Elbow arthroplasty complicated by Mycobacterium tuberculosis infection: A case report.

INTRODUCTION: Total elbow arthroplasty (TEA) is an orthopedic procedure that is relatively infrequently performed, but its use has been increasing over time. Infection remains one of the most concerning complications after TEA, although Mycobacterium tuberculosis (TB) as a microbial etiology, is extremely rare. Here, we present a case of M. tuberculosis infection after TEA. PATIENT CONCERNS: A 45-year-old woman underwent TEA for severe traumatic arthritis of the elbow following failure of conservative treatment. Four months after TEA, the patient experienced progressive elbow pain and swelling, without other external signs of infection such as a sensation of local heating and erythematous alterations. DIAGNOSIS: Pulmonary computed tomography showed stable pulmonary TB in the right upper lobe. The T-SPOT, TB, and purified protein derivative test results were positive, and M. tuberculosis exhibited growth on cultures. The final diagnosis was periprosthetic infection of M. tuberculosis. INTERVENTIONS: The patient was treated with debridement with submission of deep tissue cultures. According to these cultures and suggestions of a bacteriologist, anti-TB treatment was administered for 12 months. OUTCOMES: The symptoms of the infection were controlled, and the prosthesis was retained. At the time of writing this case report, the elbow prosthesis had survived for more than 2 years, and no recurrent infection had been observed. CONCLUSION: The diagnosis of TB infection after TEA is difficult to confirm due to its nonspecific signs and symptoms. Despite the extremely low incidence, failure to consider this possibility for diagnosis can lead to delayed treatment. Proper diagnosis allows for antitubercular therapy with retention of a prosthesis.

Secondary purulent infections of the elbow joint: a retrospective, single-center study.

BACKGROUND: Septic arthritis of the elbow joint is a rare condition. Limited data is available on infections of the elbow joint following trauma or prior surgery on this joint. The aim of this study was to describe the etiology, comorbidities, bacterial spectrum and therapy of secondary purulent elbow infections. METHODS: Patients treated in our hospital were selected through retrospective chart review between 2006 and 2015. We included all patients with an empyema of the elbow after a trauma or surgical intervention on this joint. 30 patients between 26 and 82 years (mean: 52.47) were included. RESULTS: Seven patients (23.3%) were female, 23 (76.7%) male. 22 patients (73.3%) had a history of trauma, eight (26.7%) had prior elective surgeries on their elbow. Between one and 25 surgeries (mean: 5.77) were necessary for treatment. In nine patients, debridement and synovectomy were sufficient, eight patients (26.7%) received resection of the elbow joint. One patient was treated with a chronic fistula. In 18 patients (60%), cultures of aspiration/intraoperative swabs were positive for Staphylococcus aureus, four of these were methicillin-resistant. Four patients (13.3%) had positive cultures for Staphylococcus epidermidis, in five patients (16.7%) no bacteria could be cultured. CONCLUSIONS: Secondary infections of the elbow joint are a rare disease with potentially severe courses, requiring aggressive surgical treatment and possibly severely impacting elbow function. Staphylococcus aureus was the most common bacteria in secondary infections and should be addressed by empiric antibiotic treatment when no suspicion for other participating organisms is present.

Septic elbow arthritis in children: Epidemiology and outcome.

INTRODUCTION: Septic elbow arthritis is a rare disease, especially in children. The aim of this study was to report the functional outcome of our pediatric population with both demographic and microbiological features. METHODS: We retrospectively reviewed all our cases of pediatric septic elbow arthritis between 2007 and 2017. Demographic, microbiological, biological, and radiological features were analyzed. Functional outcome was evaluated according to the Morrey Elbow Performance Score (MEPS). RESULTS: In total, 14 cases were reviewed. The mean age was 9 years. Microbiological findings revealed Staphylococcus aureus in 10 cases. The mean white blood cells count in synovial fluid was 101,306 cells per mm 3. The skin was the most frequently reported entry portal. The mean MEPS score was 86.13 points (excellent in eight cases, good in three cases, fair in two cases, and poor in two cases). Stiffness was observed in three cases. No growth disturbance was reported. DISCUSSION: Septic elbow arthritis in children is rare. Biological inflammatory markers are sensitive but not specific. White blood cell count in the synovial fluid is specific. S. aureus is the most frequently cultured agent. Treatment is based on surgical debridement, antibiotics, and elbow immobilization. Concomitant osteomyelitis is frequent and should be diagnosed and treated simultaneously. Functional outcomes are usually satisfactory in contrast to osteomyelitis. CONCLUSION: Pediatric septic elbow arthritis is rare. It may be primary or secondary to trauma and surgery of the elbow. Demographic, biological, and microbial features are similar to those reported for osteomyelitis; however, functional outcomes are better with a negligible rate of growth disturbance.

Tuberculosis of the Elbow Region in Pediatric Age Group - Experiences from a Single Centre.

BACKGROUND: Clinical series of tuberculosis of elbow region in children are few. The purpose of our study was to retrospectively review the presentation, healing response and functional results of 30 children. METHODS: The pretreatment disease presentation was studied from patient's case records. Serial radiographs of the patients were studied to see remineralization and healing of radiological lesions. For elbow's functional evaluation, pain, range of motion and recurrence were observed at final follow up. RESULTS: The mean patient age was 8.2 years. The mean duration of symptoms before presentation was 47 days. A discharging sinus was present in 6 patients. Multifocal presentation was found in 7 patients. The lesion was most commonly localized in proximal ulna or lower humerus. The classical 'ice cream scoop' appearance of proximal ulnar metaphysis was noted in 5 elbows. Most elbows were in Martini stage 2 (70%) at the time of presentation. All patients were treated non-operatively. Average follow up after completion of antitubercular therapy was 18.97 months. The resolution of regional osteopenia, sclerosis of lytic lesions, reappearance of bony trabeculae and decrease in size of cavities was the usual sequence of radiological healing. End average elbow flexion arc deteriorated with increasing Martini stage. 'Ice cream scoop lesions' resulted in a worse functional outcome with formation of an irregular proximal ulnar articular surface. CONCLUSIONS: Restriction of elbow range of motion, early discharging sinus formation and radiological 'ice cream scoop' appearance indicated a tubercular pathology. Late presentation with advanced disease, total joint involvement, and 'ice cream scoop appearance' resulted in decreased elbow flexion arc.

Endogenous bacterial endophthalmitis. A report of 2cases. / Endoftalmitis endógenas bacterianas. A propósito de 2casos.

CLINICAL CASES: The cases are presented on 2patients with bacterial endogenous endophthalmitis. The first one was caused by Streptococcus bovis, developed after colonoscopy, which had a poor outcome and resulted in evisceration. The second case was caused by a methicillin resistant Staphylococcus aureus from an arthrodesis complicated with a para-spinal abscess. It had an excellent visual outcome. DISCUSSION: Bacterial endogenous endophthalmitis is a rare, but serious ocular disease that occurs when bacteria reach the eye via the bloodstream. It requires a very early diagnosis based on the clinical symptoms and patient history. A suitable and specific treatment with intravenous and intravitreal antibiotics may prevent a bad visual prognosis in some cases.

[Osteo-cutaneous Mycobacterium marinum infection of the elbow and reconstruction with radial collateral artery perforator-based propeller flap]. / Infection ostéo-cutanée du coude à Mycobacterium marinum et reconstruction par un lambeau en hélice basé sur une perforante de l'artère collatérale radiale postérieure.

Mycobacterium marinum is an atypical and non-tuberculosis mycobacterium that mainly leads to cutaneous infections. Infections occur through inoculation of the organism through injury to the skin in the presence of contaminated water or fish. The patient often presents with unspecific symptoms and the evolution, in the absence of adequate treatment, is characterized by an expansion of the cutaneous lesion and a spread to deep structures. Infections of tendon sheaths and joints are described, rarely osteomyelitis. Sure diagnosis is hard to obtain and is established from the medical history and microbiological examination. There are no specific therapeutic guidelines. Double or triple antibiotherapy is often effective and should be continued several months after complete resolution of clinical signs. Surgical debridement is required in cases of invasive or resistant infections. We report the case of a young immunocompetent fishmonger with a rare osteocutaneous M. marinum infection of the elbow. Treatment included large surgical excision of infected skin and bone areas and a triple antibiotics administration. Reconstruction have been ensured by a radial collateral artery perforator-based propeller flap, satisfying appropriates functional and cosmetical concerns of this anatomical region. Surgery and appropriate antibiotics treatment were effective and allowed healing of an invasive cutaneous and bone M. marinum infection.

What Factors are Associated With a Surgical Site Infection After Operative Treatment of an Elbow Fracture?

BACKGROUND: Surgical site infections are one of the more common major complications of elbow fracture surgery and can contribute to other adverse outcomes, prolonged hospital stays, and increased healthcare costs. QUESTIONS/PURPOSES: We asked: (1) What are the factors associated with a surgical site infection after elbow fracture surgery? (2) When taking the subset of closed elbow fractures only, what are the factors associated with a surgical site infection? (3) What are the common organisms isolated from an elbow infection after open treatment? METHODS: One thousand three hundred twenty adult patients underwent surgery for an elbow fracture between January 2002 and July 2014 and were included in our study. Forty-eight of 1320 patients (4%) had a surgical site infection develop. Thirty-four of 1113 patients with a closed fracture (3%) had a surgical site infection develop. RESULTS: For all elbow fractures, use of plate and screw fixation (adjusted odds ratio [OR]= 2.2; 95% CI, 1.0-4.5; p = 0.041) and use of external fixation before surgery (adjusted OR = 4.7; 95% CI, 1.1-21; p = 0.035) were associated with higher infection rates. When subset analysis was performed for closed fractures, only smoking (adjusted OR = 2.2; 95% CI, 1.1-4.5; p = 0.023) was associated with higher infection rates. Staphylococcus aureus was the most common bacteria cultured (59%). CONCLUSIONS: The only modifiable risk factor for a surgical site infection after open reduction and internal fixation was cigarette smoking. Plate fixation and temporary external fixation are likely surrogates for more complex injuries, therefore no recommendations should be inferred from this association. Surgeons should counsel patients who smoke. LEVEL OF EVIDENCE: Level IV, prognostic study.

Nontyphoidal Salmonella septic arthritis of the elbow in a healthy infant.

A case of rarely encountered nontyphoidal Salmonella septic arthritis of the elbow in an infant with no preexisting disease is reported. Salmonella etiology was not suspected in this case, and the diagnosis was made only after bacterial isolation. Aspiration of the infected joint with radiological guidance initially failed to give a good clinical response. Arthrotomy was done with intravenous cefotaxime for 4 weeks followed by 2 weeks oral ciprofloxacin therapy to which the child responded favorably. Up to our knowledge this is the first case of nontyphoidal salmonella elbow septic arthritis in an infant in Saudi Arabia to be reported in the English literature.

Septic arthritis of the elbow in a child due to Pseudomonas aeruginosa: a case report.

We present a rare case of septic arthritis of the elbow in a child caused by Pseudomonas aeruginosa infection. In our patient, the 15-day delay before drainage may have led to the osteomyelitis of the capitulum and resulted in some persistent radiographic abnormalities. Although our patient has no subjective symptoms 5 years postoperatively, he has a slightly abnormal range of motion and gross lateral instability. Children with elbow pain and/or swelling with fever should be carefully examined for septic arthritis. Pseudomonas aeruginosa should always be kept in mind in such cases to avoid any delay in effective treatment.

Forked osteotomy arthroplasty for elbow tuberculosis: six years of follow-up.

BACKGROUND: Elbow tuberculosis (TB) is not rare in China. Most patients are diagnosed when it is at an advanced stage and with bony ankylosis complications. For a developing country, such as China, it is important for there to be safe and cost-effective procedures. MATERIALS AND METHODS: A retrospective study was designed to assess the effects of improved forked excision arthroplasty for treating elbow TB. There were 20 patients (average age, 48.45 years). For all patients, the preoperative diagnosis was elbow TB at an advanced stage. All patients underwent forked excision arthroplasty. Patients were evaluated preoperatively and postoperatively with the Mayo's elbow performance score (MEPS). Mean follow-up was at 74.4 months. RESULTS: At the last follow-up, the mean postoperative MEPS was 83.7 compared with the preoperative MEPS of 20.25. Results of Mayo's elbow performance index were excellent in seven patients, good in 12 and fair in one, and none were poor. The range of elbow motion also improved significantly. CONCLUSION: This study of forked elbow excision arthroplasty has shown promising results for treating elbow TB. Most patients had ideal postoperative outcomes and exhibited painless elbow joints, with satisfactory functional recovery at medium-term follow-up. Further studies with longer follow-up are warranted. LEVEL OF EVIDENCE: III.

Peliosis hepatis due to disseminated tuberculosis in a patient with AIDS.

Peliosis hepatis is a rare histopathological entity of unknown etiology. We present a case of peliosis hepatis in a 44-year-old man with disseminated tuberculosis and acquired immunodeficiency syndrome. The diagnosis of peliosis hepatis was based on liver biopsy results which were suggestive of tuberculous etiology. Diagnosis of tuberculosis was confirmed by auramine stain, rRNA amplification and culture of Mycobacterium tuberculosis from synovial fluid of the elbow joint. The patient responded favourably to tuberculostatic treatment with four drugs and the early initiation of highly active antiretroviral therapy. Histopathological evidence of peliosis hepatis, without an obvious cause, makes it necessary to rule out tuberculosis, especially in the context of immunodeficiency diseases and immigrants from endemic areas.

Supraclavicular block as a sole anesthetic technique in craniopagus twins.

This is the first report in the literature of a sole regional anesthetic for adult craniopagus twins using a supraclavicular block for an elbow incision and drainage/bursa excision procedure. It demonstrates that for these complex medical patients, a total regional anesthesia technique is preferable when possible. There are several known general anesthetic complications in these patients. Anesthetic crossover between the twins can occur and may be variable; furthermore, the incidence and severity of the crossover effects of different anesthetics vary. Positioning of the twins can be difficult with both regional and general anesthesia. However, with regional anesthesia, the twins can position themselves and report any discomfort, which could go unnoticed under general anesthesia, leading to other complications. Craniopagus twins have a high likelihood of a difficult airway due to anatomy or positioning difficulties, which is avoided by regional anesthesia. This case emphasizes the unique challenges that these patients pose and the ability of regional anesthesia to help avoid the pitfalls of general anesthesia in these patients.

Haemophilus influenzae serotype f as a rare cause of septic arthritis.

Non-type B Haemophilus influenzae emerges as a new pathogen in the post H. influenzae serotype b vaccine era. We describe a case of polyarticular septic arthritis caused by H. influenzae serotype f in an adult. The patient was successfully treated with surgical debridement and antibiotic. To the best of our knowledge, this is the fourth reported case of H. influenzae serotype f septic arthritis in adults.

The fate of elbows with unexpected positive intraoperative cultures during revision elbow arthroplasty.

BACKGROUND: An intraoperative culture sample obtained during revision elbow arthroplasty that is unexpectedly positive poses a dilemma for the surgeon. The purpose of our study was to determine the prevalence of positive cultures during revision elbow arthroplasty when infection is not suspected preoperatively, and the long-term implications of these positive cultures. METHODS: Two hundred and thirteen consecutive revision elbow arthroplasties were performed at our institution between 2000 and 2007. Of these, sixteen patients had unexpected positive intraoperative cultures. RESULTS: The majority of cultures grew either Staphylococcus epidermidis or Propionibacterium acnes. Twelve patients had more than two years of follow-up. One of the twelve patients was treated as for an infection because of unexplained early implant loosening and the isolation of Staphylococcus epidermidis. Ten of the twelve elbows were treated as "contaminants" and did not receive long-term antibiotic treatment. Nine of these ten remained infection-free at the time of the final follow-up, while the remaining one developed an infection with a different organism. CONCLUSIONS: In our series, there was a 7.5% chance of encountering an unexpected positive result on intraoperative culture at the time of revision elbow arthroplasty. The majority of patients were successfully treated without antibiotics with a low rate of failure. A minority were considered as infections, typically presenting with unexplained early loosening and isolation of an organism on solid culture medium.

Artritis séptica por Scedosporium apiospermum de lenta instauración tras infiltración periarticular / Slow onset septic arthritis by Scedosporium apiospermum after periarticular infiltration

Antecedentes. Las artritis fúngicas de origen hematógeno suelen afectar preferentemente a pacientes con afectación de la inmunidad celular o a usuarios de drogas por vía intravenosa. En el paciente inmunocompetente suele producirse por la inoculación del microorganismo mediante un mecanismo invasor. La experiencia del tratamiento con azoles en estos pacientes es muy escasa. Caso clínico. Presentamos un caso clínico de artritis por Scedosporium apiospermum caracterizado por su lenta instauración, falta de respuesta a posaconazol y caspofungina, y resolución final mediante desbridamiento y tratamiento con voriconazol. Conclusiones. La administración de voriconazol junto al desbridamiento quirúrgico constituye un tratamiento eficaz en la artritis por S. apiospermum(AU)

Background. Fungal arthritis is usually of haematogenous origin, and mainly affects patients with impaired cellular immunity or users of intravenous drugs. The infection in immunocompetent patients is generally caused by direct inoculation of the microorganism through an invasive device. The experience of azole therapy in these patients is limited. Case report. We report a case of arthritis caused by Scedosporium apiospermum characterized by its slow onset, lack of response to posaconazole and caspofungin, and its successful resolution after surgical debridement and treatment with voriconazole. Conclusions. Treatment with voriconazole and surgical debridement is an effective therapy for arthritis due to S. apiospermum(AU)

Atraumatic septic arthritis of the elbow in a young immunocompetent host secondary to distant hematogenous spread.

We present the case of elbow septic arthritis without trauma, due to hematogenous spread from a distant source in a young immunocompetent host. We discuss the importance of early recognition and treatment of septic arthritis, despite unusual presentation and history, as well as advocate aspiration of the elbow joint in equivocal cases as a low morbidity/high-yield test.

Arthroscopic treatment of septic arthritis of the elbow.

HYPOTHESIS: Septic arthritis of the elbow is a serious orthopedic concern associated with high morbidity and mortality rates, traditionally treated with open exposure of the elbow joint. This study was performed to describe the outcome of arthroscopic treatment of septic elbow arthritis. METHODS: From May 2000 through January 2008, 12 patients with septic elbow arthritis were treated arthroscopically at the Mayo Clinic, Rochester, Minnesota, a large medical center. We reviewed the patients' medical records concerning variables such as history and clinical findings, previous elbow history, surgical procedure, cultured organism, and follow-up. Using the Oxford Elbow Score and the Mayo Elbow Score, we examined current level of pain, function, and social-psychological aspects. Six patients died before initiation of this study and were therefore only studied retrospectively. RESULTS: Septic elbow arthritis without pre-existing elbow problems shows excellent outcomes after arthroscopic treatment, with scores for absence of pain, function, social-psychological well-being, and range of motion of 97.9%, 100%, 95.8%, and 100%, respectively. When elbows were treated arthroscopically within 2 days after the onset of clinical symptoms suggesting bacterial elbow arthritis, maximum scores of 100% were noted for all aspects. Positive elbow history before infection and reoperation were associated with poor outcome scores, with 62.5%, 85.4%, and 50% for absence of pain, function, and social-psychological well-being, respectively. CONCLUSION: Septic elbow arthritis occurs often in the debilitated, immunocompromised patient. Arthroscopic intervention is a reasonable alternative to open treatment. In this small series, the acutely septic elbow was successfully treated in the majority of patients, although the overall patient mortality rate remains high.