We describe a case of pyoderma gangrenosum which at handed with severe wound breakdown after elective hip replacement.

We describe a case of pyoderma gangrenosum which at handed with severe wound breakdown

after elective hip replacement. The patient was treated luckily with minimal wound debridement and steroids. This diagnosis should always be considered when faceed with an enlarging painful skin lesion which does not expand organisms when cultured and fails to answer to antibiotic therapy, especially if there are similar lesions in other sites. In patients who have a past history of pyoderma gangrenosum, prophylactic steroids may be indicated at the time of surgery or may be required early in the postoperative period.

J Bone Joint Surg [Brj 1999;81-B:893-4

Received I September 1998; Accepted after revision 23 September 1998

Pyoderma gangrenosum is a condition causing progressive necrotising ulceration of the skin.1 The exact aetiology is unknown. It may be associated with several chronic diseases including ulcerative colitis, Crohn's disease, diverticulitis, hepatitis, rheumatoid arthritis, polycythaemia rubra vera and malignancy. In about 20% to 30% of patients there is no underlying cause. 2 It is a rare condition, if it be not that previous reviews have found many reports in the literature of its adventure after surgery.3

Case report

A 69-year-old man was transferred to the Oxford Bone Infection Unit 13 days after total hip replacement. He had an lay open wound with a large surrounding area of ulceration and necrotic tissue (Fig. la). The fascia lata was visible in the base of the hurt He also had an ulcerating lesion forward the back of his hand at the site of an intravenous cannulation. He had been fit before operation. single year before he had sustained dog bites to his leg which had ulcerated. They had been extensively debrided at another hospital before a diagnosis of pyoderma gangrenosum had been made. He had required substantial skin grafting and systemic steroids for that vexed question but the wounds were healed and required no treatment at the time of the hip replacement.

The injury of the hip arthroplasty broke down sum of two units days after surgery and he became systemically unwell. No organisms were grown from superficial swabs or discerning tissue samples. Despite intravenous administration of teicoplanin, cefotaxime and metronidazole, and pair debridement procedures the wound deteriorated. His C-reactive protein plain was >300 mg/l, his ESR 121mm/hour and his WBC 34 109/1 A presumptive diagnosis of necrotising fasciitis was made. Histological specimens showed a nonspecific acute inflammatory infiltrate with patchy necrosis. No organisms were seen with Gram staining. The histological findings were consistent with a diagnosis of necrotising fasciitis or pyoderma gangrenosum.

He was therefore given prednisolone (40 mg daily) and improved dramatically above the next two days. one as well as the other wounds stopped spreading; each was cleaned and make straighted daily with flamazine dressings. sum of two units weeks later he had a minor debridement of the hip pain the deep part of which was clos from one side of to the other gentamicin-impregnated methylmethacrylate beads. Antibiotics were continued (piperacillin 45 g td for three weeks and metromidarole 400 mg td for six weeks) contamination of the hip prosthesis. Skin grafting was considered still there was concern about healing at the donor site; it prov to be unnecessary and the grief slowly healed spontaneously (Fig. lb) The patient was mobile 11 weeks after the initial operation with healed injurys He was discharged on a reducing course of oral steroids (prednisolone).

Discussion

Clinically, pyoderma gangrenosum currents with pain followed by the formation of pustules. A haematoma-like lesion forms which becomes a sterile abscess spreading concentrically, undermining the skin brink; beginning [i]or[/i] ends to become a large necrotic sore with raised blue/purple borders. Histological examination point out tos no pathognomonic features, only a non-specific acute inflammatory reaction. The griefs are sterile and the organisms cultur are considered to be contaminants to be ascribed to secondary bacterial colonisation. Pathergy is a feature of pyoderma gangrenosum with novel lesions arising at sites of minor trauma, as it was as intravenous cannulation, as occurr in our patient.

When making the diagnosis it is important to consider a past history of the disease or of any of the known associated systemic disorders. The diagnosis should always be considered if there is an enlarging, painful skin lesion, which fails to answer to antibiotic therapy, especially if there are similar appearances at other sites.

Orally administered steroids, local skin care and a search for underlying systemic disease are the mainstays of treatment. sole conservative local debridement should be undertaken since aggressive surgery can incite the disease process5 Treatment with steroids, if started early, will usually rapidly improve the condition preventing earnestly morbidity. The prophylactic use of steroids has not been reported moreover they may be indicated for patients with a clear history of a previous episode of pyoderma gangrenosum if elective surgery is contemplated. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the control of this article.