effectiveness of clindamycin therapy as only agent or part of complex therapy in orthopaedic infections is varying depending on chronicity of infection and possibilities of radical surgical intervention. In empiric antimicrobial therapy a combination of clindamycin with chinolon group antibiotics is favourable.

[Coronary angiography is not always helpful in differential diagnosis between perimyocarditis and myocardial infarction - four case reports]. / Czy zmiany ST-T elektrokardiogramu sa wynikiem zapalenia osierdzia i miesnia sercowego - czy zawalu serca. Koronarografia nie zawsze rozstrzyga watpliwosc. Opis 4 przypadków.

Four males aged 17-42 years with ST-T segment changes suggesting perimyocarditis or non-Q acute myocardial infarction are presented. Coronary angiography was performed to establish the final diagnosis. Three patients had normal coronary arteries; two of them had typical clinical signs of perimyocarditis whereas the third patient had less typical changes. The fourth patient was a smoker, had a family history of coronary heart disease and left ventricular dysfunction due to a non-Q wave apical infarction. In this patient coronary angiography revealed small atheromatous plaques in the distal part of left anterior descending artery as well as left main and right coronary artery spasm. Angiospastic aetiology of infarction and probable endothelial dysfunction due to myocarditis were diagnosed. The authors conclude that coronary angiography is not always helpful if clinical, electrocardiographic and biochemical signs of perimyocarditis are observed.

[Evaluation of femoral neck fracture treatment with hemiarthroplasty in elderly patients]. / Ocena wyników leczenia zlaman szyjki kosci udowej endoprotezoplastyka polowicza u chorych w wieku podeszlym.

The authors reviewed the medical records of 457 patients who underwent a hemiarthroplasty procedure for the treatment of displaced femoral neck fracture. The age of the patients ranged from 60 to 103 years (mean age: 83 years). Follow-up evaluation of 331 patients was done 4-114 months post-op (mean follow-up time 52 months). 19 patients (4.2%) died in hospital, 67 patients (14.6%) developed systemic conditions during hospitalisation. 12 months post-op the mortality rate was 15.7%. Mean survival was 36.5 months. According to the Merle d'Aubigne-Postel evaluation system there were 154 satisfactory results (75.9%). Cemented or uncemented implantation techniques had no influence on long term results. 94 patients (4.2%) achieved pre-injury mobility. The reoperation rate was 8.1%. Poor general conditions at admission that postponed surgery and impaired mobility were strong negative prognostic factors.