Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2023 Aug 7:47:100888.
doi: 10.1016/j.tcr.2023.100888. eCollection 2023 Oct.

Acute toxic shock syndrome associated with intra-operative debridement and instrumentation removal for chronic osteomyelitis: A report of two cases

Affiliations
Case Reports

Acute toxic shock syndrome associated with intra-operative debridement and instrumentation removal for chronic osteomyelitis: A report of two cases

Michael Ulmer et al. Trauma Case Rep. .

Abstract

Gram-positive organisms are known causative agents in toxic shock syndrome (TSS), an acute disease caused by bacterial exotoxins. During routine instrumentation removal for chronic osteomyelitis, intraoperative debridement, reaming, and irrigation can lead to cell lysis and subsequent dissemination of the bacterium exotoxin, which can result in acute cardiovascular compromise. We present two cases of chronic osteomyelitis in healed long-bone fractures that were treated with deep instrumentation removal and surgical debridement using a reamer-irrigator-aspirator (RIA) system. Both patients had positive Streptococcus agalactiae wound cultures and both developed acute intraoperative hypotension during the reaming/irrigation portion of the procedure. Case 1 experienced cardiac arrest and was resuscitated for several days in the ICU. Case 2 underwent intra-operative hypotension and was resuscitated appropriately. The RIA or standard reaming systems must be used with caution during debridement of osteomyelitis in the presence of known toxin producing bacteria. The risk of iatrogenic spread of infection or extravasation of intramedullary contents is present; a high index of suspicion with any change in vital signs and prompt response can help mitigate the effect of adverse outcomes associated with acute and severe intraoperative hypotension.

Keywords: Gram-positive organisms; Healed long-bone fracture; Instrumentation removal; Reamer-irrigator-aspirator (RIA) system; Streptococcus agalactiae.

PubMed Disclaimer

Conflict of interest statement

John C.P. Floyd, MD, has stock or stock options in Bongiovi Medical and Carbofix. Robert M. Harris, MD, is a paid consultant for NexScience. He also consults and has received research support from Citieffe. Additionally, Dr., Harris is a board or committee member for the Clinical Orthopaedic Society. For the remaining authors, none were declared.

Figures

Fig. 1
Fig. 1
A and B: Radiographs AP and lateral of the left femur demonstrates radiographic union.
Fig. 2
Fig. 2
Intraoperative fluoroscopy shows debridement of the femoral intramedullary canal.
Fig. 3
Fig. 3
A and B: Radiographs left tibia demonstrate this healed fracture with radiolucency along proximal tibia.
Fig. 4
Fig. 4
A, B, and C: MRI demonstrates this nidus formation with involucrum with sinus tract formation to the proximal tibia.

Similar articles

References

    1. Finelli C.A., Dos Reis F.B., Fernandes H.A., et al. Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients. Patient Saf. Surg. 2019;13:39. - PMC - PubMed
    1. WHO World Health Organization; 2018. Global status report on road safety. http://apps.who.int/iris/bitstream/handle/10665/277370/WHO-NMH-NVI-18.20... (Last accessed on February 7, 2023)
    1. Hotchen A.J., Dudareva M., Corrigan R.A., et al. Can we predict outcome after treatment of long bone osteomyelitis? Bone Joint J. 2020;102-B(11):1587–1596. - PubMed
    1. Tosounidis T.H., Calori G.M., Giannoudis P.V. The use of Reamer-irrigator-aspirator in the management of long bone osteomyelitis: an update. Eur. J. Trauma Emerg. Surg. 2016;42(4):417–423. - PMC - PubMed
    1. Zalavras C.G., Sirkin M. Treatment of long bone intramedullary infection using the RIA for removal of infected tissue: indications, method and clinical results. Injury. 2010;41(Suppl. 2):S43–S47. - PubMed

Publication types

LinkOut - more resources