[Septic arthritis of the finger joints. Treatment with immediate arthrodesis]

A consecutive series of 44 patients with septic arthritis of finger joints is presented. The patients were treated with antibiotics, incision, debridement and usually drainage. In 13 patients with destruction of the joint cartilage, an arthrodesis was made at the time of incision. The failure rate with conventional therapy was 42 per cent. The failure rate in the arthrodesis group, which represented all the severe cases, was 23 per cent. In septic arthritis of finger joints with destruction of the cartilage arthrodesis with Kirschner-wire and interosseous wiring is recommended at the time of primary incision.

[Fournier gangrene with involvement of the thigh--radical restoration by exarticulation of the femur. Case report]

We report a case of Fournier's gangrene of the scrotum, involving the right lower extremity. Radical surgical intervention (hip joint exatriculation) was necessary.

Clostridial sepsis: unusual clinical presentations

We present four cases exhibiting the widely diverse nature of clinical infections due to anaerobic Clostridium perfringens. These cases exemplify the need for a thorough initial physical examination, immediate Gram staining of fluid from involved tissue, and recognition of the severity of the disease in any patient who has early septic deterioration after elective or emergency surgical procedures. Management of these infections includes both high-dose parenteral penicillin therapy and aggressive initial surgical debridement of all involved tissues.

Metastatic nontraumatic Clostridium septicum osteomyelitis

Nontraumatic clostridial infections are rare, but need to be diagnosed and treated early or high morbidity and mortality rates result. We believe that this is the first reported case of metastatic nontraumatic Clostridium septicum osteomyelitis. Early treatment with surgical debridement and parenteral antibiotics without hyperbaric oxygen was used. An associated occult rectal malignancy was discovered and treated.

Gas gangrene infection of the eyes and orbits

The literature on Clostridium perfringens infections is reviewed up to 1983. An additional case is reported with bilateral clostridial infections of the eye and orbit. One eye followed the classical course of relentless panophthalmitis, amaurosis, and orbital cellulitis ending in enucleation. The second eye contained intracameral mud and gas bubbles that were removed by vitrectomy instrumentation. Subsequent removal of the toxic cataract resulted in a final aided visual acuity of 6/18, N8. This is the third report of a retained globe, and we believe the only known case where the patient was left with useful vision.

Management of abdominal wall clostridial myonecrosis: the role of total gastrointestinal diversion

We report the successful management of two patients with abdominal wall gas gangrene and emphasize the principles of proximal gastrointestinal diversion and the initial use of 100% fraction of inspired oxygen (FiO2). Each patient lacked an abdominal wall and intractable fistulas developed. Complete diversion of their gastrointestinal tracts at a proximal level facilitated closure of the fistulas and prevented possible peritoneal contamination. One patient's arterial oxygen pressure was maintained in the 200 to 300 range for two days after admission. This level has been shown to be adequate to stop clostridial alpha toxin production.

Surgical aspects of Clostridium septicum septicemia

Clostridium septicum is a virulent cause of gas gangrene and sepsis. Although thought to be rare, a survey of our affiliated hospitals for a recent five-year period disclosed eight cases. Seven of the eight had an occult malignant neoplasm. The eighth patient was thought to be preleukemic. All seven malignant neoplasms involved the gastrointestinal tract. Four patients were admitted with gangrene of an extremity, three with abdominal pain, and one with both. In four patients, C septicum septicemia appeared in an extremity before the underlying gastrointestinal malignant neoplasm was recognized. Four patients had surgical therapy and two survived; four received medical therapy and one survived. Patients who have C septicum septicemia should be assumed to harbor an underlying malignant neoplasm until proved otherwise.

Gas gangrene in traumatic hand injuries. Report of three cases

Gaseous gangrene is an infection with anaerobies germs characterized by gaseous infiltration of soft tissues with quick and serious damage to the general state. Known in war time, it rages also in civilian practice. Two etiologies are dominating: post-trauma gaseous gangrenes, post-surgery gaseous gangrenes. Among post-trauma gaseous gangrenes, the ones on departure of inferior members are the most frequent arising from fractures or from luxations open or closed. Localisation on superior limbs is scarce, specially after soft parts' trauma. We report three cases of superior limbs' gaseous gangrene after seemingly benign trauma. Diagnosis has been set by the clinical surgery, and the presence of gas bubbles at soft tissues' radiography. It didn't exist any favorising agent such as diabetes, arterial insufficiency, intercurrent disease treated with corticoïdes or with immuno-depressors. Bacteriological levyings have not put the causal germ in evidence, this is due to levying conditions. Evolution of gaseous gangrene depends on quickness of diagnosis and treatment. This one includes surgical flattening, discharge's incisions and excisions of devitalized tissues, as well as antibiotherapy with 20 000 to 60 000 U penicilline by parenteral way. We didn't need appeal to hyperbare oxygenotherapy. Simple procedures of secondary repair surgery were sufficient to restoration of a normal function. Gaseous gangrene is a real surgical urgency, even without bacteriological proof.

The risk of malignant edema following lower limb amputation for ischemic gangrene

Authors review 1360 lower limb amputations for ischemic gangrene. The incidence of postoperative malignant edema of the stump was found to be 0.2 to 0.4%, and the distribution was favourable to encourage amputating surgeons to choose possibly distal levels even in case of vascular disease.

Gas gangrene after intramuscular injection of adrenaline

A 13-year-old girl incurred gas gangrene after intramuscular injection of adrenaline to the buttock. Clinical evidence of very severe pain at the site of injection with septicemia and collapse within 24 to 48 hours should arouse the suspicion of clostridial myositis rather than pyogenic infection. Early diagnosis and treatment by adequate excision of necrotic muscle (with a wide margin of normal-appearing muscle) can prevent loss of life or limb in these patients.

Myonecrotic gas gangrene of the extremities

Twenty-three patients with proven myonecrotic gas gangrene of the extremities caused by Clostridium perfringens bacteria were treated by a combination of surgical measures, benzyl-penicillin and hyperbaric oxygen at three atmospheres. 87 per cent (20/23) of the cases were cured and half of the surviving patients (10) had to be amputated at least one level higher than on admission. No single factor could be established that influenced the course of the infection comparing age under and over 50 years, vascular insufficiency and normal vascular conditions, and toxicity and non-toxicity. Nor did the level of the infection of the limb seem to have any influence. The frequency of death in relation to the described variables could not be established when multi-variance analysis was used.

An effective method of skin traction in A-K guillotine amputation

In modern orthopedic surgery, there are still indications for the guillotine amputation of the thigh. Immediate postoperative management by effective skin traction can promote rapid healing and eliminate the need for revision surgery. Revision surgery necessitates further shortening of the stump; skin grafting likewise can be avoided as a secondary procedure. Most skin tractions for above-the-knee amputations loosen within 24 hours. The suggested method of applying skin traction on A-K amputations, if applied properly, will be effective for periods ranging from five to seven days.

Progressive necrotizing surgical infections--a unified approach

Four types of progressive necrotizing surgical infections have been described, based on the type of infecting organism, the type and depth of soft tissue penetration and clinical findings, and the type of surgical therapy recommended, e.g., necrotizing fasciitis, clostridial cellulitis. A mortality rate of up to 50% continues to be reported. An experience with 20 such cases indicates that there is a considerable overlap in clinical-physical findings and bacteriology such that classification schemes are confusing and lead to treatment delays and the use of inappropriate therapy. The infections all seem to be variations of the same disease process, a spreading, necrotizing infection. Of the 20 cases, four were treated with antibiotics and delayed (1 to 3 days) excision of necrotic tissue with 75% deaths; four cases received antibiotics and multiple surgical incisions with 100% deaths. The other 12 cases were treated with a unified approach of resuscitation, antibiotics (penicillin, clindamycin, tobramycin), immediate surgical excision (3 to 4 hours) of all necrotic tissue, aggressive nutritional support, and early skin coverage, with an 8.3% mortality. We conclude that there seems to be no need to classify necrotizing infections into different types. Recognizing them as the same disease process and treating them with a unified approach resulted in a significant reduction in mortality.

[Intestinal gas gangrene originating from the gallbladder: diagnosis, therapy, report of 2 cases]

The problems of diagnosis and therapy of gas gangrene of the gastrointestinal tube and the gallbladder are discussed. 2 cases of gas edema of the gallbladder due to clostridium perfringens are reported. One of the patients survived. The early diagnosis of gas gangrene is important because of the extraordinary way of infection and the necessary early surgical and medicamentous therapy.