Tag Archive for: infection

Pelvic Pyomyositis in Children: Current Concepts Review

Volume 8 | Issue 1 | January-April 2022 | Page: 02-07 | Archan Desai, Ashish Ranade, Mohan V. Belthur, Sandeep Patwardhan, Gauri A. Oka
DOI-10.13107/ijpo.2022.v08i01.127

Authors: Archan Desai [1], Ashish Ranade [1, 2], Mohan V. Belthur [3], Sandeep Patwardhan [4], Gauri A. Oka [1]

[1] Department of Orthopaedics, Bharati Hospital and Research Centre, Pune, Maharashtra, India.
[2] Department of Orthopaedics, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India.
[3] Department of Child Health & Orthopaedics, University of Arizona College of Medicine-Phoenix, USA.
[4] Department of Orthopaedics, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Ashish Ranade,
Consultant Paediatric Orthopaedic Surgeon, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India. Visiting Pediatric Orthopaedic Surgeon, Bharati Vidyapeeth Medical College Hospital, Pune, Maharashtra, India
E-mail: ranadea2@gmail.com

Abstract

Pyomyositis in children is an uncommon bacterial infection of skeletal muscles which has more frequently been described in tropical areas, but it is becoming increasingly recognized in temperate climates too. Any muscle group in the body can be involved, but it commonly affects the large muscle groups which are located around the pelvic girdle and lower extremities. Clinical presentation is very similar to septic arthritis of the hip and needs to be diagnosed early. MRI is the investigation of choice. Depending on the severity this condition, it can be treated conservatively with antibiotics in its early stage and with percutaneous or formal incision and drainage in later stages. Generally, if it is diagnosed early, good outcomes can be expected.
Keywords: Pelvic Pyomyositis, Septic arthritis, Infection, Magnetic resonance imaging

References

1. Bickels J, Ben-Sira L, Kessler A, Wientroub S. Primary pyomyositis. J Bone Joint Surg Am. 2002; 84(12):2277-2286.
2. Anand SV, Evans KT. Pyomyositis. Br J Surg. 1964; 51:917-920.
3. Levin MJ, Gardner P, Waldvogel FA. An un-usual infection due to staphylococcus aureus. N Engl J Med. 1971; 284(4):196-198.
4. Ciampi MA, Sadigh M, Sherwood JA, Protopapas Z, Thornton GF, Andriole VT. Temperate pyomyositis at two community hos-pitals. Infect Dis Clin Pract. 1998; 7:265-273.
5. Chiedozi LC: Pyomyositis: review of 205 cases in 112 patients, Am J Surg 137:255, 1979
6. De Boeck H, Noppen L, Desprechins B: Pyomyositis of the adductor muscles mimicking an infection of the hip. Diagnosis by magnetic resonance imaging: a case report, J Bone Joint Surg Am 76:747, 1994.
7. Hernandez RJ, Strouse PJ, Craig CL, et al: Focal pyomyositis of the perisciatic muscles in children, AJR Am J Roentgenol 179:1267, 2002.
8. Kadambari D, Jagdish S: Primary pyogenic psoas abscess in children, Pediatr Surg Int 16:408, 2000.
9. Orlicek SL, Abramson JS, Woods CR, et al: Obturator internus muscle abscess in children, J Pediatr Orthop 21:744, 2001.
10. Garcia-Mata S, Hidalgo-Ovejero A, Esparza-Estaun J. Primaryobturator-muscle pyomyositis in immunocompetent children. JChild Orthop. 2012;6:205–15.
11. Taksande A, Vilhekar K, Gupta S. Primary pyomyositis in a child. Int J Infect Dis. 2009;13(4):e149–51.
12. Christin L, Sarosi GA. Pyomyositis in North America: case reports and review. Clin Infect Dis. 1992;15:668–77.
13. Crum NF (2004) Bacterial pyomyositis in the United States. Am JMed 117(6):420–428
14. Moriarty P, Leung C, Walsh M, Nourse C (2015) Increasingpyomyositis presentations among children in Queensland,Australia. Pediatr Infect Dis J 34(1):1–4
15. Brown JD, Wheeler B (1984) Pyomyositis. Report of 18 cases inHawaii. Arch Intern Med 144(9):1749–1751
16. Verma S, Singhi SC, Marwaha RK, et al. Tropical pyomyositis inchildren: 10 years experience of a tertiary care hospital in northernIndia. J Trop Pediatr. 2013;59(3):243–5.
17. Gambhir IS, Singh DS, Gupta SS, Gupta PR, Kumar M. Tropicalpyomyositis in India: a clinico-histopathological study. J Trop MedHyg. 1992;95(1):42–6.
18. Malhotra P, Singh S, Sud A, et al. Tropical pyomyositis-experienceof a tertiary care hospital in North West India. J Assoc PhysiciansIndia. 2000;48:1057–60.
19. Chauhan S, Kumar R, Singh KK, Chauhan SS. Tropical pyomyositis: adiagnostic dilemma. J Ind Acad Clin Med. 2004;5:52–4.
20. Chauhan S, Jain S, Varma S, Chauhan SS. Tropical pyomyositis(myositis tropicans): current prospective. Postgrad Med J. 2004;80:267–70.
21. Smith MI, Vickers AB. Natural history of 338 treated and untreatedpatients with staphylococcal septicaemia (1936–1955). Lancet.1960;1(7138):1318–22.
22. Jayoussi R, Bialik V, Eyal A, Shehadeh N, Etzioni A. Pyomyositiscaused by vigorous exercise in a boy. Acta Paediatr. 1995;84(2):226–7.
23. Singh SB, Singh VP, Gupta S, Gupta RM, Sunder S. Tropical myo-sitis: a clinical, immunological and histopathological study. J AssocPhysicians India. 1989;37(9):561–3
24. Flier S, Dolgin SE, Saphir RL, et al: A case confirming the progressive stages of pyomyositis, J Pediatr Surg 38:1551, 2003.
25. .Moriarty, Leung C, Walsh M, Nourse C. Increasing pyomyositis presenting among children in Queensland, Australia. PediatrInfect Dis J. 2015;34(1):1–4.
26. Pannaraj PS, Hulten KG, Gonzalez BE, Mason Jr EO, Kaplan SL.Infective pyomyositis and myositis in children in the era of com-munity-acquired, methicillin-resistant Staphylococcus aureus infec-tion. Clin Infect Dis. 2006;43:953–60.
27. Mitchell PD, Hunt DM, Lyall H, Nolam M, et al. Panton-Valentineleukocidin-secreting Staphylococcus aureus causing sever muscu-loskeletal sepsis in children. A new threat. J Bone Joint Surg (Br).2007;89:1239–42.
28. Menge TJ, Cole HA, Mignemi ME, et al. Medial approach fordrainage of the obturator musculature in children.J Pediatr Orthop.2014;34:307–315.
29. Spiegel DA, Meyer JS, Dormans JP, et al. Pyomyositis in childrenand adolescents: report of 12 cases and review of the literature.JPediatr Orthop. 1999;19:143–150.
30. Renwick SE, Ritterbusch JF. Pyomyositis in children.J PediatrOrthop. 1993;13:769–772.
31. Mazur JM, Ross G, Cummings J, et al. Usefulness of magneticresonance imaging for the diagnosis of acute musculoskeletalinfections in children.J Pediatr Orthop. 1995;15:144–147.
32. Peckett WR, Butler-Manuel A, Apthorp LA. Pyomyositis of theiliacus muscle in a child.J Bone Joint Surg Br. 2001;83:103–105.
33. Thomas S, Tytherleigh-Strong G, Dodds R. Pyomyositis of theiliacus muscle in a child.J Bone Joint Surg Br. 2001;83:619–620.
34. Yuh WT, Schreiber AE, Montgomery WJ, et al. Magnetic resonanceimaging of pyomyositis.Skeletal Radiol. 1988;17:190–193.
35. Kocher MS, Zurakowski D, Kasser JR (1999) Differentiating be-tween septic arthritis and transient synovitis of the hip in children:an evidence- based clinical prediction algorithm. J Bone Joint SurgAm 81(12):1662–1670
36. Bertrand SL, Lincoln ED, Prohaska MG. Primary pyomyositis ofthe pelvis in children: a retrospective review of 8 cases.Orthopedics. 2011;34(12):832–40.
37. Unnikrishnan PN, Perry DC, George H, Bassi R, Bruce CE.Tropical primary pyomyositis in children of the UK: an emerging medical challenge. Int Orthop. 2010;34:109–13.
38. Kiran M, Mohamed S, Newton A, George H, Garg N, Bruce C. Pelvic pyomyositis in children: changing trends in occurrence and management. Int Orthop. 2018 May;42(5):1143-1147.
39. Birkbeck D, Watson JT (1995) Obturator internus pyomyositis. Acase report. Clin Orthop Relat Res 316:221–226
40. Tucker RE, Winter WG, Del Valle C, Uematsu A, Libke R(1978) Pyomyositis mimicking malignant tumor. Three casereports. J Bone Joint Surg Am 60:701–703
41. Karmazyn B, Loder RT, Kleiman MB, et al. The role of pelvicmagnetic resonance in evaluating nonhip sources of infection inchildren with acute nontraumatic hip pain.J Pediatr Orthop.2007;27:158–164.
42. Ovadia D, Ezra E, Ben-Sira L, et al. Primary pyomyositis inchildren: a retrospective analysis of 11 cases.J Pediatr Orthop B.2007;16:153–159.
43. Browne LP, Mason EO, Kaplan SL, et al. Optimal imaging strategyfor community-acquiredStaphylococcus aureusmusculoskeletalinfections in children.Pediatr Radiol. 2008;38:841–847.
44. Karmazyn B, Kleiman MB, Buckwalter K, et al. Acute pyomyositisof the pelvis: the spectrum of clinical presentations and MRfindings.Pediatr Radiol. 2006;36:338–343.
45. Marin C, Sanchez-Alegre ML, Gallego C, et al. Magnetic resonanceimaging of osteoarticular infections in children.Curr Probl DiagnRadiol. 2004;33:43–59.
46. Theodorou SJ, Theodorou DJ, Resnick D. MR imaging findings ofpyogenic bacterial myositis (pyomyositis) in patients with localmuscle trauma: illustrative cases.Emerg Radiol. 2007;14:89–96.
47. Damski GB, Garin EH, Ballinger WE, et al. Generalized non-suppurative myositis with staphylococcal septicemia. J Pediatr.1980;96:694–7.
48. Ameh EA (1999) Pyomyositis in children: analysis of 31 cases.Ann Trop Paediatr 19:263–265
49. Vij N, Ranade AS, Kang P, Belthur MV. Primary Bacterial Pyomyositis in Children: A Systematic Review. J Pediatr Orthop. 2021 Oct 1;41(9):e849-e854.
50. Song J, Letts M, Monson R (2001) Differentiation of psoasmuscle abscess from septic arthritis of the hip in children. ClinOrthop Relat Res 391:258–265
51. Armstrong DG, D’Amato CR, Strong ML (1993) Three cases ofstaphylococcal pyomyositis in adolescence, including one patientwith neurologic compromise. J Pediatr Orthop 13:452–455
52. Teague DC, Graney DO, Routt ML Jr. Retropubic vascular hazardsof the ilioinguinal exposure: a cadaveric and clinical study.J OrthopTrauma. 1996;10:156–159.
53. Karakurt L, Karaca I, Yilmaz E, et al. Corona mortis: incidence andlocation.Arch Orthop Trauma Surg. 2002;122:163–164.
54. Luhmann SJ, Jones A, Schootman M, et al. Differentiation betweenseptic arthritis and transient synovitis of the hip in children withclinical prediction algorithms.J Bone Joint Surg Am. 2004;86-A:956–962.
55. Chauhan S, Jain S, Varma S, Chauhan SS. Tropical pyomyositis (myositis tropicans): current perspective. Postgrad Med J. 2004 May;80(943):267-70.
56. White S, Stopka S, Nimityongskul P, Jorgensen D. Transgluteal Approach for Drainage of Obturator Internus Abscess in Pediatric Patients. J Pediatr Orthop. 2017 Jan;37(1):e62-e66.
57. Hall RL, Callaghan JJ, Moloney E, Martinez S, Harrelson JM(1990) Pyomyositis in a temperate climate. Presentation, diag-nosis, and treatment. J Bone Joint Surg Am 72:1240–1244
58. Mignemi ME, Menge TJ, Cole HA, Mencio GA, Martus JE, Lovejoy S, Stutz CM, Schoenecker JG. Epidemiology, diagnosis, and treatment of pericapsular pyomyositis of the hip in children. J Pediatr Orthop. 2014 Apr-May;34(3):316-25.
59. Gupta G, Rabbi Q, Bohra V, Shah MM. Protrusio acetabulae as a sequel to septic arthritis of the hip with obturator internus pyomyositis. J Pediatr Orthop B. 2021 Nov 1;30(6):572-578.

How to Cite this Article:  Desai A, Ranade A, Belthur MV, Patwardhan S, Oka GA | Pelvic Pyomyositis in Children: Current Concepts Review | International Journal of Paediatric Orthopaedics | January-April 2022; 8(1): 02-07.

(Article Text HTML)      (Full Text PDF)

Osteosynthesis in a 10 year old boy with Fracture neck of Femur, Infected Nonunion with Implants In-situ, Neck Resorption and Avascular Necrosis -A case report.

Vol 1 | Issue 1 | July-Sep 2015 | page:48-50 | EG Mohan Kumar, GM Yathish Kumar.

Authors : EG Mohan Kumar[1], GM Yathish Kumar[1].

[1] Department Of Orthopedic Surgery, KIMS Al Shifa Hospital, Perintalmanna, Kerala, India.

Address of Correspondence
Dr. EG Mohan Kumar
HOD Department Of Orthopedic Surgery, KIMS Al Shifa Hospital,
Perintalmanna, Kerala- 679322 India.
Email- orthomohan@rediffmail.com.

Abstract

Background: Non union fracture femoral neck is one of the common complication of intra capsular fracture neck of femur in children as well as in adults and it is the most challenging problem to treat if femoral head salvage is attempted. Other common complication is avascular necrosis (AVN) of the femoral head with most reported incidences being <15% (range 0% to 67%), which is similar to the complication rate with non-neglected femoral neck fractures. We are reporting a case of 10 year old boy who elsewhere underwent closed reduction and internal fixation with canulated cancellous screw for Delbert type III fracture neck of femur, which subsequently got infected with a draining sinus, non union and AVN of femoral head with complete absorption of the neck in 4 months time.  We received the patient at that stage. He was managed by two stage surgery. Initially the implants were removed the screw tracks were curetted out and filled with antibiotic sponge. After the infection was eradicated osteosynthesis and neck reconstruction was done using fibular strut and cancellous grafts through modified Watson Jones approach and anterior capsulotomy . We avoided metal implants for fear of infection and so also a subtrochenteric osteotomy which require fixation. A hip spica cast was given for 6 weeks. The neck length was restored, vascularity restored and fracture united with an excellently functioning hip.
Keywords: Femur neck fracture, infection, osteosysnthesis.

Introduction
Fractures of the femoral neck in children are not common[1]. They represent fewer than 1% of all the paediatric fractures2. However, complications accompanying these fractures are frequent—specifically avascular necrosis, non union and early closure of the proximal physis of the femur—resulting in decrease of neck length and coxa vara. The incidence of non union varies from 7 to 10%, depending on the location of the fracture in the neck of femur[2,3,4]. Delbet was the first to describe the fractures of the femoral neck. He published the first classification in the French literature. Since then, Colonna[5] has quoted the Delbet classification, which is still accepted in all the literature regarding this subject, and Ratliff[6] has described the evaluation criteria of the results, based on the presence of pain, joint mobility and the child’s capacity to maintain a daily activity. Most of the articles in the literature support bone grafting and a valgus osteotomy with some sort of fixation[7]. Only few cases reported with non union neck of femur treated by fibular strut graft alone without fixation and osteotomy. We feel that our case was unique due to presence of infection which makes the situation complicated. Here, we report a case of paediatric femoral neck fracture which went in for all described complications like AVN, non union, infection and neck resorption which was managed successfully by staged surgery. In the first stage eradication of infection and in second stage osteosynthesis and neck length restoration was attempted.

Figure 1, 2, 3, 4, 5, 6

Case Presentation
A 10 year old boy sustained fracture neck of right femur following fall from tree 4 months back(Fig.1) and was initially treated elsewhere by closed reduction and Canulated Cancellous Screw and K wire fixation(Fig.2), but osteosythesis was failed due to infection and poor fixation. He presented to us with non union, neck resorption, avascular necrosis of head of femur and infection with implants insitu(Fig.3). His WBC count(13000cells/cumm), ESR(40mmhg/hour) and CRP(110) were elevated. X-Ray showed loosening of implants with surrounding osteolysis and he was managed in two stages. Initially implants were removed, debridement was done, screw tracks were curetted out and antibiotic sponge was kept inside the tracks and was put on antibiotics(Fig.4). Once the infection got settled when CRP became normal after two months he was taken up for second stage surgery. He was treated by autologous fibular strut grafting and cancellous graft packing through Modified Watson Jones approach. Intra-operatively he was put on traction table, reduction and alignment was checked under C-ARM guidance(Fig.5), we could restore the length of neck with fibula graft under C-ARM guidance and cancellous gaft harvested from iliac crest was filled around fibula graft bridging fracture site through anterior capsulotomy(Fig.6,7). Patient was immobilized in hip spica cast for 6 weeks(Fig.8), POP was removed and X-ray taken .Gradually hip and knee were mobilized. He was reviewed every month with radiograph which showed good union of fracture and vascularity of the head of femur spontaneously improved(Fig.9,10). Made partial weight bearing with the support of walker at 3 months post op and gradually increased weight bearing. Fracture consolidated by 6 months. At present his fracture is completely united, vascularity of head of femur regained(Fig.10). He has got 1cm shortening of limb and patient is back to school walking without support without any pain. Since the proximal physis is fused he may develop an increase in the present limb length discrepancy which we plan to correct later.

Figure 7, 8

Discussion
Fracture neck of femur in children is a rare injury and can lead to many complications. Nonunion and AVN are very common complication which is nearly equal in neglected and treated cases of fracture neck of femur[8].Infection further adds to challenge in treating these cases. We got chance to treat such a patient with failed osteosynthesis neck of femur with all known complication like infection, pseudoarthrosis, avascular necrosis and neck resorption. Investigation of nonunion of neck of femur should include TC,DC,ESR and CRP to rule out infection especially in failed osteosynthesis, MRI may be required if x-ray features are not conclusive of vascular status of head of femur. In the literature there are few articles about treating this challenging problem. All are supporting valgus osteotomy some sort of fixation, few are supporting fibular grafting and cancellous screw fixation[4,9], but all concerning situations without infection.  We planned to tackle the infection first and go for osteosynthesis with bone grafting alone without osteotomy or use of any hardware for fixation, in view of the subsided infection. Fibular strut graft gave a very good structural support also helped us to maintain the neck length and cancellous graft helped in fracture healing and to some extent improve vascularity of femoral head which made him walk again. Patient may have LLD which is to be addressed at skeletal maturity.

Figure 9, 10

Clinical Relevance
Although fracture neck of femur in children is a rare injury, complications are very common and challenging to treat. Thorough investigations are must before treating these complications of neck of femur fracture. Infection must be ruled out in failed osteosynthesis. In selected cases fibula strut grafting and cancellous grafting allow neck reconstruction and fracture healing without fixation in children. Initial immobilization with spica cast and close follow up and monitoring during post operative period is essential to achieve the goal.

References

1. Miller WE (1973) Fractures of the hip in children from birth to adolescence. Clin Orthop Relat Res 92:155–187 [PubMed]
2. Ratliff AHC (1962) Fractures of the neck of the femur in children. J Bone Joint Surg Br 44:528–542 [PubMed]
3. Chrestian P, Bollini G, Jacquemier M, Ramaherison P (1981) Fractures du col du femur de lénfant. Chir Pediatr 22:397–403 [PubMed]
4. Ratliff AHC (1970) Complications after fractures of the femoral neck in children and their treatment. J Bone Joint Surg Br 52:175–183 .
5. Delbet cited by Colonna PC (1929) Fractures of the neck of the femur in children. Am J Surg 6:793–797.
6. RatliffAHC (1962) Fractures of the neck of the femur in children. J Bone Joint Surg Br 44:528–542[PubMed]
7. Pedro F. Tucci Neto, Fernando Baldy dos Reis, José Laredo Filho, , Edison Noboru Fujiki,Henri Bensahel, and Carlo Milani; Nonunion of fractures of the femoral neck in children ;J Child Orthop. 2008 Mar; 2(2): 97–103.
8. Amit Roshan, , The Neglected Femoral Neck Fracture in Young Adults: Review of a Challenging Problem; Clin Med Res. 2008 May; 6(1): 33–39.
9. Nagi ON, Dhillon MS, Gill SS.Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children.J Orthop Trauma. 1992;6(3):306-13.
10. Miller WE (1973) Fractures of the hip in children from birth to adolescence. Clin Orthop Relat Res 92:155–187 [PubMed]
11. Rang M (1983) Children’s fractures. 2nd edn. J B Lippincott, Philadelphia
12. Canale ST, Bourland WL (1977) Fracture of the neck of the femur and intertrochanteric region of the femur in children. J Bone Joint Surg Am 59:431–443 [PubMed]
13. Ingram AJ, Bachynski B (1953) Fractures of the hip in children. J Bone Joint Surg Am 35:867–886[PubMed]
14. Lam SF (1971) Fractures of the neck of the femur in children. J Bone Joint Surg Am 53:1165–1179[PubMed]
15. Forlin E, Guille BA, Kumar SJ, Rhee KJ (1992) Complications associated with fracture of the neck of the femur in children. J Pediatr Orthop 12:503–509 [PubMed]
16. Hughes LO, Beaty JH (1994) Fractures of the head and neck of the femur in children. J Bone Joint Surg Am 76:283–291 [PubMed]
17. Colonna PC (1928) Fracture of the neck of the femur in childhood. Ann Surg 88:902–907[PMC free article] [PubMed]
18. Weiner DS, O’dell HW (1969) Fractures of the hip in children. J Trauma 9:62–79 [PubMed]
19. Durbin FC (1959) Avascular necrosis complicating undisplaced fractures of the neck of the femur in children. J Bone Joint Surg Br 41:758–765 [PubMed]
20. McDougall A (1961) Fractures of the neck of the femur in childhood. J Bone Joint Surg Br 43:16–28
21. Ogden JA (1974) Changing patterns of proximal femoral vascularity. J Bone Joint Surg Am 56:941–50[PubMed]
22. Trueta J (1957) The normal vascular anatomy of the human femoral head during growth. J Bone Joint Surg Br 39:358–373 [PubMed]
23. Chung SMK (1976) The arterial supply of the developing proximal end of the human femur. J Bone J Surg Am 58:961–970 [PubMed]
24. Sotto-Hall R, Johnson LH, Johnson RA (1964) Variations in the intra-articular pressure of the hip joint in injury and disease. J Bone Joint Surg Am 46:509–516 [PubMed]
25. Drake JK, Meyers MH (1984) Intracapsular pressure and hemartrosis following femoral neck fracture. Clin Orthop Relat Res 182:172–175 [PubMed]
26. Pauwels F (1965) Biomechanics of the locomotor apparatus. English edn. Springer, New York
27. Touzet P, Rigault P, Padovani JP, Pouliquen JC, Mallet JF, Guyonvarch G (1979) Fractures of the neck of the femur in children. Rev Chir Orthop Reparatrice Appar Mot 65:341–349 [PubMed]
28. Trueta J (1968) Vascular pattern of the femoral head during growth. In: Studies of the development decay of the human frame, 2nd ed. J. B. Lippincott, Philadelphia.

How to Cite this Article: Kumar EGM, Kumar GMY. Osteosynthesis in a 10 year old boy with fracture neck of femur, infected nonunion with implants insitu, neck resorption and Avascular Necrosis -A case report. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):48-50.       

(Abstract)      (Full Text HTML)      (Download PDF)