This clinical case refers to a male patient, 45 years old, with a past medical history of Hepatitis C, admitted at the Emergency Department on July 2014, after a fall from 7 meters high at his workplace – dump – which resulted in an open fracture of the distal end of the right forearm bones – Gustillo & Anderson IIIA. With this work, the authors aim to describe the evolution of the patient's clinical status, from the initial fracture to the septic arthritis of the right wrist, as also the surgical interventions and other treatments he has undergone. There were used all patient's records from Hospital's archives, including Emergency Department registry, Clinical Diaries, Operative Reports, and results of diagnostic exams. It was also revised all patient's clinical process, with support of photographs obtained during the successive revaluations. The clinical case we present on this work began on July 2014, when the patient suffered an open fracture – Gustillo & Anderson IIIA – on the distal end of the right forearm bones. The lesion was subjected to washing, closed reduction and internal fixation with Kirschner wires, and also a cycle of antibiotic. At the fourth day after surgery, because of an unfavorable evolution of the wound, the patient was submitted to a bulky abscess drainage and a joint osteotaxis. About 1 month and a half after the traumatic event, it was performed a revision of the osteotaxis, following a failed attempt of osteosynthesis. By unfavorable evolution of the clinical status, with the development of septic arthritis in the right wrist, it was decided to undertake a Masquelet technique. Analyzing the evolution of the patient's clinical status, the authors conclude that, besides the appropriate therapeutic options taken at each stage, the development of septic arthritis at the right wrist was inevitable. This framework, in association to the fact that this is a 45 years old patient, with the dominant hand affected, raises issues of questionable therapeutic order.
The clinical case refers to a male patient, 34 years old, admitted at the Emergency Department after a fall of 2 meters. Of that trauma, resulted an exposed Monteggia fracture type III – Gustillo & Anderson IIA – on his left arm. With this work, the authors intend to describe the evolution of the patient's clinical condition, as well as the surgical procedures he was submitted to. The authors used the patient's records from Hospital's archives, namely from the Emergency Department, Operating Room, Infirmary and Consultation, and also the diagnostic exams performed throughout the patient's clinical evolution. The clinical case began in December 2011, when the patient suffered a fall of 2 meters in his workplace. From the evaluation in the Emergency Department, it was concluded that the patient presented, at the left forearm, an exposed Monteggia type III fracture – Gustillo & Anderson IIA – combined with a comminuted fracture of the radial head. At the admission day, the wound site was thoroughly rinsed, the fracture was reduced and immobilized with an above-the-elbow cast, and antibiotics were initiated. Six days after admission, the patient was submitted to open reduction with internal fixation with plate and screws of the fracture of the ulna and radial head arthroplasty. The postoperative period was uneventful. Two months after the surgical procedure, inflammatory signals appeared with purulent secretion in the ulnar suture. Accordingly, the patient was submitted to fistulectomy, rinsing of the surgical site and a cycle of antibiotics with Vancomycin, directed to the S. aureus isolated from the purulent secretion. The clinical evolution was unfavorable, leading to the appearance of a metaphyseal pseudarthrosis or the ulna and dislocation of the radial head prosthesis. The previously implanted material was therefore removed, 4 months after the traumatic event; at the same time an external fixation device was applied and the first part of a Masquelet Technique was conducted. The second part of the aforementioned procedure was carried out in December 2012. The patient was discharged from the consultation after a 2 years follow-up, with a range of motion of the left elbow acceptable for his daily living activities. In spite of the multiple surgical rinsing procedures and directed antibiotics, the development of a metaphyseal pseudarthrosis of the ulna was inevitable. This clinical case illustrates how the Masquelet Technique presents itself as a good solution for the cases of non-union of fractures in the context of infection.
This work refers to a male patient, 25 years of age, admitted in the Emergency Department following a bicycle accident, of which resulted an open fracture of the right forearm bones – Gustillo & Anderson I. With this work, the authors have as objective the description of the patient's clinical condition – starting with the fracture, over to the osteomyelitis – as well as the surgical procedures and remaining treatments he was submitted to. The authors used the patient's records from Hospital's archives, namely records from the Emergency Department, Operating Room, Infirmary and Consultation, and also the diagnostic exams performed throughout the patient's clinical evolution. This clinical case began in May 2013, when the patient suffered an open fracture of the right forearm bones – Gustillo & Anderson I – due to a bicycle accident. At the time, the exposure site was thoroughly rinsed, a cast immobilization was made, and antibiotics were prescribed. In the fifth day following the trauma, the patient was submitted to an open reduction with internal fixation with plate and screws of both forearm bones. In the following period, the distal segment of the suture suffered necrosis, exposing the radial plate and the tendons of the first dorsal compartment. The Plastic Surgery team was then contacted, proposing the execution of a graft over the exposed area, which was made in August 2013. In the postoperative period, about half the graft lost its viability and it was noted that a radial pseudoarthrosis had developed – in the context of osteomyelitis – with a defect of about 9 centimeters. This condition prompted the extraction of the osteosynthesis material, about 4 months after its application, and at the same time the first stage of a Masquelet Technique was performed. The second stage of the aforementioned procedure was carried out two months later. Currently, the patient is clinically stable, with right hand mobility acceptable for his daily living activities. Analyzing the patient's clinical evolution, we concluded that, even though the adequate therapeutic decisions have been made in each stage, the development of osteomyelitis was inevitable. This realization, in association with the patient's young age, raises debatable questions of therapeutic order.
Observational and retrospective comparison of incidence or prevalence of all risk factors described in the literature. These factors have been classified according to the period of risk in: epidemiologic; pre, intra and postoperative; and distant infections.
Pearson was used for comparison of qualitative variables and ANOVA for quantitative ones.
Preoperative conditions: previous surgery in the same knee (25% vs 9%), chronic therapy with glucocorticoids (19% vs 4%), immunosuppressive treatments (16% vs 3%), and non-rheumatoid inflammatory arthritis (13% vs 0%). Patients in this case-control did not present a significant difference in the prevalence of rheumatoid arthritis, diabetes, obesity (BMI>
30), chronic liver diseases, or alcohol addiction. Intraoperative facts: a prolonged surgical time (149 min vs 108 min) and intraoperative fractures. Differences were not found in the amount of bleeding or need for transfusion. Postoperative events: secretion of the wound longer than 10 days (48% vs 0%), wound haematoma (36% vs 6%), new surgery in the knee (30% vs 0%), and deep venous thrombosis in lower limbs (10% vs 1%). Distant infections (risk for haematogenous seeding): deep cutaneous (27% vs 3%), generalized sepsis (7% vs 0%), upper and lower urinary tract (27% vs 5%), pneumonias and bronchopneumonias (27% vs 5%), and diverse abdominal focus (17% vs 1%). On the contrary, significant differences were not found in the prevalence of severe oral or dental infections. Epidemiologic characteristics: significant differences were not found in gender or in the prevalence of any aetiology.
to control and minimize these risk factors when present when this is not possible not possible, to implement additional prophylactic measures.
Observational and retrospective comparison of incidence or prevalence of all risk factors described in the literature. These factors have been classified according to the period of risk in: epidemiologic; pre, intra and postoperative; and distant infections.
Pearson was used for comparison of qualitative variables and ANOVA for quantitative ones.
Epidemiologic characteristics: female gender, post-traumatic osteoarthritis (17% vs 3%). On the contrary, primary osteoarthritis is a “protective” factor. Preoperative conditions: previous surgery in the same hip (60% vs 6%), obesity (BMI>
30) (9% vs 1%), chronic therapy with glucocorticoids (13% vs 0%), immunosuppressive treatments, chronic liver diseases (20% vs 2%), alcohol addiction (13% vs 0%) and intravenous drug abuse. Patients in this case-control did not present a significant difference in the prevalence of diabetes (a recognised risk factor for spine and knee surgery) or rheumatoid arthritis. Intraoperative facts: a prolonged surgical time is the only significant risk factor (133 min vs 98 min), but differences were not found in the amount of bleeding, need for transfusion or intraoperative fractures. Postoperative events: secretion of the wound longer than 10 days (46% vs 8%), palpable deep haematoma (27% vs 1%), dislocation of the prosthesis (40% vs 6%), and need for new surgery in the hip (21% vs 1%). Distant infections (risk for haematogenous seeding): deep cutaneous (30% vs 8%), upper and lower urinary tract (36% vs 2%), pneumonias and bronchopneumonias (23% vs 5%), and diverse abdominal focus (14% vs 3%). On the contrary, significant differences were not found in the prevalence of severe oral or dental infections.
to control and minimize these risk factors when present when this is not possible not possible, to implement additional prophylactic measures.
The steering committee produced checklists of predictors and outcomes based on systematic reviews and a Delphi focus group. The international teams of experts coded each item for inclusion or exclusion, and recommended new items. This process was iterated twice to resolve disagreement between teams, and to receive scores for new items. The steering committee carried out a consensus synthesis and produced the final lists for predictors and outcome. Finally, the measurements for each factor were selected based on:
original systematic review recommendations from existing systematic review Recommendations from consensus statements and narrative reviews consultation with independent experts.
- 34 patients, 31 female. average age 72.9 +/− 7.1 years (56–90) - Level of activity previous to fracture: 82.4% level III, 14.6% level II - Displaced (Garden III and IV) fracture of femoral neck excluding pathologic fractures - Hip hemiartrhoplasty with a JRI Furlong bipolar head (22.25 mm inner head), 30 patients with a Furlong HAP-coated uncemented stem and 4 patients with an auto-blocking-type Surgival cemented stem - Follow-up: minimum 2 years, average 2.9 years (2–5) - Clinical evaluation: Merle-DAubigne-Postel six-point scale for pain and for function - Radiological evaluation: measure of joint line width at superior-lateral quadrant (weight bearing area), perpendicular distance from prosthesis head to Kohler line - Statistical analysis: Kolmogorov-Smirnov, ANOVA, Bonferroni, Pearson, and Spearman tests
- Function: average score 4.7 +/− 1.1 after 1 year, 4.7 +/− 1.4 after 2 years, 4.8 +/− 1.3 after 3 years - Radiological joint line: disappeared in 13 patients (38.2%) after 1 year, in 14 (41.2%) after 2 years, in 54.5% of patients after 3 years. Average joint line width in the other patients: 0.9 mm (0.6–1.3) immediately after surgery, 0.6 mm (0.4–0.8) after 1 year, 0.5 mm (0.3–0.7) after 2 years, 0.5 mm (0.2–0.7) after 3 years (p<
0.05) - Distance from head to Kohler line: 5.7 +/− 3.8 mm (4.6–6.8) immediately after surgery, 4.6 +/− 3.7 mm (3.6–5.6) after 1 year, 4.3 +/− 2.9 mm (3.3–5.3) after 2 years, 4.0 +/− 3.3 mm (2.5–5.5) after 3 years (p<
0.05). There were 2 cases of acetabular protrusion.
