RESUMO
INTRODUCTION: Severe open injuries of limbs, especially of the femur and tibia when associated with vascular injuries, present major challenges in management. The decision to amputate or salvage can often be a difficult one even for experienced surgeons. Mangled lower extremity results due to high-energy trauma, especially due to motor vehicle accidents, and is defined as injury to three of the four systems in the extremity that is soft tissues, bone, vascular, and nerve. Open fractures are classified by Gustilo and Anderson's classification in which type 3B is an injury where soft-tissue loss and primary closure of the wound are not possible and type 3C is any open fracture with vascular compromise. CASE REPORT: We report a series of six ipsilateral fractures of the femur and the tibia treated at the Department of Orthopaedics, Sri Ramachandra Medical College and Hospital, Chennai, Tamil Nadu, over a 3-year period (2014-2017). The mean age of our patients was 30 years old, and there were five men and one woman. The right side lower limb was frequently involved (five cases), and the main etiology was road traffic accidents (six cases). Articular involvement was found in six cases. Skin wounds were noticed in all cases (type III C of the Gustilo classification). Urgent wound care, fluid replacement, and antibiotic therapy were undertaken for open fractures. According to modified Fraser classification, all six cases was classified under type II-C. Mangled extremity severity score for five cases was 7 and for one case it was 8. Ganga Hospital Open Injury Severity Score was also used which was found to be in borderline range of 16 score for three cases, 15 score for two cases, and 14 score for one case. All six cases were managed with serial wound debridement + Ilizarov fixator + soft-tissue repair with involvement of orthopedic, vascular, and plastic surgery team. Limb salvage was done for all six cases after considering all the factors. Postoperatively, rehabilitative care and physiotherapy in the form of non-weight-bearing mobilization with walker support was given to all patients. The patients were followed up for the period of 2 years and doing symptomatically better. Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision-making in these situations. CONCLUSION: With great effort and good team work (like vascular and orthopedic surgeons), badly comminuted compound injuries (Type III C injury) can be managed well with Ilizarov fixation. Even though the decision of amputation versus salvage was based on more scientific/scoring system, patient's option should be taken, especially in borderline cases considering the present medicolegal scenario.
RESUMO
INTRODUCTION: Melioidosis caused by Gram-negative bacterium Burkholderia pseudomallei. It usually causes abscesses in lung, liver, spleen, skeletal muscle, and parotids in patient with risk factors such as diabetes mellitus, heavy alcohol use, smoking, chronic lung disease, and corticosteroid use. Musculoskeletal melioidosis is not common in India even though sporadic cases have been reported mostly involving soft tissues. CASE REPORT: A 45-year-old gentleman, farmer by occupation, belong to state of TamilNadu, type 1 diabetes mellitus with poor glycemic control, presented to us with complaints of multiple joint spain which includes severe pain over left elbow followed by mild pain over bilateral knee and right ankle for past 3 months and on and off fever for past 10 days. Clinically, patient was toxic (shows features of infection). On further investigation (Magnetic resonance imaging and X-ray left elbow, bilateral knee, and right ankle), it was found to be consistent with multifocal osteomyelitis. On arthrotomy and surgical debridement of the left elbow joint followed by intra-operative pus culture shows Staphylococcus aureus growth and patient was started on intravenous cefoperazone-sulbactam 1.5 g for 2 weeks, following which symptoms reappear. 2-d echo was done to rule out infective endocarditis. Technetium 99-methyl diphosphonate (MDP) whole-body scintigraphy shows increase uptake in the left elbow, bilateral knee, and right ankle. Now heunderwent bilateral knee and right ankle arthrotomy and surgical debridement. Polymerase chain reaction for melioidosis was positive. Gram-stain shows growth of B.pseudomallei. Serial blood cultures grew Gram-negative bacilli, later identified as B. pseudomallei, and diagnosed to have melioidosis, following which he was started on injection ceftazidime 2 g TDS (Q8 hourly) for 4 weeks followed by oral cotrimoxazole for next 6 months. The patient was followed up for a period of 2 years (1, 3, 6, and 12 months) and he was found to be recovered completely with no recurrences.. CONCLUSION: Diagnosis of melioidosis missed in many parts of the world due to lack of awareness of this infection caused by B.pseudomallei. Delay in diagnosis or treatment against melioidosis can worsen the outcome. Initial therapy with intravenous antibiotics followed by oral maintenance therapy and appropriate surgical intervention remains vital in the management.
