Posttraumatic osteomyelitis (PTO) is a complex condition that results in considerable morbidity. Tibia is one of the most common sites of PTO, with an average infection rate of 10% for open fractures and 1% for closed fractures. In most cases osteomyelitis is polymicrobial. Staphylococcus aureus is the most common infecting organism present either alone or in combination with other pathogens in 65 to 70% of patients. Developments in surgery have greatly improved the ability to treat this condition. However, some authors defend that functional outcome is often poorer after successful limb reconstruction than after treatment with amputation below the knee, especially in patients with systemic factors that might significantly compromise reconstructive treatment. Limb salvage is associated with a longer convalescence time and a higher risk of complications, additional surgeries, and rehospitalisation. We present a case report of a patient with PTO requiring amputation of the leg despite aggressive surgical treatment. The authors present a case of an 86-year-old woman with past medical history significant for diabetes, hypertension, severe peripheral artery disease and congestive heart failure. In March 2013 the patient sustained a tibia and fibula fracture (42-C1 AO Classification). Closed reduction and intramedullary nailing were performed. Osteomyelitis was diagnosed 1 month later. Implant removal, debridement, stabilization with external fixator and a vascularized skin graft were performed. Graft necrosis with bone exposure occurred after 1 month. Cultures were positive for multiple pathogens, including methicillin-sensitive Staphylococcus aureus. Several surgical debridement, vacuum-assisted closure therapy (VAC) and specific antibiotic therapy were performed for 8 weeks. Clinical deterioration with persistent bacteremia and infectious process led to the amputation below the knee in October 2014. Symptomatic relieve was achieved and C-reactive protein returned to her normal values. Minimal stump necrosis was detected. Seven months postoperatively the patient is doing well with assisted gaitpilaa and few limitations in her daily life and there are no signs of systemic or local infection. Management of posttraumatic osteomyelitis remains a challenge. Amputation may prove to be the most appropriate way of restoring function and improving patient's quality of live, if there is failure to achieve bone healing and restore function. The decision to amputate should be considered carefully and individually, involving both patient and family.
Pyogenic spondylodiscitis is an uncommon but clinically relevant infection that represents 3 to 5% of all cases or osteomyelitis. In Europe, it has an estimated incidence of 0.4 to 2.4/100.000 people/year. Mortality is less than 5%, increasing with a delay in diagnosis greater than 2 month. Patients with renal failure have greater predisposition to infections, consequence of the chronic uremic state. Infection rates in Polytetrafluoroethylene (PTFE) hemodialysis grafts in end-stage renal disease (ESRD) range from 3 to 35%. We present a rare case of concurrent spondylodiscitis and PTFE graft infection in a patient with ESRD and recurrent urinary tract infections (RUTI). The authors present a case of an 80-year-old man with past medical history significant for abdominal aortic aneurysm, bilateral ureter-hydronephrosis, Pseudomonas aeruginosa RUTI and ESRD. Three months after a dialysis PTFE graft hemoaccess was performed a Pseudomonas graft infection was diagnosed and the PTFE graft was removed. One week later, the patient was observed in the author's Department due to an insidious dorsal-lumbar mechanic back pain without neurologic deficits, with progressive deterioration over the past 6 months. A T12-L1 and L1-L2 spondylodiscitis with dural compression was diagnosed and vertebral instability was documented on MRI and TC, demanding surgical treatment. Instrumented fusion with a screw and rod construct was performed from T9 to L5, along with somatic L1 and L2 debridement, and T12-L1 interbody fusion with autograft. Microbiology results were positive for Pseudomonas aeruginosa. Antibotic therapy with ceftazidime (6 weeks) and ciprofloxacin (12 weeks) was performed. Symptomatic relieve was achieved and C-reactive protein and white blood cell count returned to normal values. No complications were documented. Four months post-surgery, the patient was asymptomatic (Visual Analogue Scale=0), with no significant limitation in his daily life activity (Disability Rating Index=85) and the vertebral body height was sustained, with imagiological signs of spinal fusion. ESRD patients are more susceptive to infections. Failure in early diagnosis and treatment may lead to disease progression and subsequent functional limitations, deformity and increase in mortality. An aggressive approach, despite delay on diagnosis, is the key factor for a worthy outcome. Despite the good results, recrudescence of spondylodiscitis is known to occur even years after the original offense is treated.
To report a rare case of successfully treated synchronous shoulder septic arthritis, total knee replacement infection and lumbar spondylodiscitis in a patient with rheumatoid arthritis. Fifty-six year old woman, with a history of rheumatoid arthritis diagnosed at twenty-five year old, and total knee replacement at fifty-four. Recently treated with etanercept, presented with acute inflammatory signs of the right shoulder in addition to right knee and lumbar back pain for 6 months. After a shoulder and knee arthrocentesis the diagnosis suspicion of shoulder septic arthritis and total knee replacement infection was confirmed. Therefore it was performed shoulder arthroscopic irrigation and debridement and the first of two stages knee revision, with implantation of antibiotic cement on cement articulating spacer. It was also diagnosed a L1–L2 and L4–L5 spondylodiscitis with dural compression documented on MRI, which determined surgical treatment. By a posterior approach it was performed instrumentation from T11 to L5, followed by L1–L2 and L4–L5 discectomy and interbody fusion with autograft. Shoulder and knee synovial fluid cultures where positive for Methicillin Sensible Staphylococcus aureus narrowing the broad-spectrum combination therapy to levofloxacin for six weeks, with symptomatic relieve and C-reactive protein and white blood cell count returning to normal values. Almost one year down the line the patient remained with no sign of infection, even under the influence of immunosuppressive therapeutic. She returned to her previous status concerning the rheumatologic disease and the second stage knee revision is being planned to happen on the short run. Rheumatoid arthritis patients are a high-risk group for septic arthritis considering, among others, the immunosuppressive therapeutics and the frequent history of arthroplasty. The presented case illustrates three different type of septic complication in the same patient. The timely and aggressive approach was the key factor for a good outcome.
We present the results of 412 core needle biopsies guided with fluoroscopy, CT and echo scan with assessment of accuracy and costs From January/96 to December/08, 56 soft tissue and 356 bone tumours and tumour-like lesions were submitted to this technique in the Oncology Unit of Hospital Santo Antònio. All biopsies were performed by the same team (one radiologist, one orthopaedic surgeon) and the histological exam by the same pathologist. There were 77 cases in which diagnosis was inconclusive (sample not representative, crushing, necrosis, hemorrhagic features or image/histological dissociation); 36 of these were soft tissue and 41 bone lesions. histiocytic elements, 65 metastases, 8 recurrent malignancies, 5 osteomyelitis and 2 metabolic diseases. Diagnosis was confirmed in 278 cases with the definitive surgery and only one was wrong. The other 57 cases were later controlled by imaging exams and there were no reasons to suspect a wrong diagnosis. No complications occurred. Costs were estimated to be less than one fifth of an open biopsy. The high accuracy (only one case was misdiagnosis), the safety, the costs and the fact that in only 18,7% the diagnosis was not established make us consider this method effective and to be encouraged. Better selection of lesions and more attention to directions of the cores may low the number of inconclusive diagnosis.
Chondrosarcoma is the second most frequent primary malignant tumour of bone, representing approximately 25% of all primary osseous neoplasms. Chondrosarcomas are a group of tumours with highly diverse features and behavior patterns, ranging from slow-growing non-metastasizing lesions to highly aggressive metastasizing sarcomas. As radio and quimio-resistant tumours, the surgery constitutes the unique chance of cure. Nowadays, besides the curative intention, the reconstructive surgery is also a priority in order to save the limb and optimize the function. This case report is about a young woman, of 24 years old, with hip-related pain and a large mass in the left pelvis. The imagiologic study showed a large mass of about 8 cm of large diameter, starting at the anterior wall of the acetabulum, involving the pubic arcs and with matrix calcification. The core needle biopsy confirmed the presence of a chondrosarcoma, staged as a IIB of Enneking. Because of its size and localization the limb salvage surgery has been a challenge. The surgery included a broad approach of the left hemipelvis, with wide excision of the tumour, reconstruction of the abdominal wall with a propylene prothesis and reconstruction of the hemipelvis with a “custom-made” prothesis with preservation of the femoral neurovascular bundle. The patient started to walk with total bearing after three months and had a normal gait and a nearly normal life during eleven months. Fifteen months after the surgery lung metastasis and local recurrence were diagnosed and she died six months after.
Synovial cell sarcoma is one of the most common soft tissue tumours. Prognosis of this tumour is related to initial care. Survival rates have improved in the past 20 years because of treatment with primary radical surgery, along with chemotherapy and radiation. This case report is about a woman, of 68 years old, with a left shoulder-related pain and mass with about four months. The image study showed a lobulated and irregular mass, with about 12x10x9cm, infiltrating the rotator cuff and glenohumeral joint. The core needle biopsy confirmed the presence of a synovial sarcoma, staged as a T2N0M0. The treatment started with neo-adjuvant chemotherapy, with a poor response. Then, surgery was performed, with a wide excision of the scapula, proximal humerus and clavicle (type IV of Malawer) without reconstruction. The treatment regime ended with the radiotherapy. Eighteen months after the surgery the patient remains disease-free and a neo-joint is starting to form. At this time the DASH score was 63.8. Despite the flail shoulder function is acceptable.
Osteoid osteomas are benign, painful osteogenic tumours of small size (≤ 1,5 cm). Surgical resection of the nidus has been the elected method of treatment for decades but some complications and difficulties (poor localization, extensive tissue damage, fractures, delayed recovery) encouraged the development of less invasive techniques such as radiofrequency. Lack of histological proof is the major concern regarding radiofrequency ablation as we make the diagnosis by the clinical findings and the image features. We present the results of 20 patients with osteoid osteoma treated with radiofrequency from January 2004 to December 2008 (mean follow up 23 months). All patients were under general anaesthesia and de access route was chosen in the CT-suite. 11 cases were located in the proximal femur (head, neck and subtrocanteric region), 2 in the distal femur, 2 in de distal humerus, 2 in the tibia, 2 in the acetabulum, and 1 in de vertebal body of D8. In all cases we used a Cool-tip TM RF electrode (water-cooled tip) reaching a heating temperature of 42°C to 48°C during 12 minutes. In 7 patients a cannulated drill bit was used to penetrate the thick cortical or to reach the nidus through the opposite side in order to avoid a neurovascular bundle. Hospital discharge was allowed after 6 to 8 hours after the procedure. No complications occurred. All patients, except one, experienced complete relief of the pain although the 6-month follow-up CT’s do not show sclerosis of the nidus. None of them recurred till data. The patient who did not recover had not had a clear diagnosis. We conclude that radiofrequency ablation is effective, safe, favouring rapid recovery and, of course, reduces economical and social costs.
