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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5205_Библиотеки_им_академика_М_И_Перельмана.pdf
9 Osteoarticular Infections inAdults
Fig. 9.32 Radiographic control after surgery
117
Drawing 9.1 The resection of the CFP prosthesis maintains the vascularity of the neck
and excellent surgical cleaning, the application of
the prosthesis will not result in any reignition of
infection [33–39].
From 2008 to 2015, we performed 12 cases of
neck-sparing hip prosthesis for septic arthritis.
(6 males and 6 females).
The pathogen was:
Fig. 9.33 Radiographic control after 4years without any
sign of septic are-up
• Tuberculosis in four cases,
• Staphylococcus aureus in six cases.
• Mixed ora two cases.
7 patients were drug-dependent.
The agreement of both basic science and
orthopedic surgery has conrmed, through the
exposition of the results, the logical foundation,
and the main characteristics of the neck-sparing
prosthesis, summarized in this «Decalogue» from
F.Pipino [40, 41]:
1. The prosthesis must integrate into the natural
joint and not replace it
2. Maximum respect for the anatomy
3. Restoration of joint biomechanics
4. Dedicated access routes
5. Dedicated instruments
6. Mini prostheses respecting the bone stock
7. Minimization of blood loss and duration of
hospitalization
8. Computer assistance
118
9. Bone-prosthesis interaction in the eld of
regenerative medicine
10. Removal of only pathological tissues while
respecting healthy tissues: TSS
9.2.2 Shoulder Arthritis 3% inTB
and0.8% inPyogenic
(Figs.9.34, 9.35, 9.36,
and9.37) [42–44]
A case of a 70-year-old patient presenting with
an infection of the right shoulder that arose suddenly after a major febrile episode. He complains
of pain, low-grade fever and on clinical examination the shoulder appears swollen, internally
rotated, and very painful.
A pain spontaneous that at minimal movements. Furthermore, there is a stula (Figs.9.34
and 9.35) on the lateral aspect of the shoulder.
Blood tests show ESR, CRP, brinogen, and
white blood cells far above the normal value.
Both synovial uid and bone biopsy samples
are taken for culture examination and
antibiogram.
In the meantime, the culture tests have arrived,
and it turns out that it is super-infected tuberculosis. The mycobacterium is sensitive to classic
antituberculosis drugs while the discovery of
Staphylococcus aureus highlights that it is methicillin resistant, and therefore both pathogens will
have to be treated. Both local and general treatment is started with teicoplanin, ciprooxacin,
and antituberculosis drugs (rifampicin, streptomycin, isoniazid, and ethambutol), according to
the scheme we have adopted for about 40years.
It is decided to carry out the rst stage of surgical
cleaning, resection of the proximal epiphysis of
the humerus, and application of an antibiotic
spacer consisting of streptomycin, vancomycin,
and clindamycin (Fig.9.36).
When the overall picture appears stabilized;
the blood tests are normal, no secretions, x-ray
does not show any images related to septic reignition and the patient is able to make some
active movements of the shoulder without pain,
with the help of a physiotherapist we move on to
F. Da Rin de Lorenzo
Fig. 9.34 Treatment is initiated with broad-spectrum
antibiotics and daily lavage through the stula
Fig. 9.35 A stulography is performed which highlights
a collection in the lower part of the glenoid
the second stage where the spacer is removed and
samples are taken for the culture test which will
later be negative and a reverse prosthesis is
applied (Fig.9.36). Normally, in these cases, the
rotator cuff appears signicantly damaged and
therefore one is forced to use only this type of
prosthesis.
9 Osteoarticular Infections inAdults
Fig. 9.36 Radiographic image highlighting the positioning of the antibiotic spacer
Fig. 9.37 Radiograph after removal of the antibiotic
spacer and application of a reverse prosthesis
119
9.2.3 Arthritis oftheElbow 2 7%
inTB and1 2% inPyogenic
(Figs.9.38, 9.39, 9.40, 9.41,
9.42, 9.43, 9.44, 9.45, 9.46,
9.47, 9.48, 9.49 and9.50)
[45–49]
The big problem of the elbow is that it tends to
stiffen and the bone is supercial to the point that
a modest skin lesion can create exposure.
A 42-year-old patient who comes to us with an
active infection at the left elbow with the formation of an abscess and pluristolized. At the
beginning, the picture made one suspect a pyogenic form because it presented all the characteristics; the laboratory tests showed an ESR, a CRP,
and increased white blood cells. Furthermore, the
situation presented, clinically, with signs of classic inammation. Finally, the X-ray showed a
bony detachment of the olecranon which had not
been traumatic but due to tearing in supporting
oneself (Fig. 9.37). In this case, the anamnesis
helps us a lot due to the fact that the patient came
from an area endemic for tuberculosis and
20 years earlier he had contracted pulmonary
tuberculosis and had no longer been checked.
Another fact was the periosteal reaction that had
developed in such a short time (start of symptoms
6months before our observation). Tuberculosis is
much more aggressive than the pyogenic form in
eutrophic patients.
Given the very active phase, with the presence
of an abscess and a lot of purulent secretion, it
was decided to immediately perform a surgical
cleaning (Figs. 9.39, 9.40, and 9.41). Samples
were taken for both culture and tuberculosis.
After 7days, we had the results of the tests,
and we found tuberculosis from an atypical
mycobacterium sensitive to rifampicin and
trimetroprim-cotrimoxazole.
120
Fig. 9.38 The X-ray of the elbow show a bony detachment of the olecranon which had not been traumatic but due to
tearing in supporting oneself
F. Da Rin de Lorenzo
Fig. 9.39 Abundant discharge of pus when squeezing the
elbow
Fig. 9.40 The ducts of the stulas
Fig. 9.41 After the obsessive surgical cleaning, the still
vital olecranon fragment can be seen
We carried out the antibiotic treatment with
local washings until the situation was stabilized,
and the stulas and the continuous solutions
closed as much as possible. Then we managed to
perform the synthesis of the olecranon (Fig.9.42)
and the patient regained satisfactory motility.
Typically, the spontaneous outcome of tuberculosis is ankylosis (Figs.9.42 and 9.43) when
the process heals, as can be seen in the following
X-ray of a patient who had had tuberculosis of
the elbow 10years earlier and had been treated
only with antibiotics and immobilization.
9 Osteoarticular Infections inAdults
Fig. 9.42 When the situation was considered stable,
from a septic point of view, the detachment of the proximal part of the olecranon was osteynthesized
121
making it on the radius, that is, removing the
radial head and restoring pronation-supination
(Figs.9.47 and 9.48).
A 78-year-old patient presents with a signicant Staphylococcus aureus infection of the
elbow.
On the X-ray, severe joint disruption
(Fig.9.49).
The blood sample revealed a Staphylococcus
aureus infection sensitive to many antibiotics.
After a period of local and general antibiotics,
we applied an elbow prosthesis (Fig.9.50) at one
time because the infection was not so aggressive,
and it was on arthritic terrain. In fact, both the
ESR and the CRP were normal, and the patient
did not wish to undergo many operations as she
was a heart patient and diabetic.
9.2.4 Wrist Arthritis 3.1% TB, 1.4%
Pyogenic (Figs.9.51, 9.52,
9.53, 9.54, 9.55, and9.56) [20,
50–55]
Fig. 9.43 Radiological aspect of a spontaneous arthrod-
esis resulting froma a tubercular of the elbow
Since he did not want to undergo surgery
again but was trying to have better functionality,
since the exion-extension was absent and the
pronation-supination was also absent, we did not
try to improve the latter by doing a reverse SauvèKapandji (Figs.9.45, 9.46, 9.47, and 9.48), that
is, not creating a pseudarthrosis on the ulna but
As already mentioned, patients who present with
signs of a joint infection are immediately examined for all possible pathogenic agents, and therefore in addition to pyogenic they are also evaluated
for tuberculous and fungal infections. A case of a
66-year-old patient suffering from a tuberculosis
pathology already diagnosed affecting the right
wrist. The X-ray shows a wrist sprain with a large
focus on the distal epiphysis of the radius with an
alteration of the normal anatomy (Fig. 9.51).
There is a volar dislocation of the lunate and clinically the wrist is almost ankylotic.
Begin both general and local antituberculous
therapy with inltration cycles of local antituberculous antibiotics (Fig.9.52).
A restraint cast shower is applied (Fig.9.53).
After a period of “cooling” of the infection we
intervene by performing a surgical cleaning by
removing the entire rst chain of the carpus
(Fig.9.54).
122
Fig. 9.44 Clinical aspect of the patient demostraiting arm movements with complete lack of pronation-supination
F. Da Rin de Lorenzo
Fig. 9.45 We removing the radial head to recover at least
pronation-supination
Fig. 9.46 The x-ray aspect after removal of the radial
head
Figs. 9.47 and 9.48 The clinical aspect with the recovery of pronation-supination
9 Osteoarticular Infections inAdults
Fig. 9.49 The X-ray shows a serious joint injury of the elbow
Fig. 9.50 The X-ray highlights the application of an
elbow prosthesis which was done in a single stage
Radiographic check-up at 2 years with no
signs of septic are-up and attempted lling of
the epiphyseal focus of the radius (Fig.9.55). In
septic forms, in the residual empty spaces, a
brous tissue is most often created which acts as
a shock absorber, taking away pain and promoting minimal movement.
Finally, the clinical aspect (Fig.9.54) is that
the wrist does not have good motility, but the
patient no longer has pain and no longer has signs
of infection and is able to use his wrist to carry
out normal life functions.
123
I would like to close this chapter by highlighting some points, especially on tuberculosis,
which has not yet disappeared and is always present in our reality as orthopedic specialists and
which we forget about:
1. It does not have a preferential age.
2. It is not preceded by sufciently indicative
diagnostic elements.
3. It is often masked at a clinical level by the
most varied and, at times, the least predictable symptoms.
4. It is often camouaged by antibiotic treat-
ments, even those that are not specic in the
strict sense.
5. It does not recognize its own morphological
characteristics.
6. It must always be treated in poly chemother-
apy also locally.
7. The therapy is mainly medical.
8. The therapy must then be continued under
medical supervision, at the patient’s home,
for at least 1year.
9. Do not hesitate to perform a biopsy and a
culture test if you are in doubt about a tuberculous form.
10. It is easily overinfected, especially if stulized.
11. It is increasingly caused by atypical myco-
bacteria resistant to common antituberculosis antibiotic therapies.
12. Each joint has its own characteristics, which
must be known to provide the most appropriate treatment.
13. Finally, it is a pathology that presents many
customizations such as the patient’s characteristics (age, sex, comorbidities, immunological and antibiotic reactivity, and the type
of life and work that the patient does and his
expectations) local characteristics (location,
type of bone and soft parts, and characteristics of the lesion).
Therefore, each patient is a case that must be
treated in a personalized way.
124
Fig. 9.51 The X-ray
shows a serious lesion of
the entire carpus and the
radiocarpal with a large
focus on the distal
epiphysis of the radius
F. Da Rin de Lorenzo
Fig. 9.52 Local inltration of targeted antibiotic. Since
1970 we have been using local antibiotic inltrations for
both tubercular and pyogenic articular forms [21, 22, 23]
Fig. 9.54 The X-ray
highlights the surgical
cleaning with the
removal of the rst row
of the carpus
Fig. 9.53 Application of a position brace removable only
to reduce the pain. When the patient is well he can remove
the brace and move
9 Osteoarticular Infections inAdults
Fig. 9.55 The X-ray
2years after surgical
cleaning ...
Fig. 9.56 .... and clinical aspect
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