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.
Since its approval by the FDA two decades ago, Negative Pressure Wound Therapy (NPWT) has become a valuable asset in the management of open fractures with significant soft tissue damage as those seen in high velocity gunshot injuries. These lesions are often associated with grossly contaminated wounds and require a prompt and effective approach. Wound dehiscence and surgical site infection are two of the most common post-operative complications, with poor results when treated with standard gauze dresses. NPTW comes as a legitimate resource promoting secondary intention healing through increased granulation and improved tissue perfusion, as well as continuous local wound drainage preventing bacterial growth and further infection. Recent evidence-based guidelines are still limited for use of NPWT in the treatment of Gustilo-Anderson type IIIB open fractures and there are few cases in literature reporting the management of upper extremity injuries. We present and discuss a successful case of a type IIIB open humeral fracture wound treated with NPWT. A 38-years-old male was admitted to the Emergency Room with a type IIIB open humeral fracture as a result of a gunshot with extensive soft tissue damage. IV antibiotic therapy was promptly started followed by surgical stabilization by intramedullary nailing with primary wound closure. The patient presented an early surgical site infection with wound dehiscence requiring secondary debridement with poor subsequent healing and deficient soft tissue coverage. After ineffective 28 days of standard gauze dresses we started NPWT. NPTW was applied using foam coverage over the dehiscence area with visible results after 13 days and complete granulation of the skin defect by the 28th day. The wound healed completely after 14 weeks of NPWT. The fracture evolved into a painless pseudarthrosis revealing an excellent functional recovery and an acceptable aesthetic result. NPTW is a valuable, effective, and well tolerated resource in the treatment of open fractures with extensive soft tissue damage such as Gustilo-Anderson type IIIB fractures. It should be considered not just as a salvage procedure but as well as a primary option especially in grossly contaminated wounds. No benefits in any form have been received from a commercial party.
