A report of two patients with a history of pyoderma gangrenosum where total knee arthroplasty was performed under prophylactic immunosuppression

Autor: Marina Morgan, Andrew D Toms, Soulat Naim, Andrew M. Watts, Chris Bower, Daniel S. Hill
Rok vydání: 2013
Předmět:
Zdroj: European Orthopaedics and Traumatology. 5:85-89
ISSN: 1867-4577
1867-4569
DOI: 10.1007/s12570-013-0195-1
Popis: IntroductionPyoderma gangrenosum (PG) is a rare relapsing autoimmuneinflammatory disorder resulting in skin necrosis and ulcera-tion. It can be idiopathic or associated with other conditions.Sterile pustular lesions can occur 24 –48 h following cutane-ous trauma in up to 30 % of patients with PG. Blobnet firstdescribed this process in 1937 that he termed pathergy [1].Lack of surgical awareness and a striking clinical similaritybetween pathergy and wound sepsis make both delayed diag-nosisandfailuretoinitiatecorrecttreatmentlikelytooccur.PGcan be extremely difficult to treat, often requiring systemicimmunosuppression. Recurrent disease is common, but itsrelative rarity means that there is a lack of published evidenceregarding its treatment. None of the commonly used agentshave been formally assessed through a randomized controlledtrial. Many of the commonly used agents are associated withunpleasant and potentially serious side effects. Descriptions ofsurgical site pathergy following arthroplasty surgery are limit-ed. Only six cases following knee arthroplasty [ 2–7]andtwofollowinghiparthroplasty[8,9]haveappearedintheliterature.Only one describes a case with a clear past history of PG [ 8].No reports have described the indication for prophylactic im-munosuppressionagainstpathergy,norwhichpharmacologicalregimen might optimally prevent this while minimizingdelayed wound healing. We describe the first reports of pro-phylacticpreoperativeimmunosuppressionintwopatientswitha known history of PG undergoing elective total knee replace-ment (TKR) surgery.Case reportsPatient 1A 76-year-old man with tricompartmental osteoarthritis waslisted for an elective right TKR. Preoperative assessmentrevealed a past history of contralateral lower limb PG thatoccurred following trauma (Fig. 1). This was initially resis-tant to high dose prednisolone and ciclosporin therapy buthealed 6 months following the administration of intravenousinfliximab. In the absence of formal guidance or evidence,the multidisciplinary team decided on a preoperative treat-ment protocol of prophylactic immunosuppression withprednisolone (60 mg daily for 14 days, commencing 5 daysprior to surgery and then reducing by 5 mg every 5 dayspostoperatively). This was on the basis that prednisolonewas felt to have the lowest risk side effect profile. A primarycemented right TKR was performed without complication.Standard intravenous antimicrobial prophylaxis was admin-istered. On day nine postsurgery, the surgical site appearedto have healed well with no evidence of pathergy. Thepatient was independently mobile and discharged.The patient returned on day 21 postsurgery with a swol-len right knee and a small amount of serous wound dis-charge. Clinically, the soft tissues were healthy, but a mildsystemic inflammatory response was present with a whitecell count (WCC) of 13.9×10
Databáze: OpenAIRE
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