A 31-year-old Pakistani man was admitted to hospital after sustaining a Grade I compound fracture of the mid-shaft of the left tibia and fibula following a motor vehicle accident. He developed septicaemic shock, acute renal failure and Group A streptococcal necrotizing fasciitis of the left leg. The patient underwent an above knee amputation followed by disarticulation of the left hip with extensive debridement. He was treated with benzylpenicillin, vancomycin, inotropes and continuous haemodialysis and survived without further sequelae. Subsequently, skin grafting was done over the wound site. This case highlights the role of Group A streptococcus as a cause of this rare and life-threatening infection.
It is very rare indeed in the practice of children's orthopaedics today in Malaysia that the natural history of long bone osteomyelitis is seen. A case is presented where a shoulder abscess in a 3-year-old child developed into septic arthritis of the shoulder and subsequently chronic osteomyelitis of the adjacent humerus. The parents refused active surgical debridement and sequestrectomies. Three years later the child had regenerated a new humerus over the sequestra. Radiographs are presented illustrating the entire natural history of osteomyelitis with the regeneration of a new humerus.
This study evaluated the effectiveness of demineralized freeze-dried bone xenograft in reducing post-surgical pocket depth in moderate to advanced adult periodontitis in patients. Nine patients with a total of eighteen intrabony defects were selected for this study. The bony defects were matched for tooth type, location and pocket depth. Following an initial non-surgical treatment, only pockets of 5 to 7 mm deep were indicated for surgery. Periodontal pockets were measured pre-operatively and at 3, 6 and 9 months post-surgically. The study protocol included a split mouth design, where surgical treatment was carried out at both test and control sites. The test sites were assigned demineralized freeze-dried bone xenograft and the control sites were subjected to debridement alone without the use of demineralized freeze-dried bone xenograft. The results from this study showed a statistically significant difference in the mean pocket depth at 6 and 9 months post-operatively for both test and control groups, but there was no statistically significant difference at 3 months. In conclusion, demineralized freeze-dried bone xenograft was ineffective in reducing periodontal pocket depth in patients with moderate to severe periodontitis, as compared to surgical debridement alone.
This is the first time we encountered a peculiar case of osteomyelitis complicating a closed fracture. The patient was a 38 year-old lady who presented just like any other patient with a closed fracture of the right femur. Intraoperatively we were surprised to find pus from the fracture site. This not only changed the surgical management but altered the subsequent outcome as well.
The aim of this study was to determine the effectiveness of demineralized freeze-dried bone xenograft (DFDBBX) in minimizing post-surgical recession in moderate to advanced adult periodontitis in patients. Nine patients with a total of eighteen intrabony defects were matched for the tooth type, location of defects and periodontal pocket depth (5 to 7mm). Following an initial nonsurgical treatment, recession at defects indicated for surgery was measured pre-operatively. Surgical treatment was carried out by split mouth design, where the test sites were assigned DFDBBX and the control sites were subjected to debridement without the use of DFDBBX. Recessions were measured at 3 months, 6 months and 9 months post-operatively. The results showed no statistically significant difference in mean recession at 3, 6 and 9 months post-operatively compared to baseline for both test and control groups. Thus, DFDBBX was ineffective in minimizing recession on patients with moderate to severe periodontitis, as compared to surgical debridement alone.
Necrotizing fasciitis is a limb- and life-threatening rapidly spreading infection affecting the deep fascia with secondary necrosis of the subcutaneous tissue. It requires immediate medical attention and emergency surgery to prevent morbidity and death. This study was undertaken to determine its co-morbidity and risk factors affecting the outcome of its surgical treatment. This is a retrospective review of 36 cases of necrotizing fasciitis of the lower limb treated in our center between 1998 and 2002. Only 19% of the cases were correctly diagnosed upon admission and 48.6% were initially diagnosed as 'cellulitis'. Diabetes mellitus was the most common co-morbid. Pseudomonas, Staphylococcus, Streptococcus and Enterobactericae were the common pathogens isolated. Ten patients (27.8%) had major amputation as part of radical debridement. The overall mortality rate was 36% with laboratory parameters: high serum urea and creatinine, and low haemoglobin levels were predictors for higher mortality. Poor white cell response which is common in diabetic patients and a delay in surgical debridement were. notable attributes to a higher mortality. Necrotizing fasciitis is a serious infection associated with significant morbidity and mortality. A poor white blood cell response, high serum urea and creatinine, and low haemoglobin level were the predictors for mortality. Early diagnosis and prompt treatment are of paramount importance in the treatment of this infection.
We report a case of a previously healthy 53-year-old man who developed an intra-operative catastrophic event occurring in association with the use of hydrogen peroxide for wound irrigation following surgical debridement of a chronic osteomyelitis lesion of the humerus. It is our intention to highlight this potentially fatal consequence of hydrogen peroxide irrigation as part of bone debridement procedure. This case will serve as a reminder to orthopaedic surgeons who frequently use hydrogen peroxide in their surgical practice.
A case of rhino-orbito-cerebral mucormycosis is presented showing its aggressive nature and progression of disease. The typical clinical features, neuroimaging and histological findings are highlighted in this report. Amphotericin B and surgical debridement remain the mainstay of treatment. However, associated co-morbidities need to be addressed.
We report here a rare presentation of an extra-nodal non-Hodgkin's lymphoma. Both clinical presentation radiological findings were suggestive of psoas abscess. Surgical debridement was performed and histopathological examination of the tissue sample revealed the diagnosis of non-Hodgkin's lymphoma. It is therefore important to note that non-Hodgkin's lymphoma can mimic psoas abscess and that psoas lesion with vertebral involvement does not necessarily indicate infection. It is always advisable to obtain needle biopsy to establish diagnosis before embarking on surgical intervention. The practice to send any suspicious tissue obtained intra-operatively for histopathological examination is also warranted.
This is prospective case-control study of more than 18 months performed to assess the effectiveness of maggot debridement therapy (MDT) with the sterile larvae of Lucilia cuprina (a tropical blowfly maggot) for the treatment of diabetic foot ulcers. Literature thus far has only reported results with the temperate maggot, Lucilia sericata. This study documents outcome in diabetic foot wounds treated with maggot debridement versus those treated by conventional debridement alone. In this series of 29 patients treated with MDT, 14 wounds were healed, 11 were unhealed and 4 were classified under others. The control group treated by conventional debridement had 30 patients of which 18 wounds were healed, 11 unhealed and 1 classified under others. There was no significant difference in outcome between the two groups. The conclusion that can be made from this study is that MDT with L. cuprina is as effective as conventional debridement in the treatment of diabetic foot ulcers. It would be a feasible alternative to those at high risk for surgery or for those who refuse surgery.
We are reporting a case of post-traumatic chronic osteomyelitis of the tibia with an open wound exposing an intra medullar nail implant for 13 years. The patient presented with fresh ipsilateral tibia plateau fracture. He was treated by removal of the implant, debridement and local placement of Gentamicin-impregnated PMMA beads according to guidelines of two-stage Belfast technique . After five months of wound treatment, the exposed bone was covered by healthy granulation tissue and the patient was able to fully bear weight.
This study aimed to detect the presence of enterococci in the root canals of untreated and treated teeth with periapical disease and to compare this to their presence in the saliva and in the immediate surgical environment during root canal treatment. Using an aseptic technique, 33 samples were obtained from 27 untreated and 6 previously treated teeth associated with apical periodontitis. Reduced Transport Fluid (RTF) was used as transport medium. Saliva samples and areas in the surgical environment were also sampled. These were performed prior to chemo-mechanical debrjdement and obturation for every case. The saliva was diluted to 10- J and was plated on Bile Aesculin Azide (BEA) agar whereas the rest of the samples were plated on Bile Aesculin (BE) agar. These plates were then incubated aerobically at 37°C for 48 hours. All the colony types that blackened the agar were sub-cultured to obtain pure isolates and tested on 6.5% sodium chloride (NaCI). Growth on this medium was Gram stained for further confirmation of cell morphology. Gram positive cocci isolated from previous positive test were identified as enterococci. Enterococci were recovered from untreated cases only; from 2 teeth (in 2 patients) prior to chemo-mechanical debridement, from 3 teeth (in 3 patients) prior to obturation and I from saliva sample. A 'total of 5 samples from 5 different patients were positive for enteroco•cci. Sampling in the immediate surgical environment revealed a low occurence in the range of3.0% (1/33) to 15_2% (5/33). In conclusion, the occurence of enterococci in patients and the immediate surgical environment was low number.
Necrotizing fasciitis of the head and neck is a rare, rapidly progressive infection involving the skin, subcutaneous tissue and fascia. We report three cases of necrotizing fasciitis that differ in their presentation and outcome. The first case involves a patient who presented with progressively enlarging anterior neck swelling that was later complicated by dehydration and reduced consciousness. The second case is a patient with neck swelling and ipsilateral otorrhea. The third case concerns a patient with a buccal ulcer complicated by ipsilateral facial swelling. All of them underwent a fasciotomy with wound debridement with the addition of a cortical mastoidectomy in the second case. Two of these patients recovered well. Unfortunately, the third case succumbed to death due to airway compromise and septicaemia. We advocate the importance of eradicating the source of infection followed by frequent, meticulous wound dressing and strict blood sugar control to obtain better outcomes in managing necrotizing fasciitis of the head and neck. However, involvement of the airway carries a grave prognosis despite aggressive treatment.
A new invention, papain-based wound cleanser is formulated by incorporating papain, a proteolytic enzyme extracted from Carica papaya into the formulation. This cleanser is invented to simplify the methods in wound management by combining wound cleansing and wound debridement using a single formulation. This study describes the preparation and preclinical study of papain-based wound cleanser in accelerating wound healing. In this study, papain-based wound cleanser was used to treat wound incision on Sprague-Dawley rats while distilled water and Betadine were used as negative and positive control. Twenty-seven clinically healthy white rats were randomly divided into three groups and treated accordingly until the 21st day post-incision. Wound reduction rates and histological analysis were obtained to asses the healing pattern. Rats treated with papain-based wound cleanser showed a progressive wound healing based on the wound reduction rates and histological analysis when compared with rats treated with distilled water and Betadine. Better collagen deposition and presence of skin organelles in rats treated with papain-based wound cleanser demonstrated its efficacy in promoting wound healing. In addition to its wound healing effect, papain-based wound cleanser is also integrated with antibacterial properties which make it a complete package for wound management. However, further studies should be carried out to ensure its safety for human usage.
Chronic osteomyelitis (Brodie's abscess) is essentially a problem of diagnosis, and there may be considerable difficulty in distinguishing it from other benign and malignant bone lesions. Early diagnosis of Brodie's abscess is deemed important as the disease has a good curative potential following an appropriate antibiotic treatment. Of late, PET/CT using (18)F-FDG is taking a centre stage in the imaging of bone infection though documentation on its role in characterising the feature of Brodie's abscess is exceedingly scarce. On the other hand, it is well known that MRI imaging plays a very important role in distinguishing abscess loculation from malignancy. The authors present the case of a 13-year-old boy with pain in the right heel for few months. Radiograph of the right foot revealed a lucent focus with sclerotic margin in the right calcaneum. MRI T1-weighted images were inconclusive of penumbra sign to characterise abscess cavity due to the small volume lesion. Whole-body (18)F-FDG PET/CT scan showed multiple small avid lesions at the margin of the sclerotic rim in the right calcaneum. Final diagnosis of Brodie's abscess with Klebsiella culture was confirmed via bone debridement.
Snakebite is very common especially in Asia. We report a rare case of Providencia rettgeri infection following snakebite on the foot. This patient was treated with early and aggressive wound debridement, daily wound dressing during hospitalization and then skin coverage with split skin graft. No anti-venom was given administered. Appropriate intravenous antibiotics were given to the patient while hospitalized and oral antibiotic were prescribed upon discharge. The outcome of this treatment was successful.