1/2219. Salvage of the lower leg using a reversed long free fibular flap. The advantages of end-to-side anastomoses have been well documented in microvascular surgery. The vessels of the fibular flap do not usually permit end-to-side anastomosis to recipient vessels in the proximal part of the lower leg because the pedicle length of the free fibular flap is usually too short. Therefore, vein grafts are used to elongate the vessels. If a harvested long free fibular flap that is used to bridge a massive defect of the tibia is reversed and placed into the medullary cavity of the tibia, the flap vessels can be anastomosed, using the end-to-side technique, to the recipient vessels without vein grafts in the distal part of the lower leg. Thus, the flap artery (the peroneal artery) fills in a retrograde fashion. The patient reported was reconstructed with a reversed long free fibular flap. The postoperative period was uneventful. The patient can stand and walk with a protective shoe 2 years postoperatively. ( info) |
2/2219. vancomycin-induced neutropenia associated with fever: similarities between two immune-mediated drug reactions. A 39-year-old woman being treated for osteomyelitis with vancomycin developed severe neutropenia and drug fever. After she discontinued therapy, both disorders quickly resolved. These adverse reactions have rarely been reported with vancomycin, and share many similarities with regard to clinical features and postulated mechanisms of induction. To our knowledge this is the first case documenting drug fever as a principal component of vancomycin-induced neutropenia, and provides further evidence in support of an immune-mediated mechanism. ( info) |
| The case of a 9-year-old girl with cat-scratch disease (CSD) complicated by development of a paravertebral mass and osteomyelitis is presented. Following multiple scratches and inguinal lymphadenopathy, she developed back pain, and imaging demonstrated a paravertebral mass with evidence of osteomyelitis involving vertebra T9. The diagnosis was made on the basis of detection of bartonella henselae by use of molecular techniques on an aspirate from the vertebral column and supportive serology for infection with B. henselae. Eleven other cases of this unusual manifestation associated with CSD have been reported in the literature and are reviewed. The patient was treated with gentamicin, followed by rifampicin and trimethoprim-sulfamethoxazole, orally and made a favorable recovery over 7 months. This is comparable with other case reports, regardless of the choice of antibiotic therapy. CSD in immunocompetent hosts is not always self-limiting, and tissues beyond the lymph nodes can be involved. ( info) |
4/2219. Vertebral osteomyelitis in insulin-dependent diabetics. Vertebral osteomyelitis continues to be a diagnostically and therapeutically challenging disease with a relatively high incidence in diabetics. The clinical features, investigations and treatment of 7 insulin-dependent diabetics with vertebral osteomyelitis are presented and possible aetiological factors in this group are discussed. ( info) |
| ochrobactrum anthropi (O. anthropi ), formerly known as achromobacter CDC group Vd, is a gram-negative bacillus that is aerobic, oxidase producing, and nonlactose fermenting. This organism has been found in environmental and hospital water sources and has pathogenic potential in humans. Most reports in the literature of O. anthropi bacteremia are associated with intravenous line infections. We describe a case of bacteremia with O. anthropi in a 33-month-old boy with acute osteomyelitis. O. anthropi bacteremia also has been reported in immunocompromised hosts. Rarely, O. anthropi has been a cause of soft tissue or bone infection. ( info) |
6/2219. Salvage of contaminated fractures of the distal humerus with thin wire external fixation. Fractures and osteotomies of the distal humerus that are contaminated or infected represent a difficult management problem. Stable anatomic fixation with plates and screws, the acknowledged key to a good result in the treatment of bicondylar fractures, may be unwise. A thin wire circular (Ilizarov) external fixator was used as salvage treatment in such complex situations in five patients. The fixator allowed functional mobilization of the elbow while allowing achievement of the primary goal of eradicating the infection or colonization. Two patients required a second operation for fixation of a fibrous union of the lateral condyle. One patient with a vascularized fibular graft later required triple plate fixation for malalignment at the distal host and graft junction. Four of five patients ultimately achieved complete union. The fracture remained ununited in one patient who has declined additional intervention. All five patients achieved at least 85 degrees ulnohumeral motion, two after a secondary elbow capsulectomy performed after healing was achieved. This experience suggested that the Ilizarov construct, although not a panacea, represents a reliable method of skeletal stabilization that allows functional mobilization while elimination of infection or colonization is ensured. If necessary, stiffness and incomplete healing can be addressed with an increased margin of safety at subsequent operations. ( info) |
7/2219. Recurrent subcutaneous abscess of the sternal region in ulcerative colitis. An 18-yr-old female patient with extensive ulcerative colitis suffered from several episodes of recurrent aseptic subcutaneous abscesses of the sternal region with a course paralleling that of her colitis. The abscess seemed to occur secondarily to osteomyelitis of the sternum, which is a manifestation of the synovitis, acne, pustulosis, hyperostosis, and osteomyelitis (SAPHO) syndrome. ( info) |
8/2219. Successful treatment of candidal osteomyelitis with fluconazole following failure with liposomal amphotericin b. A case of multiple relapses of candida albicans infection of deep tissues is described. Treatment was complicated by renal impairment, but therapy with a liposomal amphotericin product failed to eradicate the third recurrence which subsequently resolved after protracted exposure to oral fluconazole. ( info) |
| Spinal epidural abscess (SEA) is a rare disease with an unknown incidence rate. This paper will illustrate that early diagnosis and rehabilitation may result in improved outcomes for patients with neck or back pain presenting with neurological deficits. Three cases of SEA in individuals without the commonly acknowledged risk factors of intravenous drug abuse (IVDA), invasive procedures, or immunosuppression were seen at our institution during a 10-month period between October 1995 and July 1996. The patients presented with neck or thoracic back pain and progressive neurological deficits without a febrile illness. Predisposing factors were thought to be urinary tract infection with underlying untreated diabetes mellitus in the first case, a history of recurrent skin infection in the second, and alcoholism without a definite source of infection in the third. leukocytosis, elevated sedimentation rate, and confirmatory findings reported on magnetic resonance imaging (MRI) led to the diagnosis of SEA in all three cases. Immediate surgical drainage and decompression followed by proper antibiotic treatment and early aggressive rehabilitation led to good functional outcomes. All the individuals became independent in activities of daily living, wheelchair mobility, and bowel and bladder management. Two eventually became ambulatory. ( info) |
10/2219. Purulent osteomyelitis of the cervical spine with epidural abscess. Operative treatment by means of dorsal and ventral approach. The present case concerns an acute purulent osteomyelitis with an epidural abscess, located particularly in the intervertebral foramen between C5 and C6, which led to infection by staphylococci of the adjacent vertebral arches and vertebral bodies. An obstruction of the CSF passage was discovered by myelography at the level between C5 and C6. The bony tissue changed by inflammation was removed as far as possible by laminectomy. After irrigation of the epidural space with antibiotics and after control of the severe inflammation, the vertebral bodies C6 and C7 which were destroyed by the spreading inflammatory granulations, could be removed by a ventral approach 4 weeks later. The defect was filled with spongiosa chips. After immobilisation in a plaster shell and Crutchfield extension for 8 weeks the patient was slowly mobilized. A fusion of the vertebral bodies C5 and C6, C6/C7 and C7/C1 was achieved. A dislocation of the cervical spine did not occur and the patient recovered completely except for a paresis of the right hand. Treatment of this very rare and severe case was only possible by a combined dorsal and ventral procedure on the cervical spine. ( info) |