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Kipers T, Tolkachjov SN. Postoperative and Peristomal Pyoderma Gangrenosum: Subtypes of Pyoderma Gangrenosum. Dermatol Clin 2024; 42:171-181. [PMID: 38423679 DOI: 10.1016/j.det.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Postoperative pyoderma gangrenosum and peristomal pyoderma gangrenosum are 2 subtypes of pyoderma gangrenosum. The diagnosis is made as a clinicopathologic correlation when assessing a rapidly progressing ulcer with irregular and undermined borders following a surgical procedure, trauma, or the creation of a stoma. Familiarity with the associated risk factors and distinguishing features of these disorders can facilitate prompt recognition, proper diagnosis, and the initiation of treatment. Management usually involves the use of corticosteroids and steroid-sparing agents as immunomodulators to shift the inflammatory neutrophilic dermatoses to chronic noninflammatory wounds and eventual healing.
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Affiliation(s)
- Théodora Kipers
- School of Medicine, Texas A&M University School of Medicine, 5536 Tremont Street, Dallas, TX 75214, USA
| | - Stanislav N Tolkachjov
- Mohs Micrographic & Reconstructive Surgery, Epiphany Dermatology; Department of Dermatology, Baylor University Medical Center; University of Texas at Southwestern; Texas A&M University School of Medicine, 1640 FM 544, Suite 100, TX 75056, USA.
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2
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An aggressive course of pyoderma gangrenosum mimicking bacterial osteomyelitis after open reduction and internal fixation of a distal radius fracture with a titanium plate. Reumatologia 2022; 60:292-302. [PMID: 36186837 PMCID: PMC9494791 DOI: 10.5114/reum.2022.119046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare condition characterized by the development of aseptic, non-healing skin ulcers. Any skin trauma, such as a surgical incision, can trigger an outbreak of lesions. Our case and literature review show that a physician should consider PG in every event of a non-healing, aseptic wound after surgery. The treatment of PG requires collaboration within a multidisciplinary team and immunosuppressive therapy is the first line of treatment, while surgical interventions should be avoided in the active stage of PG.
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3
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Mizushima M, Miyoshi H, Yonemori K. Pyoderma Gangrenosum After Total Hip Arthroplasty Associated with Administration of Granulocyte Colony-Stimulating Factor: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00041. [PMID: 33878038 DOI: 10.2106/jbjs.cc.20.00924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 69-year-old woman with myelodysplastic syndrome-related pancytopenia was administered granulocyte colony-stimulating factor (G-CSF) before total hip arthroplasty to prevent postoperative infection. One week postoperatively, she developed peri-incisional ecchymosis and associated leukocytosis. Over the next few weeks, surgical site infection was suspected; however, dermatologist evaluation and subsequent biopsy supported a diagnosis of pyoderma gangrenosum, which resolved after prompt steroid administration. CONCLUSION Postoperative pyoderma gangrenosum should be included in the differential diagnosis when considerable postoperative ecchymosis and leukocytosis occur, particularly after preoperative G-CSF administration.
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Affiliation(s)
- Masaki Mizushima
- Department of Orthopaedics, Yonemori Hospital, Ryokusenkai Group, Kagoshima, Japan
| | - Hayao Miyoshi
- Department of Dermatology, Takada Hospital, Gyokushoukai Group, Kagoshima, Japan
| | - Koji Yonemori
- Department of Orthopaedics, Yonemori Hospital, Ryokusenkai Group, Kagoshima, Japan
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Russo F, Mancini V, Flori ML, Pelosi P, Carta S, Provvidenziale L, Pellegrino M, Taddeucci P, Fimiani M. Pyoderma gangrenosum secondary to total hip replacement. Ital J Dermatol Venerol 2019; 156:27-28. [PMID: 31042853 DOI: 10.23736/s2784-8671.19.06256-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Filomena Russo
- Section of Dermatology, Department of Clinical Medicine and Immunological Science, University of Siena, Siena, Italy -
| | - Virginia Mancini
- Section of Pathology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Maria L Flori
- Section of Dermatology, Department of Clinical Medicine and Immunological Science, University of Siena, Siena, Italy
| | - Piergiorgio Pelosi
- Department of Orthopedics and Traumatology, University of Siena, Siena, Italy
| | - Serafino Carta
- Department of Orthopedics and Traumatology, University of Siena, Siena, Italy
| | - Luca Provvidenziale
- Section of Dermatology, Department of Clinical Medicine and Immunological Science, University of Siena, Siena, Italy
| | - Michele Pellegrino
- Section of Dermatology, Department of Dermatology, Misericordia Hospital, Grosseto, Italy
| | - Paolo Taddeucci
- Section of Dermatology, Department of Clinical Medicine and Immunological Science, University of Siena, Siena, Italy
| | - Michele Fimiani
- Section of Dermatology, Department of Clinical Medicine and Immunological Science, University of Siena, Siena, Italy
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Ebrad S, Severyns M, Benzakour A, Roze B, Derancourt C, Odri GA, Rouvillain JL. Pyoderma gangrenosum after orthopaedic or traumatologic surgery: a systematic revue of the literature. INTERNATIONAL ORTHOPAEDICS 2017; 42:239-245. [PMID: 29119297 DOI: 10.1007/s00264-017-3672-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 10/16/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised by a painful ulceration mimicking infection of the operative site. To this day, there is still no general agreement on the medical and surgical treatment of PG. This systematic review of the literature aims to summarise recent studies about post-operative PG in orthopaedic surgery to improve its medical and surgical management. METHOD In April 2017, we carried out an exhaustive review of the literature in MEDLINE, PubMed and Cochrane databases. Key words were pyoderma gangrenosum, orthopaedic surgery, and surgical wound infection. We identified 183 articles. After excluding articles reporting idiopathic PG, cases secondary to non-orthopaedic surgery, and cases about other subtypes of dermatosis, 30 studies were identified. We only included articles reporting PG after orthopaedic or trauma surgery. RESULTS Thirty-one cases of PG have been reported, 58% (18) of which were in women, whose mean age was 56.5 years. Clinical signs were constant, the most frequently affected site was lower limbs [77.4% (24)] and delay of symptom onset was two to 17 days. Systemic corticosteroid therapy was systematic, polyvalent immunoglobulins were used in two cases and immunosuppressive drugs in one. Negative pressure therapy was used in seven cases and hyperbaric oxygen in three. DISCUSSION Delayed diagnosis leads to one or more surgical revisions, which could have been avoided by using early and adapted medical treatment. Early onset of a painful and infected ulcer at the operating site in a patient at risk of PG is an indicator that dermatologist advice is recommended before surgical debridement. Surgical revision, outside the inflammatory phase and/or covered by a systemic corticosteroid therapy, does not lead to PG relapse. LEVEL OF EVIDENCE IV: Systematic revue of the literature.
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Affiliation(s)
- Stephan Ebrad
- Orthopaedic and Traumatologic Department, Military Hospital Robert Picqué, 351 route de Toulouse, 33140, Villenave d'Ornon, France
| | - Mathieu Severyns
- Orthopaedic and Traumatologic Department, La Meynard University Hospital, CS 90632, 97261, Fort-de-France, Martinique.
| | - Ahmed Benzakour
- Orthopaedic and Traumatologic Department, La Meynard University Hospital, CS 90632, 97261, Fort-de-France, Martinique
| | - Benoit Roze
- Department of Infectiology, La Meynard University Hospital, CS 90632, 97261, Fort-de-France, Martinique
| | - Christian Derancourt
- Department of Dermatology, La Meynard University Hospital, CS 90632, 97261, Fort-de-France, Martinique
| | - Guillaume-Anthony Odri
- Orthopaedic and Traumatologic Department, Lariboisière University Hospital, rue Ambroise Paré, 75010, Paris, France
| | - Jean-Louis Rouvillain
- Orthopaedic and Traumatologic Department, La Meynard University Hospital, CS 90632, 97261, Fort-de-France, Martinique
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Vaysse-Vic M, Mathieu PA, Charissoux A, Charissoux JL, Marcheix PS. Pyoderma gangrenosum or necrotising fasciitis? Diagnostic and therapeutic wanderings. Orthop Traumatol Surg Res 2017; 103:615-617. [PMID: 28286096 DOI: 10.1016/j.otsr.2017.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 01/10/2017] [Accepted: 01/17/2017] [Indexed: 02/02/2023]
Abstract
A case of post-traumatic lower-limb pyoderma gangrenosum (PG) in a 77-year-old female is reported. The diagnosis of PG is frequently one of exclusion, and it is therefore unsurprising that the condition was initially mistaken for necrotising fasciitis then for necrotising bacterial dermo-hypodermitis. Medical and surgical treatment for those conditions proved ineffective. This fact, together with the atypical presentation, promoted a re-evaluation of the diagnosis. The clinical findings and investigation results converged to suggest PG, and a therapeutic trial was initiated. The good treatment response and negative findings from tests for other conditions established the diagnosis of post-traumatic PG.
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Affiliation(s)
- M Vaysse-Vic
- Service d'orthopédie-traumatologie, hôpital universitaire de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France.
| | - P-A Mathieu
- Service d'orthopédie-traumatologie, hôpital universitaire de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - A Charissoux
- Service d'anatomo-pathologie, hôpital universitaire de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - J-L Charissoux
- Service d'orthopédie-traumatologie, hôpital universitaire de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - P-S Marcheix
- Service d'orthopédie-traumatologie, hôpital universitaire de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
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She GR, Chen JY, Zhou ZQ, Zha ZG, Liu N. Total hip arthroplasty for femoral neck fracture with pyoderma gangrenosum patient: A case report. Int J Surg Case Rep 2016; 30:134-137. [PMID: 28012329 PMCID: PMC5192037 DOI: 10.1016/j.ijscr.2016.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/06/2016] [Accepted: 12/06/2016] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Pyoderma gangrenosum is a rare inflammatory aseptic, ulcerative neutrophilic dermatosis which manifest as skin recurrent, painful ulcers. PRESENTATION OF CASE A 65-year-old man with pyoderma gangrenosum underwent left total hip arthroplasty because of femoral neck fractures. Glucocorticoid, antibiotic, anticoagulant drug, etc. were given in perioperative period. Complication of pyoderma gangrenosum was prevented successfully in perioperative period. DISCUSSION No consensus has been reached about whether to use glucocorticoid, as well as the dosage and administration, in perioperative periods for pyoderma gangrenosum patients as prophylactic means of wound complication. CONCLUSION We herein report a case of pyoderma gangrenosum patient underwent total hip arthroplasty, meanwhile raise the issue of management in perioperative period for pyoderma gangrenosum patient, especially explore series of standardized therapies for this disease during arthroplasty.
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Affiliation(s)
- Guo Rong She
- Department of Bone and Joint Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Jun Yuan Chen
- Department of Bone and Joint Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
| | - Zi Qi Zhou
- Department of Radiation Therapy, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Zhen Gang Zha
- Department of Bone and Joint Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China.
| | - Ning Liu
- Department of Bone and Joint Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China
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Tolkachjov SN, Fahy AS, Cerci FB, Wetter DA, Cha SS, Camilleri MJ. Postoperative Pyoderma Gangrenosum: A Clinical Review of Published Cases. Mayo Clin Proc 2016; 91:1267-79. [PMID: 27489052 DOI: 10.1016/j.mayocp.2016.05.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/26/2016] [Accepted: 05/02/2016] [Indexed: 12/12/2022]
Abstract
Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by PG at surgical incisions. It is often misdiagnosed as wound infection, and pathergy may complicate wound debridement. From September 1, 2013, through November 30, 2013, a literature search was conducted of articles published from January 1, 1978, through December 31, 2012. We referenced PubMed, MEDLINE, and Mayo Clinic Libraries using the keywords pyoderma gangrenosum, postoperative pyoderma gangrenosum, postsurgical pyoderma gangrenosum, superficial granulomatous pyoderma, pathergic pyoderma, and pyoderma gangrenosum associated with surgery, incision, breast, and wound dehiscence. In addition, all titles from PubMed with the words pyoderma gangrenosum were reviewed manually for postoperative cases. Of 136 patients, 90 (66%) did not have associated systemic diseases. If a comorbidity was present, hematologic disorders were most common. In addition, 29% (28) of women had predisposing disease vs 53% (19) of men. Women had more frequent breast involvement (P<.001); chest involvement was more common in men (P=.005). Girls and women aged 13 to 64 years had more frequent breast involvement (P=.01). Sites were distributed equally for men regardless of age (P=.40). Antibiotic drug therapy was begun and debridement occurred in 90% (110 of 122 treated patients) and 73% (90 of 123 available patients), respectively. Postoperative PG has less association with systemic disease than its nonpostoperative counterpart. Antibiotic drug therapy is routinely initiated. Affected sites are often debrided, causing additional wound breakdown. Early diagnosis may prevent complications.
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Affiliation(s)
| | | | - Felipe B Cerci
- Department of Dermatology, Hospital Santa Casa de Curitiba, Curitiba, Brazil
| | | | - Stephen S Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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Gómez B, Olea A, Martínez A. Pioderma gangrenoso tras una polectomía. REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2016. [DOI: 10.1016/j.ricma.2016.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
El pioderma gangrenoso (PG) es una dermatosis no infecciosa y necrótica que puede ocurrir después de cualquier cirugía, aunque de forma poco frecuente en traumatología y menos aún en cirugía de la mano.La baja sospecha diagnóstica y el retraso en su detección pueden llegar a tener consecuencias devastadoras, a nivel local y sistémico.Presentamos el caso de una mujer de 61 años que, tras una polectomía de A1 en el dedo anular, desarrolla un PG resolviéndose con corticoides intravenosos.
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Affiliation(s)
- B. Gómez
- Servicio de Traumatología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - A. Olea
- Servicio de Traumatología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - A. Martínez
- Servicio de Medicina Interna-Infecciosas, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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Burnett RSJ, Nair R, Sawyer DM, Zbar AZ, Mathers JW. Pyoderma Gangrenosum in Revision Total Hip Arthroplasty: Clinical and Histopathological Findings with a Seven-Year Follow-up: A Case Report. JBJS Case Connect 2015; 5:e113. [PMID: 29252819 DOI: 10.2106/jbjs.cc.o.00067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASE We describe the clinical and histopathological findings associated with a case of pyoderma gangrenosum (PG) after revision total hip arthroplasty. The patient developed an expanding purple-red, necrotic, ulcerative lesion at the surgical site, which was initially suspected to be either a surgical-site infection or warfarin-induced skin necrosis. After treatment with empiric intravenous antibiotics, surgical debridement, and vacuum-assisted closure of the wound, the patient had a painless hip with a remodeled scar and was asymptomatic at the seven-year follow-up. CONCLUSION Confirmation of the diagnosis of surgical-site PG requires clinical-pathological correlation and familiarity with the PG skin lesion. Treatment of PG differs from treatment of infection; therefore, misdiagnosis and surgical treatment may exacerbate the clinical findings in PG.
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Affiliation(s)
- R Stephen J Burnett
- Department of Orthopaedic Surgery, University of British Columbia, Island Health, Royal Jubilee Hospital, Rebalance MD, Suite 104, 3551 Blanshard Street, Victoria, BC V8Z-0B9, Canada
| | - Rajesh Nair
- Rebalance MD, Suite 104, 3551 Blanshard Street, Victoria, BC V8Z-0B9
| | - Douglas M Sawyer
- Department of Anatomic Pathology, University of British Columbia, Island Health, Royal Jubilee Hospital, 5th floor, 1952 Bay Street, Victoria, BC V8R-1J8, Canada
| | - Ariella Z Zbar
- Island Medical Program, Medical Science Building, University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC V8W-2Y2, Canada
| | - James W Mathers
- Island Medical Program, Medical Science Building, University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC V8W-2Y2, Canada
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Tolkachjov SN, Wetter DA, Fahy AS, Nagorney DM, Camilleri MJ. Necrotic ulcerations after splenectomy. Int J Dermatol 2014; 54:251-4. [DOI: 10.1111/ijd.12697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | | | - Michael J. Camilleri
- Department of Dermatology; Mayo Clinic; Rochester MN USA
- Division of Anatomic Pathology; Mayo Clinic; Rochester MN USA
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Severe, Steroid-responsive, Myositis Mimicking Necrotizing Fasciitis following Orthopedic Surgery: A Pyoderma Variant with Myonecrosis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2014; 2:e175. [PMID: 25289368 PMCID: PMC4174247 DOI: 10.1097/gox.0000000000000124] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/29/2014] [Indexed: 01/18/2023]
Abstract
Summary: Postoperative pyoderma gangrenosum is a rare neutrophilic dermatosis that may be confused for necrotizing fasciitis. The inflammatory response is triggered by the trauma of surgery and thus must be managed nonsurgically. Clinical and pathological findings in the 2 diseases can be identical, leading to misdiagnosis and massive surgical defects from the ensuing surgery. This report documents a severe case of postsurgical pyoderma following an elective rotator cuff repair presenting with myositis and myonecrosis. The patient was initially treated as having an infection, which resulted in multiple aggressive surgical debridements. Despite this, the patient continued to deteriorate and was in a critical and hemodynamically unstable condition. Following administration of high-dose intravenous corticosteroids, the patient made a dramatic recovery and went on to have internal fixation of the shoulder and closure of the wound with a combination of a free flap and a rotational flap. Extensive myositis, as seen in this case, has not been previously reported in postoperative pyoderma gangrenosum variants. Clinicians should be aware that the presence of myositis and myonecrosis should not preclude this diagnosis.
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Concha-Garzón MJ, Solano-López Morel G, Pérez-Plaza A, de Argila D. [Pyoderma gangrenosum following a hip surgical procedure]. Rev Clin Esp 2014; 214:283-4. [PMID: 24698002 DOI: 10.1016/j.rce.2014.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 02/16/2014] [Indexed: 10/25/2022]
Affiliation(s)
- M J Concha-Garzón
- Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, España.
| | | | - A Pérez-Plaza
- Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, España
| | - D de Argila
- Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, España
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Fang Z, Waizy H, Berger S, Stukenborg-Colsman C, Plaass C. Pyoderma Gangrenosum Following Orthopaedic Surgery: A Case Report and Literature Review. JBJS Case Connect 2013; 3:e84. [PMID: 29252243 DOI: 10.2106/jbjs.cc.m.00031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Zhenhua Fang
- Department of Orthopaedics, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
| | - Hazibullah Waizy
- Clinic for Foot and Ankle Surgery, Hessing Foundation, Hessingstrasse 17, 86199 Augsburg, Germany
| | - Stefan Berger
- Department of Orthopaedics, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
| | | | - Christian Plaass
- Department of Orthopaedics, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
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Suarez C, Mercier E, Piquet P, Montané de la Roque P, Bordes JP, Piton C. Comments on: "Pyoderma Gangrenosum following an orthopedic surgical procedure" by E. de Thomasson, and I. Caux, published in Orthop Traumatol Surg Res 2010;96:600-602. Orthop Traumatol Surg Res 2011; 97:890-1; author reply 892. [PMID: 22100177 DOI: 10.1016/j.otsr.2011.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 09/15/2011] [Indexed: 02/02/2023]
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