The Great Masquerader - TB Osteoarthritis.

OBJECTIVES: TB arthritis is a rarely reported entity in Western literature and its ability to masquerade as many other diseases makes it difficult to diagnose. We report an interesting case of TB arthritis of the ankle. METHODS: We present a 44 year-old diabetic Chinese male with a recent history of worsening pain, swelling, and redness in his left foot with an abscess and X-ray findings consistent with Charcot foot. RESULTS: At first, the presentation was believed to be Charcot's foot with MSSA osteomyelitis but after the wound culture and bone biopsy were both positive for Mycobacterium tuberculosis as well, the diagnosis of tuberculous arthritis was confirmed. CONCLUSIONS: While the prevalence of TB and other diseases is low in the majority of the United States, we still need to be aware of such diseases in populations with increasing migration and be cognizant of the potential impact of a patient's background on a diagnosis is critical to properly diagnosing and treating patients. Vascular surgeons may be seeing patients with abscesses of the lower extremities and may miss the diagnosis if cultures for TB are not sought.

Burkholderia pseudomallei peri-prosthetic infection following medial malleolar internal fixation: a case report.

BACKGROUND: Melioidosis-associated peri-prosthetic infection is extremely rare. To date, melioidosis associated septic arthritis of the ankle joint following a medial malleolar internal fixation has not been reported. CASE PRESENTATION: We describe a 49-year-old male with a history of long standing diabetes who presented with fever, constitutional symptoms and right ankle pain for 1 week. Ten years ago, he underwent a medial malleolar screw fixation following a traumatic closed fracture. His initial right ankle radiographs showed no evidence of osteomyelitis. He underwent a wound debridement and washout of the right ankle joint. The peripheral blood and pus from the ankle joint was culture positive for Burkholderia pseudomallei with very high antibody titres. His subsequent radiographs showed features of chronic osteomyelitis. He was treated with a prolonged course of antibiotics and repeated wound debridement. At follow up after 6 months, he had no clinical features of recurrent infection. CONCLUSIONS: Melioidosis should be entertained in the differential diagnosis of peri-prosthetic infections in high risk patients.

A novel intraoperative technique seeding morselized bone tissue into pediatric blood culture bottles improves microbiological diagnosis in patients with foot and ankle osteomyelitis.

BACKGROUND: Osteomyelitis, particularly cases involving the foot and ankle, is a challenging situation that frequently leads to amputations and major sequelae. Targeted antibiotics treating an identified pathogen are key to a successful outcome; however, traditional culture methods for bone tissue have poor sensitivity. This study prospectively compared a novel method for obtaining and processing infected bone tissue with the standard technique. METHODS: 107 patients presenting with a diagnosis of osteomyelitis of the foot and ankle between 2008 and 2017 were prospectively included. Diagnosis was done according to clinical, laboratory and imaging findings. We obtained paired samples of bone tissue from all patients; they were processed through a usual culture method (UCM), but they were also morselized and seeded into pediatric blood culture bottles (PBCBs). We compared the culture yield and the number of agents detected using both the McNemar and the Mann-Whitney tests, respectively. RESULTS: We studied 107 patients (63 with diabetic foot infection and 44 with nondiabetic osteomyelitis). The causative agent was identified in 60.7% of cases using the UCM and in 97.2% of cases using PBCBs (p < 0.001). We detected a mean of 1.05 ± 1.03 bacteria using the UCM and 1.67 ± 0.92 bacteria using PBCBs (p < 0.01). CONCLUSION: Cultures using morselized bone seeded in PBCBs identified the causative agent in a significantly larger percentage than the UCM. Additionally, this method identified a larger number of pathogen agents. A better agent identification method has advantages such as identifying more specific antibiotic treatment in these cases.

Three-Stage Masquelet Technique and One-Stage Reconstruction to Treat Foot and Ankle Tuberculosis.

BACKGROUND: The purpose of this article was to report the feasibility and effectiveness of 3-stage Masquelet technique and 1-stage operation for different stages of foot and ankle tuberculosis (TB). METHODS: Ten consecutive patients with foot and ankle TB were retrospectively analyzed between January 2014 and December 2018. Five patients were treated with the 3-stage Masquelet technique, including thorough debridement with vacuum sealing drainage, implantation of antibiotic cement spacer, and subsequent reconstruction. Five patients were treated with a 1-stage reconstruction. The American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) pain scores were recorded at the last follow-up. The follow-up was 30.3 ± 17.8 months. RESULTS: No reactivation of TB was observed in any patients. For the 3-stage operation group, 1 patient developed a distal tibia fracture. The duration of anti-TB therapy was 12.0 ± 0.8 months. The AOFAS score increased from 39.5 ± 9.9 preoperatively to 75.3 ± 7.0 postoperatively (P < .05). The VAS pain score decreased from 6.3 ± 1.9 to 1.5 ± 1.3 (P < .05). For the 1-stage operation, 1 patient had wound necrosis. The duration of anti-TB therapy was 13.8 ± 1.1 months. The AOFAS score increased from 51.8 ± 15.0 to 81.8 ± 6.3 (P < .05). The VAS pain score decreased from 5.4 ± 1.1 to 1.0 ± 0.7 (P < .05). CONCLUSION: Three-stage operation was effective for foot and ankle TB with stage IV, sinus tracts or other infections, and 1-stage reconstruction was effective for early-stage TBs. LEVEL OF EVIDENCE: Level IV, case series.

Tubercular involvement of the lateral malleolus and adjacent calcaneus: presentation of a rare case and review of the literature.

Osteoarticular tuberculosis (TB), despite being on the wane in the developed world, stays a problem of significance in the developing world. The issue is compounded by unusual presentations, inadequate diagnostic skills and limited understanding of its management. For foot infections, despite an increased awareness, many patients may be misdiagnosed, with associated treatment delays. A 19-year-old man presented with pain and swelling on lateral aspect of right ankle for 2 months. The patient had an undermined discharging sinus with surrounding induration and the skin adherent to the underlying bone. Patient was diagnosed as a case of ipsilateral TB lateral malleolus and calcaneus, managed with antitubercular drugs with complete resolution at 3 years of follow up. Foot and ankle TB can have atypical presentations causing delay in diagnosis. Contiguous spread of infection occurs through the synovium or the joint; however, extra-articular spread along the tendon sheaths or other soft tissues is possible, which is highlighted by the present case.

Candy Closure Technique for Chronic Open Infective Lateral Malleolus Bursitis.

The aim of this study was to report the effectiveness of the Candy closure technique as a treatment for chronic open infective lateral malleolus bursitis. From June 2014 to March 2018, we performed the Candy closure technique as a treatment for chronic open infective lateral malleolus bursitis in nine patients without secondary operation. We first performed infectious tissue debridement to control infection, and if primary closure was not possible, we performed the Candy closure technique for small wounds. The duration of the wound prior to surgery varied from 4 weeks to 2 years. Seven cases were due to infection on the bursa and two cases were ulcer-type bursitis. All the wounds were small (average, 3.80 cm2; range, 2.25-4 cm2) and circular. Seven wounds showed complete healing at 4 weeks after surgery, one wound showed complete healing at 8 weeks after surgery, and one wound with infected state was lost to missing follow-up. Of the seven wounds that showed complete healing, one wound recurred 6 months after surgery. The Candy closure technique is a simple method for ensuring healing and coverage of chronic open lateral malleolus bursitis, especially for small wounds with dead space.

A chronic sinus tract infection developing after suture anchoring of the ankle: A case report.

RATIONALE: Suture anchors are increasingly used to fix soft tissue to bone. Favorable outcomes of the modified Brostrom operation (MBO) using suture anchors have been reported. However, to the best of our knowledge, few complications of suture anchors used in ankle surgery have been described. Here, we present a rare case of successful treatment of a chronic sinus tract infection developing after the MBO using a suture anchor. PATIENT CONCERNS: A healthy 18-year-old high school student presented with a chronic ulcerative wound in his right ankle 1 year after anterior talofibular and calcaneofibular ligament repair using a suture anchor at a local clinic. Clinical examination revealed a 1.5 × 2-cm-sized ulcerative wound, accompanied by a red-black discharge, on the anterior border of the right lateral malleolus. The wound could be approximated to the joint capsule level using a forceps. DIAGNOSIS: A simple standing anteroposterior radiograph of the right ankle revealed mild, lateral soft-tissue swelling. Magnetic resonance imaging showed that a sinus tract running from the wound to the talar body crossed the anterior joint capsule, and bone marrow edema surrounding the talus. INTERVENTIONS: We removed the sinus tract and the infected suture anchor. We rendered the wound zigzag-shaped and then performed simple suturing and applied a short leg cast. OUTCOMES: The wound healed completely by 4 weeks after surgery. The patient reported no complication or recurrence of infection at the 1-year follow-up. LESSONS: To obtain wound healing, the chronic sinus tract must be removed. If the suture anchor is the cause of infection, it should be removed.

Musculoskeletal infections caused by Aerococcus urinae: a case-based review.

Aerococcus are Gram-positive bacteria that have been historically misidentified using standard techniques. We report a case of a 63-year-old man with septic oligoarthritis caused by Aerococcus urinae (isolated in two ankle synovial fluid cultures and in two blood cultures). Due to the lack of evidence found in a search performed to identify similar cases, a systematic review was conducted with the objective to identify and analyze all documented cases of musculoskeletal infections caused by Aerococcus urinae. A total of 8 cases were selected: 6 spondylodiscitis, 1 periarticular hip abscess, and 1 prosthetic hip infection. Similarly, as in other Aerococcus urinae invasive infections, these were presented predominantly in older males with history of urinary tract disease, being identified mostly by sequencing of the 16S rRNA or by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS), with an increasing incidence in the last years and generally with good sensitivity to beta-lactams (aminoglycosides were associated in some cases due to its synergistic effect). Additionally, 4 cases of musculoskeletal infections caused by Aerococcus viridans and 4 cases of Aerococcus urinae with ammoniacal and pervasive malodorous urine were identified; the last was a symptom also present in our case. In this review, we identify a recent increase of musculoskeletal infections caused by Aerococcus urinae, which as well as in series of other invasive infections could be well correlated with an increasing use of more sensible diagnosis methods in clinical laboratories. Therefore, we suggest that these probably will be more frequently diagnosed in the future.

Arthroscopic Management of a Rare Case of Melioidotic Septic Arthritis of the Ankle in a New Endemic Area on the Southwest Coast of India: A Case Report.

CASE: We report a case of melioidotic septic arthritis of the ankle and secondary osteomyelitis of the talus in a 64-year-old farmer with diabetes mellitus. Arthroscopic drainage and debridement, followed by 6 months of appropriate antibiotic therapy, resulted in a good short-term outcome. CONCLUSION: Melioidotic septic arthritis of the ankle is extremely rare. This case report highlights the possibility of this disease occurring on the Indian subcontinent.

Comparative Genomics Study of Staphylococcus epidermidis Isolates from Orthopedic-Device-Related Infections Correlated with Patient Outcome.

Staphylococcus epidermidis has emerged as an important opportunistic pathogen causing orthopedic-device-related infections (ODRI). This study investigated the association of genome variation and phenotypic features of the infecting S. epidermidis isolate with the clinical outcome for the infected patient. S. epidermidis isolates were collected from 104 patients with ODRI. Their clinical outcomes were evaluated, after an average of 26 months, as either "cured" or "not cured." The isolates were tested for antibiotic susceptibility and biofilm formation. Whole-genome sequencing was performed on all isolates, and genomic variation was related to features associated with "cured" and "not cured." Strong biofilm formation and aminoglycoside resistance were associated with a "not-cured" outcome (P = 0.031 and P < 0.001, respectively). Based on gene-by-gene analysis, some accessory genes were more prevalent in isolates from the "not-cured" group. These included the biofilm-associated bhp gene, the antiseptic resistance qacA gene, the cassette chromosome recombinase-encoding genes ccrA and ccrB, and the IS256-like transposase gene. This study identifies biofilm formation and antibiotic resistance as associated with poor outcome in S. epidermidis ODRI. Whole-genome sequencing identified specific genes associated with a "not-cured" outcome that should be validated in future studies. (The study has been registered at ClinicalTrials.gov with identifier NCT02640937.).

Candida arthritis in a patient diagnosed with spondyloarthritis.

Candida arthritis is an unusual manifestation that usually affects the knees. A 35-year-old man presented with a 2-month history of pain and swelling in the right knee. Swelling persisted after anti-inflammatory treatment. Peripheric spondyloarthritis was considered, but methotrexate, sulfasalazine, and methylprednisolone did not reduce the swelling. Direct examination of synovial fluid and a culture were positive for Candida albicans. Intravenous and intra-articular amphotericin-B were administered. The arthritis regressed and a culture and direct staining showed negative results. Candida arthritis should be considered in patients with arthritis that is resistant to treatment and prolonged, even if risk factors are absent.

Mycotic Septic Arthritis of the Ankle Joint.

Septic arthritis is a debilitating acute orthopedic emergency. Unfortunately, the diagnosis can be delayed or missed in immunocompromised patients with diabetes mellitus, and the result can be catastrophic. These patients are also at risk for atypical infections, including mycotic subtypes, which are more insidious than their more aggressive, more common Staphylococcus counterparts. The result is increased morbidity. In this article, we report a case of Candida albicans septic arthritis in a patient with diabetes mellitus and rheumatoid arthritis. Her case highlights the complexities of this specific disease entity. With early diagnosis, treatment is multimodal, involving surgical débridement and prolonged antifungal therapy.

First reported case of peroneal tenosynovitis caused by Coccidioides immitis successfully treated with fluconazole.

Coccidioidomycosis is an insidious infection caused by Coccidioides spp (C. immitis and C. posadasii). Disseminated disease occasionally involves tendon sheaths and synovium of the joints leading to tenosynovitis. Here, we describe the case of a 72-year-old woman from southern Arizona, who presented with right ankle pain, redness and swelling for 2 months. Her serum IgG was positive for C. immitis on complement fixation, and her MRI of the right ankle joint showed extensive tenosynovitis of the right peroneal tendons, and subtalar joint effusions with associated synovitis. The purpose of this case is to report an extremely rare manifestation of disseminated C. immitis, that is, peroneal tenosynovitis and challenges involved with diagnosis and treatment. We also document that azole therapy is an effective treatment option for peroneal tenosynovitis caused by C. immitis, and we had to double the dose for slow symptom resolution with 4-week trial with usual 400 mg oral dose of fluconazole.

Candida arthritis in a patient diagnosed with spondyloarthritis

Abstract Candida arthritis is an unusual manifestation that usually affects the knees. A 35-year-old man presented with a 2-month history of pain and swelling in the right knee. Swelling persisted after anti-inflammatory treatment. Peripheric spondyloarthritis was considered, but methotrexate, sulfasalazine, and methylprednisolone did not reduce the swelling. Direct examination of synovial fluid and a culture were positive for Candida albicans. Intravenous and intra-articular amphotericin-B were administered. The arthritis regressed and a culture and direct staining showed negative results. Candida arthritis should be considered in patients with arthritis that is resistant to treatment and prolonged, even if risk factors are absent.