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.