Extensive Debridement Research Articles

Necrotizing Fasciitis Caused By Staphylococcus Haemolyticus and Escherichia Coli: A Rare Case Report

Necrotizing fasciitis (NF) is a severe, life-threatening, and rapidly progressive soft tissue infection. It is characterized by myonecrosis and necrotizing cellulitis, which requires expeditious surgical debridement. We report a rare case of necrotizing fasciitis caused by Staphylococcus haemolyticus and Escherichia coli in 21-years-old male patient with history of surgery and using a traditional medication at the right thigh. The patient is underwent an extensive debridement, OREF, and treated with prompt antibiotics in the intensive care unit.

The Utility of Flap Coverage for Limb Salvage in Patients With Severe Prosthetic Joint Infections of the Knee Requiring Implant Exchange.

Prosthetic joint infection (PJI) is a challenging complication of knee arthroplasty, which can require amputation in severe cases. This study analyzes the utility of flap reconstruction in PJIs requiring hardware removal and extensive soft tissue debridement. This was a retrospective analysis of patients who were treated according to a multistage extremity salvage protocol between 2018 and 2022. The protocol involved at least 3 planned surgeries including (1) hardware removal with antibiotic spacer placement and soft tissue debridement, (2) spacer exchange with flap coverage, and (3) hardware reimplantation with simultaneous or delayed extensor mechanism reconstruction. All patients had large periprosthetic tissue defects that would necessitate an amputation if not reconstructed. Primary outcomes were extremity salvage and successful defect coverage. Fifty-two patients (25 female) underwent 62 reconstructions (52 primary, 10 salvage). Flap techniques included pedicled muscular (n = 32), fasciocutaneous (n = 4), combined muscular and fasciocutaneous (n = 2), and free flaps (n = 24). Overall rate of successful defect coverage was 95% (98% in primary and 80% in salvage reconstructions). At a median follow-up of 11 months, 41 patients completed the treatment protocol with a 68% (n = 28) extremity salvage rate (reimplantation arthroplasty, n = 15; permanent knee fusion, n = 13). On the multivariate model including demographic factors, defect size, and flap type, no single factor independently predicted limb salvage. Alongside intensive orthopedic surgical treatment, flap coverage may aid in extremity salvage in severe knee PJIs by reestablishing healthy soft tissue coverage and allowing reimplantation arthroplasty. We recommend a multispecialty approach including plastic surgeons for this challenging condition.

Extensive skin necrosis following total hip arthroplasty performed through the direct anterior approach

BackgroundTotal hip arthroplasty is a widely performed surgical procedure, which enables patients to regain mobility, alleviates pain, and improves overall quality of life. Periarticular multimodal drug infiltration (PAI) is increasingly being used as an effective postoperative pain management, decreasing the systemic consumption of opioids. Extensive postoperative skin necrosis without a deep joint infection as a complication of total hip arthroplasty with PAI has not yet been described.Case presentationA 71-year-old patient who underwent total hip arthroplasty of the right hip for primary osteoarthritis through the Direct Anterior Approach presented postoperatively a large area of necrotic skin at the incision. Joint infection was excluded. An extensive debridement was performed and the tissue defect was reconstructed by a pedicled anterolateral thigh flap. The skin maintained a satisfactory appearance at 1 year postoperatively, and the hip was pain-free with restored ranges of motion. The patient was able to walk with no support and without limitation.ConclusionWe address the possible risk factors, discuss the use of epinephrine in PAI and explore possible treatment options for such a complication.

A case of necrotizing fasciitis developing after cesarean section

Necrotizing fasciitis (NF) is a rare condition that is observed in obstetric and gynecological practices. It is a rapidly progressive and often fatal complication. Failure to obtain an early diagnosis and delay in initiating appropriate treatment can lead to significant morbidity and mortality. Our case was 25 years old, and she was in her first pregnancy. The patient had no systemic disease or history of previous surgery. Our patient’s baby was delivered by cesarean section with an indication of emergency fetal distress. During the cesarean section, it was observed that the amniotic fluid contained very dark meconium. No complications occurred during the cesarean section. Our patient presented with complaints of severe pain, bullae, and hyperemia at the level of the incision line one week later. In her vital findings, fever was 39.3 ºC, blood pressure was 90/60 mmHg, and heart rate was 110 /min. In laboratory tests, white blood cell count was 25,280 /mm3, C-reactive protein (CRP) was 431 mg/dL, and sedimentation was 100 mm/hour. On the ultrasonographic examination, air, significant edema, and thickening were observed in the incision line, skin, and subcutaneous tissues. On the computed tomography scan, thickening of the skin and subcutaneous tissues, fluid locations, and areas of air densities were observed over a wide area extending to the level of the thoracic 10th and 11th vertebrae superiorly and to the mons pubis inferiorly. Based on these findings, the patient was diagnosed with NF. After broad-spectrum antibiotic therapy and fluid-electrolyte support, extensive surgical debridement was performed under emergency conditions. Before applying the skin graft, vacuum-assisted wound closure was performed, and a very good response was obtained. The patient, whose pathology result was compatible with necrotizing fasciitis, was discharged on the 20th post-operative day. In this case, we aimed to present a case of NF after cesarean section.

A NOVEL TECHNIQUE FOR MANAGEMENT OF A CRITICALLY-SIZED BONE DEFECT IN THE OPEN PROXIMAL TIBIAL FRACTURE: EMPLOYING THE CAPANNA TECHNIQUE IN TRAUMA

A NOVEL TECHNIQUE FOR MANAGEMENT OF A CRITICALLY-SIZED BONE DEFECT IN THE OPEN PROXIMAL TIBIAL FRACTURE: EMPLOYING THE CAPANNA TECHNIQUE IN TRAUMA

THE MODIFIED BALANCED CABLE TRANSPORT SYSTEM: A CASE SERIES UTILIZING A NOVEL TECHNIQUE FOR BONE TRANSPORT IN THE TIBIA

IntroductionBone transport and distraction osteogenesis have been shown to be an effective treatment for significant bone loss in the tibia. However, traditional methods of transport are often associated with high patient morbidity due to the pain and scarring caused by the external frame components transporting the bone segment. Prolonged time in frame is also common as large sections of regenerate need significant time to consolidate before the external fixator can be removed. Cable transport has had a resurgence with the description of the balanced cable transport system. However, this introduced increasingly complex surgery along with the risk of cable weave fracture. This method also requires frame removal and intramedullary nailing, with a modified nail, to be performed in a single sitting, which raised concern regarding potential deep infection. An alternative to this method is our modified cable transport system with early intramedullary nail fixation. Internal cables reduce pain and scarring of the skin during transport and allow for well controlled transport segment alignment. The cable system is facilitated through an endosteal plate that reduces complications and removes the need for a single-stage frame removal and nailing procedure. Instead, the patients can undergo a pin-site holiday before nailing is performed using a standard tibial nail. Early intramedullary nailing once transport is complete reduces overall time in frame and allows full weight bearing as the regenerate consolidates. We present our case series of patients treated with this modified cable transport technique.MethodolgyPatients were identified through our limb reconstruction database and clinic notes, operative records and radiographs were reviewed. Since 2019, 8 patients (5 male : 3 female) have undergone bone transport via our modified balanced cable transport technique. Average age at time of transport was 39.6 years (range 21–58 years) with all surgeries performed by the senior author. Patients were followed up until radiological union. We recorded the length of bone transport achieved as well as any problems, obstacles or complications encountered during treatment. We evaluated outcomes of full weight bearing and return to function as well as radiological union.Results4/8 bone defects were due to severely comminuted open fractures requiring extensive debridement. All other cases had previously undergone fixation of tibial fractures which had failed due to infection, soft tissue defects or mal-reduction. The mean tibial defect treated with bone transport was 41mm (range 37–78mm). From the start of cable transport to removal of external fixator our patients spent an average of 201 days in frame. 7/8 patients underwent a 2-week pin-site holiday and subsequent insertion of intramedullary nail 2 weeks later. One patient had sufficient bony union to not require further internal fixation after frame removal. 10 problems were identified during treatment. These included 4 superficial infections treated with antibiotics alone and 5 issues with hardware, which could be resolved in the outpatient clinic. 1 patient had their rate of transport slowed due to poor skin quality over the site of the regenerate. 4 obstacles resulted in a return to theatre for additional procedures. 1 patient had a re-do corticotomy and 3 had revision of their internal cable transport constructs due to decoupling or screw pull out. 1 patient had residual ankle joint equinus following treatment which required an Achilles tendon lengthening procedure. Another patient underwent treatment for DVT. There were no deep infections identified and no significant limb length discrepancies or deformities.ConclusionsOverall, we have found that our modified balanced cable transport technique has allowed for successful bone transport for significant defects of the tibia. We have learned from the obstacles encountered during this case series to avoid unnecessary return trips to theatre for our future transport patients. The internal cable system allowed all patients to complete their planned transport without excessive pin tract scarring or pain. Early conversion to intramedullary nail allowed for a shorter time in frame with continued full weight bearing as the regenerate consolidated. No metalwork failure or deformity has occurred in relation to docking site union. All patients have made a good return to pre-operative function during their follow-up period with no evidence of late complications such as deep infection.

Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study.

A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients. This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted. The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%). Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

Necrotizing Fasciitis of the Abdominal Wall Secondary to Complicated Appendicitis: A Case Report

Acute appendicitis is one of the most common surgical emergencies worldwide. Many complications can occur secondary to complicated appendicitis including abscess formation, gangrene, sepsis, and perforation, rarely, leading to abdominal wall necrotizing fasciitis. The incidence of necrotizing fasciitis as a complication of ruptured appendicitis is extremely uncommon. The formation of an enterocutaneous fistula leading to this complication further emphasizes the rarity of such occurrence with few cases reported in the literature. Herein, we present a case of abdominal wall necrotizing fasciitis in a 72-year-old female presenting to the local emergency room with complaints of severe suprapubic abdominal pain associated with abdominal distension and acute onset foul-smelling drainage. Physical exam was significant for suprapubic and right lower quadrant abdominal tenderness with associated large indurated tender lesion and purulent weeping with large ecchymosis. Abdominal computed tomography (CT) revealed extensive subcutaneous emphysema, a large cavity with layering fluid extending into the peritoneal space, and a possible fistula formation between the intra-abdominal cavity and subcutaneous tissue. Following the diagnosis of probable necrotizing fasciitis secondary to fistula formation, the patient underwent emergent exploratory laparotomy and extensive debridement of necrotic tissue. In this report, we take the opportunity to highlight the importance of promptly recognizing and treating this uncommon complication and maintaining a high level of suspicion to prevent life-threatening consequences.

A Case Series on COVID-19 Associated Mucormycosis (CAM): Experience from a Tertiary Care Centre in India

Aim: During the second wave of the COVID 19 pandemic, a life threatening fungal infection, mucormycosis have been detected in patients post COVID 19 disease. Commonly known as the ‘black fungus’ can causes tissue necrosis, inflammation and necrosis of the head and neck regions, paranasal sinuses, facial bones, orbits and it can also cause intracranial spread. In the current study we describe a series of cases of COVID 19 associated mucormycosis (CAM), the clinical presentations, risk factors, diagnosis, management and follow up experience from a tertiary care centre in India.
 Methods: This is a retrospective observational study conducted over a period of one year (April 2021 to April 2022) at our tertiary care centre. The diagnosis of COVID 19 was done by RT PCR (reverse transcription-polymerase chain reaction). The diagnosis of Mucormycosis was done by Histopathology and fungal cultures. The demographic details of the patients were retrieved from the medical records.
 Results: In the present study we report four cases of Rhino-orbital-cerebral Mucormycosis, three cases of Rhino-orbital Mucormycosis, two cases of Pulmonary Mucormycosis and one case of Disseminated Mucormycosis. All the patients had undergone extensive surgical debridement and received Liposomal Amphotericin B as initial antifungal medication and Posaconazole or Isavuconazole as step down therapy. Six patients responded to treatment while four patients did not have a favorable outcome and succumbed to the illness. 
 Conclusion: Mucormycosis is a deadly disease with high mortality and morbidity if not diagnosed and treated at an early stage. Factors like poor control of blood sugars, inadvertent use of corticosteroids, immune dysfunction due to COVID 19 can result in poor outcome of the disease despite aggressive treatment interventions.

512 Mean Arterial Pressure, Morbidity, and Mortality Associated with Necrotizing Soft Tissue Infection

Abstract Introduction Adequate mean arterial pressure (MAP), or the average pressure in arteries during one cardiac cycle, plays an important role in ensuring adequate blood flow and perfusion in critically ill patients. MAP values of 65 mmHg or greater have been widely regarded as the ideal value for hospitalized patients in the past, especially those suffering from septic shock. Necrotizing soft tissue infections (NSTIs) present a unique challenge due to their rapid progression and high mortality, which creates the need for specific diagnostic and treatment guidelines that differ from those directed toward the care of sepsis secondary to other causes. Further research is still required to better understand the complex interactions between mean arterial pressure and morbidity and mortality among those with necrotizing soft tissue infections. Methods Data was collected from a retrospective cohort study of 50 adult patients hospitalized with an NSTI from 2015-2021. MAP ranges in the first 48 hours of admission were sorted into four categories: under 60 mmHg, 60-69 mmHg, 70-79 mmHg, and above 79 mmHg. We investigated outcomes relating to increased morbidity, including need for repeat debridement, need for dialysis, or development of acute kidney injury. Statistical logistic regressions were fitted to model the outcome as a function of the available pool of predictors: demographic variables, co-morbidities, and hemodynamic variables, such as MAP and use of vasopressors. Results In this small study, we found no significant association between time spent in different MAP groups or vasopressor volumes on the need for repeat debridement for NSTI patients or overall patient morbidity and mortality (p=0.1742). Patients who were significantly more likely to need a repeat debridement included those with previously diagnosed diabetes and hypertension (p=0.0485 and 0.0252, respectively). Conclusions NSTI patients can tolerate mild fluctuations in MAP without these pressures significantly impacting their need for repeat debridement or other sources of morbidity. However, patients who are hypertensive at baseline or diabetic are significantly more likely to require a second surgery, necessitating a more extensive primary debridement. Applicability of Research to Practice Patients hospitalized for NSTI can fluctuate at pressures below the established MAP goal of 65 mmHg without a significant need for pressors. Those with a history of hypertension or diabetes should be followed closely for possible spread of infection after primary surgery.

Lights, fluorescence, action-Influencing wound treatment plans including debridement of bacteria and biofilms.

High bacterial loads within chronic wounds increase the risk of infection and complication. Detection and localization of bacterial loads through point-of-care fluorescence (FL) imaging can objectively inform and support bacterial treatment decisions. This single time-point, retrospective analysis describes the treatment decisions made on 1000 chronic wounds (DFUs, VLUs, PIs, surgical wounds, burns, and others) at 211 wound-care facilities across 36 US states. Clinical assessment findings and treatment plans derived from them, as well as subsequent FL-imaging (MolecuLight®) findings and any associated treatment plan changes, were recorded for analysis. FL signals indicating elevated bacterial loads were observed in 701 wounds (70.8%), while only 293 (29.6%) showed signs/symptoms of infection. After FL-imaging, treatment plans changed in 528 wounds as follows: more extensive debridement (18.7%), more extensive hygiene (17.2%), FL-targeted debridement (17.2%), new topical therapies (10.1%), new systemic antibiotic prescriptions (9.0%), FL-guided sampling for microbiological analysis (6.2%), and changes in dressing selection (3.2%). These real-world findings of asymptomatic bacterial load/biofilm incidence, and of the frequent treatment plan changes post-imaging, are in accordance with clinical trial findings using this technology. These data, from a range of wound types, facilities, and clinician skill sets, suggest that point-of-care FL-imaging information improves bacterial infection management.

TREATMENT OF VERY LARGE TRAUMATIC BONE DEFECTS WITH A BIODEGRADABLE POLYCAPROLACTONE-TRICALCIUM PHOSPHATE 3D-PRINTED SCAFFOLD: A REVIEW OF THREE CLINICAL CASES

The need for an artificial scaffold in very large bone defects is clear, not only to limit the risk of graft harvesting, but also to improve clinical success. The use of custom osteoconductive scaffolds made from biodegradable polyester and ceramics can be a valuable patient friendly option, especially in case of a concomitant infection.Multiple types of scaffolds for the Masquelet procedure (MP) are available, however these frequently demonstrate central graft involution when defects exceed a certain size and the complication rates remains high. This paper describes three infected tibial defect nonunions with a segmental defect over ten centimeters long treated with a customized 3D printed polycaprolactone-tricalcium phosphate (PCL-TCP) cage in combination with biological adjuncts.Three male patients, between the age of 37 and 47, were treated for an infected tibial defect nonunion after sustaining Gustilo grade 3 open fractures. All had a segmental midshaft bone defect of more than ten centimeters (range 11–15cm). First stage MPs consisted of extensive debridement, external fixation and placement of anterior lateral thigh flaps (ALT). Positive cultures were obtained from all patients during this first stage, that were treated with specific systemic antibiotics during 12 weeks. The second stage MP was carried out at least two months after the first stage. CT scans were obtained after the first stage to manufacture defect-specific cages. In the final procedure a custom 3D printed PCL-TCP cage (Osteopore, Singapore) was placed in the defect in combination with biological adjuncts (BMAC, RIA derived autograft, iFactor and BioActive Glass). Bridging of the defect, assessed at six months by CT, was achieved in all cases. SPECT-scans 6 months post-operatively demonstrated active bone regeneration, also involving the central part of the scaffold. All three patients regained function and reported less pain with full weight-bearing.This case report shows that 3D printed PCL-TCP cages in combination with biological adjuncts is a novel addition to the surgical treatment of very large bone defects in (infected) posttraumatic nonunion of the tibia. This combination could overcome some of the current drawbacks in this challenging indication.

A Rare Case of a Second-Degree Chemical Burn due to Successive Contacts of Acidic Wart Removal Solution and Paint Solution

Introduction: Chemical burns are an uncommon form of burn injury, accounting for 2.1% to 6.5% of all burn centre admissions. We presented one rare case of a second degree chemical burn due to successive contacts of acidic wart removal solution and paint mixture solution. Case: A 38-year-old male with chemical burn on both feet due to reckless usage of a self-purchased wart removal solution, and accidental contact with paint mixture solution. Our surgeon author diagnosed a superficial partial thickness (second-degree) chemical burn on this patient, and performed surgical debridement followed by hyaluronic-enhanced silver sulfadiazine topical dressing to provide antimicrobial protection to the wound and topical petrolatum-based ointment to maintain moist environment for the wound and the periwound. Our team also gave Ceftaroline, a cephalosporin for serious infections of the skin and tissues below the skin, intravenously. Result: One day after the surgical procedure, the wound dimensions were slightly more extensive than the initial size due to extensive debridement and necrotomy. All wounds produced no or minimal exudate, showed no slough nor pus inside the granulation area, and no swelling nor maceration in the periwound area. The fifth day after the surgical procedure, the wound on the lateral side of patient’s right foot was almost completely covered by epithelialization. The wound on the sole of patient’s right foot was about 70-80% covered by epithelialization, and the wound on the sole of patient’s left foot was also about 70% covered by epithelialization. Discussion: Topical solution for wart removal consists of many chemicals agents (i.e. salicylic acid and acetic acid) and its application should strongly be under guidance and monitoring by physician due to its potential to harm human bodies and trigger chemical burn injury in varying degrees. Paint mixture is usually safe, risks no or minimal harms when in contact with skin, however it can provide a more difficult scenario and consequently a more extensive cleansing during the wound debridement procedure. Immediate decontamination and adequate dilution through massive irrigation is a major determinant of burn severity after chemical injury. Application of 1% silver sulfadiazine topical antibiotics enhanced with 0.2% hyaluronic acid for moisturizer displayed significant improvement for the burn wound healing. Conclusion: Knowing exactly what type of chemical substance in contact with the skin and tissues that caused the chemical burn injury is as equally important as the comprehensive management itself. For acidic burn injuries, a proper and sometimes extensive necrotomy procedure is mandatory to provide a good tissue regeneration.

BONE DEFECT HEALING USING THE INDUCED MEMBRANE TECHNIQUE AFTER CHRONICALLY INFECTED NONUNION IN A NOVEL RABBIT MODEL

In chronically infected fracture non-unions, treatment requires extensive debridement to remove necrotic and infected bone, often resulting in large defects requiring elaborate and prolonged bone reconstruction. One approach includes the induced membrane technique (IMT), although the differences in outcome between infected and non-infectious aetiologies remain unclear. Here we present a new rabbit humerus model for IMT secondary to infection, and, furthermore, we compare bone healing in rabbits with a chronically infected non-union compared to non-infected equivalents.A 5 mm defect was created in the humerus and filled with a polymethylmethacrylate (PMMA) spacer or left empty (n=6 per group). After 3 weeks, the PMMA spacer was replaced with a beta-tricalcium phosphate (chronOs, Synthes) scaffold, which was placed within the induced membrane and observed for a further 10 weeks. The same protocol was followed for the infected group, except that four week prior to treatment, the wound was inoculated with Staphylococcus aureus (4×106 CFU/animal) and the PMMA spacer was loaded with gentamicin, and systemic therapy was applied for 4 weeks prior to chronOs application.All the animals from the infected group were culture positive during the first revision surgery (mean 3×105 CFU/animal, n= 12), while at the second revision, after antibiotic therapy, all the animals were culture negative. The differences in bone healing between the non-infected and infected groups were evaluated by radiography and histology. The initially infected animals showed impaired bone healing at euthanasia, and some remnants of bacteria in histology. The non-infected animals reached bone bridging in both empty and chronOs conditions.We developed a preclinical in vivo model to investigate how bacterial infection influence bone healing in large defects with the future aim to explore new treatment concepts of infected non-union.

Management of Hardware-Exposed Soft Tissue Defects Using Dermal Substitutes and Negative Pressure Wound Therapy.

Reconstruction of complex injuries of the extremities with full-thickness wounds is a challenging but important task. If primary closure is not feasible, more complex procedures are required, such as split-thickness skin graft or flap surgery. Recently, several studies have shown good results when combined with negative pressure wound therapy (NPWT) and artificial dermal replacement therapy after extensive surgical debridement and NPWT administration for severe complex wounds accompanied by tendon or bone exposure. However, flap surgery remains the only treatment for wounds in which the hardware is exposed after fracture fixation. Therefore, in this study, we attempted to prove the usefulness of the combined treatment using artificial dermal substitutes (MatriDerm) and NPWT by focusing on hardware-exposed wounds, which have not been studied before. From 2019 to 2021, we treated with our wound management procedure 14 patients with hardware-exposing wounds after internal fixation using plates, out of 48 patients with full-thickness posttraumatic skin defect. Before skin grafting, after surgical debridement and thorough washouts, MatriDerm was placed and NPWT was applied over it. This staged approach aimed at conditioning even the most complex wounds so that closure with MatriDerm-augmented skin grafting would become possible in a one-step approach. We stratified the duration of treatment and number of replacements in NPWT according to the type of injury. Cases with open fractures required significantly longer NPWT than those with closed fractures (P = 0.01); however, there was no significant difference between the Gustilo-Anderson classification within open fractures (P > 0.05). Patients with open fractures underwent a mean of 6.6 changes while those with closed fractures underwent 2.5 (P = 0.002) until the final wound closure with MatriDerm-augmented skin grafting was performed. There was no significant difference in the treatment period based on the location and size of the wound, and there was no significant difference in the number of NPWT replacements. Skin grafting was successful in all 14 patients. This study revealed that NPWT and artificial dermis-augmented skin grafting after combined treatment with NPWT and artificial dermis were sufficiently useful for hardware-exposed wounds, where flap surgery has been considered the only treatment to date.

Outcomes of chlorhexidine lavagewithout capsulectomy versuscomplete capsulectomy after lead extraction for the treatment of cardiac implantable electronicdevice infection.

Capsulectomy is recommended in patients with cardiac implantable electronic device (CIED) infection after transvenous lead extraction (TLE) but is time-consuming and requires extensive tissue debridement. In this study, we describe the outcomes of chlorhexidine gluconate (CHG) lavage in lieu of capsulectomy for the treatment of CIED infections. This retrospective study included patients who underwent TLE for CIED-related infections in two institutions in Colombia. In the capsulectomy group, complete capsulectomy was performed after hardware removal. In the CHG group, exhaustive lavage of the generator pocket with 20 cc of CHG at2%followed by irrigation with approximately 500 cc of normalsaline(0.9%sodiumchloride) was performed. The primary outcomes included reinfection and hematoma formation in the generator pocket. Secondary outcomes included the occurrence of any adverse reaction to chlorhexidine, the need for reintervention, infection-related mortality, and total procedural time. A total of 102 patients (mean age 67.2 ± 13 years, 32.4% female) underwent CIED extraction with either total capsulectomy (n = 54) or CHG (n = 48) lavage. Hematoma formation was significantly higher in the capsulectomy group versus the CHG group (13% vs. 0%, p = .014), with no significant differences in the reinfection rate. Capsulectomy was associated with longer procedural time (133.7 ± 78.5 vs. 89.9 ± 51.8 min, p = .002). No adverse reactions to CHG were found. Four patients (4.3%) died from worsening sepsis: three in the capsulectomy group and one in the CHG group (p = .346). In patients with CIED infections, the use of CHG without capsulectomy resulted in a lower risk of hematoma formation and shorter procedural times without an increased risk of reinfection or adverse events associated with CHG use.

Wear debris in metal-on-metal bearings and modular junctions : What have we learned from the last decades?

Metal-on-metal (MoM) bearing hip arthroplasty saw increasing utilization and peaked in the 1990s and early 2000s. Although the linear and volumetric wear rate for aMoM bearings was lower than its polyethylene counterpart, metal ion particles were found to be approximately 10 × smaller and 500 × higher in quantity compared to polyethylene wear debris. Research into these articulations have demonstrated their relationship to the formation of lymphocyte-mediated adverse local tissue reactions. The work-up for metal particle-associated conditions (metallosis) includes athorough patient history and physical examination, blood laboratory studies for metal ion concentrations, and advanced imaging studies including magnetic resonance imaging (MRI). The treatment of metallosis and adverse local tissue reactions ranges from close serial observation to extensive debridement and full revision of arthroplasty components, when indicated.

Revision total hip arthroplasty by a ceramic bearing surface after a third- and fourth-generation ceramic head or liner fracture.

Although rare, fractures of ceramic components are difficult to revise, mainly due to the presence of residual ceramic debris that can cause catastrophic wear of the replacement components. Modern ceramic-on-ceramic bearings are suggested to improve outcomes of revision total hip arthroplasty (THA) for ceramic fractures. However, there are few published reports of mid-term outcomes of revision THA using ceramic-on-ceramic bearings. We evaluated clinical and radiographic outcomes of 10 patients who received ceramic-on-ceramic bearings during revision THA for ceramic fractures. All patients but one received fourth-generation Biolox Delta bearings. Clinical evaluation was performed using the Harris hip score at latest follow-up, and all patients received a radiographic evaluation to analyze the fixation of the acetabular cup and of the femoral stem. Osteolytic lesions and the presence of ceramic debris were noted. After a mean follow-up of 8.0 years, there were no complications or implant failures, and all patients reported satisfaction with their implant. The average Harris hip score was 90.6. There was neither osteolysis nor loosening, but despite our extensive synovial debridement, ceramic debris was noted in the radiographs of five patients (50%). We report excellent mid-term outcomes, with no implant failures after eight years despite ceramic debris being found in a significant proportion of patients. We conclude that modern ceramic-on-ceramic bearings are an advantageous option for the revision of THA due to the fracture of initial ceramic components.

Labium superius oris mucormycosis: an enigma

Mucormycosis is an aggressive opportunistic fungal infection affecting immunocompromised patients. It has six manifestations: rhinocerebral, pulmonary, cutaneous, gastrointestinal, disseminated and localized infection. However, isolated mucormycosis of upper lip (labium superius oris) without any bony invasion has not been reported in literature to the best of our knowledge. Hence this poses a diagnostic challenge. A 50-year-old male came with left sided nasal pain and left sided nasal obstruction associated with very mild uniform swelling of upper lip of 24 months duration. He underwent FESS in a local hospital and was misdiagnosed as granulomatous origin probably Tuberculosis. Even on ATT the symptoms didn’t subside and hence presented to our hospital. On incisional biopsy deep fungal infection probably mucor was reported and he was put on tab Posaconazole 300 mg OD. On recurrent upper lip swelling, excision biopsy was done. HPE was reported as fibrocollagenous stroma interspersed by multiple non-caseating epitheloid granulomas with plenty of foreign body type of giant cells. PAS showed broad aseptate acute angled hyphal forms suggestive of mucor. The follow up clinical presentation of the patient was very satisfactory with complete regression of upper lip swelling and no damage to surrounding structures. The case report highlights the existence of localized form of mucormycosis without bony necrosis in immunocompetent patients which require minimal surgical intervention along with oral medical therapy rather than extensive debridement.

Rhinocerebral mucormycosis (RCM): To study the clinical spectrum and outcome of 61 cases of RCM managed at a tertiary care center in India.

Mucormycosis is a life-threatening infection of the paranasal sinuses and nasal cavities that can easily spread to the orbit and the brain. It is caused by fungi of the family Mucoraceae. We present a case series of 61 patients diagnosed and treated for rhinocerebral mucormycosis (RCM) at a single tertiary health care center. After obtaining ethical clearance, all patient files with a final diagnosis of RCM were thoroughly analyzed in departmental records and a master chart was prepared. The study evaluated the etiology, clinical spectrum, diagnosis, management, complications, and outcome at 3 months of RCM cases. About 93.4% of the RCM cases were diabetic and an equal number had a past history of COVID infection. About 85.2% had received steroids for the treatment of coronavirus disease 2019 infection. The most common presentation of RCM was temporal lobe abscess (25.7%) followed by frontal lobe abscess (16.6%). At 3 months post-diagnosis, mortality in our study was 42.6%. About 26.2 % of the RCM cases had no disease, 23% had a static disease, and 8.2% had progressive disease at the end of 3 months. We report the largest single-center case series of RCM, comprising 61 patients. This case series underscores the importance of the early diagnosis and prompt treatment for a better prognosis for this dreadful disease. The three pillars of treatment for RCM cases include reversal of the immunosuppressive state, administration of antifungal drugs, and extensive surgical debridement. In spite of all this, mortality remains high.