title: A multi-disciplinary approach to the management of fungal osteomyelitis: current concepts in post-traumatic lower extremity reconstruction: a case report.
abstract: Limb salvage in fungal osteomyelitis of the post-traumatic lower extremity represents a difficult clinical problem requiring aggressive management. We report lower extremity salvage by radical bony debridement, free tissue transfer, distraction osteogenesis with bone-docking, and a novel antifungal regimen in a clinical setting of infection with Scedosporium inflatum, historically requiring amputation in 100% of cases. We treated Scedosporium inflatum osteomyelitis of the tibia and calcaneus with radical debridement of infected bone, free partial medial rectus abdominis muscle flap coverage, transport distraction osteogenesis, and combination voriconazole/terbinafine chemotherapy, a novel antifungal regimen. We achieved successful control of the infection, limb salvage, and an excellent functional outcome through aggressive debridement of infected bone and soft tissue, elimination of dead space within the bony defect, the robust perfusion provided by the free flap, the hypervascular state induced by distraction osteogenesis, and the synergism of the novel antifungal regimen.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital-Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA 02114, USA. ccetrulo@partners.org
authors.forename: Curtis L
authors.initials: CL
authors.lastname: Cetrulo
authors.forename: Angelo A
authors.initials: AA
authors.lastname: Leto Barone
authors.forename: Kathleen
authors.initials: K
authors.lastname: Jordan
authors.forename: David S
authors.initials: DS
authors.lastname: Chang
authors.forename: Kevin
authors.initials: K
authors.lastname: Louie
authors.forename: Rudolf F
authors.initials: RF
authors.lastname: Buntic
authors.forename: Darrell
authors.initials: D
authors.lastname: Brooks
mesh_terms: D000058:Accidental Falls; D000935:Antifungal Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D003646:Debridement / Q000379:methods; D005360:Fibula / Q000293:injuries / Q000601:surgery; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000009:adverse effects* / Q000379:methods; D005597:Fractures, Open / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D007869:Leg Injuries / Q000000981:diagnostic imaging / Q000601:surgery; D023821:Limb Salvage; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000175:diagnosis* / Q000188:drug therapy; D019857:Osteogenesis, Distraction / Q000379:methods; D010019:Osteomyelitis / Q000175:diagnosis / Q000382:microbiology / Q000628:therapy*; D011183:Postoperative Complications / Q000382:microbiology / Q000628:therapy; D011859:Radiography; D018570:Risk Assessment; D021681:Scedosporium / Q000302:isolation & purification*; D016038:Skin Transplantation / Q000379:methods*; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000601:surgery; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology
chemical_list: D000935:Antifungal Agents