Fulminant Pyoderma Gangrenosum After Outpatient Knee Arthroscopy

Abstract

Pyoderma gangrenosum is an immunologic, ulcerative cutaneous condition often associated with systemic disease and frequently precipitated by trauma. It is noninfectious, but the inflammatory assault can resemble a malignant infection such as necrotizing fasciitis. Despite its clinical resemblance to infection, surgical de ´bridement worsens the condition and may remove morphologic clues to the true disease, thus creating a vicious cycle of surgical de ´bridements and disease progression. Furthermore, diagnostic histopathologic and laboratory features are nonspecific, requiring exclusion of other processes. Therefore, appropriate nonsurgical treatment and immunosuppression are commonly delayed, often at a significant cost to the patient. We present a case of pyoderma gangrenosum occurring after outpatient knee arthroscopy that masqueraded as a postsurgical infection. We discuss the diagnostic approach and how a complex reconstruction involving cartilage restoration and soft-tissue coverage was achieved. P yoderma gangrenosum (PG) is an immunologic ulcerative cutaneous condition of an undetermined cause that is often precipitated by trauma. The incidence varies between studies with estimates typically ranging from 3 to 10 per million per year. [1][2][3][4] The disease typically presents in the fourth through sixth decade of life and has a female predominance. 1,[5][6][7] It can be easily mistaken for an infectious process such as necrotizing fasciitis (NF) due to the rapidly progressing wound deterioration in the presence of elevated inflammatory markers and leukocytosis. In contrast to infectious processes, such as NF, surgical débridement promotes the malignant immunologic response, leading to further skin breakdown.A high index of suspicion and the use of a multidisciplinary approach can help differentiate PG from other etiologies, such as a surgical site infection (SSI). Timely workup is paramount because a failure to differentiate the two processes-immunologic and infectious-will lead to misdiagnosis and detrimental interventions. Therefore, early involvement of infectious disease specialists and dermatologists when the diagnosis is in question can help determine whether serial débridements should be initiated or continued.

Wound Debridement in Pyoderma Gangrenosum

“…In nearly all of the cases (33/34) described in these reports, the lesions worsened after debridement (Table ). 4,7,[17][18][19][20][21][22][23][24][25][26][27][39][40][41][42][43][44][45][46][47][48][49]51 In addition, 13 reports describe patients with PG on immunosuppressant medication who had lesions debrided and sometimes grafted. None of these patients had any reported worsening of their PG wounds (Table ).…”

Infection mimicking skin condition: pyoderma gangrenosum

“…Ebrad et al 19 conducted a review and found three cases of PG that occurred after THA 19. Also, a case has been reported where PG was seen after knee arthroscopy 20. Recently, Mizushima et al 21 described a patient with myelodysplastic syndrome who received granulocyte colony stimulating factor to prevent postoperative infections 21.…”

“… 19 Also, a case has been reported where PG was seen after knee arthroscopy. 20 Recently, Mizushima et al 21 described a patient with myelodysplastic syndrome who received granulocyte colony stimulating factor to prevent postoperative infections. 21 The patient developed PG a few days after the procedure.…”

Postsurgical Pyoderma Gangrenosum Requiring Plastic Surgical Intervention: A Practical Review

“…81 (Supplemental Digital Content 4, http://links.lww.com/PRSGO/C962.) Orthopedic Surgery PSPG manifested in six patients after total knee arthroplasty, 65,73,76 knee arthroscopy, 49 intramedullary nail osteosynthesis, 64 or internal fixation. 65 (Supplemental Digital Content 5, http://links.lww.com/PRSGO/C963) One of the patients had a previous episode of PSPG.…”