Pre-operative Course
A 71-year-old male with a past medical history of a spinal cord injury (SCI) and resultant paraplegia with chronic tracheostomy, colostomy, suprapubic catheter and prior right above knee amputation (AKA) who originally presented to the emergency department on Day 0 (D0) with altered mental status. On arrival, he was found to be newly anemic (Hgb: 9.7 from baseline of 12) with chronic decubitus ulcers. A stage 4 right-sided ITPW, which tunneled 10 cm toward the proximal femur, was present during initial examination (Figure 1A and B). Imaging revealed a chronic fluid collection in the left hip joint. The patient was on 81 mg aspirin prior to arrival and continued this regimen throughout his hospitalization but was not on therapeutic anticoagulation. The patient was admitted to the intensive care unit for sepsis and encephalopathy due to C. difficile infection, chronic osteomyelitis of the left proximal femur, and concerns for acute-on-chronic septic arthritis. He began a treatment course of fidaxomicin for the C. difficileinfection and intravenous Zosyn for broad antimicrobial coverage given concerns for sepsis.
The patient underwent a left hip joint aspiration on D1. Blood cultures were negative and left hip synovial fluid cultures were found to grow pseudomonas aeruginosa. Orthopedic surgery performed irrigation and debridement of left hip joint with left proximal femoral resection (Girdlestone procedure) due to concern for acute on chronic septic arthritis of left hip on D3. He received one unit of pRBCs intraoperatively (and an additional unit on D5) and was started on intravenous levofloxacin for pseudomonas infection. Given the concern for possible worsening of the right ITPW, the general surgery team was consulted on D2. Upon initial evaluation by general surgery, no necrotic tissue or infectious concerns were visualized, and as such debridement was not indicated.
The wound care nurse team reassessed the right ITPW on D8 due to reports of intermittent bleeding from the wound since the patient’s admission and concern for chronic hemorrhage due to a hemoglobin of 7.5 on D8 (down from 9.7 on admission). The dressings from the right ITPW were removed which caused the wound to bleed continuously despite reapplied pressure dressings. General surgery was subsequently consulted for acutely worsening bleeding from the chronic right ITPW. On exam, there was a 1-2 cm right opening over the ischial tuberosity that was persistently oozing with copious amounts of blood seen on the wound dressings. The wound depth was investigated by digital palpation and the origin of bleeding could not be found as the wound was deep and narrow, limiting visibility. The surgery team discussed conservative management with wound packing versus surgical intervention. The patient elected for operative intervention.