Uncooperative Patient With an Infected Elbow Osteosynthesis: Alternative Management With Topical Sevoflurane.

INTRODUCTION: Treatment of an infected osteosynthesis is usually a complicated process, with its complexity increasing when unforeseen situations appear. Typically, the therapeutic management of such situations is challenging because they are not anticipated in the medical literature and physicians have to look for and adapt novel solutions to a specific patient condition. CASE REPORT: A 41-year-old, uncooperative, homeless man, presented to the emergency room with a left olecranon fracture. After planned surgery, the surgical wound became infected with a methicillin-sensitive Staphylococcus aureus because the treatment took place in an unhygienic outpatient hospital setting. The patient refused to remain in the hospital and also failed to complete antibiotic courses prescribed (culture-guided rifampicin 600 mg daily plus levofloxacin 500 mg daily). Instead of removing the osteosynthesis material, the infection was successfully treated by repeated applications of 5 mL of sevoflurane into the surgical wound. Subsequently, wound healing was achieved with a combination of a brief course of negative pressure wound therapy (NPWT), use of silver-impregnated dressings, and irrigation of the wound with sevoflurane. Sevoflurane also provided topical analgesic to ameliorate the pain caused by removing the NPWT sponge. Interestingly, despite extremely poor compliance by the patient to all standard treatment regimens, and the clinical decision to retain the implant, the infection was resolved, and the fracture was consolidated. CONCLUSIONS: Local application of sevoflurane in the wound bed appears to exhibit analgesic, antimicrobial, and positive healing effects. It could be a promising alternative treatment to be included as a therapeutic option for wound care.

Spinal Epidural Hematoma Related to Vertebral Fracture in an Atypical Rigid Diffuse Idiopathic Skeletal Hyperostosis: A Case Report.

INTRODUCTION: Spinal epidural hematoma (SEH) is a rare disease that causes cord compression and neurologic deficit. Spontaneous SEH is related to minor trauma, bleeding disorders, and anticoagulant medications. Posttraumatic SEH has been associated with low-energy spine hyperextension injuries in patients with ankylosing spinal disorders such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis (DISH). A variant named atypical DISH-like with SEH is reported. OBJECTIVE: To describe the management, diagnosis, and treatment of an unusual SEH case in a patient causing delayed neurologic deficit with rigid atypical DISH-like spine. CASE DESCRIPTION: An elderly woman with prior antiplatelet therapy presented with delayed neurological deficit suffering trauma after falling. Computed tomography (CT) imaging studies reveal hyperextension fracture pattern and signs mimic DISH missed on standard X-ray images. Magnetic resonance (MR) study demonstrates posterior epidural mass compatible with SEH in thoracic spine with cord compression. Using a midline posterior approach, an urgent intervention and a left multiple partial unilateral decompressive laminectomy at T4-T7 and a long instrumented fusion at T3-T9 were performed for achieving spinal stability and neurological improvement, both of which were observed. CONCLUSION: Patients with rigid spine who sustain low-energy injuries may be prone to have a fracture and epidural hematoma, especially if they take anticoagulant medications. Imaging studies including MR and CT scans should be reviewed carefully to rule out any occult fracture. Urgent or early surgical hematoma drainage and instrumented fusion must be performed to achieve stability and functional recovery.