EQUINE VETERINARY EDUCATION / AE / JANUARY 2017
27
Case Report
Treatment of chronic septic osteoarthritis of the antebrachiocarpal joint with a synovial-cutaneous fistula utilising arthroscopic lavage combined with ultrasonic assisted wound therapy and vacuum assisted closure with a novel wound lavage system
M. J. Rettig* and C. J. Lischer
Equine Clinic at the Faculty of Veterinary Medicine, Free University of Berlin, Germany. *Corresponding author email:
matthias.rettig@
fu-berlin.de Keywords: horse; synovial fistula; septic arthritis; multiresistant microorganisms; fistulating wound; chronic wound
Summary This case report describes the successful management of a chronic multidrug resistant infection of the antebrachiocarpal joint with a synovial-cutaneous fistula 7 weeks after initial trauma in a 14-year-old Icelandic stallion. Resolution of the multiresistant Enterobacter cloacae (extended-spectrum b- lactamase) infection from the joint and complete closure of the fistula was achieved by arthroscopic lavage under general anaesthesia repeated on 3 occasions, surgical debridement, ultrasound assisted wound therapy and vacuum assisted closure. Lavage of the wound with the vacuum assisted closure in place was facilitated via the novel VeraFlo instillation system consisting of specially designed therapeutic regulated accurate care pad tubing. The combination of these therapies resulted in resolution of the septic arthritis and fistula. Six weeks after admission the horse was discharged from the hospital with a completely healed wound and was not lame at a walk.
Introduction
Synovial-cutaneous fistulae originating from infected joints are rare in horses. One of the primary complications when managing wounds communicating with a joint is the inability to decontaminate the synovial cavity in order to resolve the infection (Baxter 2008). Synovial fistulae can occur between adjacent congenital synovial cavities (intersynovial fistula) or between the skin and the synovial cavity termed synovial- cutaneous fistula (Johnson and Ryan 1975; Llewellyn 1979; Mcllwraith 1989; Bertone 2011; Marshall and Adkins 2013). Synovial-cutaneous fistulae can occur secondary to post operative surgical site infection of an arthrotomy or when wounds penetrating the joint capsule are left open for second
intention healing and fail to heal (Baxter 2008). Synovial fistulae tend to be more common in digital flexor tendon sheaths or bursae than other synovial cavities (Baxter 2008). In the human literature, synovial fistulae of the knee joint are most commonly seen as a complication of arthroscopic surgery (Jain and Varma 1999) and generally have a good prognosis with conservative management (Proffer et al. 1991; M
endez-Fern andez 1993; Odumala et al. 2001;
Yiannakopoulos 2007). In horses, conservative management can be successful, if temporary immobilisation of the affected joint is feasible. Surgical intervention to facilitate closure is required (Baxter 2008), if reinfection of the joint occurs and the wound fails to heal. Synovial herniation in horses has been
Case history
A 14-year-old Icelandic horse with a chronic synovial fistula into the antebrachiocarpal joint was admitted to the equine department of the Free University Berlin. Approximately
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seen as a complication following arthroscopic surgery (Wilson 1989; Marshall and Adkins 2013) but also as a cause of lameness with unknown origin (Smith 2009). Techniques such as ultrasound assisted wound treatment
(UAWT)1 or vacuum assisted closure (VAC)2 have been introduced to improve surgical management of chronic wounds infected with multiresistant microorganisms. UAWT is primarily based on the cavitation effect generated by low- frequency (25 kHz) ultrasound, which allows improved penetration depth combined with a minimum of thermal stress on the treated tissue (Herberger et al. 2011). Contact between the ultrasound wave generating handle and the tissue is achieved by constant flow of irrigation liquid flowing through the probe (Herberger et al. 2011; Rheiner et al. 2011). Damaged and necrotic tissue, even biofilm formations are removed without any damage occurring to the healthy tissue. It has been shown that low frequency ultrasound in wounds leads to a reduction of bacterial burden, selective necrosectomy, and stimulation of granulation tissue (McDonald and Nichter 1994). Vacuum assisted closure is widely used in human medicine
for treating complex acute as well as chronic wounds (Orsini 2005; Gabriel et al. 2009) and has been applied in veterinary surgery as well (Gemeinhardt and Molnar 2005; Rijkenhuizen et al. 2005). Application of this system has been described in the literature. Wounds are covered with a fitted sterile open- cell polyurethane foam and rendered air tight with adhesive drapes (Gemeinhardt and Molnar 2005). A small hole is cut into the barrier drape, an evacuation tube placed, and the entire system covered with a multilayered splint bandage resulting in an airtight atmosphere allowing the application of continuous suction (Orsini 2005). The vacuum leads to an increase in tissue blood flow, reduces the overall bacterial count within the wound, accelerates granulation tissue formation and reduces oedema at the margins of the wound (Orsini 2005; Schultheiss
2006; Gabriel et al. 2009). To the authors’ knowledge, this is the first veterinary report of successful management of synovial- cutaneous fistula in an infected joint using a combination of UAWT and the novel VAC VeraFlo Instillation Therapy, with Therapeutic Regulated Accurate Care (TRAC) Pad Tubing.
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