Surgical interventions in chronic osteomyelitis

Abstract Chronic osteomyelitis is a leading cause of morbidity in orthopaedic practice in Nepal. Various factors like health service inaccessibility, inadequate treatment, malnutrition, poverty, and to some extent antibiotic resistance contribute to disease progression from acute osteomyelitis to chronic osteomyelitis in this region of the world. This paper presents our experience of managing ninety patients with chronic osteomyelitis over a period of four years

AAC's Charge #6 - Proposed Student Leave of Absence Policy (Document and PPt) 4/20/2017

AAC's Charge #6 - Proposed Student Leave of Absence Policy (Document and PPt) 4/20/2017Academic Senat

Key Indexing Terms: AORTIC INSUFFICIENCY MITRAL INSUFFICIENCY ARTHRITIS JUVENILE SPONDYLOARTHRITIS Personal, non-commercial use only

Heart involvement is a recognized complication of spondyloarthritis in adults occurring in 10-20% of the patients. Juvenile spondyloarthritis (JS) is the second most common form of juvenile chronic arthropathies with an estimated prevalence of 11 to 86 per 100,000 children. Until now only 8 cases, all males, with juvenile spondyloarthropathies with cardiac involvement have been reported in the English medical literature. We report the first case of a female patient with JS, in whom a severe cardiac involvement was seen. All reported cases of JS with cardiac involvement in the English medical literature are reviewed. CASE REPORT One year before admission an 8-year-old Caucasian girl developed pain in the left groin. The hip ultrasound showed an effusion in the left hip. In the further course the arthritis in the left hip persisted and a decreased range of internal rotation developed. The patient suffered from several episodes of episcleritis associated with anterior uveitis. The family history revealed that her father, who is HLA-B27 positive, had been diagnosed with a Morbus Reiter, associated with a chlamydial infection that had presented with arthritis in both knees and ankles, conjunctivitis, and urethritis. Our patient was negative for antinuclear antibodies and HLA-B27, but positive for HLA-B07 and B57. JS was diagnosed based on the European Spondylarthropathy Group preliminary criteria for classification of spondyloarthropathy 1 (asymmetric synovitis, predominantly in the lower extremity and a positive family history) and according to the ILAR classification criteria for juvenile idiopathic enthesitis related arthritis 2 (arthritis and a family history of HLA-B27 associated disease and anterior uveitis, which is usually associated with pain, redness, and photophobia). Two weeks before admission a grade 3 holosystolic heart murmur was first heard; the murmur was loudest at the heart apex. Echocardiography showed a mitral valve and aortic valve insufficiency. She was admitted to our hospital. We saw a normally developed 9-year-old girl, heart rhythm normal, grade 3 holosystolic heart murmur audible in the apex, and a grade 2 diastolic decrescendo murmur in the left 2nd and 3rd intercostal space. The musculoskeletal examination showed a limited internal rotation of the left hip, which was painful at the end of the range; the other joints were normal. No other clinical abnormality was seen. The following laboratory tests were all normal: hematologic values, Creactive protein, serum electrolytes, transaminases and serum creatinine, iron and iron-binding capacity, antistreptolysine titer, anti-DNAseB-titer, complement factors, and sterile blood cultures. Echocardiography (ECG) on admission showed a grade 3 mitral valve insufficiency with a prolapse of the anterior leaflet, dilated mitral anulus and dilated left atrium (34.8 mm), grade 3 aortic valve insufficiency with diastolic retrograde flow in the abdominal aorta Our diagnosis was cardiac involvement consistent with juvenile spondylarthropathy. We began a therapy with furosemide (2 mg/kg/day) and enalapril (0.3 mg/kg/day) for management of heart failure. Despite this therapy her cardiac condition progressed, including increased aortic and mitral insufficiency. Therefore we started immunosuppressive treatment with 30 mg/kg of methylprednisolone as a pulse therapy with 10 mg/m 2 of methotrexate (MTX) orally once a week as a second line intended to reduce her cardiac inflammation and to avoid a future valve replacement. After 8 months, because cardiac function deteriorated, MTX was increased to 15 mg/m 2 weekly and the administration was changed from oral to subcutaneous. In the next 2 months her cardiac function worsened and she developed aortic insufficiency III and mitral insufficiency III-IV. The progressive valve insufficiency was the indication for the valve replacement of the aortic and mitral valve with a mechanical valve (Carbomedics®, Austin, TX, USA). The histology of the removed valves showed myxoid degeneration with some fibrinoid necrosis and focal signs of inflammation with the infiltration of lymphocytes and granulocytes. According to the histology and the macroscopic description, no subaortic structures were involved. To date her disease has shown only joint involvement of her hip. ABSTRACT. Heart involvement is a recognized complication in 10-20% of all adults with spondyloarthritis. Until now only 8 cases of cardiac involvement in juvenile spondyloarthritis (JS) have been reported, all male patients. We describe the first female patient with JS, in whom progressive cardiac involvement developed, and summarize the pediatric JS cases with cardiac involvement