Effectiveness of negative pressure wound therapy in complex surgical treatment of necrotizing fasciitis of the upper limb

BACKGROUND Necrotizing fasciitis(NF)of the upper extremities is a severe surgical pathology,and the incidence of this disease has been steadily increasing in recent decades.Surgical treatment is accompanied by the formation of extensive wounds,which can be treated with significant difficulties.In recent years,negative pressure wound therapy(NPWT)has proven to be highly effective.It is also promising for the treatment of NF.AIM To explore the effectiveness of NPWT in the treatment of NF of the upper extremities.METHODS The results of the treatment of 36 patients with NF of the upper extremities in two groups(NPWT group and control group;2022−2023)were retrospectively analyzed.In the NPWT group,the NPWT method(120 mmHg;constant mode)was used after surgical treatment.The number of vacuum-assisted dressings in patients ranged from 1 to 3,depending on the dynamics of the wound process.The duration of fixation of one bandage was up to 2−3 d.In the control group,conventional methods of local wound treatment were used.The following indicators were analyzed:The treatment delay,the prevalence of inflammation,the microbial landscape,the number of debridements,the duration of wound preparation for surgical closure,and the nature of skin plastic surgery.RESULTS Most patients experienced a significant treatment delay[4 d,interquartile range(IQR):2–7 d],which led to the spread of the pathological process to the forearm and shoulder.The most common pathogens were Staphylococcus aureus(14;38.9%)and Streptococcus pyogenes(22;61.1%).The average number of debridements per patient was 5(IQR:3–7),with no difference between groups.The average time to prepare wounds for surgical closure was 11±4 d in the NPWT group and 29±10 d(P=0.00001)in the control group.In the NPWT group,the wounds were more often closed with local tissues(15;83.3%),and in the control group,split-thickness skin grafts were more often used(4;50%).CONCLUSION The predominant isolation of Staphylococcus aureus and/or Streptococcus pyogenes from the lesions allowed us to classify these patients as NF type II.Multiple debridement procedures have become a feature of this disease treatment.The use of NPWT has significantly reduced the time required to prepare wounds for surgical closure.Early closure of wounds allows for more frequent use of local tissue repair,which ensures better results.NPWT is a highly effective way to prepare wounds for early surgical closure in patients with upper extremity NF.

New classification for septic arthritis of the hand

The severity of septic arthritis of the hand and the prospects for restoration of joint function are determined by a complex of factors. Among them, the leading role belongs to local changes in tissue structures. This includes the destruction of articular cartilage and bone tissue with the development of osteomyelitis, the involvement of paraarticular soft tissues in the purulent process, and the destruction of the flexor/extensor tendons of the fingers. The currently missing specialized classification of septic arthritis could help in systematizing the diseases, determining treatment tactics, and predicting the results of treatment.The classification of septic arthritis of the hand proposed for discussion is based on the following principle: Joint-Wound-Tendon(Jx Wx Tx);Jx characterizes damage to the osteochondral structures of the joint, Wx is the presence of paraarticular purulent wounds or fistulas, and Tx is destruction of the flexor/extensor tendons of the finger. The classification of the diagnosis makes it possible to assess the nature and severity of damage to the structures of the joint and may also be useful when comparing the results of treatment of septic arthritis of the hand.

Septic arthritis of the hand: From etiopathogenesis to surgical treatment

BACKGROUND Septic arthritis of the hand,which is the second most common after damage of the knee joint,remains one of the leading causes of temporary disability.An inflammation can cause dysfunction of the joint,and in the most severe cases,the need for amputation of the finger may arise.The results of their treatment today,especially from a functional point of view,cannot be considered satisfactory.Urgent surgical treatment is extremely important in septic arthritis of the hand,as it helps to prevent cartilage destruction and the development of osteomyelitis.AIM To explore the features of the course of septic arthritis of the hand as well as approaches to surgical treatment and its results,depending on the nature of the damage to the articular structures.METHODS The results of the treatment of 170 patients with septic arthritis of the hand,which were treated in the period of 2020-2021,were analyzed.Inflammation of the interphalangeal and metacarpophalangeal joints(MCP)of fingers 1,2,and 3 was more often noted in 147(81.6%)joints.The most common cause of arthritis was a penetrating injury as a result of household trauma(101,59.4%),animal bite(30,17.6%),and clenched fist injury(15,8.8%).Septic arthritis with contiguous osteomyelitis was observed in 98(54.4%)cases.Surgical treatment was completed with drainage and irrigation of the joint.Early mobilization was used to restore function.In patients with osteomyelitis,it was aimed at the formation of neoarthrosis.Arthrodesis was not applied.Long-term results of treatment were assessed in 142(83.5%)patients within 1 mo to 12 mo after discharge from the hospital[the median was 7 mo(IQR:4-9)].RESULTS The most commonly isolated organism was Staphylococcus aureus(35.3%).The median treatment delay in patients without osteomyelitis was 5 d(IQR:4-7);for septic arthritis with contiguous osteomyelitis,it was 14 d(IQR:5-21).Radiography for osteomyelitis within 2 wk was uninformative:41.2%of diagnoses.A single surgical treatment was required in 138(81.2%)patients,two treatments in 22(12.9%),and three or more in 10(5.9%).Total elimination of the infection was achieved in 163(95.9%)patients.The best functional results of treatment were noted in patients without osteomyelitis.After septic arthritis,Total Active Motion(TAM)for the MCP was 96.2%(IQR:85.1-98.0),for the proximal interphalangeal joint(PIP)82.4%(IQR:54.5-98.5),and for the distal interphalangeal joint(DIP)69.4%(IQR:65.4-74.1).In cases with osteomyelitis,it was possible to achieve the formation of neoarthrosis with TAM for MCP-64.2%(IQR:45.3-90.1),for PIP-62.5%(IQR:41.8-68.9),and for DIP-59.4%(IQR:50-62.1).Additionally,the severity of pain during movements did not exceed 1 point.CONCLUSION The delay in treatment of patients with septic arthritis of the hand was accompanied by a high incidence of osteomyelitis,especially in the presence of diabetes mellitus.Urgent surgical treatment,along with continued irrigation of the joint and antibiotic therapy,made it possible to eliminate the infection,and early rehabilitation restored the range of motion.The best results were noted in patients without osteomyelitis.With the development of osteomyelitis,a complex of early rehabilitation measures also made it possible to partially restore the range of motion due to the formation of neoarthrosis,without resorting to arthrodesis.

Septic arthritis of the hand:Current issues of etiology,pathogenesis,diagnosis,treatment

Septic arthritis of the hand is a serious disease that often results in dysfunction of the joint or even the need to perform amputation of the finger.They rank second in the frequency of occurrence after lesions of the knee joint.Many points concerning the etiology,the timing of the development of cartilage destruction and the development of osteomyelitis,approaches to surgical treatment,the duration of antibiotic therapy,and the start of rehabilitation measures remain the subject of numerous discussions.Based on a search in the PubMed,Web of Science and Google Scholar databases down to 1990-2021,publications on septic arthritis of the hand were found and analyzed.The following inclusion criteria were used in our review:(1) Septic arthritis of the hand;(2) Published in a peer review journal;(3) Written in English;and(4) Full text version available.Studies were excluded if they met any of the following criteria:(1) Letters;(2) Articles published in abstract form only;and(3) Cadaveric studies.Septic arthritis of the hand was characterized by the most frequent damage to the joints of the index and middle fingers(> 50% of cases).Up to 90% of cases,the infection enters the joint as a result of penetrating trauma,animal bites,etc.Staphylococcus aureus became the most frequently isolated microorganism(30%-55%),and its polyantibiotic-resistant form Methicillin-resistant Staphylococcus aureus was found,according to various sources,from 0% to 73% among all isolated Staphylococcus aureus.In arthritis,Pasteurella multocida(6%-11%) is often isolated as a result of animal bites.Articular cartilage destruction in the experiment developed within 24-48 h after infection.In clinical studies,the development of osteomyelitis was noted when treatment was delayed by more than 10 d.X-ray data during the first two weeks were uninformative.Priority of surgical treatment of septic arthritis.Drainage and surgical treatment,and with the development of osteomyelitis,the implementation of arthrodesis.Antibacterial therapy for 2-4 wk and early start of rehabilitation measures.Timely surgical treatment in combination with antibiotic therapy and rehabilitation makes it possible to obtain a positive result in the treatment of septic arthritis of the hand.