Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca
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Acta Chir Orthop Traumatol Cech · Jan 2016
Case Reports[Pyoderma Gangrenosum Mimicking Necrotising Fasciitis after Rotator Cuff Reconstruction].
Gangrenous pyoderma is a rare complication of surgical treatment mimicking bacterial necrotizing fasciitis. The characteristic symptoms include a pre-existing immune disorder, negative results of the relevant microbiological examinations, no response to any antibiotic therapy, and deteriorating of the condition after radical debridement. Another typical feature is a discrepancy between an ominous appearance of the wound accompanied by leucocytosis and an elevated CRP level, and the patient s good general condition with low-grade fever and no signs of sepsis. The case of a 68-year-old man who underwent an elective open reconstruction of rotator cuff tears of the left shoulder is presented. The surgery was complicated with pyoderma gangrenosum that was first treated unsuccessfully by repeated revision surgery and broad-spectrum antibiotic therapy. The patient was ultimately cured with corticosteroids. The sequellae included limited motion of the shoulder joint and extensive destruction and scarring of the adjacent soft tissue. ⋯ gangrenous pyoderma, necrotizing fasciitis, corticosteroids.
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Acta Chir Orthop Traumatol Cech · Jan 2016
Comparative Study[Effect of Negative Pressure Wound Therapy on Infectious Complications in Grade III Open Fractures].
PURPOSE OF THE STUDY Grade III open fractures are associated with infectious complications in 25-66% of injuries. Negative pressure wound therapy (NPWT) applied to an injured soft tissue coverage provides an impermeable barrier between the injured structures and the external environment, in addition to early secretion draining and a positive effect on the site of application. All this also prevents secondary bacterial contamination. The objective of the study was to compare the results of treatment methods in view of infectious complications in patients with soft tissue injury in grade-III open fractures managed either by NPWT and primary closure or by covering with combined dressing fabric (COM) in combination with continual wound lavage. MATERIAL AND METHODS This retrospective study comprised 77 patients with 80 grade III open fractures treated in the years 2008-2012; of these, 39 patients with 41 fractures met the inclusion criteria and were finally evaluated. The patients were divided into two groups. The control group included 19 patients with 20 fractures treated by the standard surgical procedure using stabilisation with an external fixator or intramedullary nail, thorough soft tissue debridement, continual wound lavage and suture of skin lesions or using a primary coverage of the defect with COM. The trial group consisted of 20 patients with 21 fractures treated according to the same principle, but NPWT was applied to injured soft tissue coverage first and skin suture or any other type of skin defect coverage was carried out when the healing process was good and bacteriological findings were negative. The results of both methods were evaluated based on the following criteria: development of superficial or deep infection in the wound, interval to negative bacteriological findings and osteomyelitis rate. The results were analysed by Fisher's exact test and the Man Whitney U test. RESULTS Infectious complications were recorded in a total of 15 (37%) fractures: 11 (55%) in the control group and four (19.1%) in the trial group (p = 0.025). Recurrent infection was observed in five control group fractures (25%) and in none of the trial group fractures (p = 0.021). Osteomyelitis was found only in two control group fractures. The average interval before negative bacteriological results were obtained was 22 days in the control group and 12 days in the trial group (p = 0.001). DISCUSSION The NPWT use as a temporary coverage of soft tissue defects in open fractures results in a significant reduction of infectious complications, as shown by many relevant studies including this study. In comparison with Gopal's "fix and flap" concept, the NPWT in our patient group had slightly higher incidence of infectious complications (15.4% versus 19.1%). However, these results can be achieved only if a specialist in reconstructive surgery and appropriate technical facilities are readily available. If this is not possible, then the NPWT, in comparison with conventional methods, provides the best possible way of temporary protection for an injured soft tissue coverage. CONCLUSIONS Application of NPWT within the primary treatment of injured soft tissue coverage in grade III open fractures results in a statistically significant reduction of bacterial contamination at the site of injury, as well as a reduction of the subsequent incidence of infectious complications. Primary application of NPWT also significantly reduced the risk of recurrent infection. ⋯ open fracture, negative pressure wound therapy, continual wound lavage, infection.
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Acta Chir Orthop Traumatol Cech · Jan 2016
Review Case Reports[Infectious Inflammation of Pubic Symphysis (Symphysitis Pubis Purulenta): Five Case Reports and Literature View].
Purulent inflammation of the pubic symphysis is a rare condition involving the symphysis and parasymphyseal parts of the pubic bones. It is usually found in immuno-compromised patients and its most frequent cause is Staphylococcus aureus. Conservative treatment is based on long-term administration of antibiotics and has been efficient, as reported, in about 50% of the patients. ⋯ Based on the experience with the treatment of five patients with infection of the pubic symphysis, the authors suggest that the late phase with abscess formation or purulent discharge should be managed by surgery. This treatment has good clinical outcomes although it may be complicated by slow healing of soft tissues around the symphysis and instability of the anterior pelvic segment with its sequelae. Key words: infection of the symphysis, infection of the pubic symphysis, septic arthritis of the pubic symphysis, pubic osteomyelitis.
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Acta Chir Orthop Traumatol Cech · Jan 2016
[Patient Satisfaction after Total Knee Arthroplasty. Analysis of Pre-Operative and Peri-Operative Parameters Influencing Results in 826 Patients].
PURPOSE OF THE STUDY The aim of the study was, first, to assess satisfaction of our patients after primary total knee arthroplasty (TKA) at various intervals of follow-up. Second, a list of pre- and peri-operative factors with potential effects on patient satisfaction was analysed. The third objective was to identify conditions under which a result of replacement could be considered definite with a little probability of further unexpected development. A more detailed knowledge of unsatisfied patients may provide valuable information for use in pre-operative evaluation, indication for surgery, as well as in the surgery itself. MATERIAL AND METHODS This prospective study consisted of 826 patients who underwent primary TKA between September 2010 and March 2015 and had at least one complete post-operative examination. Our group included 296 men and 530 women. The average age at primary TKA was 68.9 (45-87). Primary osteoarthritis was the most frequent indication to surgery (82.6 %). The followup period ranged from 1 month to 3 years. On each follow-up examination, every patient received an original questionnaire with 24 questions concerning the course of their post-operative period (between the discharge from hospital and the planned follow-up). The patients assessed the degree of satisfaction with surgery outcomes on a scale ranging from "fully satisfied" to "dissatisfied" and expressed their overall satisfaction in percents. RESULTS At the final follow-up, 6.5% of the patients were not satisfied with the outcome. The patients' overall satisfaction was 90.2 % (i.e., responses to the question of how you were satisfied with surgery). Significantly more satisfied patients were among those with primary osteoarthritis. Their satisfaction was related to the level of the UCLA activity rating, feelings of uncertainty when walking and to the functional ability component of the KSS system. On the other hand, more dissatisfied patients were found among those with several previous operations, a higher ASA score or a higher number of risk factors (Charlson comorbidity score etc.). The duration of pre-operative complaints had no relation to post-operative satisfaction. Similarly, there was no relation between VAS-evaluated pain intensity before TKA and patient satisfaction after arthroplasty. Obesity and satisfaction were not inter-related either. DISCUSSION Assessment of satisfaction is one of the Patient Reported Outcome Measures (PROMs) used by patients to evaluate the effect of a therapeutic method. These instruments aid in assessing the degree to which the method has met the needs and expectations of patients. It is relevant to emphasise that subjective factors, such as expectation or satisfaction, do not depend on the therapeutic procedure only. Recent reports have shown that, in 10% to 30% of the patients, the TKA outcome has not met their expectations. More detailed studies draw attention to the fact that there are more dissatisfied patients after TKA than those after THA. When satisfaction with pain relief is considered, the number of dissatisfied patients is even lower (72%-86%). CONCLUSIONS An analysis of the patients' responses shows that the rate of satisfaction is high shortly after surgery but declines gradually thereafter. The overall satisfaction is stable about 12 months after the surgery. The number of dissatisfied patients or those reporting pain after TKA in our study is in agreement with the results reported in relevant literature. The associations found here will be used in preparing a tool for clinical outcome prediction. ⋯ total knee arthroplasty, outcome evaluation, patient-reported outcome measures, satisfaction, dissatisfaction, pain after total knee arthroplasty, function after total knee arthroplasty.
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PURPOSE OF THE STUDY Perilunate dislocations and perilunate fractures are serious wrist injuries which are often overlooked at primary treatment. Their inadequate therapy results in severe wrist damage and patient disability. An early diagnosis and correct therapy can prevent such conditions. ⋯ CONCLUSIONS Good outcomes in perilunate injuries depend on an early and correct diagnosis, an appropriate therapeutic procedure and an orthopaedic surgeon who has experience with management of such injuries. A deep knowledge of wrist kinetics is necessary for this therapy as not all injuries happen according to textbook descriptions. Key words: perilunate dislocation, carpal instability, damage to carpal ligaments.