Postoperative Wound Breakdown Caused by Pyoderma Gangrenosum After Bilateral Simultaneous Total Knee Arthroplasty

doi:10.1016/j.arth.2006.09.017

The Journal of Arthroplasty

Volume 22, Issue 8, December 2007, Pages 1232-1235

https://doi.org/10.1016/j.arth.2006.09.017 Get rights and content

Abstract

Pyoderma gangrenosum is a noninfective necrosis of dermal tissues. Rarely, it occurs after surgery or trauma. However, lack of awareness and its striking similarity to a clinical picture of sepsis usually delay diagnosis and initiation of the correct management. We describe a unique case of its occurrence in both surgical wounds after bilateral total knee arthroplasty and discuss the differential diagnoses and management.

Section snippets

Case Report

An 80-year-old woman underwent bilateral simultaneous cemented total knee arthroplasty in November 2003 for primary tricompartmental osteoarthritis (Fig. 1) using the PFC posterior cruciate-retaining prosthesis (Depuy, Inc, Leeds, UK). She had no previous significant medical history and had undergone previous gynecologic surgery with no complications. The immediate postoperative period was uneventful, and a standard postoperative regimen of 2 doses of intravenous cefuroxime and knee

Discussion

A MEDLINE search for pyoderma gangrenosum returned 1300 articles. Of these, there were only 18 articles per case reports related to postoperative pyoderma gangrenosum of which only 2 case reports 2, 3 (3 cases) have been described in the orthopedic literature. The most frequent occurrence of postoperative pyoderma gangrenosum is after breast surgery [4], but it has also been described after thoracotomy, hernia surgery, abdominal surgery, and orbital surgery. The orthopedic literature describes

References (10)

B. Horner et al.
Pyoderma gangrenosum complicating bilateral breast reduction
Br J Plast Surg
(2004)
M. Ogon et al.
A surgical wound infection?
Lancet
(2000)
D.A. Warrell et al.
P.M. Armstrong et al.
Pyoderma gangrenosum. A diagnosis not to be missed
J Bone Joint Surg Br
(1999)
C.R. Bennett et al.
Pyoderma gangrenosum mimicking postoperative infection in the extremities. A report of two cases
J Bone Joint Surg Am
(1999)

There are more references available in the full text version of this article.

Cited by (32)

Pyoderma Gangrenosum After Bilateral Total Knee Arthroplasty
2021, Arthroplasty Today
Pyoderma gangrenosum is a neutrophilic dermatosis, which mimics both infection and necrotizing fasciitis, that can present after surgical interventions. We present the case of a 62-year-old male who underwent one-stage bilateral total knee arthroplasty. Nine days after the surgery, he presented with wound breakdown, high fever, and elevated white blood cell count. Repeated debridement was performed, and empiric antibiotics were given. All tissue cultures and aspirates remained negative throughout treatment course, and the patient remained unresponsive to therapy. The patient was eventually diagnosed with pyoderma gangrenosum after infectious etiologies were ruled out and after a skin biopsy and dermatologic consultation. His condition rapidly improved after treatment with corticosteroids, and soft-tissue defects were repaired with skin substitute and full-thickness skin grafting. In patients with aseptic wound breakdown after total knee arthroplasty, pyoderma gangrenosum is a rare but devastating complication and should be considered.
Total hip arthroplasty for femoral neck fracture with pyoderma gangrenosum patient: A case report
2017, International Journal of Surgery Case Reports
Citation Excerpt :
Pyoderma gangrenosum may occurs after surgery or trauma such as the surgery of breast or abdomen. It is very rare but do occurred after orthopedic surgery such as total hip replacement [2] and total knee arthroplasty [3]. Such disease is strikingly similar to the manifestation of infection.
Pyoderma gangrenosum is a rare inflammatory aseptic, ulcerative neutrophilic dermatosis which manifest as skin recurrent, painful ulcers.
A 65-year-old man with pyoderma gangrenosum underwent left total hip arthroplasty because of femoral neck fractures. Glucocorticoid, antibiotic, anticoagulant drug, etc. were given in perioperative period. Complication of pyoderma gangrenosum was prevented successfully in perioperative period.
No consensus has been reached about whether to use glucocorticoid, as well as the dosage and administration, in perioperative periods for pyoderma gangrenosum patients as prophylactic means of wound complication.
We herein report a case of pyoderma gangrenosum patient underwent total hip arthroplasty, meanwhile raise the issue of management in perioperative period for pyoderma gangrenosum patient, especially explore series of standardized therapies for this disease during arthroplasty.
Postoperative Pyoderma Gangrenosum: A Clinical Review of Published Cases
2016, Mayo Clinic Proceedings
Citation Excerpt :
This investigation was compliant with the US Health Insurance Portability and Accountability Act. Case reports of 156 unique patients were reviewed, and 140 cases were selected (Supplemental Table 1, available online at http://www.mayoclinicproceedings.org).3-5,13-130 Publications of 18 patients had no English translation or did not meet the inclusion timeline (Supplemental Table 2, available online at http://www.mayoclinicproceedings.org).9,131-146
Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by PG at surgical incisions. It is often misdiagnosed as wound infection, and pathergy may complicate wound debridement. From September 1, 2013, through November 30, 2013, a literature search was conducted of articles published from January 1, 1978, through December 31, 2012. We referenced PubMed, MEDLINE, and Mayo Clinic Libraries using the keywords pyoderma gangrenosum, postoperative pyoderma gangrenosum, postsurgical pyoderma gangrenosum, superficial granulomatous pyoderma, pathergic pyoderma, and pyoderma gangrenosum associated with surgery, incision, breast, and wound dehiscence. In addition, all titles from PubMed with the words pyoderma gangrenosum were reviewed manually for postoperative cases. Of 136 patients, 90 (66%) did not have associated systemic diseases. If a comorbidity was present, hematologic disorders were most common. In addition, 29% (28) of women had predisposing disease vs 53% (19) of men. Women had more frequent breast involvement (P<.001); chest involvement was more common in men (P=.005). Girls and women aged 13 to 64 years had more frequent breast involvement (P=.01). Sites were distributed equally for men regardless of age (P=.40). Antibiotic drug therapy was begun and debridement occurred in 90% (110 of 122 treated patients) and 73% (90 of 123 available patients), respectively. Postoperative PG has less association with systemic disease than its nonpostoperative counterpart. Antibiotic drug therapy is routinely initiated. Affected sites are often debrided, causing additional wound breakdown. Early diagnosis may prevent complications.
Successful treatment of wound breakdown caused by pyoderma gangrenosum after total knee arthroplasty
2011, Knee
Citation Excerpt :
However, it very rarely occurs after orthopedic limb procedures. In fact, there have only been five previous cases, which followed total hip arthroplasty [5], tarsal tunnel release [6], surgery on a rheumatoid hand [6], total knee arthroplasty [7], and knee arthroscopy [8]. All cases were initially misdiagnosed as wound infection.
Pyoderma gangrenosum is a rare ulcerative disorder of the skin of unknown etiology. We present a case of pyoderma gangrenosum that occurred following total knee arthroplasty, which was initially misdiagnosed as severe wound infection. Repeated debridement procedures resulted in a large soft tissue defect around the anterior knee joint. The patient was treated successfully with a latissimus dorsi musculocutaneous flap under immunosuppressive therapy. Pyoderma gangrenosum is often misdiagnosed as an infected wound, but the treatment for theses differential diagnoses is completely different. When a lesion is refractory to thorough treatment for infection, a diagnosis of pyoderma gangrenosum should be considered.
Pyoderma gangrenosum: A report of a rare complication after knee arthroplasty requiring muscle flap cover supplemented by negative pressure therapy and hyperbaric oxygen
2011, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Cutaneous trauma can lead to lesions in up to 30% of patients with PG – a concept termed pathergy. Only four cases following knee arthroplasty1–4 and two following hip arthroplasty have been reported in the literature.5,6 We describe a case where suppurative PG following knee arthroplasty required large soft tissue defect coverage.
Pyoderma gangrenosum (PG) is rare ulcerating skin condition easily confused with wound infection following surgery. We report a complicated case of PG following knee arthroplasty where delayed diagnosis and repeated debridements lead to significant tissue loss. Successful reconstruction was achieved with a muscle flap, but subsequent reactivation of PG and superadded infection placed both the reconstruction and patient’s life at risk. Prolonged combined use of negative pressure therapy (NPT), immunosuppression and hyperbaric oxygen (HBO) was successfully used to reduce the wound size, enhance wound granulation, promote re-epithelialisation, and provide pain relief. There is little or no published literature on these treatment modalities for the management of PG, with only one reported case using both NPT and HBO for PG (not following knee arthroplasty). More studies are necessary to determine the role of both modalities in the management of pathergy in large and complex wounds and the rare nature of this complication following knee arthroplasty explains the lack of evidence-based guidance.
In conclusion, we suggest a surgical algorithm. This is the first report of PG following knee arthroplasty with the use of both NPT and HBO in order to achieve soft tissue coverage.
Pyoderma gangrenosum following trauma of the knee: A case of pathergy and review of orthopaedic cases
2011, Injury
Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic dermatosis. Its course can be mild or malignant, chronic or relapsing with remarkable morbidity. We describe a case of PG, which presented with severe wound breakdown following a closed tibial plateau fracture of the left knee. Two weeks after the trauma, the patient developed ulcers in both lower legs. Sepsis was suspected and concomitant treatment was begun. No causal agent was found. A suspicion of PG arose and a treatment with corticosteroids was started. The patient recovered swiftly.
The very rare pathology of PG is discussed and a review of the literature of this pathology is given.
This diagnosis should always be considered when confronted with an enlarging painful skin lesion, which does not grow organisms when cultured and fails to respond to antibiotic therapy, especially if there are similar lesions in other sites. To our knowledge, this is the first case report of PG following trauma without any skin lesions at initial trauma.

View all citing articles on Scopus

: No benefits or funds were received in support of the study.

View full text

Case ReportPostoperative Wound Breakdown Caused by Pyoderma Gangrenosum After Bilateral Simultaneous Total Knee Arthroplasty

Abstract

Section snippets

Case Report

Discussion

Br J Plast Surg

Lancet

Pyoderma gangrenosum. A diagnosis not to be missed

J Bone Joint Surg Br

Pyoderma gangrenosum mimicking postoperative infection in the extremities. A report of two cases

J Bone Joint Surg Am

Case Report
Postoperative Wound Breakdown Caused by Pyoderma Gangrenosum After Bilateral Simultaneous Total Knee Arthroplasty