Clostridial Infection After Open Fractures of the Lower Extremity – Report of Two Cases and Discussion of Pathomechanism and Treatment

Abstract

Background: Management of post-traumatic open fractures resulting from severe injuries of the lower extremity continues to challenge orthopedic and reconstructive surgeons. Moreover, post-traumatic osteoarticular infections due to Clostridium species are rare, with few reports in the literature. We describe possible pathomechanisms and propose treatment options for cases of delayed diagnosis of osteoarticular infections with Clostridium spp. Case Reports: Two patients sustained severe osteoarticular infection due to Clostridium spp. after open epi-and metaphyseal fractures of the lower extremity. In combination with radical debridement, ankle arthrodesis and long-term antibiotic treatment, satisfactory results were achieved after a followup of 18 months and 24 years. Conclusion: Clostridium species are difficult to identify, treatment is usually delayed and most patients have unfavourable outcomes. Although Clostridium species can be found regularly in posttraumatic wounds, post-traumatic osteoarticular infection due to Clostridium is rare. Approximately 20 cases have been reported in patients with open fractures, located mainly in the diaphyseal area (1-4). Clostridium species are found most often in fractures with severe environmental contamination of the wound during trauma (5). Clostridium species are anaerobic or occasionally aerotolerant gram-positive rods, found in soil, feces, sewage and marine sediments (6). They have the ability to form endospores, mainly under anaerobic conditions. These spores display high resistance to physical and chemical influences and are not sensitive to antibiotics. In addition, several Clostridium species have the ability to produce numerous protein toxins, causing necrotizing tissue destruction (7). Thus, bone marrow necrosis or necrotic bone fragments may occur (1, 8). The laboratory diagnosis of clostridial diseases depends on proper collection and handling of tissue samples (6). However, diagnosis is complicated by the fact that bone and joint infections due to Clostridium species are often polymicrobial (2). Although identification can be time-consuming, complete identification and testing of antimicrobial sensitivities have to be pursued. Species other than C. perfringens display a high variability in sensitivity testing, including to penicillin, cephalosporins, carbapenems and clindamycin (9). Once the strain has been identified, aggressive surgical treatment is mandatory (10). When in doubt, temporary or definitive external fixation should be preferred over internal fixation to allow repeated lavage if necessary (2). Wound excision and lavage without extensive bone tissue resection nearly always fails (2), probably due to persistence of spores in surrounding tissue. All the infected tissue must be excised and any internal fixation hardware removed (2). As a rule of thumb, Clostridium spp. complicating diaphyseal fractures cause extended bone loss due to necrosis. Reconstruction requires time-consuming segmental bone reconstruction, frequently combined with soft tissue ...

Case series of Anaerococcus prevotii infection in road traffic accidents in New Delhi, India

“…Anaerobic infection is usually developing at the site of bacterial colonization and range from simple local abscesses to life-threatening infections and can become fatal. Clostridium bacteria species are commonly found in the post-traumatic wounds of patients [11]. Clostridium spp.…”

Promising applications of D-amino acids in periprosthetic joint infection

“…and anaerobes such as Clostridium spp. 130,131 account for ~3%-8% of orthopedic implant-associated infections. [30][31][32][33][34] Bacterial spores are robust, vegetative, and metabolically dormant, and are produced to survive the severe and adverse climatic conditions of starvation and stress.…”

Clostridium cadaveris Osteomyelitis: an Unusual Pathogen which Highlights the Importance of Deep Tissue Sampling in Chronic Osteomyelitis

“…There are approximately 30 cases of Clostridial osteomyelitis published to date (Table 1 [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]). Of note, since 2016, Clostridioides difficile (previously Clostridium difficile) is considered a different genus based on phenotypic, chemotaxonomic and phylogenetic analysis [26] and so is not considered further here.…”

“…Over 30 cases of clostridial septic arthritis have also recently been summarised [27]. Osteomyelitis due to clostridial species usually follows trauma [14] or open fractures [7,8,11,12,[15][16][17][18], some obviously contaminated with soil [12,15,17] or sewerage [8,11]. In non-traumatic cases hosts may be immunocompromised by lymphoma [13,22] or diabetes [10], though sometimes there is neither a clearly identifiable source nor host risk factor [9].…”