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Introduction Necrotizing soft tissue infections (NSTIs) carry high morbidity and mortality. While early aggressive surgical debridement is well-accepted treatment for NSTIs, the optimum duration of adjunct antibiotic therapy is unclear. An increasing focus on safety and evidence-based antimicrobial stewardship suggests a value in addressing this knowledge gap. Objective To determine whether shorter antibiotic courses have similar outcomes compared to longer courses in patients with NSTI following adequate source control. Population 142 consecutive patients with surgically managed NSTI were identified on retrospective chart review between December 2014 and December 2018 at two academic medical centers. Results Patients were predominately male (74%) with a median age of 52 and similar baseline characteristics. The median number of debridements to definitive source control was 2 (IQR 1-3) with the short course group undergoing a greater number of debridements control 2.57 ± 1.8 vs 1.9 ± 1.2, ( P = .01). Of 142 patients, 34.5% received a short course and the remaining 65.5% received a longer course of antibiotics. There was no significant difference in the incidence of bacteremia or wound culture positivity between groups. There was also no significant difference in in-hospital mortality, 8% vs 6% ( P = .74), incidence of C. difficile infection, median length of stay, or 30-day readmission. Conclusion Provided adequate surgical debridement, similar outcomes in morbidity and mortality suggest antibiotic courses of 7 days or less are equally safe compared to longer courses.

Invasive fungal rhinosinusitis (IFRS) is a serious illness requiring early diagnosis, surgical debridement, and administration of antifungals. We report a case of an acute IFRS caused by Curvularia in a patient with diabetes mellitus. An 18-year-old female presented to the emergency department with an acute onset of fever, headache, facial discomfort, and a blood glucose reading of 500 mg/dL. The patient was admitted for the management of hyperosmolar hyperglycemia. Her past medical history includes uncontrolled type 1 diabetes mellitus and a recent toothache. A computed tomography scan of the facial maxillary region revealed sinus disease with bony erosion. Empiric therapy with liposomal amphotericin B 400 mg i.v. every 24 hours, piperacillin/tazobactam 4.5 g i.v. every 6 hours and vancomycin 1 g i.v. every 12 hours was started. A functional endoscopic sinus surgery revealed invasive rhinosinusitis and cultures were positive for fungal elements. The patient was discharged on liposomal amphotericin B 400 mg i.v. daily and cefuroxime 500 mg orally twice daily. However, she was readmitted for the management of acute kidney injury and was discharged on itraconazole capsules 200 mg orally twice daily. Sinus cultures grew Curvularia and itraconazole was prescribed for 6 weeks, but the patient discontinued treatment after 3 weeks and had no signs or symptoms of rhinosinusitis when she was last seen in the clinic. The possibility of IFRS should be explored in patients with diabetes and signs and symptoms of rhinosinusitis.

Nonhealing leg ulcers are a major health problem worldwide with a high economic burden since they require human and material resources. Moreover, nonhealing ulcers are a major nontraumatic cause of lower limb amputations. Dermal substitutes have emerged as an effective therapeutic option for treatment of skin lesions, but data on leg ulcers are scarce. We evaluated safety and efficacy of a porcine-derived dermal substitute in the treatment of chronic vascular leg ulcers. Records of patients with nonhealing ulcers seen at our unit from 2018 to 2019 were retrospectively reviewed. Wound etiology, wound area, and complications were evaluated. Each patient received one application of porcine-derived dermal substitute and was followed-up. Six patients (5 females and 1 male) with a mean age of 61.3 (52-81) years presented with nonhealing leg ulcers. After surgical debridement and wound bed preparation, porcine-derived dermal substitute was applied onto the ulcer. Granulation was satisfactory within 10 days. All wounds healed after an average time of 14 weeks. Graft take was good, and no graft loss, rejection, or associated infection were observed. In conclusion, the data presented indicate that dermal substitutes are safe and effective for treatment of chronic nonhealing vascular leg ulcers.

Comprehensive management of a severe diabetic foot infection focus on clear treatment pathways. Including rapid, radical debridement of all infection in addition to intravenous antibiotics and supportive measures. However, inexperienced surgeons can often underestimate the extent of infection, risking inadequate debridement, repeated theatre episodes, higher hospital morbidity, and hospital length of stay (LOS). This study aims to assess protocolized diabetic-foot-debridement: Red-Amber-Green (RAG) model as part of a value-based driven intervention. The model highlights necrotic/infected tissue (red-zone, nonviable), followed by areas of moderate damage (amber-zone), healthy tissue (green-zone, viable). Sequential training of orthopedic surgeons supporting our emergency service was undertaken prior to introduction. We compared outcomes before/after RAG introduction (pre-RAG, n = 48; post- RAG, n = 35). Outcomes measured included: impact on number of debridement/individual admission, percentage of individuals requiring multiple debridement, and length-of-hospital-stay as a function-of-cost. All-patients fulfilled grade 2/3, stage-B, of the Texas-Wound-Classification. Those with evidence of ischemia were excluded. The pre-RAG-group were younger (53.8 ± 11.0 years vs 60.3 ± 9.2 years, P = .01); otherwise the 2-groups were matched: HbA1c, white blood cell count, and C-reactive protein. The post-RAG-group underwent significantly lower numbers of debridement’s (1.1 ± 0.3 vs 1.5 ± 0.6/individual admission, P = .003); equired fewer visits to theatre (8.6% vs 38%, P = .003), their LOS was reduced (median LOS pre-RAG 36.0 vs post-RAG 21.5 days, P = .02). RAG facilitates infection clearance, fewer theatre-episodes, and shorter LOS. This protocolized-management-tools in acute severely infected diabetic foot infection offers benefits to patients and health-care-gain.

Myiasis is defined as an infestation of the organs or tissues of live vertebrates (humans or animals) by dipterous larvae, commonly referred to as maggots. Wound myiasis is a common presentation in the emergency department. The presence of wild maggots and larvae in wounds is concerning for subsequent myiasis-induced infections and complications. Proper extraction of wild maggots and larvae is required to avoid complications that may occur with wound myiasis. Surgical debridement is often utilized to extract wild maggots and larvae, but can be painful and time-consuming. There is limited literature available on alternative approaches for removal of wild maggots and larvae. We present a case of lower extremity wound myiasis that had wild maggots and larvae successfully removed with no complications using ether. This procedure is a novel, noninvasive, and pain-free way to extract wild maggots and larvae from wound myiasis.

Objectives: Invasive fungal rhinosinusitis is a rare, life-threatening condition that affects the paranasal sinuses. The standard of care after diagnosis includes surgical debridement and aggressive medical management. Despite treatment, mortality remains unacceptably high. Most data are derived from small cohort experiences, with limited identification of mortality risk factors in the acute setting. The authors used a large national database to better understand clinical factors associated with inpatient mortality for this challenging condition. Methods: Using the 2000-2014 National (Nationwide) Inpatient Sample database, the authors identified 979 adult patients with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of mucormycosis or aspergillosis and a procedure code of sinus surgery. Multivariate imputation by chained equation was performed to account for missing data, followed by multivariate logistic regression to identify predictors of inpatient mortality. Results: In total, 979 adult patients were identified, with a median age of 57 years. The inpatient mortality rate was 15.8%. The most prevalent comorbidity was hematologic disorders (42.9%). Mucormycosis versus aspergillosis was associated with increased odds of inpatient mortality (odds ratio, 2.95; 95% confidence interval, 2.00-4.34; P < .001). The odds of inpatient mortality were significantly increased between patients with hematologic disorders and those without (odds ratio, 1.92; 95% confidence interval, 1.08-3.39; P = .024). Diabetes (odds ratio, 0.53; 95% confidence interval, 0.34 − 0.80; P = .003) was associated with the lowest odds of inpatient mortality. Conclusions: This represents the first population-based study evaluating the factors associated with inpatient mortality. These findings support prior observations demonstrating that the underlying immune dysfunction and type of fungal infection are important predictors of early mortality.

Head and neck necrotising soft-tissue infection is exceptionally uncommon in the paediatric population. necrotising soft-tissue infection is severe and often life-threatening. Rapid spread of infection and systemic illness make necrotising soft-tissue infection a challenge for the medical and surgical teams. Early identification and surgical intervention are essential for a favourable patient outcome. This report details the case of periorbital necrotising soft-tissue infection in a 12-year-old male patient following an uncomplicated facial laceration. Prompt surgical debridement with planned return visits to theatre and guided empirical antibiotic therapy ensured that a satisfactory patient outcome was achieved. The failure of current necrotising soft-tissue infection diagnostic scoring tools to be positive in this case may suggest that these tools require refinement and validation.

Malignant fungating wounds (MFWs) represent a major problem for public health. The most common symptoms associated with MFWs are pain, exudate, bleeding and odor. The aim of the study was to optimize the local management and dressing of MFWs. We developed a standardized 4- step approach to MFWs based on Pain, Exudate, Bleeding and Odor management in a case series of 24 patients: we call this the PEBO approach. We analyzed etiologies, localization, Quality of Life (QoL), pain and clinical signs and symptoms. We assessed the ulcers at baseline, after two weeks and after one month. In our study, most patients showed an improvement in the QoL using PEBO approach, although some experienced a deterioration in their general clinical conditions. Non-cytolesive cleansing, atraumatic dressings were applied to allow pain relief. Non-adherent dressings were combined with a secondary dressing in the case of exudate. Achieving hemostasis with dressing or medication is a priority in MFW management. Antibacterial dressings and odor absorbent dressings were used for odor absorption. Surgical debridement, adherent dressing and occlusive dressings were avoided. Dressing changes were programmed twice a week for four weeks. PEBO simplified the complex aspects of this type of ulcer, and could help physicians, nurses, and also the rest of the team, including the patients themselves and their family, in the multidisciplinary palliative care of MFWs.

Category: Diabetes Introduction/Purpose: Diabetic foot infection (DFI) is a devastating condition which poses risk to both life and limb. Treatment principles revolve around surgical debridement, dead space management, delivery of both local and systemic antibiotics and soft tissue cover. Dead space management and local antibiotic delivery can be achieved simultaneously by using an antibiotic loaded bone substitute. We report our retrospective case series of patients treated with surgical management involving local antibiotic delivery via calcium sulphate bone substitute (Stimulan™; Biocomposites, Keele, UK). Methods: All patients between January 2015 and June 2018 with DFI and proven bony involvement presenting to our university teaching hospital were treated via our extensive MDT approach. A total of 102 patients were included. Surgical debridement was performed along with simultaneous insertion of 10 ml calcium sulphate with 1 g vancomycin and 240 mg gentamycin. Outcome was classified as resolved, requiring prolonged treatment from other medical (endocrinologist) or surgical (plastic surgery, limb reconstruction) services or salvage surgery in the form of proximal amputation. Results: 45.1% of patients had a partial amputation at the index surgery. 52% had bony debridement and just 2.9% had soft tissue debridement in conjunction with calcium sulphate insertion. The surgical wound was primarily closed in 56.8% of patients. 7 patients had delayed wound closure and 36.2% of patients healed via secondary intention. 74 patients (72.5%) had resolution of their DFI with bony involvement following surgical intervention. 21 (20.6%) patients needed further treatment from allied specialties. 7 (6.9%) patients required salvage surgery in the form of a below knee amputation. There was no correlation between either closure type (2 p-value 0.75) or index surgery type and outcome (2 p-value 0.64). Conclusion: DFI is a difficult clinical scenario to treat effectively. An MDT approach is undoubtedly key to a good outcome. We believe that the use of calcium sulphate can be a useful adjunct at the time of surgical debridement to aid in both dead space management and allow local antibiotic delivery.

Purpose: To identify the independent risk factors for adverse outcomes and determine the effect of L5-S1 involvement on the outcome of surgical treatment of lumbar pyogenic spondylitis (PS). Methods: A retrospective analysis was performed for all consecutive patients who underwent surgery for lumbar PS between November 2004 and June 2020 at a single institution. The patients were divided into two groups based on the outcomes: good and adverse (treatment failure, relapse, or death). Treatment failure was defined as persistent or worsening pain with C-reactive protein (CRP) reduction less than 25% from preoperative measurement or requiring additional debridement. Relapse was defined as the reappearance of symptoms and signs with an elevated white blood cell count, erythrocyte sedimentation rate, and CRP after the first period of treatment. Binary logistic regression analyses were performed to identify the independent risk factors for adverse outcomes. Results: Twenty-four (21.2%) of the 113 patients were classified as having adverse outcomes: treatment failure, relapse, and death occurred in 15, 7, and 2 patients, respectively. The involvement of L5-S1 (adjusted odds ratio [aOR] = 6.561, P = 0.004), Methicillin-resistant Staphylococcus aureus (MRSA) infection (aOR = 6.870, P = 0.008), polymicrobial infection (aOR = 12.210, P = 0.022), and Charlson comorbidity index (CCI; P = 0.005) were identified as significant risk factors for adverse outcomes. Conclusion: Involvement of L5-S1, MRSA, polymicrobial infection, and CCI were identified as independent risk factors for adverse outcomes after surgical treatment of lumbar PS. Because L5-S1 is anatomically demanding to access anteriorly, judicious access and thorough debridement are recommended in patients requiring anterior debridement of L5-S1.

Necrotizing fasciitis is a rare and life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. These children should be managed promptly with broad-spectrum antibiotics and possible surgical debridement. Here, we present a 5-week-old female infant who presented with fever and ulcer on right lower jaw. She had a sudden onset of darkening of the right lower jaw, which progressed to reddish discoloration, and then an ulcer developed in the middle of this area of discoloration. She had a tender swelling extending from the right pre-auricular area to the right upper neck, crossing the right jaw and extending toward the right cheek and maxillary area. Swelling had areas of hyperpigmentation with an ulcer measuring 2 by 3 cm at the center of the lesion, oozing purulent fluid, and Staphylococcus aureus was cultured. The surgeons conducted incision and debridement in theater after suspecting necrotizing fasciitis of the jaw and the baby was kept on intravenous antibiotics, antiretroviral therapy and was dressed daily. The child fared well thereafter.

Background: Purpura fulminans is a condition characterized by rapidly evolving skin necrosis and disseminated intravascular coagulation. Early recognition and aggressive supportive management has led to a decrease in its mortality rate, but most of these patients must undergo extensive soft tissue debridement and partial or total limb amputation. There is controversial evidence about the timing of surgery, suggesting that some patients may benefit from delayed debridement with limb preservation. Methods: We present a case of an 86-year-old patient who developed skin necrosis of his four limbs after infectious purpura fulminans. He was treated in the ICU with supportive measures and antibiotic treatment. Surgical debridement was delayed for 4 weeks until necrosis delimitation. Results: Only upper extremity debridement was necessary. Four fingers, including one thumb, were salvaged and successfully treated with semi-occlusive dressing without complications. Conclusion: Early recognition of infectious PF and timely supportive management are important pillars of its treatment. Delayed surgical debridement allows for less aggressive resection and good functional outcome.

Background: The effect of microfracture (MF) or surgical debridement of concomitant full-thickness cartilage lesions in anterior cruciate ligament–reconstructed knees on patient-reported outcomes remains to be determined. Purpose: To evaluate the effect of debridement or MF compared with no surgical treatment of concomitant full-thickness cartilage lesions on patient-reported outcomes 5 years after anterior cruciate ligament reconstruction (ACLR). Study Design: Cohort study; Level of evidence, 2. Methods: Included in this study were 644 patients who were registered in the Norwegian and the Swedish National Knee Ligament Registries from 2005 to 2008 as having undergone unilateral primary ACLR and having a concomitant full-thickness cartilage lesion (International Cartilage Repair Society [ICRS] grades 3-4). Of these patients, 129 were treated with debridement, 164 were treated with MF, and 351 received no surgical treatment simultaneously with ACLR. At 5-year follow-up, 368 (57%) patients completed results on the Knee injury and Osteoarthritis Outcome Score (KOOS). Multivariable linear regression was used to estimate the effect of surgical debridement or MF of concomitant full-thickness cartilage lesions on patient-reported outcomes 5 years after ACLR. Results: Compared with no surgical treatment, there were no unadjusted or adjusted effects of debridement or MF of concomitant full-thickness cartilage lesions on KOOS scores at 5-year follow-up. Conclusion: Compared with leaving concomitant full-thickness cartilage lesions untreated at the time of ACLR, debridement and MF showed no effect on patient-reported outcomes 5 years after surgery.

The purpose of this study was to establish the safety of negative pressure wound therapy (NPWT) in the treatment of acutely debrided, deep diabetic foot infections (DDFI) and to determine the value of inflammatory markers in monitoring of treatment of these infections with negative pressure wound therapy.A group of ten patients with DDFI treated by radical surgical debridement and simultaneous NPWT was prospectively studied. During the debridement, a deep tissue sample was obtained and sent for microbiological testing. The patients were followed clinically for 10 days and NPWT dressings were changed every 2 to 3 days or sooner when indicated. The peripheral blood samples were obtained before the radical debridement and 3 and 10 days afterwards and concentrations of white blood cell, neutrophils, lymphocytes and C-reactive protein (CRP) were measured. The changes in concentration of inflammatory markers were analyzed with a Friedman test.In all but one patient the presence of DDFI was confirmed by the culture results. At baseline, the elevated WBC and neutrophil concentrations were observed only in half of the patients while the CRP concentration was elevated in nine patients. During followup, all patients showed a favorable clinical evolution and statistically significant decrease of WBC, neutrophils and CRP (p0.001). There were not statistically significant changes in lymphocyte count.NPWT can be safely applied in acutely debrided DDFI. CRP seems to be the most adequate parameter for both diagnosis and monitoring of treatment of DDFI.

Vernal Keratoconjunctivitis (VKC) is a severe chronic bilateral inflammation of the ocular surface characterized by seasonal exacerbations. Long-term prognosis is generally good; however, 6% develop sequelae responsible for permanent visual impairment. Corneal involvement is almost always present, consisting of punctate keratitis, shield ulcers (3–11%) and late corneal neovascularization. In recent years, topical cyclosporine A preparations at 2% in oil or at 1% in polyvinyl alcohol, have been successfully proposed for long term VKC treatments. It has been previously proven that medical treatment is not always sufficient, especially when it is employed to treat shield ulcer plaques. In such conditions, surgery may be effective for avoiding long term complications such as amblyopia, strabismus, infections and corneal perforation. In this paper, we show the efficacy of surgical debridement by means of simple scraping associated with topical cyclosporine treatment for the management of vernal shield ulcers complicated with plaques.

Empyema necessitatis is a rare complication of empyema, in which the pleural infection spreads outside of the pleural space to involve the soft tissues of the chest wall, and is difficult to diagnose with sonography alone. In the case presented, sonography to evaluate a focal anterior chest wall pain in a patient resulted in findings consistent with an abscess and prompted additional workup. Further testing included sonography-guided aspiration and computed tomography scan to establish the diagnosis followed by surgical debridement.

Background and Aims Necrotizing fasciitis (NF) and gas forming myonecrosis (GFM), both being subtypes of necrotizing soft tissue infection (NSTI), are life threatening conditions sharing certain similarities. Despite the necessity of early and radical surgical debridement in necrotizing infections, the distinction between these entities is of clinical relevance since gas forming myonecrosis in a number of cases results from an underlying abdominal cause and the focus of infection can be missed. This study was to evaluate the incidence and risk factors as well as the mortality rate in patients with NSTI and GFM. Material and Methods All patients with NSTI treated in the authors' hospital between January 2005 and December 2009 were enrolled in the study. Medical records, histological slides, microbiological and laboratory parameters as well as Computerized Tomography (CT) and magnetic resonance imaging (MRI) scans were reviewed for all patients. Differences between NF and GFM regarding hospital stay, number of surgical interventions and pre-existing comorbidities as well as mortality rate were analyzed. The laboratory risk factor for necrotizing fasciitis (LRINEC) score was calculated in all patients on admission. Results and Conclusions Thirty patients (17 female, 13 male) with necrotizing fasciitis with a mean age of 55 years (SD 15.5) were included in the study. There was no statistically significant difference between survivors and deceased patients comparing the LRINEC score (n.s.). Patients with necrotizing fasciitis secondarily involving the trunk had a significantly higher mortality rate (OR 11.2; 95% CI = 1.7–72.3). In the majority of cases (12 cases), minor skin lesions were identified as the site of origin. Amongst all necrotizing soft tissue infections six patients (female n = 3; male n = 3) with a mean age of 61.5 years (SD 12.2) with non-clostridial gas forming myonecrosis were identified. Three patients had a history of malignancy and in three patients the infection was secondary to major surgery. The mean LRINEC score was 8.5 (SD 1). Three patients (50%) died due to GFM. Early diagnosis and appropriate intervention is critical to provide accurate treatment decisions. Eradicating the differing primary sources of infection in GFM and NF will have a positive impact on outcome.

Chronic wounds are associated with significant morbidity, mortality, and economic burden. Once a wound has settled into a senescent phase, outside factors must be used to convert that wound back to a more acute phase. Traditional methods, such as surgical debridement or biologic debridement, can cause removal of healthy tissue as well as pain to the patient. Enzymatic debridement has been under much scrutiny lately as popular drugs have been pulled by the Food and Drug Administration. The purpose of this study was to test feasibility, safety, and primary efficacy of 5 control subjects and 10 treatment subjects to the DermaStream system. It is a device that uses a continuously streaming infusion to create a stable, granular wound bed in a relatively short amount of time. The device provides for continuously streaming of therapeutic solutions to the wound while removing exudates by vacuum-assisted drainage throughout the treatment cycle.

Infected pancreatic necrosis (IPN) continues to be a challenging problem for the surgeon. We reviewed the experience on a hepatobiliary surgical service with patients who required operative intervention for IPN with emphasis on surgical approach, timing of surgery, and complications. Between 2002 and 2008, 21 patients underwent surgery for IPN. The initial surgical approach in these 21 patients included either direct pancreatic debridement (DPD, n = 13) or transgastric debridement using cyst-gastrostomy (CG, n = 8). Fifteen patients (71%) required only a single procedure, whereas three (14%) required two procedures and three (14%) required three procedures. The mean time from onset of pancreatitis to operation was 77 days. Patients requiring a single intervention had a longer interval from onset of pancreatitis to surgery compared with those requiring multiple interventions. When comparing CG and DPD groups, there was a longer interval from onset of pancreatitis to debridement, a lower chance of needing multiple debridements, and fewer pancreatic fistulae in the CG group. Overall survival was 95 per cent. Our results demonstrate that CG can be successfully used in select patients with IPN. Patients undergoing CG are less likely to require repeat surgical debridement and to develop pancreatic fistulae compared with patients undergoing DPD.

Purpose The surgical management of necrotizing fasciitis usually involves early radical/wide and aggressive debridement of involved areas. We describe 5 cases of periorbital necrotizing fasciitis (NF), managed using a computed tomographic (CT)-guided approach to surgical debridement. Methods Retrospective case series review. Results Five patients (4 female, 1 male; age range 39–81) were treated for periorbital NF. The diagnosis was confirmed in all cases with blood cultures and wound swabs. All patients were managed medically by a surviving sepsis regimen. CT scans confirmed suprafascial infection and excluded orbital cellulitis. Four patients had minimal surgical debridement to the surface muscle. All patients survived. Four out of 5 patients underwent delayed reconstruction. Conclusions Periorbital NF behaves differently from NF of other areas. CT-guided surgical debridement of the superficial muscle maximizes preservation of healthy tissue and facilitates reconstruction. Delayed reconstruction allows fibrosis to settle and good cosmetic and functional results are possible. However, NF remains potentially lethal and close observation and a flexible management plan are required.

Chronic invasive Aspergillus sinusitis is a rare and potentially devastating infection. Management typically requires extensive surgical debridement followed by long-term antifungal therapy, primarily with intravenous amphotericin B. We describe the case of an elderly woman who had been diagnosed with extensive Aspergillus sinusitis that had invaded critical structures. The extensiveness of the infection and the patient's frailty and unwillingness to undergo a disfiguring procedure precluded surgery, and her medical condition was too fragile to withstand amphotericin B therapy. Therefore, we decided to treat her with a combination of caspofungin and voriconazole, two relatively nontoxic antifungal agents that have different mechanisms of action. After administration of this novel regimen, the infection resolved rapidly.

Case series summary Three cats with suspected Fournier’s gangrene had an acute onset of clinical signs and bloodwork changes consistent with sepsis. All cases had similar progression of wounds that were managed without aggressive surgical debridement, which is the currently accepted treatment of choice. All cats survived and have maintained an excellent long-term quality of life. Relevance and novel information Fournier’s gangrene is a potentially fatal disease, with few cases reported in the veterinary literature. This retrospective case series describes the only known reports of survival from suspected Fournier’s gangrene cats, none of which required aggressive surgical debridement.

Granulation tissue is an important pathogenic feature of all types of chronic ear disease, and it can be controlled and treated with good aural toilet, appropriate antibiotic therapy, topical steroids, and chemical cautery or surgical debridement.

We describe two cases of chemical necrotizing fasciitis in the upper extremities, anterior chest wall and epigastric region of the abdominal wall caused by household insecticide injection. We suggest that surgical debridement can be successfully performed in the subacute period under close observation in hemodynamically stable patients.

A patient with a history of aortic valve endocarditis and surgical debridement presented with acute congestive heart failure because of severe aortic stenosis. During valve replacement surgery, an aortic annular enlargement was required to overcome a potential patient-prosthesis mismatch. We describe the use of a novel, bioresorbable, acellular xenograft for the enlargement patch. This material is expected to remodel into native patient tissue over time. This case offers an alternative implant for left heart reconstruction using a regenerative patch.

Eleven patients with medial impingement syndrome of the anterior tibio-talar fascicle (ATTF) of the deltoid ligament on the talus were identified. Six sustained inversion injuries, one talus and four ankle fractures. The mean preoperative Ankle-Hindfoot Scale (AHS) was 56 and the postoperative was 87.Surgical debridement of the ATTF was performed. A thickened ATTF and localized synovitis were seen. Talar osteophytes were removed in 8 patients. Mean follow up 4 years. Nine patients had good to excellent results and all patients returned to work.

A 45-year-old human immunodeficiency virus (HIV)-positive male presented with massive gas-forming cellulitis of the chest wall and left arm, which developed one month after the onset of a Staphylococcus aureus pneumonia that was untreated. This condition was due to an empyema necessitans – an empyema that had drained through the chest wall to the soft tissues of the chest and left arm. Surgical debridement and long term intravenous antibiotic therapy successfully treated the condition.

A patient with a history of type II diabetes mellitus (DM), end stage renal disease (ESRD), and congestive heart failure (CHF) developed necrotizing fasciitis caused by Serratia marcescens after scraping his leg on rocks in a river while fishing. Aggressive management with surgical debridement, antibiotics, and pressure support was unsuccessful.

Category: Basic Sciences/Biologics Introduction/Purpose: When performing surgical debridement to treat chronically infected orthopaedic cases our unit routinely samples 5 intraoperative specimens for microbiology. Best practice and achieving accurate sampling would suggest that a new scalpel and forceps for each sampling site would yield the most valid results.The alternate option would be to use the same instruments. The aim of this prospective study was to compare the two techniques in treating infected foot and ankle cases. Methods: Ten consecutive patients undergoing debridement for foot and ankle infection were prospectively included. Both techniques were performed on same patient to minimise any bias related to the type of host and severity of infection. This was achieved by collecting 5 tissue samples from 5 different sites initially using fresh instruments for each . We then used the first scalpel and forceps to sample the 2nd, 3rd, 4th, and 5th sites again. Samples were labelled from 1 to 9 where the 6th to 9th samples were from the same sites as the 2nd to 5th samples but taken by different technique. This allowed differentiating a genuine growth at a particular site from a contaminant carried on from another site. Results: In 7 patients the scalpel transferred microorganisms from one site to another as some of the 5 sites showed no organisms when biopsied by fresh instruments but showed growth when sampled by the re-used first scalpel. In the remaining 3 patients, the growth form the sites sampled by re-used first scalpel was consistent with the growth from those sites when ampled by fresh instruments . Conclusion: Our preliminary results showed that fresh scalpel and forceps are required for each sampling site to avoid transferring contamination from one site to another. This helps guide the extent of future debridement and also the type of antibiotics to be used.

AimTo determine the safety and efficacy of surgical debridement with instrumentation in treating pyogenic infection of the spine.Material/MethodsBetween June 2006 and December 2013, 229 consecutive patients suffering from spondylodiscitis were admitted to our department. 211 (92%) underwent surgical debridement and instrumentation while 18 were treated conservatively. Surgically treated patients were analyzed. Clinical outcome was assessed with neurological and laboratory examinations at 3 months following surgery. Long-term clinical outcome was assessed at a minimum of 12 months following surgery with a telephone interview.ResultsThe mean age at presentation was 67 years, 139 patients were male (66%). Distribution of the inflammation was lumbar in 134 (63%), thoracic in 37 (18%) and cervical in 30 (14%) cases. Ten patients (5%) had two concomitant non-contiguous spondylodiscitis in different segments of the spine. Epidural abscess was found in 74 patients (35%). 191 patients (90%) had pain. Neurological ...

Figure skaters are unique athletes who must train for extended periods of time performing motions and routines that create excessive compressive and shear forces between their malleoli and boots. As a result, they are susceptible to the development of a painful adventitious malleolar bursitis. Most often these patients will relate a recent increase in their training schedule or the purchase of a new pair of skating boots. This condition usually responds favorably to nonoperative measures including stretching of the boot over the affected area and protective padding placed around the inflamed bursa. If the swelling is marked, then an aspiration, subsequent injection with cortisone, and a compressive wrap may be indicated. This treatment regimen will enable the majority of figure skaters to continue skating. If the symptoms continue or increase despite nonoperative measures, then cessation of skating for a brief period must be considered. If this is not a viable option for the skater, surgical excision of the bursa may be warranted. If septic bursitis occurs, immediate surgical debridement and intravenous antibiotics are indicated. A Staphyloccocus aureus organism is most often responsible and should be treated with appropriate antibiotics. These patients may return to skating when there is no sign of further infection, the soft tissues have fully healed, and there is no sign of residual inflammatory bursa, usually at 4 to 6 weeks after surgery.

A 60-year-old man involved in a high-speed collision with a hay wagon was admitted with multiple trauma. He developed life-threatening invasive musculo-cutaneous zygomycosis caused by Rhizopus species, which is found in soil from cultivated land and woodland. A high index of suspicion given the nature of the injury, aggressive surgical debridement and appropriate anti-fungal therapy prevented a fatal outcome.

The clinical presentation and course of two patients with Eikenella corrodens infection of the hand is recorded. This recently recognised organism must not be regarded as a harmless commensal and should be differentiated from the Bacteroides group because of its resistance to clindamycin. Radical surgical debridement is the most important aspect of therapy.

This issue contains two papers on herpes simplex infection of the hands. One by Gang describes such an infection in an infant, treated by surgical debridement and topical Acyclovir. The other is by Haedicke, Grossman and Fisher who report their experience with ten patients treated by a programme of local wound care, without incision unless there was super-infection; two patients were treated with Acyclovir. It is important to have a controlled study of randomised patients employing Acyclovir (Trade name Zovirax) to see if it does have any efficacy in the management of these individuals. This may require a multi-institutional co-operative effort in order to obtain sufficient numbers of patients. In treating these patients, we have preferred to avoid incisions because of the risk of secondary infection as they state in their article. Also two of our patients have required amputations which we felt were brought about by such infections after ill-advised incision and drainage procedures. Intractable pain has not been a problem in ou.r patients in whom the disease has become quiescent but, with each outbreak of new vesicles, pain usually returns promptly. Several of our patients have had cyclic bouts of herpetic infections. To avoid this, we have begun to treat all early or suspected cases with large doses of the amino acid 1-lysine 500 mg three or four times a day. Once the acute episode has passed, patients with a previous history are kept on 300 mg, two to three times per week, indefinitely. To date, as long as they have faithfully continued taking the maintenance dose, no recurrences have transpired in 24-48 months. The mechanism of action of the I-lysine is unknown, but we have had a sufficient number of patients who have developed rapid recurrence of their herpetic lesions on the hand or elsewhere after acute cessation of the drug to believe in its value. We only treated a single patient with Acyclovir: he happened to be one of the two who eventually underwent an amputation. In treating patients with herpetic lesions of the hand, the risk of recurrence must be appreciated and further studies are necessary to evaluate the acute and long-term value of Acyclovir. Currently 1-lysine provides a very inexpensive, safe and possibly effective agent which may abort the acute course of the disorder, reduce the intensity of an established infection and provide an innocuous method of prophylaxis.