Persistent synovial actinomycosis in a native knee joint: A case report.

INTRODUCTION AND IMPORTANCE: 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. CASE PRESENTATION: 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. CLINICAL DISCUSSION: 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. CONCLUSION: 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.

Microvascular Free Tissue Transfer for Complex Soft Tissue Injuries in Lower Extremities: Brief Report of a Hispanic Population.

OBJECTIVE: Microvascular free-tissue transfer (M-FTT) is a surgical technique for traumatic injuries that allows tissue reconstruction based on donor tissue composition. The aim of this study is to describe the surgical experiences of M-FTT for reconstruction of complex soft tissue injuries in the lower extremities of a Hispanic population. METHODS: This is a descriptive study of all M-FTT procedures performed by a single plastic surgeon from 2012 to 2016 at Puerto Rico Medical Center. Demographics, admission diagnosis, mechanism of trauma, type of free flap, co-morbidities, length of stay, donor site and complications were evaluated. RESULTS: Eight patients who underwent single M-FTT procedures at lower extremity were enrolled in the study. The average age at time of surgical reconstruction was 36.9+13.2 years with six males and two females. The transfer procedures were performed using donor sites of six rectus abdominis flaps and 2 radial forearm flaps. Posterior tibial artery was used in 62.5% and popliteal artery were used in 37.5% as recipient arteries. Average surgical time was 4.4+0.7 hours with an average length of hospital stay of 22.9+20.1 days. Post-operative complications were reported in three M-FTT procedures: two cases who suffered venous thrombosis and one case who suffered partial necrosis. CONCLUSION: The M-FTT offers an adequate surgical option for patients who present with complex soft tissue traumatic injuries at the lower extremities.

Extraskeletal presentation of Ewing's Sarcoma.

The case of a 27-year-old Hispanic female who presented with an occipito-parietal tumor after suffering trauma to the area. A physical examination revealed no tenderness to palpation and with evidence of healing ulcerations. The biopsy was consistent with a synovial sarcoma. A wide excision of the mass (15cm x 14cm x 6cm) followed by a pericranial flap was performed. A follow-up CT showed recurrence involving the parietal sagittal sinus. After a second biopsy the mass was determined to be a small-cell sarcoma, consistent with Ewing's sarcoma. Chemotherapy included 8 cycles of doxorubicin, vincristine, and cyclophosphamide, with alternating cycles of etoposide and ifosfamide. A year later, a second wide excision of the mass was performed, followed by bilaminate skin substitute and skin graft placement for reconstruction of the soft-tissue defect. After chemotherapy, a follow-up PET scan showed no signs of re-uptake in any soft tissue or skeletal structures. After 2 years, the patient remains in complete remission.