Osteomyelitis in limb amputated by amniotic band sequence.

A preterm (30+2 week) neonate with below-knee amputation (right lower limb), constriction rings and syndactyly, subsequent to amniotic band sequence, developed pus discharge from the right tibial stump. The neonate did not have clinical features of systemic sepsis. Blood culture was sterile. The pus culture, however, grew methicillin-resistant coagulase-negative Staphylococcus and bone scan was suggestive of osteomyelitis of right proximal tibial stump. Osteomyelitis was likely caused by the contiguous spread of infection from the exposed stump. Neonate was treated with intravenous antibiotics for 4 weeks and discharged on oral feeds.

[Recidives of Mycetoma after Amputation in Dakar (Senegal)]. / Récidives de mycétome après amputation à Dakar (Sénégal).

The treatment of fungal mycetoma is essentially surgical. This carcinological-like surgery consists of amputation in case of bone involvement. The recurrences after amputation are rare and address the problem of the operative indication. We report 5 cases of recurrence of fungal black-grain mycetoma after amputation of leg or thigh. Case 1: a 52-year-old patient with a mycetoma of the knee evolving for 8 years. There is no history of surgery. A thigh amputation with ganglion dissection is performed. One year after the surgical procedure, the patient presents a recurrence on the amputation stump and on the lymph node dissection site. An indication of hip disarticulation is made and performed 17 months after amputation. Case 2: a 25-year-old patient who has a black-grain mycetoma of the foot with osteitis evolving since 10 years. A leg amputation was performed. The patient had a recurrence at the popliteal level at 15 months postoperatively. An indication of amputation of the thigh is posed and refused by the patient. Case 3: a30-year-old woman with black-grain mycetoma of the knee with bone involvement for more than 10 years. A thigh amputation was performed and at nine months postoperativeshe presented a recurrence in the amputation stump. She was lost of sight despite the decision of surgical revision. Case 4: a 43-year-old patient operated on his foot and leg mycetoma at least 5 timesbefore amputation in 2000. The recurrence occurred one year after amputation. 18 years after amputation, a new surgical procedure was difficult due to extension of the lesions in the pelvis. Case 5: a 50-year-old female patient operated in Mauritania in 2012 (thigh amputation for mycetoma of the knee). She presented a recurrence on the amputation stump in 2018. An indication of disarticulation of the hip was posed and refused by the patient. These recurrences were testified by to the persistence of grains on the preserved segment. They pose the problem of the level of amputation and therefore of preoperative planning. Good preoperative planning allows optimization of the surgical procedure and avoids certain recurrences.

La chirurgie constitue le temps essentiel du traitement des mycétomes fongiques. Elle consiste en une amputation en cas d'atteinte osseuse. Nous avons observé 5 cas de récidives après amputation pour mycétome. Il s'agit dans tous les cas de patients présentant des mycétomes à grain noir avec atteintes osseuses. Les récidives sont survenues à moins de 18 mois de l'amputation faisant parler de reprise évolutive et posant le problème du niveau de l'amputation.

Majocchis Granuloma Caused by Trichophyton mentagrophytes in 2 Immunocompetent Patients.

Majocchi granuloma is an uncommon deep follicular inflammation caused by dermatophytes and affects immunocompetent and immunocompromised patients. The clinical findings overlap with other skin conditions such bacterial infections and inflammatory skin diseases, thereby delaying correct diagnosis. We describe 2 cases in immunocompetent patients.

Mucormycosis: a rare complication of an amputation.

Mucormycosis is a rare but serious opportunistic fungal infection. Several clinical forms have been described, including cutaneous localization that is frequently associated with soft tissue trauma or burns. We report a case of cutaneous mucormycosis in a diabetic patient with severe occlusive arterial disease. The diagnosis was made early with mold growth on an amputation wound and the presence of nonseptate hyphae on direct microscopic examination, later identified on culture as Lichtheimia ramosa. Aggressive treatment, including the control of underlying diseases, systemic and local amphotericin B, and extensive surgical debridement permitted successful outcomes.

Stump infections after major lower-limb amputation: a 10-year retrospective study.

BACKGROUND AND PURPOSE: There is little published data on the diagnostic and therapeutic management of lower-limb stump infections (excluding toe and forefoot amputations). PATIENTS AND METHODS: We made a retrospective observational study of 72 patients having undergone a major lower-limb amputation for a vascular or traumatic reason, complicated by post-surgical stump infection, between January 1, 2000 and December 31, 2009. RESULTS: Stump infection was diagnosed more than 6weeks after amputation in half of the patients. Staphylococcus was the most frequently isolated bacterium. Ultrasonography and CT scan combined with fistulography were useful to confirm the diagnosis and to determine the extension of infection. Thirty-two patients (44%) needed surgical revision in addition to antibiotic treatment. Patients diagnosed with bone infection more frequently required complementary surgery than those with soft tissue infection (P<0.001). CONCLUSION: The optimal management of this type of infection requires obtaining reliable bacteriological documentation (abscess aspiration in case of soft tissue infection or bone biopsy in case of osteomyelitis) to adapt to the antibiotic treatment. The management should be multidisciplinary (orthopedic or vascular surgeons, rehabilitation specialists, and infectious diseases physicians). Most patients may use prosthesis once the infection is treated.

[Stump problems after a lower limb amputation]. / Stompklachten na een beenamputatie.

Problems in the amputation stump occur frequently in lower limb amputees. These problems can range from skin defects to serious vascular insufficiency and have a major impact on the amputee's quality of life. We illustrate this with 2 patients aged 20 and 65. The first patient developed a Candida skin infection of the stump skin as a result of silicone liner use. She was successfully treated with miconazole/hydrocortisone and hygiene measures. The second patient developed progressive lower limb ischemia that resulted in a stump wound and claudication. He was treated with vascular surgery. Patients with stump problems should be referred to a rehabilitation physician for thorough examination of the stump in determining the cause of the symptoms and subsequent instalment of adequate treatment.

Delayed amputation following trauma increases residual lower limb infection.

INTRODUCTION: Residual limb infection following amputation is a devastating complication, resulting in delayed rehabilitation, repeat surgery, prolonged hospitalisation and poor functional outcome. The aim of this study was to identify variables predicting residual limb infection following non-salvageable lower limb trauma. METHODS: All cases of non-salvageable lower limb trauma presenting to a specialist centre over 5 years were evaluated from a prospective database and clinical and management variables correlated with the development of deep infection. RESULTS: Forty patients requiring 42 amputations were identified with a mean age of 49 years (±19.9, 1SD). Amputations were performed for 21 Gustilo IIIB injuries, 12 multi-planar degloving injuries, seven IIIC injuries and one open Schatzker 6 fracture. One limb was traumatically amputated at the scene and surgically revised. Amputation level was transtibial in 32, through-knee in one and transfemoral in nine. Median time from injury to amputation was 4 days (range 0-30 days). Amputation following only one debridement and within 5 days resulted in significantly fewer stump infections (p = 0.026 and p = 0.03, respectively, Fisher's exact test). The cumulative probability of infection-free residual limb closure declined steadily from day 5. Multivariate analyses revealed that neither the nature of the injury nor pre-injury patient morbidity independently influenced residual limb infection. CONCLUSION: Avoiding residual limb infection is critically dependent on prompt amputation of non-salvageable limbs.

Long-term treatment with linezolid in a patient with osteomyelitis undergoing hemodialysis.

Anemia and/or thrombocytopenia are the most relevant adverse effects of linezolid treatment. We report the case of a patient under hemodialysis who developed osteomyelitis involving the amputation stump of the left limb due to a vancomycin-resistant and teicoplanin-resistant Enterococcus faecium successfully treated with linezolid for 6 months. Close monitorization of the patient probably contributed to maintenance of treatment with linezolid despite hematological alterations observed, which could be attributed to either the underlying patient's clinical condition or antimicrobial treatment.

An analysis of risk factors associated with traumatic extremity amputation stump wound infection in a Nigerian setting.

PURPOSE: We aimed to determine the risk factors associated with traumatic extremity amputation stump wound infection in our environment. METHOD: This was a retrospective analysis of databases that included the entire patient population with traumatic extremity amputation seen in Ebonyi State University Teaching Hospital and Federal Medical Centre Abakaliki from January 2001 to December 2011. RESULT: There were 63 patients studied and stump wound infection was a complication in 38 (60 %) of them. Stump wound infection rate significantly correlated with the form of amputation, i.e., a higher rate in crushing than guillotine (sharp clear-cut) amputation (80.5 vs. 22.7 % p < 0.000); severity, i.e., a higher rate in major than minor amputation (80.6 vs. 33.3 % p < 0.000); and limb involvement, i.e., a higher rate in lower than upper extremity amputation (71.1 vs. 60.7 % p < 0.002). Haematocrit level on admission (p < 0.002), injury to hospital admission interval (p < 0.012) and injury to first surgical debridement / amputation interval (p < 0.02) were all significantly related to incidence of wound infection. Multivariate analysis identified crushing amputation as an independent risk factor (p < 0.009) for traumatic amputation stump wound infection. CONCLUSION: The only independent predictor of traumatic extremity amputation stump wound infection is a crushing form of amputation; it should be accorded a high priority in interventions aimed at reducing infection rate.

Caracterización clínica de pacientes diabéticos con lesiones infecciosas en amputaciones de miembros inferiores / Caracterización clínica de pacientes diabéticos con lesiones infecciosas en amputaciones de miembros inferiores Clinical characterization of diabetes patients with infectious lesions in lower extremities amputations

Objetivo: determinar las características clínicas de los pacientes con infección en las amputaciones de miembros inferiores; identificar los gérmenes más frecuentes, así como los antibióticos más utilizados.Métodos: se realizó un estudio en 191 pacientes con lesiones sépticas en las amputaciones de miembros inferiores, atendidos en el Servicio de Angiología y Cirugía Vascular del Hospital General Docente Enrique Cabrera, en un período de 5 años. Se recogieron las siguientes variables: la edad, el sexo, el color de la piel; el nivel de amputación (menor o mayor: infra o supracondílea), el tipo y tiempo de evolución de la diabetes mellitus, la extensión de la lesión y el tiempo de evolución de esta, los gérmenes aislados (grampositivo, gramnegativo aerobios y anaerobios), así como los antibióticos más utilizados. Resultados: se encontró una mayor incidencia de lesiones sépticas en los hombres negros portadores de diabetes mellitus tipo 2 entre 50 y 69 años. La mayoría de los pacientes presentaron lesiones de no más de 20 cm2 y de hasta un mes de evolución. Fueron aislados gérmenes grampositivos, gramnegativos y anaerobios. Los gérmenes más frecuente fueron el Staphylococcus aureus (44,6 por ciento) y la Pseudomonas aeruginosa (22,2 por ciento). El antibiótico más utilizado fue la cefalosporina de tercera generación.Conclusiones: los pacientes negros, con diabetes mellitus tipo 2, del sexo masculino, y mayores de 50 años, tienen una alta probabilidad presentar infección en el muñón de amputación de los miembros inferiores, con un área de la lesión menor a 20 cm2(AU)

ABSTRACTObjective: to determine the clinical features of patients presenting with infections in the lower limb amputations; to identify the most frequent germs, and the most used antibiotics.Methods: a study was conducted in 191 patients presenting with septic injures in lower limb amputations seen at the Angiology and Vascular Surgery of the Enrique Cabrera Teaching and General Hospital during 5 years. The following variables were collected: age, sex, race, amputation level (minor or major: infra- of supracondylar) the type and the course of diabetes mellitus, isolated germs (Gram-positive, Gram-negative, aerobic and anaerobic) as well as the most used antibiotics. Results: there was high incidence of septic lesions in black men with diabetes mellitus type 2 aged 50 to 69 years. The majority of patients showed lesions not greater than 20 cm2 and up to a one month of evolution. Gram-positive, gram-negative and aerobe germs were isolated. The more frequent germs were Staphylococcus aureus (44.6 percent) and Pseudomonas aeruginosa (22.2 percent). The most used antibiotic was the third generation cephalosporin. Conclusions: the black patients with type diabetes mellitus, the male sex and aged over 50, are more likely to present infection in amputation stump of lower extremities, with over 20 cm2 injured area (AU)

Antibiotic prophylaxis for the prevention of infection after major limb amputation.

BACKGROUND: Major limb amputation is often required by patients with a limited capacity to tolerate post-operative complications. Amputation stump infection is common and may necessitate re-amputation, potentially exposing a vulnerable patient to further serious complications. Effective antibiotic strategies should be employed to reduce wound infection after major amputation. METHODS: Online databases were searched to identify studies regarding reduction in wound infection following major limb amputation. Only four randomised studies were identified comparing antibiotic prophylaxis with control; a further three evaluated the efficacy of specific antibiotics. Study design, end-points and outcome data were recorded. The data were too heterogeneous for formal meta-analysis. RESULTS: Prophylactic antibiotics significantly reduced rates of stump infection in all studies, and were associated with a reduced rate of re-amputation in one. Where investigated, the type of antibiotic did not affect rates of infection. In non-randomised studies, infection with methicillin resistant Staphylococcus aureus (MRSA) increased the risk of complications and post-operative death. CONCLUSION: It is agreed that prophylactic antibiotics are part of the standard of care for amputation surgery, and this is supported by limited, mostly historical-controlled data. Evolution of the bacterial threat means that future studies should assess the role and type of prophylaxis for patients with existing bacterial colonisation or infection.

Microbiology of amputation wound infection in a Nigerian setting.

OBJECTIVE: To identify the microbial pathogens responsible for amputation wound infections, their distribution and antibiotic-sensitivity patterns. METHOD: Consecutive patients who had limb amputations from April 2002 to March 2006 in an Nigerian hospital were recruited into this prospective observational study. The patients' demographic features, indications for amputation, microbiology of stump wound infections and the effects on length of hospital stay were reported. RESULTS: Fifty-seven patients (mean age 34.6 +/- 19.2 years) had amputations in 58 limbs. Trauma leading to limb gangrene following treatment by traditional bone setters was the most common indication for amputation (64%). Approximately 76% of the amputations were in the lower limbs. Wound infection occurred in 48% of the stumps, of which 71% had been amputated because of a trauma injury. Pseudomonas aeruginosa was the most commonly isolated pathogen (40%).There was a very low correlation between the aetiologic bacterial agents and the age of patient, source of referral, indication for amputation and level of amputation. Amputation wound infections significantly prolonged the patients' length of hospital stay (p=0.002). CONCLUSION: Amputation wound infection constitutes a serious morbidity in our practice. Most of the causes are preventable.

Skin problems in amputees: a descriptive study.

BACKGROUND: Skin problems are common in amputee patients. These problems may restrict the normal use of a prosthetic limb. We aimed to determine the range, incidence, causes and patterns of dermatological problems seen in a population of amputees. MATERIALS AND METHODS: One hundred and forty two amputees, were enrolled to the study. Age, sex, age at the time of amputation, level of amputation, reason for amputation, and types of prosthesis were noted. Dermatological problems were recorded. Stumps were swabbed for bacteriological and mycological examination, and patch tests were performed in suspected patients. RESULTS: Of these 142 patients, 139 (97.9%) were males and 3 (2.1%) were females. The reasons for amputation in the majority of the cases were wounds due to mine explosion (n = 114, 80.3%) and gunshot wounds (n = 19, 13.4%). The other reasons were arterial diseases, traffic accidents, congenital absence of the tibia, and vascular complication of diabetes. At least one skin problem was detected in 105 (73.9%) of 142 cases. Positive reactions to allergens have been detected in 28 (43%) of 65 cases with dermatitis. Bacterial infection was detected in 12 patients and fungal infection was detected in 4 patients. CONCLUSION: Our descriptive study shows that skin problems have a high prevalence, up to 73.9% in amputee patients. This high percentage indicates that dermatological problems are important in amputees. Early recognition and treatment of these problems can prevent the amputee's mental, social, and economic losses.

Pathogenic bacteria in an orthopaedic hospital in India.

BACKGROUND: The problem of changes in pathogenic microbiological flora and the emergence of bacterial resistance has created major problems in the management of orthopaedic diseases and fractures. Due to the use of implants for open reduction and internal fixation, which are foreign bodies to the body, orthopaedic trauma surgery is at grave risk of microbiological contamination and infection. METHODOLOGY: With new microbiological agents in vogue, we have conducted a retrospective study to determine the pattern of bacterial infection, sensitivity to various antimicrobial agents, and their relations to various orthopaedic illnesses and procedures. RESULTS: Gram negative (E. coli and Pseudomonas spp.) infections have emerged as the major threat (74.37%) in orthopaedic cases in contrast to Staphylococcus aureus (23.31%). These bacteria infected patients with open fractures (34.3%), spinal instrumentation with bedsores (23.31%), osteomyelitis of bone (24.42%) and guillotine amputation stumps (14.43%). CONCLUSION: Cefaperazone and ceftriaxone were found to be the most effective antibiotics against gram negative bacteria while cefaperazone was equally effective against S. aureus. Emerging resistance was found against amoxicillin, ampicillin and the aminoglycoside: amikacin.

Influencia de la presencia de Staphylococcus aureus resistente a la meticilina en las complicaciones postoperatorias y en el pronóstico de los pacientes con amputación de extremidad inferior / Methicillin resistant Staphylococcus aureus infection postoperatory complications and prognosis of patients with lower extremity amputatio

Fundamento y objetivo: El aumento de la incidencia y la gravedad de las infecciones es actualmente un importante problema terapéutico. Staphylococcus aureus resistente a la meticilina (SARM) se asocia a un aumento en la morbimortalidad cuando se compara con otras infecciones bacterianas; sin embargo, esta asociación no resulta clara debido a peores condiciones de comorbilidad en los pacientes con SARM. El objetivo de este estudio fue analizar las complicaciones postoperatorias y la mortalidad asociada a la presencia de SARM en pacientes con enfermedad vascular sometidos a amputación (mayor o menor) de la extremidad inferior. Pacientes y método: Pacientes consecutivos sometidos a la amputación de la extremidad inferior en nuestro Servicio durante el año 2004 que presentaron cultivo microbiológico positivo de la herida. Se comparó a los pacientes con SARM frente a los que tenían un germen diferente. Se evaluaron sus características generales, la indicación quirúrgica, la microbiología de la herida quirúrgica, la tasa de reamputación, la morbimortalidad y la estancia media. Resultados: Se amputó a un total de 117 pacientes (edad media 73 años, 68% varones) durante este período. De ellos, 82 mostraron cultivo positivo y en el 30% de éstos se aisló SARM. Ambos grupos fueron comparables y no registraron diferencias estadísticamente significativas en relación con la tasa de reamputación, morbimortalidad y estancia media. Conclusiones: La presencia de SARM no predispone a un riesgo adicional de reamputación ni a un incremento de las complicaciones postoperatorias. Hay que realizar la vigilancia de la herida, el desbridamiento quirúrgico y la antibioterapia racional en todos los pacientes amputados, con independencia de la flora bacteriana ai

Background and objective: Methicillin-resistant Staphylococcus aureus (MRSA) is associated with an increasing morbimortality when compared with other microorganisms. The aim of this study was to examine the complications and prognosis of the presence of MRSA in vascular patients with amputation of lower limbs. Patients and method: We included patients who had lower extremity amputation in our department in 2004 and displayed positive surgical wounds cultures. We compared patients with MRSA positive cultures with other microrganisms. We evaluated general characteristics, operative indications, surgical wounds microbiology, reamputations, morbimortality and mean time of stay in hospital. Results: 117 patients (median age 73, 68% male) underwent lower extremity amputation. 82 of them had positive cultures and MRSA were isolated in 30% cases. Two two groups were comparable and no statistical differences were found in relation to reamputation rate, morbimortality and mean time of stay in hospital. Conclusion: Presence of MRSA does not represent an additional risk of reamputation or an increase of postoperative complications. Careful wound surveillance, through wound debridement and optimal administration of antibiotics must be applied to all patients, regardless of the bacterial flora

MRSA in lower limb amputation and the role of antibiotic prophylaxis.

AIM: Methicillin Resistant Staphylococcus Aureus (MRSA) colonisation is reported in 3-20% of vascular patients. Many develop infective complications. MRSA is associated with poor prognosis. Aim of the study is to assess MRSA in lower limb amputation and efficacy of antibiotic prophylaxis. METHODS: Prospective study of lower limb amputation. MRSA screen and wound swabs were taken at operation. Antibiotic prophylaxis included teicoplanin (400 mg) 1 dose at operation. RESULTS: Twenty-five patients underwent 33 primary amputations. At operation 15 legs (45%) were colonised with MRSA and 18 legs (58%) had active wound infection; MRSA (4) and other (14). Following surgery 3 patients died. Twenty-two legs (76%) had primary healing. Infection developed in 7 stumps (24%), MRSA (5) and Pseudomonas (2). Stump infection increased time to wound healing (p<0.0001). MRSA stump infection increased revision amputation (p=0.009) and duration of hospital stay (p<0.0074). MRSA wound infection at operation increased the risk of MRSA stump infection (p=0.007). Non-MRSA wound infection at operation was not associated with a worse outcome. No patient colonised with MRSA at operation developed postoperative MRSA stump infection. CONCLUSIONS: MRSA is more prevalent that previously reported. MRSA infection has a poor prognosis. Prophylaxis may be effective for patients colonised with MRSA.

[Choice of surgical approach in the treatment of patients with deep frost bites]. / Vybor khirurgicheskoi taktiki pri lechenii bol'nykh s glubokimi otmorozheniiami.

Two main approaches to surgical treatment were studied in 114 patients with deep frost bites of the extremities. First - early necrectomy with subsequent local treatment of wounds and their surgical closure on the final stage. Second - long-term conservative treatment until formation of demarcation line and limitation of necrotic tissues with subsequent surgical treatment including their resection and simultaneous formation of the stump of the extremity. It is demonstrated that active surgical policy has significant advantages over expectant one as evident from reduce time of treatment and less number of postoperative pyonecrotic complications (21,7% vs 78,4%).

Use of tissue expansion in revision of unhealed below-knee amputation stumps.

When local tissue is insufficient for the revision of unhealed below-knee stumps tissue expansion offers an interesting alternative for local coverage. We used this method in seven patients (five men, two women; mean age 30 years) who had had below-knee amputations, six of them after injury to a healthy limb and one for purpura fulminans. Ten tissue expanders were inflated slowly and intermittently either weekly or twice weekly depending on the patients. The mean expansion period was 92 days. Mean hospital stay for the two operations was 5.8 (range 4-9) and 7.6 (range 6-10) days, respectively. Using subjective and objective criteria, functional outcome was excellent in five patients and good in one. Expansion failed in one because of infection. Expanded skin flaps allow good cover with a minimal scar area in appropriate cases, while preserving the skin sensitivity and length of the tibial shaft.

[Gas gangrene: A discussion of 3 cases and review of the literature]. / Gasgangreen. 'n Bespreking van 3 gevalle en literatuuroorsig.

Three patients with gas gangrene of the lower limbs are presented. In 2 of the 3 patients gas gangrene developed after lower-limb amputation, indications for amputation being atherosclerotic and diabetic gangrene. In the third patient associated leukaemia was diagnosed. All 3 patients presented with the typical clinical manifestations of gas gangrene. Clostridium perfringens was isolated from the affected leg in each patient. The current application of surgery and hyperbaric oxygen therapy in the treatment of gas gangrene is discussed.