546864 research-articleXXXX
FASXXX10.1177/1938640014546864Foot & Ankle SpecialistFoot & Ankle Specialist
vol. XX / no. X
Foot & Ankle Specialist
〈 Case Report 〉 Treatment of Catastrophic Infection After Surgery for Insertional Achilles Enthesopathy
Justin M. Kane, MD, and Steven M. Raikin, MD
A Case Report and Review of the Literature Abstract: Wound complications after surgical treatment of insertional Achilles enthesopathy are well documented. Skin and tendon necroses pose a significant dilemma with the potential for catastrophic outcomes. Numerous treatment algorithms have been described to treat the resultant skin and tendon defects after catastrophic infection; however, to date, there is no consensus as to the optimal treatment modality. We report our experience in the management of deep infection of 2 patients who had previously undergone surgical treatment for insertional Achilles enthesopathy. A comprehensive review of the literature was undertaken with a focus on described treatment options. Levels of Evidence: Therapeutic, Level IV: Case Report Keywords: insertional Achilles enthesopathy; infection; reconstruction; allograft
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after operative intervention on all nsertional Achilles enthesopathy Achilles pathologies and noted an overall recalcitrant to nonoperative treatment complication rate of 11%. Surgery modalities may be treated with conducted specifically for insertional operative intervention. Surgical enthesopathy had a lower rate of methodology differs among surgeons but as a whole includes resecting the inflamed retrocalcaneal bursa and Preventing postoperative infection debridement of the diseased and calcific and preservation of the tendon repair is tendon insertion. Results paramount to a successful outcome.” vary between studies and a lack of standardization of procedures and terminology makes complications (4.7%). The majority of interpretation difficult. Success rates of problems encountered after Achilles up to 82% have been reported with tendon surgery are related to wound surgical treatment of insertional Achilles healing complications with studies enthesopathy with 77% of patients from reporting a rate of 7% to 14% in all that study satisfied with the procedure Achilles tendon surgeries.2 1 and willing to undergo it again. Preventing postoperative infection and Complications after surgery for preservation of the tendon repair is insertional Achilles enthesopathy are well paramount to a successful outcome. Skin documented in the literature. Paavola and tendon necroses pose a significant et al2 conducted a study of complications dilemma to the surgeon with the
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DOI: 10.1177/1938640014546864. From Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (JMK); and Rothman Institute, Philadelphia, Pennsylvania (SMR). Address correspondence to Steven M. Raikin, MD, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107; e-mail: steven.raikin@ rothmaninstitute.com. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)
Downloaded from fas.sagepub.com at FORDHAM UNIV LIBRARY on June 22, 2015
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2
Mon XXXX
Foot & Ankle Specialist
potential for catastrophic outcomes. An extensive review of the literature was conducted with the use of PubMed and OvidSP to identify English-language articles addressing deep infections and tendon necrosis after surgery. Numerous case reports describe treatment algorithms addressing the skin and tendon defects by using scar tissue, an flexor hallucis longus (FHL) transfer or free muscle flaps.3-15 All the studies describing these procedures pertain to the treatment of infection after operative repair of Achilles tendon ruptures. Additionally, to our knowledge, Achilles allograft implantation for the treatment of deep infection and Achilles tendon necrosis for operative treatment of insertional Achilles enthesopathy has not previously been reported. We report 2 such patients who were treated operatively for insertional Achilles enthesopathies and subsequently developed deep infections.
Case Report Case 1 History A 49-year-old woman who had previously underwent insertional Achilles tendon debridement with FHL tendon augmentation presented to our clinic for second opinion. After the initial debridement, the patient developed a postoperative pseudomonas infection. This had been treated with two irrigation and debridement procedures with intraoperative cultures positive for pseudomonas. After each procedure, the patient underwent 2 courses of intravenous antibiotics prior to her presenting to our institution. On presentation she was afebrile and nontoxic but had a chronically purulent draining wound from her distal incision (Figure 1). Thompsons tense revealed a nonintact Achilles mechanism. Serology studies revealed a white blood cell count of 8.0 × 103/µL (normal 3.8-10.8 × 103/ µL), a C-reactive protein of 7.3 (normal
FASXXX10.1177/1938640014546864Foot & Ankle SpecialistFoot & Ankle Specialist
vol. XX / no. X
Foot & Ankle Specialist
〈 Case Report 〉 Treatment of Catastrophic Infection After Surgery for Insertional Achilles Enthesopathy
Justin M. Kane, MD, and Steven M. Raikin, MD
A Case Report and Review of the Literature Abstract: Wound complications after surgical treatment of insertional Achilles enthesopathy are well documented. Skin and tendon necroses pose a significant dilemma with the potential for catastrophic outcomes. Numerous treatment algorithms have been described to treat the resultant skin and tendon defects after catastrophic infection; however, to date, there is no consensus as to the optimal treatment modality. We report our experience in the management of deep infection of 2 patients who had previously undergone surgical treatment for insertional Achilles enthesopathy. A comprehensive review of the literature was undertaken with a focus on described treatment options. Levels of Evidence: Therapeutic, Level IV: Case Report Keywords: insertional Achilles enthesopathy; infection; reconstruction; allograft
I
after operative intervention on all nsertional Achilles enthesopathy Achilles pathologies and noted an overall recalcitrant to nonoperative treatment complication rate of 11%. Surgery modalities may be treated with conducted specifically for insertional operative intervention. Surgical enthesopathy had a lower rate of methodology differs among surgeons but as a whole includes resecting the inflamed retrocalcaneal bursa and Preventing postoperative infection debridement of the diseased and calcific and preservation of the tendon repair is tendon insertion. Results paramount to a successful outcome.” vary between studies and a lack of standardization of procedures and terminology makes complications (4.7%). The majority of interpretation difficult. Success rates of problems encountered after Achilles up to 82% have been reported with tendon surgery are related to wound surgical treatment of insertional Achilles healing complications with studies enthesopathy with 77% of patients from reporting a rate of 7% to 14% in all that study satisfied with the procedure Achilles tendon surgeries.2 1 and willing to undergo it again. Preventing postoperative infection and Complications after surgery for preservation of the tendon repair is insertional Achilles enthesopathy are well paramount to a successful outcome. Skin documented in the literature. Paavola and tendon necroses pose a significant et al2 conducted a study of complications dilemma to the surgeon with the
“
DOI: 10.1177/1938640014546864. From Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (JMK); and Rothman Institute, Philadelphia, Pennsylvania (SMR). Address correspondence to Steven M. Raikin, MD, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107; e-mail: steven.raikin@ rothmaninstitute.com. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)
Downloaded from fas.sagepub.com at FORDHAM UNIV LIBRARY on June 22, 2015
1
2
Mon XXXX
Foot & Ankle Specialist
potential for catastrophic outcomes. An extensive review of the literature was conducted with the use of PubMed and OvidSP to identify English-language articles addressing deep infections and tendon necrosis after surgery. Numerous case reports describe treatment algorithms addressing the skin and tendon defects by using scar tissue, an flexor hallucis longus (FHL) transfer or free muscle flaps.3-15 All the studies describing these procedures pertain to the treatment of infection after operative repair of Achilles tendon ruptures. Additionally, to our knowledge, Achilles allograft implantation for the treatment of deep infection and Achilles tendon necrosis for operative treatment of insertional Achilles enthesopathy has not previously been reported. We report 2 such patients who were treated operatively for insertional Achilles enthesopathies and subsequently developed deep infections.
Case Report Case 1 History A 49-year-old woman who had previously underwent insertional Achilles tendon debridement with FHL tendon augmentation presented to our clinic for second opinion. After the initial debridement, the patient developed a postoperative pseudomonas infection. This had been treated with two irrigation and debridement procedures with intraoperative cultures positive for pseudomonas. After each procedure, the patient underwent 2 courses of intravenous antibiotics prior to her presenting to our institution. On presentation she was afebrile and nontoxic but had a chronically purulent draining wound from her distal incision (Figure 1). Thompsons tense revealed a nonintact Achilles mechanism. Serology studies revealed a white blood cell count of 8.0 × 103/µL (normal 3.8-10.8 × 103/ µL), a C-reactive protein of 7.3 (normal
