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Pyoderma gangrenosum after orthopaedic or traumatologic surgery: a systematic revue of the literature

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Abstract

Introduction

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised by a painful ulceration mimicking infection of the operative site. To this day, there is still no general agreement on the medical and surgical treatment of PG. This systematic review of the literature aims to summarise recent studies about post-operative PG in orthopaedic surgery to improve its medical and surgical management.

Method

In April 2017, we carried out an exhaustive review of the literature in MEDLINE, PubMed and Cochrane databases. Key words were pyoderma gangrenosum, orthopaedic surgery, and surgical wound infection. We identified 183 articles. After excluding articles reporting idiopathic PG, cases secondary to non-orthopaedic surgery, and cases about other subtypes of dermatosis, 30 studies were identified. We only included articles reporting PG after orthopaedic or trauma surgery.

Results

Thirty-one cases of PG have been reported, 58% (18) of which were in women, whose mean age was 56.5 years. Clinical signs were constant, the most frequently affected site was lower limbs [77.4% (24)] and delay of symptom onset was two to 17 days. Systemic corticosteroid therapy was systematic, polyvalent immunoglobulins were used in two cases and immunosuppressive drugs in one. Negative pressure therapy was used in seven cases and hyperbaric oxygen in three.

Discussion

Delayed diagnosis leads to one or more surgical revisions, which could have been avoided by using early and adapted medical treatment. Early onset of a painful and infected ulcer at the operating site in a patient at risk of PG is an indicator that dermatologist advice is recommended before surgical debridement. Surgical revision, outside the inflammatory phase and/or covered by a systemic corticosteroid therapy, does not lead to PG relapse.

Level of evidence

IV: Systematic revue of the literature.

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References

  1. Brunsting LA (1930) Pyoderma (echtyma) gangrenosum: clinical and experimental observations in five cases occuring in adults. Arch Dermatol Syphilol 22:655. https://doi.org/10.1001/archderm.1930.01440160053009

    Article  Google Scholar 

  2. Powell FC, Daniel Su WP, Perry HO (1996) Pyoderma gangrenosum: classification and management. J Am Acad Dermatol 34:395–409. https://doi.org/10.1016/S0190-9622(96)90428-4

    Article  CAS  PubMed  Google Scholar 

  3. Braswell SF, Kostopoulos TC, Ortega-Loayza AG (2015) Pathophysiology of pyoderma gangrenosum (PG): an updated review. J Am Acad Dermatol 73:691–698. https://doi.org/10.1016/j.jaad.2015.06.021

    Article  CAS  PubMed  Google Scholar 

  4. Bagouri E, Smith J, Geutjens G (2012) Anterior cruciate ligament reconstruction complicated by pyoderma gangrenosum. Ann R Coll Surg Engl 94:e257–e259. https://doi.org/10.1308/003588412X13373405387573

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Ogon M, Sepp NT, Wimmer C, Behensky H (2000) A surgical wound infection? Lancet Lond Engl 356:1652. https://doi.org/10.1016/S0140-6736(00)03161-5

    Article  CAS  Google Scholar 

  6. Verma SB (2009) Atypical pyoderma gangrenosum following total knee replacement surgery: first report in dermatologic literature. An Bras Dermatol 84:689–691

    Article  PubMed  Google Scholar 

  7. Yari SS, Reichel LM (2014) Case report: misdiagnosed olecranon bursitis: pyoderma gangrenosum. J Shoulder Elb Surg 23:e207–e211. https://doi.org/10.1016/j.jse.2014.06.032

    Article  Google Scholar 

  8. Henault B, Duvernay A, Legré R, Zwetyenga N (2011) Dermo-hypodermites nécrosantes neutrophiliques postopératoires de la main. Un diagnostic à ne pas rater. Chir Main 30:288–293. https://doi.org/10.1016/j.main.2011.06.003

    Article  CAS  PubMed  Google Scholar 

  9. Long CC, Jessop J, Young M, Holt PJ (1992) Minimizing the risk of post-operative pyoderma gangrenosum. Br J Dermatol 127:45–48

    Article  CAS  PubMed  Google Scholar 

  10. Ayestaray B, Dudrap E, Chartaux E et al (2010) Necrotizing pyoderma gangrenosum: an unusual differential diagnosis of necrotizing fasciitis. J Plast Reconstr Aesthetic Surg JPRAS 63:e655–e658. https://doi.org/10.1016/j.bjps.2010.02.008

    Article  Google Scholar 

  11. Tolkachjov SN, Fahy AS, Wetter DA et al (2015) Postoperative pyoderma gangrenosum (PG): the Mayo Clinic experience of 20 years from 1994 through 2014. J Am Acad Dermatol 73:615–622. https://doi.org/10.1016/j.jaad.2015.06.054

    Article  PubMed  Google Scholar 

  12. Wadia F, Malik MHA, Porter ML (2007) Postoperative wound breakdown caused by pyoderma Gangrenosum after bilateral simultaneous Total knee arthroplasty. J Arthroplast 22:1232–1235. https://doi.org/10.1016/j.arth.2006.09.017

    Article  Google Scholar 

  13. Madsen JT, Skov O, Andersen KE (2009) Pyoderma gangraenosum as a complication to knee arthroscopy. Knee 16:299–300. https://doi.org/10.1016/j.knee.2008.12.006

    Article  PubMed  Google Scholar 

  14. Armstrong PM, Ilyas I, Pandey R et al (1999) Pyoderma gangrenosum A DIAGNOSIS NOT TO BE MISSED. J Bone Joint Surg Br 81-B:893–894

    Article  Google Scholar 

  15. De Thomasson E, Caux I (2010) Pyoderma gangrenosum following an orthopedic surgical procedure. Orthop Traumatol Surg Res 96:600–602. https://doi.org/10.1016/j.otsr.2009.12.014

    Article  PubMed  Google Scholar 

  16. Hill DS, O’Neill JK, Toms A, Watts AM (2011) Pyoderma gangrenosum: a report of a rare complication after knee arthroplasty requiring muscle flap cover supplemented by negative pressure therapy and hyperbaric oxygen. J Plast Reconstr Aesthet Surg 64:1528–1532. https://doi.org/10.1016/j.bjps.2011.03.024

    Article  CAS  PubMed  Google Scholar 

  17. Attar S, Spangehl MJ, Casey WJ, Smith AA (2010) Pyoderma gangrenosum complicating bilateral total knee arthroplasty. Orthopedics 33:441. https://doi.org/10.3928/01477447-20100429-28

    PubMed  Google Scholar 

  18. Fang Z, Waizy H, Berger S et al (2013) Pyoderma Gangrenosum following Orthopaedic surgery. JBJS Case Connect 3:e84. https://doi.org/10.2106/JBJS.CC.M.00031

    Article  Google Scholar 

  19. Melo Grollmus R, Fernández de Retana P (2013) Pyoderma gangrenosum following foot and ankle surgery: a case report. Foot Ankle Int 34:745–748. https://doi.org/10.1177/1071100712471661

    Article  PubMed  Google Scholar 

  20. Wanich T, Swanson AN, Wyatt AJ, Kelly AM (2012) Pyoderma gangrenosum following patellar tendon repair: a case report and review of the literature. Am J Orthop Belle Mead NJ 41:E4–E9

    PubMed  Google Scholar 

  21. Steenbrugge F, Raaijmaakers M, Caekebeke P, Van Landuyt K (2011) Pyoderma gangrenosum following trauma of the knee: a case of pathergy and review of orthopaedic cases. Injury 42:421–423. https://doi.org/10.1016/j.injury.2010.06.015

    Article  PubMed  Google Scholar 

  22. Lee HS, Choi YR, Ha SH, Jeong JJ (2013) Pyoderma Gangrenosum mimicking a diabetic foot infection: a case report. J Foot Ankle Surg 52:67–71. https://doi.org/10.1053/j.jfas.2012.09.002

    Article  PubMed  Google Scholar 

  23. Nizamoglu M (2015) Pyoderma Gangrenosum mimicking an infected wound following dynamic hip screw fixation. Case Rep Orthop 2015:571472. https://doi.org/10.1155/2015/571472

    PubMed  PubMed Central  Google Scholar 

  24. Yik JH, Bigliardi PL, Sebastin SJ et al (2015) Pyoderma gangrenosum mimicking early acute infection following total knee arthroplasty. Ann Acad Med Singap 44:150–151

    PubMed  Google Scholar 

  25. Bennett CR, Brage ME, Mass DP (1999) Pyoderma Gangrenosum mimicking postoperative infection in the extremities. A report of two cases*. J Bone Jt Surg Case Connect 81:1013–1018

    Article  CAS  Google Scholar 

  26. Wangia MW, Mitchell CL, Wesson SK et al (2013) Pyoderma gangrenosum or necrotizing fasciitis? A diagnostic conundrum Case report and literature review. J Pediatr Surg Case Rep 1:139–142. https://doi.org/10.1016/j.epsc.2013.05.005

    Article  Google Scholar 

  27. Choe H, Sakano H, Takigami H et al (2013) Pyoderma gangrenosum with wrist joint destruction: case report. J Hand Surg 38:357–361. https://doi.org/10.1016/j.jhsa.2012.10.049

    Article  Google Scholar 

  28. Reid AB, Stanley P, Grinsell D, Daffy JR (2014) Severe, steroid-responsive, myositis mimicking necrotizing fasciitis following orthopedic surgery: a pyoderma variant with Myonecrosis. Plast Reconstr Surg Glob Open 2:e175. https://doi.org/10.1097/GOX.0000000000000124

    Article  PubMed  PubMed Central  Google Scholar 

  29. Nakajima N, Ikeuchi M, Izumi M et al (2011) Successful treatment of wound breakdown caused by pyoderma gangrenosum after total knee arthroplasty. Knee 18:453–455. https://doi.org/10.1016/j.knee.2010.06.005

    Article  CAS  PubMed  Google Scholar 

  30. Jain A, Nanchahal J, Bunker C (2000) Pyoderma gangrenosum occurring in a lower limb fasciocutaneous flap — a lesson to learn. Br J Plast Surg 53:437–440. https://doi.org/10.1054/bjps.2000.3351

    Article  CAS  PubMed  Google Scholar 

  31. Mandal A, Addison P, Stewart K, Neligan P (2005) Vacuum-assisted closure therapy in pyoderma gangrenosum. Eur J Plast Surg 28:529–531. https://doi.org/10.1007/s00238-005-0014-1

    Article  Google Scholar 

  32. Suarez C, Mercier E, Piquet P et al (2011) À propos de l’article : « Pyoderma gangrenosum après chirurgie orthopédique » de E. de Thomasson et I. Caux, publié dans Rev Chir Orthop 2010;96:672–4. Rev Chir Orthopédique Traumatol 97:865–866. https://doi.org/10.1016/j.rcot.2011.10.013

    Article  Google Scholar 

  33. Hackl S, Merkel P, Hungerer S et al (2015) Pyoderma gangraenosum nach Marknagelosteosynthese bei Tibiaschaftfraktur: Eine Differenzialdiagnose zur nekrotisierenden Fasziitis. Unfallchirurg 118:1062–1066. https://doi.org/10.1007/s00113-015-2737-1

    Article  CAS  PubMed  Google Scholar 

  34. Ruocco E, Sangiuliano S, Gravina A et al (2009) Pyoderma gangrenosum: an updated review. J Eur Acad Dermatol Venereol 23:1008–1017. https://doi.org/10.1111/j.1468-3083.2009.03199.x

    Article  CAS  PubMed  Google Scholar 

  35. Amazan E, Baubion E, Thimon S et al (2013) Incidence du Pyoderma gangrenosum en Martinique (Antilles françaises). Ann Dermatol Vénéréologie 140:S372. https://doi.org/10.1016/j.annder.2013.09.029

    Article  Google Scholar 

  36. Zuo KJ, Fung E, Tredget EE, Lin AN (2015) A systematic review of post-surgical pyoderma gangrenosum: identification of risk factors and proposed management strategy. J Plast Reconstr Aesthet Surg 68:295–303. https://doi.org/10.1016/j.bjps.2014.12.036

    Article  PubMed  Google Scholar 

  37. Crowson AN, Mihm MC Jr, Magro C (2003) Pyoderma gangrenosum: a review. J Cutan Pathol 30:97–107. https://doi.org/10.1034/j.1600-0560.2003.00024.x

    Article  PubMed  Google Scholar 

  38. Ahronowitz I, Harp J, Shinkai DK (2012) Etiology and Management of Pyoderma Gangrenosum. Am J Clin Dermatol 13:191–211. https://doi.org/10.2165/11595240-000000000-00000

    Article  PubMed  Google Scholar 

  39. DeFilippis EM, Feldman SR, Huang WW (2015) The genetics of pyoderma gangrenosum and implications for treatment: a systematic review. Br J Dermatol 172(6):1487–1497. https://doi.org/10.1111/bjd.13493

    Article  CAS  PubMed  Google Scholar 

  40. Van de Vijver E, van den Berg TK, Kuijpers TW (2013) Leukocyte adhesion deficiencies. Hematol Oncol Clin North Am 27:101–116. https://doi.org/10.1016/j.hoc.2012.10.001

    Article  PubMed  Google Scholar 

  41. Marzano AV, Fanoni D, Antiga E et al (2014) Expression of cytokines, chemokines and other effector molecules in two prototypic autoinflammatory skin diseases, pyoderma gangrenosum and Sweet’s syndrome. Clin Exp Immunol 178:48–56. https://doi.org/10.1111/cei.12394

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Wollina U (2007) Pyoderma gangrenosum – a review. Orphanet J Rare Dis 2:19. https://doi.org/10.1186/1750-1172-2-19

    Article  PubMed  PubMed Central  Google Scholar 

  43. Wollina U (2015) Pyoderma gangrenosum—a systemic disease? Clin Dermatol 33:527–530. https://doi.org/10.1016/j.clindermatol.2015.05.003

    Article  PubMed  Google Scholar 

  44. Maejima H, Watarai A, Tanabe K, Takasu H, Katsuoka K, Sada M (2014) Osteomyelitis in association with pyoderma Gangrenosum and ulcerative colitis. Cutis 93(4):E14–E16

    PubMed  Google Scholar 

  45. Wolff DA (1884) Zur Aetiologie der Psoriasis. Vierteljahresschr Für Dermatol Syph 11:337–340. https://doi.org/10.1007/BF01843434

    Google Scholar 

  46. Su WPD, Davis MDP, Weenig RH et al (2004) Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria. Int J Dermatol 43:790–800. https://doi.org/10.1111/j.1365-4632.2004.02128.x

    Article  PubMed  Google Scholar 

  47. Waterworth AS, Horgan K (2004) Pyoderma gangrenosum—an unusual differential diagnosis for acute infection. Breast 13:250–253. https://doi.org/10.1016/j.breast.2003.10.012

    Article  CAS  PubMed  Google Scholar 

  48. Lê Huu S, Spertini F, Roggero P et al (2009) Le pyoderma gangrenosum : pathologie rare ou diagnostic omis ? Ann Chir Plast Esthét 54:82–87. https://doi.org/10.1016/j.anplas.2008.05.006

    Article  PubMed  Google Scholar 

  49. Barr KL, Chhatwal HK, Wesson SK et al (2009) Pyoderma gangrenosum masquerading as necrotizing fasciitis. Am J Otolaryngol 30:273–276. https://doi.org/10.1016/j.amjoto.2008.05.005

    Article  PubMed  Google Scholar 

  50. Villarreal-Villarreal CD, Ocampo-Candiani J, Villarreal-Martínez A (2016) Sweet syndrome: a review and update. Actas Dermosifiliogr 107(5):369–378. https://doi.org/10.1016/j.ad.2015.12.001

    Article  CAS  PubMed  Google Scholar 

  51. Gibson LE, Daoud MS, Muller SA, Perry HO (1997) Malignant pyodermas revisited. Mayo Clin Proc 72:734–736. https://doi.org/10.1016/S0025-6196(11)63593-3

    Article  CAS  PubMed  Google Scholar 

  52. Reichrath J, Bens G, Bonowitz A, Tilgen W (2005) Treatment recommendations for pyoderma gangrenosum: an evidence-based review of the literature based on more than 350 patients. J Am Acad Dermatol 53:273–283. https://doi.org/10.1016/j.jaad.2004.10.006

    Article  PubMed  Google Scholar 

  53. Chow RKP, Ho VC (1996) Treatment of pyoderma gangrenosum. J Am Acad Dermatol 34:1047–1060. https://doi.org/10.1016/S0190-9622(96)90285-6

    Article  CAS  PubMed  Google Scholar 

  54. Ormerod AD, Thomas KS, Craig FE et al (2015) Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomised controlled trial. BMJ 350:h2958. https://doi.org/10.1136/bmj.h2958

    Article  PubMed  PubMed Central  Google Scholar 

  55. Dobson CM, Parslew RA, Evans S (2003) Superficial granulomatous pyoderma treated with intravenous immunoglobulin. J Am Acad Dermatol 48:456–460. https://doi.org/10.1067/mjd.2003.172

    Article  PubMed  Google Scholar 

  56. Novo-Torres A, Céspedes-Guirao FJ, Restituyo NG, Lorda-Barraguer E (2015) Management of pyoderma gangrenosum with combination of systemic treatment, vacuum-assisted closure and synthetic dermal substitute. Eur J Plast Surg 39:297–302. https://doi.org/10.1007/s00238-015-1147-5

    Article  Google Scholar 

  57. Ghersi MM, Ricotti C, Nousari CH, Newman MI (2007) NEgative pressure dressing in the management of pyoderma gangrenosum ulcer. Arch Dermatol 143:1249–1251. https://doi.org/10.1001/archderm.143.10.1249

    Article  PubMed  Google Scholar 

  58. Geller SM, Longton JA (2005) Ulceration of pyoderma Gangrenosum treated with negative pressure wound therapy. J Am Podiatr Med Assoc 95:171–174. https://doi.org/10.7547/0950171

    Article  PubMed  Google Scholar 

  59. Fraccalvieri M, Fierro MT, Salomone M et al (2014) Gauze-based negative pressure wound therapy: a valid method to manage pyoderma gangrenosum. Int Wound J 11:164–168. https://doi.org/10.1111/j.1742-481X.2012.01058.x

    Article  PubMed  Google Scholar 

  60. Pichler M, Larcher L, Holzer M et al (2016) Surgical treatment of pyoderma gangrenosum with negative pressure wound therapy and split thickness skin grafting under adequate immunosuppression is a valuable treatment option: case series of 15 patients. J Am Acad Dermatol 74:760–765. https://doi.org/10.1016/j.jaad.2015.09.009

    Article  PubMed  Google Scholar 

  61. Cabalag MS, Wasiak J, Lim SW, Raiola FB (2015) Inpatient management of pyoderma gangrenosum: treatments, outcomes, and clinical implications. Ann Plast Surg 74:354–360. https://doi.org/10.1097/SAP.0b013e31829565f3

    Article  CAS  PubMed  Google Scholar 

  62. Mazokopakis EE, Kofteridis DP, Pateromihelaki AT et al (2011) Improvement of ulcerative pyoderma gangrenosum with hyperbaric oxygen therapy. Dermatol Ther 24:134–136. https://doi.org/10.1111/j.1529-8019.2010.01387.x

    Article  PubMed  Google Scholar 

  63. Vieira WA, Barbosa LR, Martin LMM (2011) Hyperbaric oxygen therapy as an adjuvant treatment for pyoderma gangrenosum. An Bras Dermatol 86:1193–1196. https://doi.org/10.1590/S0365-05962011000600022

    Article  PubMed  Google Scholar 

  64. Wasserteil V, Bruce S, Sessoms SL, Guntupalli KK (1992) Pyoderma Gangrenosum treated with hyperbaric oxygen therapy. Int J Dermatol 31:594–596. https://doi.org/10.1111/j.1365-4362.1992.tb02728.x

    Article  CAS  PubMed  Google Scholar 

  65. Chiang IH, Liao YS, Dai NT, Chou CY, Chen SG, Chen TM, Chang SC (2016) Hyperbaric oxygen therapy for the adjunctive treatment of pyoderma Gangrenosum: a case report. Ostomy Wound Manage 62(2):32–36

    PubMed  Google Scholar 

  66. Niezgoda JA, Cabigas EB, Allen HK et al (2006) Managing pyoderma Gangrenosum: a synergistic approach combining surgical D??Bridement, vacuum-assisted closure, and hyperbaric oxygen therapy. Plast Reconstr Surg 117:24e–28e. https://doi.org/10.1097/01.prs.0000200776.13868.02

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Orthopaedic and Traumatologic Department, Military Hospital Robert Picqué, 351 route de Toulouse, 33140, Villenave d’Ornon, France

    Stephan Ebrad

  2. Orthopaedic and Traumatologic Department, La Meynard University Hospital, CS 90632, 97261, Fort-de-France, Martinique

    Mathieu Severyns, Ahmed Benzakour & Jean-Louis Rouvillain

  3. Department of Infectiology, La Meynard University Hospital, CS 90632, 97261, Fort-de-France, Martinique

    Benoit Roze

  4. Department of Dermatology, La Meynard University Hospital, CS 90632, 97261, Fort-de-France, Martinique

    Christian Derancourt

  5. Orthopaedic and Traumatologic Department, Lariboisière University Hospital, rue Ambroise Paré, 75010, Paris, France

    Guillaume-Anthony Odri

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  1. Stephan Ebrad
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Ebrad, S., Severyns, M., Benzakour, A. et al. Pyoderma gangrenosum after orthopaedic or traumatologic surgery: a systematic revue of the literature. International Orthopaedics (SICOT) 42, 239–245 (2018). https://doi.org/10.1007/s00264-017-3672-2

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