Tsung Jen Huang

Necrotizing soft-tissue infections and sepsis caused by Vibrio vulnificus compared with those caused by Aeromonas species

BACKGROUND Vibrio and Aeromonas species, which can cause necrotizing fasciitis and primary septicemia, are members of the Vibrionaceae family and thrive in aquatic environments. Because the clinical symptoms and signs of necrotizing fasciitis and sepsis caused by these two bacteria are similar, the purposes of this study were to describe the clinical characteristics of Vibrio vulnificus and Aeromonas infections, to analyze the risk factors for death, and to compare the effects of surgical treatment on the outcome. METHODS The cases of thirty-two patients with necrotizing soft-tissue infections and sepsis caused by Vibrio vulnificus (seventeen patients) and Aeromonas species (fifteen patients) were retrospectively reviewed over a four-year period. Surgical débridement or immediate limb amputation was initially performed in all patients. Demographic data, underlying diseases, laboratory results, and clinical outcome were analyzed for each patient in both groups. RESULTS Six patients in the Vibrio vulnificus group and four patients in the Aeromonas group died. The patients who died had significantly lower serum albumin levels than did the patients who survived (p < 0.05). The patients with a combination of hepatic dysfunction and diabetes mellitus had a higher mortality rate than those with either hepatic disease or diabetes mellitus alone (p < 0.05). The patients with Vibrio vulnificus infections had a significantly lower systolic blood pressure at presentation (p = 0.006). The patients with Aeromonas infections who died had significantly lower white blood-cell counts (p = 0.03) with significantly fewer numbers of segmented white blood cells than those who died in the Vibrio vulnificus group (p = 0.01). CONCLUSIONS The contact history of patients with a rapid onset of cellulitis can alert clinicians to a differential diagnosis of soft-tissue infection with Vibrio vulnificus (contact with seawater or raw seafood) or Aeromonas species (contact with fresh or brackish water, soil, or wood). Early fasciotomy and culture-directed antimicrobial therapy should be aggressively performed in those patients with hypotensive shock, leukopenia, severe hypoalbuminemia, and underlying chronic illness, especially a combination of hepatic dysfunction and diabetes mellitus.

Pulmonary function after thoracoplasty in adolescent idiopathic scoliosis.

The current study evaluated sequential pulmonary function tests prospectively at a minimum of 2 years after thoracoplasty in adolescent patients with idiopathic scoliosis. Twenty patients were divided into two groups: Group I (n=12) was comprised of patients who had posterior instrumented fusion with external thoracoplasty, and Group II (n=8) was comprised of patients who in addition to a posterior instrumented fusion, had an anterior release and fusion via video-assisted thoracoscopic surgery (n=4) or open thoracotomy (n=4) because of rigid severity. Forced vital capacity and forced expiratory volume in 1 second of percent predicted values in Group I declined 9% at 3 months postoperatively and returned to the preoperative baseline at 1 year. However, forced vital capacity and forced expiratory volume in 1 second of percent predicted values in Group II declined 11% to 18% postoperatively and did not return to the preoperative baseline at 2 years. Posterior instrumented fusion with thoracoplasty in adolescent patients with idiopathic scoliosis significantly decreased pulmonary function at 3 months, but returned to the preoperative baseline at 1 year. The addition of an anterior releasing procedure resulted in poorer pulmonary function, which did not return to the preoperative baseline by the 2-year followup.

Systemic vibrio infection presenting as necrotizing fasciitis and sepsis: A series of thirteen cases

BACKGROUND Vibrio species are an uncommon cause of necrotizing fasciitis and primary septicemia, which are likely to occur in patients with hepatic disease, diabetes mellitus, adrenal insufficiency, and immunocompromised conditions. These organisms are found in warm sea waters and are often present in raw oysters, shellfish, and other seafood. The purposes of the present report were to describe a series of patients who had this potentially lethal infection and to identify clinical features associated with a poor prognosis. METHODS We retrospectively reviewed the records of thirteen patients (ten men and three women) who had necrotizing fasciitis and sepsis caused by Vibrio species. All patients had a history of contact with seawater or raw seafood. Eight patients had a hepatic disease such as hepatitis or cirrhosis of the liver, three had diabetes mellitus (without hepatic disease), and two had chronic renal or adrenal insufficiency (without hepatic disease). RESULTS Twelve patients underwent fasciotomy or limb amputation. Five patients (38%) died within two to six days after admission, and eight patients survived. Patients with a systolic blood pressure of < or =90 mm Hg and leukopenia in the emergency room had a significantly higher mortality rate (p < 0.05). CONCLUSIONS The diagnosis of Vibrio necrotizing fasciitis should be suspected when a patient has the appropriate clinical findings and a history of contact with seawater or raw seafood. The treatment should begin as early as possible, essentially when the patient has symptoms of sepsis. Although emergency fasciotomy or limb amputation did not reduce the mortality rate in this series, we consider such operations to be an important aspect of treatment.

Minimal access spinal surgery (MASS) in treating thoracic spine metastasis

Study Design. A retrospective study was conducted. Objective. This study aims to analyze the feasibility and efficacy of using minimal access spinal surgery (MASS) for managing thoracic spine metastasis. Summary of Background Data. Literature regarding minimally invasive surgical treatment for thoracic spine metastasis is sparse. In the past decade, the role of minimally invasive or endoscopic technique in managing metastatic thoracic disease has evolved. Methods. From February 1997 to March 2003, 46 patients with spine metastases, from T3–T12, were enrolled in this study. There were 29 patients undergoing MASS. Seventeen patients received standard thoracotomy (ST) in the early study period served as the control group. The indications for MASS include intractable back pain and/or neurologic deficits or neurologic deterioration during or after radiotherapy. Inclusion criteria for this study included tumor limited to one or two vertebral segments. Results. In the MASS and ST groups, no patient died as a result of an immediate intraoperative event. The mean operative blood loss was 1,110 versus 1,162 mL (P = 0.63), and the mean operative length was 179 versus 180 minutes (P = 0.54). Complication rates and 1-year, 2-year, and overall survival rates were comparable and the mean grade of neurologic recovery was 1.2 on the Frankel scale in both groups. Only 6.9% of MASS patients required a 2-day postoperative ICU stay compared with 88% of ST patients (P < 0.0001). Conclusions. The MASS technique is safe and effective and has proved to be an excellent alternative in managing thoracic spine metastasis. Surgeons may use progressively smaller incisions (5–6 cm in length) for the procedure. The learning curve for performing MASS procedures was not steep.

Necrotizing soft-tissue infections and primary sepsis caused by Vibrio vulnificus and Vibrio cholerae non-O1.

BACKGROUND Vibrio species are a rare cause of necrotizing soft-tissue infections and primary septicemia, which are likely to occur in patients with hepatic disease, diabetes, adrenal insufficiency, and immunocompromised conditions. These organisms thrive in warm seawater and are often present in raw oysters, shellfish, and other seafood. This study examined fulminating clinical characteristics of Vibrio vulnificus and Vibrio cholerae non-O1 soft-tissue infections and identified outcome predictors. MATERIALS Thirty patients with necrotizing fasciitis and sepsis caused by Vibrio species were retrospectively reviewed. Twenty-eight patients had a history of contact with seawater or raw seafood. Eight patients had hepatic disease such as hepatitis or liver cirrhosis, and seven patients had diabetes mellitus. Nine patients had hepatic dysfunction combined with diabetes mellitus. Microbiology laboratory culture studies confirmed V. vulnificus in 23 patients and V. cholerae non-O1 in seven patients. RESULTS Surgical debridement or immediate limb amputation was initially performed in all patients with necrotizing soft-tissue infections. Eleven patients (37%) died within several days of admission and 19 survived. The mortality of V. cholerae non-O1 group (57%) is higher than that of the V. vulnificus group (30%). A significantly higher mortality rate was noted in patients with initial presentations of a systolic blood pressure of < or =90 mm Hg, leukopenia, decreased platelet counts, and a combination of hepatic dysfunction and diabetes mellitus. CONCLUSIONS Vibrio necrotizing soft-tissue infections should be suspected in patients with appropriate clinical findings and history of contact with seawater or seafood. V. cholerae non-O1 may cause bacteremia more often than V. vulnificus in patients with liver cirrhosis. Early fasciotomy and culture-directed antimicrobial therapy are aggressively recommended in patients with hypotensive shock, leukopenia, high band forms of white blood cells, decreased platelet counts, severe hypoalbuminemia, and underlying chronic illness, such as hepatic dysfunction and diabetes mellitus.

Ankle arthrodesis with cross-screw fixation. Good results in 36/40 cases followed 3-7 years

Tibiotalar arthrodesis by an anterior approach, using internal compression with cancellous crews, offers wide exposure, good possibilities of correcting deformities, and good bony apposition. From 1987 to 1991, we used this technique in 42 ankle joints (40 patients). The indications were posttraumatic arthrosis, sequelae of septic arthritis, necrosis of the talus and failed ankle arthrodesis. In 13 ankles with severe deformity, a bone graft was also used. 38 patients (40 ankle joints) were available for follow-up after 4 (3-7) years. Solid union was achieved in 38 ankles after an average of 13 weeks. The clinical result was good-to-excellent in 36 ankles. We conclude tha this is a simple and effective method for ankle arthrodesis in both low-risk and, coupled with bone grafting, in properly selected high-risk patients.

Management of giant pseudomeningoceles after spinal surgery

BackgroundPseudomeningoceles are a rare complication after spinal surgery, and studies on these complex formations are few.MethodsBetween October 2000 and March 2008, 11 patients who developed symptomatic pseudomeningoceles after spinal surgery were recruited. In this retrospective study, we reported our experiences in the management of these complex, symptomatic pseudomeningoceles after spinal surgery. A giant pseudomeningocele was defined as a pseudomeningocele >8 cm in length. We also evaluated the risk factors for the formation of giant pseudomeningoceles.ResultsAll patients were treated successfully with a combined treatment protocol of open revision surgery for extirpation of the pseudomeningoceles, repair of dural tears, and implantation of a subarachnoid catheter for drainage. Surgery-related complications were not observed. Recurrence of pseudomeningocele was not observed for any patient at a mean follow-up of 16.5 months. This result was confirmed by magnetic resonance imaging.ConclusionsWe conclude that a combined treatment protocol involving open revision surgery for extirpation of pseudomeningoceles, repair of dural tears, and implantation of a subarachnoid catheter for drainage is safe and effective to treat giant pseudomeningoceles.

Video-assisted thoracoscopic surgery in managing tuberculous spondylitis.

The literature includes no studies on the use of video-assisted thoracoscopic surgery in the management of tuberculous spondylitis, and its role in the management of tuberculosis involving the thoracic spine remains unclear. The authors experience with 10 consecutive patients (six women, four men) who underwent video-assisted thoracoscopic surgery for the treatment of spinal tuberculosis involving levels from T5 to T11, from January 1996 to December 1997, was analyzed. Using the extended manipulating channel method (2.5–3.5 cm portal incisions), video-assisted thoracoscopic surgery was performed with a three-portal technique (seven patients) or a modified two-portal minithoracotomy technique that required a small incision for the thoracoscope and a larger incision, measuring 5 to 6 cm, for the procedures in three patients. All the patients were studied prospectively. The followup ranged from 17 to 42 months (mean, 24 months). Postoperative complications included one lung atelectasis. Pleural adhesions, owing to local inflammation or paravertebral abscess, were seen in four patients and one patient with severe pleurodesis needed an open technique for treatment. Postoperative air leaks were seen in four (40%) of 10 patients but all were transient. The average neurologic recovery was 1.1 grades on the Frankel’s scale. The data from this series of patients with tuberculous spondylitis show that video-assisted thoracoscopic surgery has diagnostic and therapeutic roles in the management of tuberculous spondylitis. Technically, a combination of thoracoscopy and conventional spinal instruments to perform video-assisted thoracoscopic surgery through the extended manipulating channels, which were placed slightly more posterior than usual, was effective and safe.

Subtalar distractional realignment arthrodesis with wedge bone grafting and lateral decompression for calcaneal malunion

BACKGROUND The purpose of this study was to evaluate prospectively the efficacy of subtalar distractional realignment arthrodesis in the treatment of calcaneal malunion associated with subtalar arthritis, collapse of height, talonavicular subluxation, malalignment of the heel axis, and widening heel with calcaneofibular abutment. METHODS Thirty-four patients with severe calcaneal malunion were treated with a lateral approach, lateral decompression, medial subtalar capsulotomy, and distraction and realignment of the subtalar joint with an anteriorly and laterally tapered wedge bone graft. The patients were evaluated with a functional rating scale and radiographs, both before and after surgery. RESULTS Thirty-two of the 34 patients were evaluated at a mean of 71 months (range, 60-92 months) after the arthrodesis. Solid subtalar fusion was achieved in 31 of the 32 patients. The average gain of subtalar distraction was 12 mm. Neutral or mild valgus alignment was achieved in 26 of the 32 patients. The mean postoperative score (83) showed significant improvement over the mean preoperative score (47). Overall, the functional rating scale revealed excellent or good results in 26 patients and fair results in 6 patients. CONCLUSION Coupled with wedge bone grafting, the subtalar distractional realignment arthrodesis achieved restoration of hindfoot height and axial alignment with a good union rate and significant improvement in the majority of patients with calcaneal malunion.

Metastatic meningioma in the sacrum: a case report.

Study Design. This report describes a 51-year-old woman with a sacral metastatic meningioma that originated from an intracranial meningioma. Objectives. To describe an unusual presentation of a metastatic meningioma in the sacrum. Summary of Background Data. Extracranial metastases of meningioma are very rare. The phenomenon of metastasis may have more to do with the ability to invade the wall of a blood vessel than with the mitotic activity of a tumor. Therefore, metastases of the meningioma can occur even with a benign histologic picture in the original intracranial meningioma. Methods. A 51-year-old woman had experienced low back pain and sciatica of the left leg for several months. Plain radiographs of the lumbosacral spine showed an osteolytic lesion with an irregular margin that occupied the left side of the sacrum. Magnetic resonance imaging revealed a soft mass invading the left sacrum, ilium, and presacral space. Results. Surgical removal of the sacral tumor via an anterior-posterior-anterior approach was done. Histopathologic examination revealed a metastatic meningioma with a meningotheliomatous histologic composition. Sixteen months after excision of the metastatic sacral lesion, the patient was ambulating freely and experiencing mild constipation and urine retention. Conclusions. In this case of metastatic meningioma in the sacrum, which is the first such report to the authors’ best knowledge, total excision of the tumor was successful.