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Introduction: Chronic osteomyelitis in children is a rare condition. Debridement surgery, along with appropriate antibiotic therapy, is widely agreed to represent the best procedure in the treatment of chronic osteomyelitis but can result in an extensive dead space formation. In this study, we evaluated the use of bioactive glass to address dead space management.Methods: Four consecutive cases of chronic osteomyelitis treated with antibiotic therapy, one stage- surgical debridement and bioglass implantation between September 2016 and February 2017 were prospectively followed for a minimum of three years. Two cases followed acute hematogenous osteomyelitis, two cases followed fracture fixation. Clinical, histology, laboratory and radiographic findings were recorded. Primary endpoint was eradication of infection. Possible complication related to bioglass application were investigated.Results: All patients achieved healing at the latest follow-up of minimum three years. No successive surgical treatments were required at any time. No complications related to the bioglass were detected. Radiographic reconstruction of normal anatomy progressed through the years.Conclusions: Bioglass for the treatment of dead space after surgical debridement appears a viable option in the treatment of chronic osteomyelitis in children. [ABSTRACT FROM AUTHOR]

Necrotizing Fasciitis (NF) is a life-threatening, rapidly progressive infection of the skin and underlying soft tissues. Bacterial pathogens induce a toxic-shock reaction that reduces vascular flow, causing thrombosis, sepsis, and tissue necrosis. Treatment consists of immediate IV antibiotics and oftentimes surgical intervention. We present a case of acute NF that was misdiagnosed as cellulitis. A 17-year-old male was transferred to an emergency department from a rural hospital for further management of right lower extremity cellulitis and suspected sepsis. On examination, there was an ulcerated lesion on his right lower leg. Within 4 h, the patient underwent fasciotomy and debridement. The patient was hospitalized for 10 days, received a 3-week-course of Cefazolin, and underwent a meshed split-thickness skin graft. By the end of his hospital stay, he showed significant clinical improvement. Misdiagnosis of NF will almost always lead to a poorer prognosis. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is used to differentiate NF from other soft tissue infections. Yet, other diagnostic clues such as presentation or pain out of proportion to physical findings may be more relevant clinical indicators for a NF diagnosis. Moreover, though imaging findings of NF may be relevant, surgical fascial examination must not be delayed for the purpose of imaging. It is also important to note that cellulitis and NF do share a disease spectrum. A life-threatening NF infection may seem to be a benign-appearing case of cellulitis, and thus early detection is vital. • Necrotizing fasciitis misdiagnosed as cellulitis can lead to delayed intervention. • Unlike cellulitis, NF progresses rapidly with disproportionate pain. • Imaging and diagnostic clues are useful; the gold standard is surgical examination. • NF treatment requires immediate antibiotics, debridement, and reconstruction. • In early-stage NF, diagnostic distinction from cellulitis may be difficult. [ABSTRACT FROM AUTHOR]

The rising incidence of sickle-cell disease in European countries has led to an increase in associated complications. Osteomyelitis, a rare complication in non-traumatic adult cases, poses diagnostic challenges and presents treatment difficulties due to limited cases and studies. A 23-year-old woman diagnosed with sickle-cell disease presented with a six-day fever and painful swelling in the left upper extremity persisting for a fortnight. She had no history of trauma but had experienced a previous episode of bacteremia due to Salmonella, four years prior. Magnetic resonance imaging revealed an intramedullary bone injury with cortical rupture extending into soft tissues, forming a collection that raised clinical suspicion of osteomyelitis, despite negative blood and aspirate cultures. Empiric antibiotic therapy was initiated, followed by surgical debridement of infected tissues. The resulting dead space was filled with antibiotic-coated calcium phosphate beads and tissue grafting. Anatomopathological studies confirmed findings consistent with chronic osteomyelitis. Stabilization of the arm was achieved with an orthopedic brace, and antibiotic administration continued for 6 weeks post-surgery. The injury consolidated 4 months after treatment, and nearly two years later she has not suffered a recurrence. The scarcity of literature implies the absence of clinical guidelines for treating osteomyelitis in these patients. Empirical antibiotic therapy combined with surgery when there are abscesses that need debridement can be an effective approach. Humeral osteomyelitis in sickle-cell disease patients can be effectively managed using a pharmaco-surgical strategy, but it should be tailored to the patient's needs. • Humeral osteomyelitis is a rare complication in sickle-cell disease patients. • Empiric antibiotic therapy should be a first option when the condition is suspected in these patients. • A combined strategy with a surgical approach is necessary when abscess formation occurs. • External fixation may not be necessary when there is sufficient bone quality and structural integrity. [ABSTRACT FROM AUTHOR]

Osteomyelitis represents a challenging condition in the diabetic foot with an associated high risk of major amputation. S53P4 Bioactive Glass (BG) has bacterial inhibiting properties on the market and indicated to be used in osteomyelitis. The objective of the study was to test the efficacy and safety of BG in treating diabetic foot osteomyelitis. This was an observational, retrospective, single-centre study involving subjects with diabetes affected by osteomyelitis of the foot who underwent surgical debridement from 01/2016 to 10/2018. Overall, 44 diabetic patients (14 [31.8%] female, aged 68.0 ± 10.2 years, diabetes duration 26.8 ± 11.9 years) were studied: 22 (50%) treated with surgical debridement and a local application of BG; 22 (50%) treated by means of surgical debridement. The primary outcome was the osteomyelitis resolution. Revascularization was performed before surgical procedure in 31 (70.5%) of patients. Systemic antibiotics were used in both groups. The osteomyelitis resolution rate was significantly higher in subjects treated with BG than in subjects treated with traditional procedure (18 [90%] vs 13 [61.9%], respectively p =.03). The odds of BG to reach osteomyelitis resolution was 5.54 times greater than for traditional treatment (odds ratio 5.54, 95% confidence interval 1.10-30.5). The use of BG was associated with an 81% lower probability to need additional antibiotic therapy compared to subjects treated with traditional procedure (odds ratio 0.19, 95% confidence interval 0.04-0.87). The debridement of osteomyelitis followed by application of BG could be an effective and safe option in the treatment of osteomyelitis of the diabetic foot. [ABSTRACT FROM AUTHOR]

Patients with febrile neutropenia presenting a cutaneous portal of entry for an infectious agent are at high risk of death (19-32%). If medical management is well codified, surgical management represents a therapeutic dilemma because the only available option is an aggressive debridement of the infected area which is associated with a high morbidity rate. Our objective was to implement a low-risk technique that is quick to perform and does not delay major surgical debridement if the latter turns out to be necessary. We performed an early subcutaneous drainage of the infected areas by percutaneous approach in order to avoid the evolution towards skin and subcutaneous necrosis. Five consecutive patients were treated with this technique associated with the recommended medical treatment between March and September 2017. This technique is based on the mechanical concept of the evacuation of the edema from the inflammatory area which would allow a better efficiency of the antibiotic treatment thanks to a better blood perfusion and a higher tissue concentration of antibiotics. Of the 5 patients managed in the department, no skin necrosis occurred, no surgical debridement was necessary, and no patient died during the episode of febrile neutropenia. Early subcutaneous drainage by percutaneous approach of an area of skin infection in a patient with febrile neutropenia may be considered as an interesting option. This technique allows without loss of chance for the patient to increase survival and decrease the number of aggressive surgical debridement and their high morbidity. [ABSTRACT FROM AUTHOR]

• Fournier's gangrene (FG) is a rare disease which usually affects men. It is characterized by progressive necrotizing fasciitis. • A 66-year-old man with uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, reported the onset of symptoms about 14 days before his hospitalization, without consulting any doctor due to Covid-19 pandemic. • The combination therapy of surgical debridement and antibiotics infusion was effective. Fournier's gangrene is a potentially fatal emergency condition, supported by an infection of perineal and perianal region, characterized by necrotizing fasciitis with a rapid spread to fascial planes. FG, usually due to compromised host, may be sustained by many microbial pathogens. A 66-year-old man, with a history of uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, was admitted to the Emergency Department with a large area of necrosis involving the perineal and perianal regions. Fournier's gangrene is favoured by hypertension, obesity, chronic alcoholism, renal and heart failure. Generally, Fournier's gangrene needs other procedures in addition to wound debridement such as colostomy, cystostomy, or orchiectomy. We report a case of FG found as complication in a patient with uncontrolled type 2 diabetes, treated with effective combination therapy with surgical debridement and antibiotics infusion. [ABSTRACT FROM AUTHOR]

• Limited data are available on septic thrombosis caused by Gram-negative bacilli. • In the intensive care unit, polytrauma patients are at highest risk of this condition. • The optimal therapeutic approach requires targeted antibiotics plus anticoagulation. • Follow-up blood cultures are essential to establish the diagnosis and duration of therapy. Data on septic thrombosis caused by Gram-negative bacilli (GN-ST) in intensive care unit (ICU) patients are currently limited. The aim of this retrospective case–control study (matched 1:3) performed over a 15-month period on ICU patients with bacteraemia, associated (cases) or not (controls) with GN-ST, was to assess 30-day mortality and clinical/microbiological features of GN-ST. During the study period, 16 patients with GN-ST and 48 controls were analyzed. Polytrauma was the cause of ICU admission in 12 (75%) cases and 22 (46%) controls (p = 0.019). In no case of septic thrombosis was surgical debridement performed. The site of venous thrombosis was more frequently in the lower limbs, associated with bone fracture in nine out of 12 (75%) cases. The median duration of bacteraemia (22 days vs 1 day; p < 0.001) and time to clinical improvement (15 days vs 4 days; p < 0.001) were significantly longer in cases than in controls. On analysis of the receiver operating characteristics (ROC) curve, bacteraemia >72 h was significantly associated with GN-ST (area under the curve (AUC) 0.95, sensitivity 0.996 and specificity 0.810; p < 0.001). Finally, 30-day mortality was 20% in cases and 67% in controls (p < 0.001). Critically ill patients with GN-ST showed specific clinical features. Despite delayed bacteraemia clearance, targeted antibiotic therapy plus anticoagulation usually provided clinical improvement and a low 30-day mortality rate. [ABSTRACT FROM AUTHOR]

• Vacuum-assisted closure is a well-established technical resource for treating complicated wounds. • In cases of suspicion of bone infection, VAC therapy is not enough to prevent bar removal. • Multiple surgical debridement sessions are mandatory before wound closure in cases of infection. • We present a case of surgical wound dehiscence with hardware exposure. • After VAC therapy and surgical debridement, the bilateral pectoralis muscle flap mobilization has been used. Multiple surgical debridement sessions are mandatory before wound closure in cases of infection after a modified Ravitch procedure for pectus excavatum. Vacuum-assisted closure (VAC) is a well-established technical resource for treating complicated wounds; however, in cases of suspicion of bone infection, this approach is not enough to prevent bar removal. We present a case of surgical wound dehiscence with hardware exposure in a patient who had undergone chondrosternoplasty for pectus excavatum. Several sessions of debridement (three) and VAC were applied every time. The final result was achieved without the necessity to remove the hardware; however, to avoid the risk of infection, a bilateral pectoralis muscle flap mobilization was performed as the final step after the surgical wound revisions, although this approach is suggested to be used during the modified Ravitch procedure. This approach allows for a significant reduction in late complications and improves morphological outcomes. In summary, the pectoralis muscle flap transposition is very useful not only for aesthetical results but also in combination with multiple surgical revisions for conservative management in case of wound infection during a modified Ravitch procedure. In our case, this technique was adopted after accurate care of the wound and before the final closure, which helps to maintain good vascularization and a very satisfying result. It is important to consider this approach during the modified Ravitch procedure, not only for better aesthetical results but also to prevent infections or wound dehiscence at the level of the bar. [ABSTRACT FROM AUTHOR]

Background Traditionally, nonoperative management with long-term antibiotics and bed rest has been recommended as first-line treatment for most patients with postoperative discitis. A recent trend in treatment under a limited range of indications has been to perform surgical débridement followed by long-term administration of antibiotics. This descriptive study investigated whether transforaminal lumbar interbody débridement and fusion (TLIDF) combined with intravenous antibiotics is appropriate to manage postdiscectomy discitis. Methods This study retrospectively analyzed demographic data, laboratory data, and radiography and magnetic resonance imaging of 10 patients with postoperative discitis who underwent surgical TLIDF followed by antibiotic treatment. Preoperative and postoperative spine sagittal alignment, visual analog scale scores, and Kirkaldy-Willis criteria for functional outcomes were evaluated. Results An infection clearance rate of 100% was ultimately achieved for the patients who underwent TLIDF with short posterior instrumentation. TLIDF yielded better outcomes than traditional conservative treatment in terms of spine alignment correction, functional outcomes, and quality of life. Conclusions Based on previously reported data and the findings of this study, we suggest that surgical intervention should be used in certain cases, as it can achieve better outcomes than conservative treatment. We recommend a novel single posterior approach with TLIDF and posterior pedicle screw instrumentation for management of postdiscectomy discitis. Highlights • A retrospective study analyzed clinical data in 10 patients with postdiscectomy discitis who underwent TLIDF. • TLIDF and IV antibiotics achieved better functional outcomes and higher infection clearance than conservative treatment. • We present a novel single posterior approach with TLIDF and short posterior pedicle screw instrumentation. • Our novel approach is a safe and effective treatment for postdiscectomy discitis. [ABSTRACT FROM AUTHOR]

Diabetic foot ulcers are a severe complication of diabetes mellitus, affecting a significant proportion of the diabetic population. In some cases, ulcer progression and infection can lead to the need for amputation. An 84-year-old male with a history of poorly controlled type 2 DM and HTN presented with an infected DFU on the plantar aspect of his right foot. This case report illustrates the successful management of an 84-year-old patient with a DFU amputation candidate, emphasizing the effectiveness of a combined treatment approach. Conventional treatment options, including antibiotic therapy, often fail to provide adequate healing in these high-risk patients. Alternative approaches, such as maggot therapy, which involves the application of sterile maggots to the wound bed, have shown promising results. This case highlights the potential therapeutic benefits and clinical efficacy of such a combined treatment approach, particularly in challenging cases with limited response to conventional therapies. Further studies and randomized trials may be warranted to support the incorporation of this therapy combination into clinical practice guidelines for DFU management. • DFUs can lead to amputation. • DFUs do not respond to common approaches. • DFUs can be managed by Maggot Therapy, Alginate Dressing, and Surgical Sharp Debridement. [ABSTRACT FROM AUTHOR]

Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes. A variety of treatments available to help heal diabetic foot ulcers, including sharp debridement, maggot therapy, and negative pressure wound therapy. This case report presents the case study of a male patient with an 8-year history of diabetes who developed a diabetic foot ulcer. The patient was undergoing treatment with metformin and insulin. Despite the severity of the ulcer, a combination therapy approach, including surgical debridement, maggot therapy, and negative pressure wound therapy, was implemented, leading to successful healing. DFUs are caused by various pathological mechanisms, the single therapy would lead to a very low level of recovery. Therefore, DFU management requires multimodal care and interdisciplinary treatment. This case study highlights the effectiveness of a multimodal treatment strategy for diabetic foot ulcers, emphasizing the importance of individualized care and combining evidence-based practices. • DFUs can lead to amputation. • DFUs do not respond to routine drug therapies. • DFUs can be managed by combination therapy. [ABSTRACT FROM AUTHOR]

Abstract Objectives The mortality of patients with bacteremic osteoarticular infections (B-OAIs) is poorly understood. Whether certain types of OAIs carry higher mortality or interventions like surgical debridement can improve prognosis, are unclarified questions. Methods Retrospective analysis of a prospective cohort of patients with B-OAIs treated at a teaching hospital in Barcelona (1985–2014), analyzing mortality (30-day case-fatality rate). B-OAIs were categorized as peripheral septic arthritis or other OAIs. Factors influencing mortality were analyzed using logistic regression models. The association of surgical debridement with mortality in patients with peripheral septic arthritis was evaluated with a multivariate logistic regression model and a propensity score matching analysis. Results Among 650 cases of B-OAIs, mortality was 12.2% (41.8% of deaths within 7 days). Compared with other B-OAI, cases of peripheral septic arthritis were associated with higher mortality (18.6% vs 8.3%, p < 0.001). In a multiple logistic regression model, peripheral septic arthritis was an independent predictor of mortality (adjusted odds ratio [OR] 2.12; 95% CI: 1.22–3.69; p = 0.008). Cases with peripheral septic arthritis managed with surgical debridement had lower mortality than those managed without surgery (14.7% vs 33.3%; p = 0.003). Surgical debridement was associated with reduced mortality after adjusting for covariates (adjusted OR 0.23; 95% CI: 0.09–0.57; p = 0.002) and in the propensity score matching analysis (OR 0.81; 95% CI: 0.68–0.96; p = 0.014). Conclusions Among patients with B-OAIs, mortality was greater in those with peripheral septic arthritis. Surgical debridement was associated with decreased mortality in cases of peripheral septic arthritis. [ABSTRACT FROM AUTHOR]

Abstract Mucormycosis is a rare clinical entity, often affect immunocompromised patients. It is an emergency situation and has poor prognosis. Prompt diagnosis with tissue biopsy, local control of the disease by aggressive surgical debridement and appropriate systemic antifungal treatment improve the prognosis and survival of the patients. Treatment of mucormycosis needs antifungal agents such as Amphotericin B and wide surgical debridement. Early diagnosis and treatment is often needed for survival of the patients. We describe a rare case of mucormycosis affecting facio-orbital area without involving sinon-nasal cavity. [ABSTRACT FROM AUTHOR]

Background: Multiple antiseptics have been described for use in total joint arthroplasty infection, and the use of multiple antiseptic solutions during a single operation has been described. Our clinical experience is that chlorhexidine (CHX) and Dakin's solution (NaOCl) interact and form a precipitate. The purpose of this study is to determine whether this reaction could be replicated in a laboratory setting, and to determine if other commonly used antiseptics also visibly react when mixed.Methods: Four percent chlorhexidine gluconate (CHX), 0.5% sodium hypochlorite (NaOCl), 3% hydrogen peroxide (H2O2), and 10% povidone-iodine (BTD) solutions were obtained and all possible combinations were mixed. Any visible reactions were noted and recorded, and a literature search was performed to characterize the reaction and products.Results: CHX and NaOCl, CHX and H2O2, and CHX and BTD reacted instantly, forming a precipitate. NaOCl and H2O2 reacted to produce a gas. NaOCl and BTD reacted and produced a color change. The literature review revealed that at least 2 of the reactions tested (CHX + NaOCl and NaOCl + H2O2) could result in byproducts toxic to humans.Conclusion: Surgeons must be aware of these interactions when using antiseptic solutions during procedures. Caution should be used combining or mixing antiseptics, and we recommend against concomitant introduction in a surgical wound. [ABSTRACT FROM AUTHOR]

Background Lack of risk stratification among patients with varying severities of compound head injury has resulted in too-inconsistent and conflicting results to support any management strategy over another. The purpose of this study was to validate a new clinico-radiological grading scheme with implications on outcome and the need for surgical debridement. Methods Patients who sustained an external compound head injury with no serious systemic injury and no pre-established infection and who continued the entire treatment were studied prospectively for their proposed grade of compound injury in relation to infective complications, unfavorable Glasgow Outcome Scale (GOS), delayed seizures, mortality, and hospital stay for 3 months. Appropriate univariate and multivariate analyses were performed. Results Among a total of 344 patients, 182 (53%) had no dural violation or midline shift (Grade 1), 56 (16%) had cerebrospinal fluid leak or pneumocephalus (Grade 2), 34 (10%) had exposed brain (Grade 3), 47 (14%) had midline shift (Grade 4), and 25 (7%) had both exposed brain and midline shift (Grade 5). Each successive grade of compound injury had significant incremental impact on all the outcome measures studied. Infective complications in Grades 1 to 5 were noted among 7%, 9%, 27%, 28%, and 36% of patients, respectively ( P < 0.001). There was a significant difference in unfavorable GOS (23% vs. 56%, odds ratio [OR] 4.3, P < 0.001) and mortality (17% vs. 42%, OR 3.5, P < 0.001) between Grades 1–2 and Grades 3–5. Delayed seizures were noted in 4%, 4%, 9%, 13%, and 16% of patients in Grades 1–5 ( P = 0.04). The median hospital stay was 1, 3, 6, 6, and 8 days, respectively ( P < 0.001). All patients in Grades 4–5 (72) underwent surgery. Only 32 of 182 (18%) patients in Grade 1, 9 of 56 (16%) patients in Grade 2, and 23 of 34 (68%) patients in Grade 3 underwent surgical debridement, whereas the rest were managed conservatively. Patients who were managed conservatively had significantly lower infective complications (3% vs. 25%, OR 9.67, P < 0.001) in Grade 1, and (2% vs. 44%, OR 36.8, P = 0.002) in Grade 2, compared with those who underwent surgical debridement. In multivariate analysis, the proposed grade had significant independent association with infection ( P < 0.001), unfavorable GOS ( P = 0.01), delayed seizures ( P = 0.001), and hospital stay ( P < 0.001), and each successive grade had significant incremental impact on both infective complications and unfavourable GOS, independent of GCS and other prognostic factors. Conclusion The new grading scheme appears to be of practical clinical significance. It shows significant statistical associations with the rates of infection, unfavorable neurologic outcome, delayed seizures, mortality, and duration of hospital stay. The incremental impact of each successive grade on infective complications and unfavorable GOS was independent of GCS and other prognostic factors. Conservative management had significantly lower infection compared to surgical debridement, at least in patients with Grades 1 and 2. [ABSTRACT FROM AUTHOR]

The present study aims to assess the results of single-stage instrumentation and fusion at the time of surgical debridement of spinal infections; vertebral osteomyelitis or epidural abscess. Nine patients with spinal infection were treated with instrumentation and fusion after radical debridement in a single-stage operation. Predisposing factors and comorbidities, pain, American Spinal Injury Association motor scores, primary pathologies, microbiology and perioperative markers were recorded. Seven patients with pyogenic and two with tuberculous spinal infection were encountered; the most common pathogen was Staphylococcus aureus . Five patients were predisposed to infection because of diabetes mellitus. Duration of antibiotic therapy lasted up to 12 months. Six patients had thoracic infection, two lumbar and one cervical. No post-operative complications were encountered. There was a significant reduction in pain scores compared to pre-operatively. All patients with neurological deficits improved post-operatively. Despite introduction of hardware, no patients had a recurrence of their infection in the 12 month follow up period. Single-stage debridement and instrumentation appeared to be a safe and effective method of managing spinal infections. The combination of debridement and fusion has the dual benefit of removing a focus of infection and stabilising the spine. The current series confirms that placing titanium cages into an infected space is safe in a majority of patients. Stabilisation and correction of spinal deformity reduces pain, aids neurologic recovery and improves quality of life. The small patient population and retrospective nature limit the present study. [ABSTRACT FROM AUTHOR]

Necrotizing soft tissue infections (NSTI) are caused by toxin-producing bacteria and fungi that results in rapid progression of disease with significant local tissue destruction. We present a case report of a 57-year-old male patient in line with the SCARE 2020 criteria. He was admitted to the emergency department with a small abrasion on the right antero-lateral chest wall, and a diffuse necrotic patch of skin and soft tissues with purulent discharge. Clinical examination, routine blood investigations, CT scan chest, and chest x-ray were performed. Patient underwent debridement six times, followed by negative pressure wound therapy (NPWT). After negative culture report, Integra Meshed Dermal Regeneration Template (IMDRT), measuring 4 × 5 in. was applied and NPWT continued. The outer layer of IDRT was removed on Day 19. Split thickness skin grafting (STSG) was performed once neodermis formation was confirmed. NPWT was continued post skin grafting for a week. IDRT was successfully taken up over the raw area with exposed lung. Patient was discharged 10 days after STSG. The patient's condition improved remarkably and he was able to breathe normally. There was no puckering or tethering effect on the grafted area and not much fibrosis. He showed speedy recovery with healed donor site and 100% uptake of grafted tissue. IDRT along with NPWT is an effective and useful technique for spontaneous regeneration of the dermis and basement membrane to promote wound healing in traumatic patients with NSTIs. Level V. Therapeutic. • IDRT results in formation of neodermis. • Neodermis forms through deposition of collagen matrix by patient's own fibroblasts. • IDRT may be considered in massive chest wall soft tissue defects NSTIs. • Useful in patients with failed myocutaneous flaps. • Can be used when free tissue transfer is indicated. [ABSTRACT FROM AUTHOR]

Introduction Necrotizing fasciitis (NF), a necrotizing infection of the soft tissue, is a medical emergency usually occurring in the lower extremities and abdominal regions and often difficult to diagnose promptly. Presentation of case This case report looks at one atypical presentation of NF with the unusual location of the vulva and no known associated comorbidities or risk factors. Discussion Diagnosing this patient was particularly difficult due to the inconsistent clinical, laboratory and imaging findings. The CT scans and WBC count were indicative of NF, but the LRINEC score was not high enough to make the diagnosis of NF. As a result, we relied on the hemodynamic instability and clinical findings of the physical exam to be strong indicators of NF, and acted on that indication. Conclusion Acting quickly on the hemodynamic findings and suspicion as opposed to waiting for a confirmed diagnosis resulted in a good prognosis since immediate surgical debridement is imperative to surviving this acute condition. Despite major advancements in the imaging modalities and the introduction of a laboratory score, our case suggests that the diagnosis still heavily relies on clinical findings, such as hemodynamic instability. Furthermore, our case suggests that NF should be included in the differential regardless of atypical location and lack of common clinical associations. [ABSTRACT FROM AUTHOR]

Abstract: Necrotizing fasciitis (NF) of cervical region is an uncommon sequelae of odontogenic infection. It has been described in the past with different names such as hospital gangrene, necrotizing erysipelas, haemolytic streptococcal gangrene, suppurative fasciitis, bacterial synergistic gangrene and acute dermal gangrene [1,2]. It is a highly aggressive infectious process characterized by spread along the fascial planes. It can rapidly involve overlying skin, subcutaneous tissues, muscle, and other adjacent soft tissue structures. The most frequently involved areas are the thorax, limbs, perineum, abdomen, and groin [3,4]. Occurrence in the head and neck region is relatively rare. The most common causes of cervical necrotizing fasciitis are odontogenic infection, blunt trauma, radiotherapy, and necrotizing fasciitis of unknown origin. It is a debilitating condition, with a high mortality rate and poor prognosis is aggravated with development of mediastinitis and septic shock. The predisposing factors include diabetes mellitus, steroid administration, arteriosclerosis, chronic renal failure, hypothyroidism, obesity, alcoholism, cancer, cirrhosis, drug abuse, and a poor nutritional state, as it involves suppression of host defence mechanism. We present two cases of NF, originating from odontogenic infection, successfully managed in our department. [Copyright &y& Elsevier]

Actinomycosis is a chronic granulomatous disease associated with the Actinomyces species. This unusual condition, especially in the musculoskeletal system, has been considered a diagnostic challenge due to its initial non-specific symptoms requiring high clinical suspicion and an adequate diagnostic approach for its identification. We present the case of a 39-year-old Hispanic female with right knee pain and associated purulent secretions for the past four years, who demonstrated persistent synovial actinomycosis despite arthrotomy with cleansing and debridement plus a long-term antibiotic regime. Actinomyces species remain a rare cause of musculoskeletal disease. Its presentation could include localized swelling, tissue fibrosis, sinus tracts, or an abscess, yet these symptoms are not specific, requiring high clinical suspicion to avoid a potential misdiagnosis. Culture in an anaerobic media and pathologic specimens are vital diagnostic tools. Among the treatment alternatives, antimicrobial therapy and surgery are usually required to manage bone and joint infections. Adequate antibiotic selection is crucial, as suboptimal treatment could promote the development of a persistent infection. This case highlights the diagnostic challenge of synovial actinomycosis, a rarely reported condition in native knee joints. High clinical suspicion is critical as early diagnosis, and adequate management is essential to avoid a persistent infectious process. • Consider Actinomyces species among the atypical organisms causing native joint infection. • Culture in anaerobic media and pathologic specimens are essential diagnostic tools. • Penicillin remains the drug of choice in the treatment of Actinomycosis. • This case contributes to the scarce literature regarding Actinomycosis in native joints. [ABSTRACT FROM AUTHOR]

Introduction: Burn in the elderly has a high mortality. Scoring systems incorporating age, and/or co-morbidities have been developed to assist in predicting outcomes in this high risk group. Life expectancy has increased in the general population and within the elderly age group medical co morbidity, physiological response to injury and socioeconomic factors give rise to the concept of biological versus chronological age. For a given age, baseline pre morbid state can vary. It is more valid to consider biological rather than chronological age when calculating risk. The Canadian Study of Health and Aging (CSHA) clinical frailty scale, incorporating fitness, co-morbidities and level of dependence was used to analyse our elderly burn patients admitted to Burns ITU, their surgical management and one-year survival. Method: Data from patients with burns greater than 10% and aged over 65years managed on the Burns ITU between 2005 and 2009 were obtained. A frailty score (1–7) was assigned to each patient based on the records of their admission assessment. 42 patients met the study criteria for analysis. 18 (42.9%) patients, with mean age 74.9years (range 65–95years) survived (S) their ITU stay and of these, 83.3% survived at 1year. 24 (57.2%) patients, mean age 78.4years (range 66–95years) died (D) whilst on ITU. There was no significant difference between the two groups with regard to age, percentage burn (30% TBSA range 10–85%) (P >0.05 using T Test) or inhalational injury (p >0.05 using Z test). Using Mann–Whitney U test analysis, the frailty score between the two groups showed a significant difference at p =0.0001 (Mann–Whitney U test=78), median=3 (S) and median=5 (D). This suggests patients with better pre-morbid capacity, as evaluated by the frailty scoring system, were more likely to survive their burn insult and treatment. Significantly, more patients in the group that survived underwent surgical debridement (Mann–Whitney U test=111, p =0.02). Conclusion: Frailty scoring system appears to be a useful adjunct in predicting outcome in burns requiring admission to HDU/ITU in the senior population. The frailty score may predict which patients will benefit from surgery which also continues to be an important determinant of outcome in these patients. [Copyright &y& Elsevier]

Abstract: Introduction: Pyoderma gangrenosum (PG) is an uncommon, but serious, non infectious, neutrophilic dermatosis that causes cutaneous necrosis with a characteristically rapid evolution. Presentation of case: A 13 year-old girl was admitted with a postoperative infected wound, which was surgically debrided. A new more aggressive lesion on the left upper extremity led the patient to the intensive care unit. Clinical diagnosis of pyoderma gangrenosum was introduced with a crucial delay. An immediate clinical improvement after immunosuppressive therapy with systemic corticosteroids and cyclosporine was observed. The extensive cutaneous deficits were covered with keratinocyte cultured cells with an aesthetically good outcome. Discussion: Diagnosis of PG in young children is very difficult, especially without dermatological evaluation. This deforming ulcerative skin disease is probably a result of altered immunologic reactivity. Its early recognition may prevent unnecessary surgical treatment which leads to dangerous complications. Conclusion: To our knowledge this is the first case of PG with such a widespread distribution reported in a child, as a consequence of iatrogenic pathergy. [Copyright &y& Elsevier]

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Interventional therapy in necrotizing pancreatitis is evolving. Efforts to modify or prevent pancreatic necrosis by intra-arterial infusion of antibiotics and antiproteases have been described. Moreover, traditional approaches to the surgical management of infected pancreatic necrosis are being challenged by a host of endoscopic and percutaneous techniques. While these approaches are potentially valuable additions to interventional therapy in necrotizing pancreatitis, few evidence-based studies are available to support their supplanting more traditional approaches at this time. Cooperative evidence-based multiinstitutional studies will be required to address the validity of these proposals. [ABSTRACT FROM AUTHOR]

One hundred-six patients underwent emergency debridement of a deep foot space abscess. While 43 patients were admitted after an outpatient visit with immediate surgical debridement (group A), 63 patients were transferred from other hospitals after a mean stay of 6.2 ± 7.5 days without debridement (group B). No significant differences were observed in the demographic and clinical features between the 2 groups, except for the following differences in group B: higher blood glucose level on admission (P = .015), lower serum albumin level (P = .005), and a more frequent extension of the infection to the heel (P = .005). Eradication of the infection was obtained in group A without amputation in 9 patients, with an amputation of 1 or more rays in 21, with metatarsal amputations in 12, and with a Chopart amputation in 1. In group B, incision and drainage alone were performed in 4 patients, amputation of 1 or more rays in 21, metatarsal amputations in 10, Chopart amputations in 23, and an above-the-ankle amputation in 5. The amputation level was significantly more proximal in group B (χ2 = 24.4, P < .001). There was no significant difference in the presence of peripheral arterial occlusive disease between the 2 groups (P = .841). Regression logistic analysis showed a significant relationship between the amputation level and the number of days elapsed before debridement (odds ratio, 1.61; P = .015; confidence interval, 1.10-2.36), but not with the presence of peripheral occlusive disease (odds ratio, 1.73; P = .376; confidence interval, 0.29-15.3). These data show that a delay in the surgical debridement of a deep space abscess increases the amputation level. Accuracy in the diagnosis of peripheral occlusive disease and immediate revascularization yield similar outcomes in patients with or without peripheral occlusive disease. [Copyright &y& Elsevier]

Abstract: Bumblefoot is a progressive, granulomatous pedal disease primarily affecting large species of raptors maintained in captivity. Disease is usually initiated by repeated trauma to weight-bearing plantar skin surfaces causing devitalization and allowing subsequent invasion of bacterial pathogens. Treatment failure and disease recurrence have been common, because prior regimes have failed to address the granulomatous nature of the disease and the initiating cause. The author found that a 4-pronged therapeutic regime consisting of (1) systemic antibiotic therapy, (2) direct intralesional antibiotic delivery, (3) surgical debridement, and (4) postoperative protective foot casting has offered the most effective therapy for the majority of bumblefoot cases to date. The following is a step-by-step illustrated guide to achieving each phase of therapy with an accompanying explanation of the importance of each phase. [Copyright &y& Elsevier]

Abstract: Necrotizing fasciitis of the perineum is a rare but of fast evolution, and potentially fatal infectious disease process. It is characterized by progressive inflammation and extensive necrosis of subcutaneous tissue involving the fascia and other adjacent tissues. This infection may be idiopathic or secondary to local trauma or pelvic surgery. Its mortality rate is 20%. We report a case of necrotzing fasciitis of the perineum in a 34-year-old woman following incision and drainage of Bartholin''s gland abscess. Streptococcus A, Proteus mirabilis, Escherichia coli, and Candida albicans were isolated. Intravenous broad spectrum antibiotic therapy was promptly instituted. Concurrent surgical debridement of all necrotic areas was required. Post debridement therapy required a long period of dressing changes until cicatrisation. Necrotizing fasciitis of the perineum is a surgical emergency. Early diagnosis and prompt aggressive debridement are the keys to successful management. [Copyright &y& Elsevier]

Background context: Vertebral osteomyelitis can be successfully treated with spinal immobilization and parenteral antibiotics. Failure of medical therapy may necessitate surgical treatment consisting of anterior debridement and structural anterior column reconstruction. Autologous structural bone graft has traditionally been the gold standard in anterior column reconstruction. Because of the morbidity related to graft harvest, vertebral body replacement cages have emerged as a viable option for reconstructing a deficient anterior column.Purpose: To evaluate the efficacy of titanium mesh cages in the reconstruction of anterior column defects in the presence of active pyogenic infection.Study design: Prospective case series.Methods: Eleven patients underwent operative treatment for osteomyelitis of the thoracolumbar spine using staged anterior debridement and reconstruction with cylindrical titanium mesh cages followed by delayed posterior spinal fusion with pedicle screw instrumentation during a 2-year period. Patients were postoperatively evaluated clinically and radiographically.Results: Follow-up averaged 17±9 months. Average increase in kyphosis of 10±6 degrees corresponding to 4±4 mm loss in the height (subsidence) of the anterior construct. One patient died during revision surgery for hardware failure. Seven of the remaining 10 patients have not required antibiotics after the initial postoperative course of treatment. Three patients are maintained on chronic suppressive therapy as a precaution. There has been no evidence of recurrence or residual infection in any patient. Seven of the 10 patients were pain free at latest follow-up. There has been one case of pseudarthrosis.Conclusion: Cylindrical titanium mesh can be used with consistently good results for large anterior column defect reconstructions even in the face of active pyogenic infection. In our cohort of patients with pyogenic vertebral osteomyelitis, the use of titanium mesh cages has not been associated with early recurrence of infection. [Copyright &y& Elsevier]

Summary: We describe a case of successful treatment of cutaneous zygomycosis using a combination of extensive surgical debridement and the oral antifungal agent, posaconazole. [Copyright &y& Elsevier]

Necrotizing soft tissue infections (NSTIs) are rare but often lethal. Early diagnosis and aggressive surgical debridement are essential to achieve the best possible outcome. A 12-year old boy was diagnosed with a necrotizing soft tissue infection following elective revision surgery for functional impairment resulting from scar tissue of the neck. Fever and inflammation of the surgical wound manifested 24–36 hours postoperatively. Antibiotic therapy with amoxicillin-clavulanic acid was initiated, but the patient was unresponsive. Ultrasonography, a wound culture and surgical exploration confirmed the diagnosis. The culture was positive for a Streptococcus pyogenes infection and antibiotic treatment was switched to penicillin and clindamycin. Following the diagnosis, surgical debridement was performed subcutaneously, and only necrotic tissue was removed to preserve as much skin tissue as possible. After eradication of the infection, vacuum-assisted closure of the wound was used to close the subcutaneous space. The patient was discharged after 40 days. In this patient, we treated a necrotizing soft tissue infection with antibiotics, skin sparing surgeries and negative pressure wound therapy (NPWT). We used ultrasonography as imaging technique to help with the diagnosis. The extensiveness of surgical debridement was rather limited. We focused on opening all affected fascial layers. The surgical debridement was subcutaneous, and only necrotic tissue was removed. Because of the location in the neck, we tried to avoid an aggressive skin debridement to preserve as much skin tissue as possible. Negative pressure wound therapy is not frequently used in this context but it contributed to an enhanced wound healing. Ultrasonography for diagnosing NSTIs is useful, but the clinical findings and an explorative surgery will remain most important. [ABSTRACT FROM AUTHOR]

A 4-year-old, 20 kg, female mixed breed dog was referred to our Veterinary Teaching Hospital for severe respiratory distress. Thoracic ultrasonography revealed severe pleural effusion with multiple anechoic cystic structures within the fluid. Abdominal cavity presented few small and irregular cystic structures. Diagnosis of infection by larval stages of Mesocestoides spp. on the basis of a PCR approach was performed and therapy with oral fenbendazole was started. Due to an incomplete clinical response, the dog underwent to remove metacestodes cysts by surgical debridement. The dog showed no recurrence of clinical signs for 12 months after the surgery. Pleural larval cestodiasis should be added as a differential diagnosis in the list of diseases causing pleural effusion in dogs. [ABSTRACT FROM AUTHOR]

Abstract: Cervical necrotizing fasciitis is a fast spreading acute soft tissue inflammation. Death can occur within 12–24h. Early identification and treatment is needed. We report the case of a 75 year old woman with diabetes and high cholesterol, adipositas who developed cervical necrotizing fasciitis of odotongenic origin with massive subcutaneous air collection and first sign of septicaemia. Surgical treatment with debridement and drainage in combination with intravenous broadbased antibiotics as well as daily irrigation of the wound with iodine solution (Betaisodona®) and metronidazol (local antibiotic treatment) was performed. The patient recovered completely. Surgical debridement combined with broad-spectrum of antibiotics showed satisfying result for the management of cervical necrotizing fasciitis of dentogenous origin. [Copyright &y& Elsevier]

Blending two polymers is an effective technique to obtain a novel material with desirable properties. Chitosan (CH) has limited applications in tissue engineering owing to its poor mechanical strength in a wet state. Polycaprolactone (PCL) has low toxicity with good mechanical strength and controlled release properties, but lack cell recognition signals. Thus, the blending of CH and PCL (CH/PCL) polymers would provide a better biomaterial required for the management of chronic osteomyelitis (OM) after surgical debridement possessing superior physicomechanical and controlled release properties. Herein, blend sponges using different ratios of CH and PCL, i.e., 100%CH/00%PCL, 75%CH/25%PCL, 50%CH/50%PCL and 25%CH/75%PCL were prepared, which are denoted as 100CH/00PCL, 75CH/25PCL, 50CH/50PCL and 25CH/75PCL, respectively. These blend sponges were characterized using FTIR, XRD, DSC, SEM, and contact angle. The results revealed that CH and PCL polymers were well dispersed in a blend at a molecular level without any chemical interactions. Blend sponges were loaded with ciprofloxacin hydrochloride (CIP) and ibuprofen. Further, in vitro efficacy of drug-loaded blend sponges was evaluated for drug release, antibacterial potential, and anti-inflammatory activity. Amongst four blend sponges, the 75CH/25PCL sponge demonstrated the controlled release of ibuprofen and an ideal release profile of CIP along with potential antibacterial as well as anti-inflammatory activity over the study period. Thus, it can be concluded that the 75CH/25PCL sponge is a promising candidate for the management of chronic OM after surgical debridement. [ABSTRACT FROM AUTHOR]

Abstract: Pyogenic liver abscess in the pediatric population is a rare entity and can be difficult to manage. Surgical infections caused by Streptococcus anginosus are exceedingly rare. Here we present a case of pyogenic liver abscess caused by S anginosus in an adolescent presenting with fever, nausea, emesis, and right upper quadrant abdominal discomfort. [Copyright &y& Elsevier]