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Infected total knee arthroplasty complicated with mycotic aneurysms
Injury, Int. J. Care Injured (2004) 35, 83—85
Case report
Infected total knee arthroplasty complicated with mycotic aneurysms A case report and review of the literature Ting-Wen Huang, Ching-Jen Wang* Department of Orthopedic Surgery, Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung, Taiwan Accepted 7 January 2002
Introduction Most mycotic aneurysms occur in the aorta. Mycotic aneurysms at other locations especially the popliteal artery and its branches are relatively rare.2,5—7, 9,12,14—16 Most aneurysms, especially mycotic peripheral aneurysms are the result of emboli lodging from bacterial endocarditis and the common site is the bifurcation of the common femoral artery.1,2,6,11,12,14 It may become catastrophic if not diagnosed and treated promptly. To our knowledge mycotic aneurysm of the popliteal artery and its branches due to an infected total knee arthroplasty (TKA) has not be reported. This article reports a case of mycotic aneurysm of the anterior and posterior tibial arteries secondary to an infected TKA.
Case report A 63-year-old female had a left TKA for advanced osteoarthritis 3 years previously. The left knee was doing well until recent onset of increasing pain and decreased range of motion due to Staphylococcus aureus infection. The left knee infection was managed by arthrotomy, removal of prosthetic components, debridement and implantation of septopal (gantamycin impregnated bone cement) and intra*Corresponding author. Tel.: þ886-7-733-5279; fax: þ886-7-733-5515. E-mail address: [email protected] (C.-J. Wang).
venous vancomycin 500 mg q12 h based on the culture and sensitivity results. The infection indices including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were monitored. The patient was discharged with improved left knee condition 4 weeks later. Her past medical history included a history of non-insulin dependent diabetes mellitus and hypertension. There was no history of congestive heart failure or valvular heart disease. She was a housewife and denied history of drug abuse. The left knee infection recurred and got progressively worse in spite of repeated surgical debridements and the implantation of vancomycin-impregnated cement spacer. Therefore, arthrodesis of the left knee with an intramedullary nail fixation (Huckstep nail) was performed 4 months later because of uncontrollable infection. In addition, intravenous antibiotic therapy with vancomycin was given for 6 weeks. The infection indices including ESR and CRP were monitored through the course of treatment. The patient did better and was discharged with improved general health and local knee condition. Six months later, the S. aureus infection of the left knee had recurred. The intramedullary nail and screws were removed and thorough debridement of the knee and application of vancomycin-impregnated cement beads were performed. A Hoffman external fixator was used to stabilize the left knee postoperatively. The neurovascular status of the left leg was intact. There was no evidence to suggest the possibility of vascular injury from the
0020–1383/$ — see front matter ß 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(02)00037-2
84
T.-W. Huang, C.-J. Wang
Figure 1 The first arteriogram of the left leg showing a saccular aneurysm of the anterior tibial artery distant from the fixation pin.
Figure 2 The second arteriogram of the left leg showing multiple aneurysms of the posterior tibial artery.
fixation pins. The patient was afebrile and not toxic, and there was no evidence suggesting bacteremia. Therefore, no blood culture was performed. On the third postoperative day, excessive discharge of serosanguinous fluid from the wound was noted. There were no cardiopulmonary complaints or general toxicity. Extensive laboratory studies revealed no coagulopathy, and there was no gastrointestinal bleeding. Blood transfusions were given because of low blood count and hypotension. The clinical findings strongly suggested the possible source of bleeding was from the knee area, and an arteriogram was performed. The results of arteriogram study showed a ruptured saccular aneurysm of the anterior tibial artery that is not at the proximity of the fixation pin (Fig. 1). A vascular surgeon performed an emergency ligation of the anterior tibial artery aneurysm. The blood pressure and blood count became stable postoperatively. On the second day, increasing serosanguinous discharge from the knee was again noted, and the blood counts steadily
decreased and the patient became hypotensive. Other studies including blood gas and electrocardiogram showed no evidence of cardiopulmonary pathology. Physical findings were suggestive of bleeding from the knee area and a second arteriogram was warranted. The results of the second arteriogram showed multiple ruptured aneurysms of the posterior tibial artery. (Fig. 2). No new aneurysm was noted in the anterior tibial artery. Due to this lifethreatening emergency, above the knee amputation of the left leg was performed. Postoperatively, the blood counts and blood pressure were brought under control and remained within normal limits and did not deteriorate further with time. The postoperative course after amputation procedure was uneventful. The pathological report revealed ruptured aneurysms with acute inflammatory cell infiltration and nuclear debris in the necrotic wall of the posterior tibial artery with soft tissue hemorrhage and necrosis at lower thigh and upper leg compatible with the diagnosis of mycotic aneurysm. Arteriosclerosis of
Infected total knee arthroplasty complicated with mycotic aneurysms
the anterior and posterior tibial arteries was also noted. Six months postoperatively, she was doing well and the amputation stump has healed completely. There was no recurrent infection or aneurysm formation. The patient was ready for prosthetic fitting and training.
Discussion A mycotic aneurysm is a dilatation of an arterial wall resulting from infection from bacterial or fungal contamination that can develop from the seeding of the vasa vasorum in septicemia, septic remobilization in bacterial endocarditis or direct extension from infection of the adjacent tissues.16 Most peripheral aneurysms especially mycotic aneurysms are from embolic lodging from bacterial endocarditis. The incidence of mycotic aneurysm has markedly decreased with aggressive treatment with antibiotics and valvular replacement surgery in bacterial endocarditis.1 Mycotic aneurysm of the tibial artery due to direct extension of infection from adjacent tissues like our case is an extremely rare incidence. Akers Jr. et al.1 reported a case of a mycotic aneurysm of the tibioperoneal trunk after an episode of S. viridians endocarditis. To our best knowledge, our case is the first case report of an aneurysm of the tibial artery caused by direct extension from an infected TKA rather than from bacterial endocarditis. The causes of aneurysms include atherosclerosis, trauma and infection. Atherosclerotic aneurysms of the distal vessels are rare, while distal popliteal artery and the bifurcation are almost never involved.2,4,7 Traumatic aneurysms are due to disruption of the arterial walls and surrounded by the peripheral tissue and clot and result in pseudoaneurysm. The arterial walls are not attenuated which differs from atherosclerotic or mycotic aneurysm. The etiologies of mycotic aneurysm include dissemination of emboli from an infected endocarditis, bacteremia from atherosclerosis, congenital malformation etc and contiguous infection secondary to osteomyeltis, abscess or aterial trauma.3,6,10,11,13,14 The majority of mycotic aneurysms originate from infective endocarditis and rarely from direct extension from local infection like our case. Approximately 25% of the mycotic aneurysms were culture negative.5 The diagnosis is confirmed with the pathological examinations. No blood culture was performed in our case because the patient was not febrile, nor toxic to suspect bacteremia. The findings of multiple aneurysms in arteriogram favored the diagnosis of mycotic aneurysm. The pathological
85
examination clearly showed microscopic findings compatible with mycotic aneurysm. The management of mycotic aneurysm should be individualized.2,4,7,11 Most mycotic aneurysms required surgical treatment.8 Simple ligation of the peripheral aneurysm is recommended in cases with adequate collateral circulation.17 In cases with inadequate collateral circulation, bypass vascular surgery with autogenous graft is suggested.1 In addition, the original sources of infection should also be treated including intravenous antibiotics and valve repair or replacement.2—4,11,16,17 In our case, above the knee amputation was performed because of life-threatening emergency and poor medical condition and this represents as the salvage procedure in patients with mycotic aneurysm.
References 1. Akers Jr DL, Fowl RJ, Kempczinski RF. Mycotic aneurysm of the tibioperoneal trunk: case report and review of the literature. J Vasc Surg 1992;16(1):71—4. 2. Anderson CB, Butcher Jr HR, Ballingar WF. Mycotic aneurysms. Arch Surg 1974;109:712—7. 3. Bennett DE, Cherry JK. Bacterial infection of aortic aneurysms: a clinicopathologic study. Am J Surg 1979;113:321. 4. Bonds JW, Fabian RC. Surgical treatment of mycotic popliteal artery aneurysm: a case report and review of the literature. Surgery 1985;98:979—82. 5. Brown SL, Busutill RW, Baker JD, et al. Bacteriologc and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984;1:541—7. 6. Dean RH, Waterhouse G, Meacham PW, et al. Mycotic embolism and embolomycotic aneurysms. Ann Surg 1986; 204:300—7. 7. Haimovici H, Peripheral arterial aneurysms. In: Vascular surgery: principles and techniques. Norwalk (CT): AppletonCentury-Crofts 1984. p. 682—4. 8. Jenyo MS. Silent posterior tibial artery aneurysm: report of a case and review of literature. J Cardiovasc Surg 1987;28: 456—9. 9. McHenry MC, Rehm SJ, Krajewski LO. Vertebral osteomyelitis and aortic lesions: case report and review of literature. Rev Infect Dis 1991;13(6):1184—94. 10. Mendelowitz DA, Ramsteadt R, Yao JST, et al. Abdominal aortic salmonellosis. Surgery 1979;85:514. 11. Nabseth DC, Deterling Jr RA. Surgical management of mycotic aneurysms. Surgery 1961;50:347—53. 12. Osler W. The gulstonian lectures on malignant endocarditis. Br Med J 1885;1:467. 13. Payne-James JJ. Infected aneurysm of the anterior tibial artery. Br J Clin Pract 1988;42:522—4. 14. Reddy D J, Ernest C B. Infected aneurysms. In: Rutherford red: vascular surgery. WB Saunders, Philadelphia, 1989. p. 983—96. 15. Rose AF. Diseases of medium-sized arteries, including hypertension. In: Silver MD, editor. Cardiovascular pathology. New York: Churchill Livingstone, 1983. p. 739—96. 16. Rubery PT, Smith MD, Cammisa FP, et al. Mycotic aortic aneurysm in patients who have lumbar vertebral osteomyelitis. J Bone Joint Surg 1995;77-A(11):1729—32. 17. Vasilakis A, Jackson RJ, Rozar Jr FE, et al. Revascularization of a symptomatic pseudoaneurysm of the anterior tibial artery. Am Surg 1990;56:209—13.
Case report
Infected total knee arthroplasty complicated with mycotic aneurysms A case report and review of the literature Ting-Wen Huang, Ching-Jen Wang* Department of Orthopedic Surgery, Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung, Taiwan Accepted 7 January 2002
Introduction Most mycotic aneurysms occur in the aorta. Mycotic aneurysms at other locations especially the popliteal artery and its branches are relatively rare.2,5—7, 9,12,14—16 Most aneurysms, especially mycotic peripheral aneurysms are the result of emboli lodging from bacterial endocarditis and the common site is the bifurcation of the common femoral artery.1,2,6,11,12,14 It may become catastrophic if not diagnosed and treated promptly. To our knowledge mycotic aneurysm of the popliteal artery and its branches due to an infected total knee arthroplasty (TKA) has not be reported. This article reports a case of mycotic aneurysm of the anterior and posterior tibial arteries secondary to an infected TKA.
Case report A 63-year-old female had a left TKA for advanced osteoarthritis 3 years previously. The left knee was doing well until recent onset of increasing pain and decreased range of motion due to Staphylococcus aureus infection. The left knee infection was managed by arthrotomy, removal of prosthetic components, debridement and implantation of septopal (gantamycin impregnated bone cement) and intra*Corresponding author. Tel.: þ886-7-733-5279; fax: þ886-7-733-5515. E-mail address: [email protected] (C.-J. Wang).
venous vancomycin 500 mg q12 h based on the culture and sensitivity results. The infection indices including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were monitored. The patient was discharged with improved left knee condition 4 weeks later. Her past medical history included a history of non-insulin dependent diabetes mellitus and hypertension. There was no history of congestive heart failure or valvular heart disease. She was a housewife and denied history of drug abuse. The left knee infection recurred and got progressively worse in spite of repeated surgical debridements and the implantation of vancomycin-impregnated cement spacer. Therefore, arthrodesis of the left knee with an intramedullary nail fixation (Huckstep nail) was performed 4 months later because of uncontrollable infection. In addition, intravenous antibiotic therapy with vancomycin was given for 6 weeks. The infection indices including ESR and CRP were monitored through the course of treatment. The patient did better and was discharged with improved general health and local knee condition. Six months later, the S. aureus infection of the left knee had recurred. The intramedullary nail and screws were removed and thorough debridement of the knee and application of vancomycin-impregnated cement beads were performed. A Hoffman external fixator was used to stabilize the left knee postoperatively. The neurovascular status of the left leg was intact. There was no evidence to suggest the possibility of vascular injury from the
0020–1383/$ — see front matter ß 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0020-1383(02)00037-2
84
T.-W. Huang, C.-J. Wang
Figure 1 The first arteriogram of the left leg showing a saccular aneurysm of the anterior tibial artery distant from the fixation pin.
Figure 2 The second arteriogram of the left leg showing multiple aneurysms of the posterior tibial artery.
fixation pins. The patient was afebrile and not toxic, and there was no evidence suggesting bacteremia. Therefore, no blood culture was performed. On the third postoperative day, excessive discharge of serosanguinous fluid from the wound was noted. There were no cardiopulmonary complaints or general toxicity. Extensive laboratory studies revealed no coagulopathy, and there was no gastrointestinal bleeding. Blood transfusions were given because of low blood count and hypotension. The clinical findings strongly suggested the possible source of bleeding was from the knee area, and an arteriogram was performed. The results of arteriogram study showed a ruptured saccular aneurysm of the anterior tibial artery that is not at the proximity of the fixation pin (Fig. 1). A vascular surgeon performed an emergency ligation of the anterior tibial artery aneurysm. The blood pressure and blood count became stable postoperatively. On the second day, increasing serosanguinous discharge from the knee was again noted, and the blood counts steadily
decreased and the patient became hypotensive. Other studies including blood gas and electrocardiogram showed no evidence of cardiopulmonary pathology. Physical findings were suggestive of bleeding from the knee area and a second arteriogram was warranted. The results of the second arteriogram showed multiple ruptured aneurysms of the posterior tibial artery. (Fig. 2). No new aneurysm was noted in the anterior tibial artery. Due to this lifethreatening emergency, above the knee amputation of the left leg was performed. Postoperatively, the blood counts and blood pressure were brought under control and remained within normal limits and did not deteriorate further with time. The postoperative course after amputation procedure was uneventful. The pathological report revealed ruptured aneurysms with acute inflammatory cell infiltration and nuclear debris in the necrotic wall of the posterior tibial artery with soft tissue hemorrhage and necrosis at lower thigh and upper leg compatible with the diagnosis of mycotic aneurysm. Arteriosclerosis of
Infected total knee arthroplasty complicated with mycotic aneurysms
the anterior and posterior tibial arteries was also noted. Six months postoperatively, she was doing well and the amputation stump has healed completely. There was no recurrent infection or aneurysm formation. The patient was ready for prosthetic fitting and training.
Discussion A mycotic aneurysm is a dilatation of an arterial wall resulting from infection from bacterial or fungal contamination that can develop from the seeding of the vasa vasorum in septicemia, septic remobilization in bacterial endocarditis or direct extension from infection of the adjacent tissues.16 Most peripheral aneurysms especially mycotic aneurysms are from embolic lodging from bacterial endocarditis. The incidence of mycotic aneurysm has markedly decreased with aggressive treatment with antibiotics and valvular replacement surgery in bacterial endocarditis.1 Mycotic aneurysm of the tibial artery due to direct extension of infection from adjacent tissues like our case is an extremely rare incidence. Akers Jr. et al.1 reported a case of a mycotic aneurysm of the tibioperoneal trunk after an episode of S. viridians endocarditis. To our best knowledge, our case is the first case report of an aneurysm of the tibial artery caused by direct extension from an infected TKA rather than from bacterial endocarditis. The causes of aneurysms include atherosclerosis, trauma and infection. Atherosclerotic aneurysms of the distal vessels are rare, while distal popliteal artery and the bifurcation are almost never involved.2,4,7 Traumatic aneurysms are due to disruption of the arterial walls and surrounded by the peripheral tissue and clot and result in pseudoaneurysm. The arterial walls are not attenuated which differs from atherosclerotic or mycotic aneurysm. The etiologies of mycotic aneurysm include dissemination of emboli from an infected endocarditis, bacteremia from atherosclerosis, congenital malformation etc and contiguous infection secondary to osteomyeltis, abscess or aterial trauma.3,6,10,11,13,14 The majority of mycotic aneurysms originate from infective endocarditis and rarely from direct extension from local infection like our case. Approximately 25% of the mycotic aneurysms were culture negative.5 The diagnosis is confirmed with the pathological examinations. No blood culture was performed in our case because the patient was not febrile, nor toxic to suspect bacteremia. The findings of multiple aneurysms in arteriogram favored the diagnosis of mycotic aneurysm. The pathological
85
examination clearly showed microscopic findings compatible with mycotic aneurysm. The management of mycotic aneurysm should be individualized.2,4,7,11 Most mycotic aneurysms required surgical treatment.8 Simple ligation of the peripheral aneurysm is recommended in cases with adequate collateral circulation.17 In cases with inadequate collateral circulation, bypass vascular surgery with autogenous graft is suggested.1 In addition, the original sources of infection should also be treated including intravenous antibiotics and valve repair or replacement.2—4,11,16,17 In our case, above the knee amputation was performed because of life-threatening emergency and poor medical condition and this represents as the salvage procedure in patients with mycotic aneurysm.
References 1. Akers Jr DL, Fowl RJ, Kempczinski RF. Mycotic aneurysm of the tibioperoneal trunk: case report and review of the literature. J Vasc Surg 1992;16(1):71—4. 2. Anderson CB, Butcher Jr HR, Ballingar WF. Mycotic aneurysms. Arch Surg 1974;109:712—7. 3. Bennett DE, Cherry JK. Bacterial infection of aortic aneurysms: a clinicopathologic study. Am J Surg 1979;113:321. 4. Bonds JW, Fabian RC. Surgical treatment of mycotic popliteal artery aneurysm: a case report and review of the literature. Surgery 1985;98:979—82. 5. Brown SL, Busutill RW, Baker JD, et al. Bacteriologc and surgical determinants of survival in patients with mycotic aneurysms. J Vasc Surg 1984;1:541—7. 6. Dean RH, Waterhouse G, Meacham PW, et al. Mycotic embolism and embolomycotic aneurysms. Ann Surg 1986; 204:300—7. 7. Haimovici H, Peripheral arterial aneurysms. In: Vascular surgery: principles and techniques. Norwalk (CT): AppletonCentury-Crofts 1984. p. 682—4. 8. Jenyo MS. Silent posterior tibial artery aneurysm: report of a case and review of literature. J Cardiovasc Surg 1987;28: 456—9. 9. McHenry MC, Rehm SJ, Krajewski LO. Vertebral osteomyelitis and aortic lesions: case report and review of literature. Rev Infect Dis 1991;13(6):1184—94. 10. Mendelowitz DA, Ramsteadt R, Yao JST, et al. Abdominal aortic salmonellosis. Surgery 1979;85:514. 11. Nabseth DC, Deterling Jr RA. Surgical management of mycotic aneurysms. Surgery 1961;50:347—53. 12. Osler W. The gulstonian lectures on malignant endocarditis. Br Med J 1885;1:467. 13. Payne-James JJ. Infected aneurysm of the anterior tibial artery. Br J Clin Pract 1988;42:522—4. 14. Reddy D J, Ernest C B. Infected aneurysms. In: Rutherford red: vascular surgery. WB Saunders, Philadelphia, 1989. p. 983—96. 15. Rose AF. Diseases of medium-sized arteries, including hypertension. In: Silver MD, editor. Cardiovascular pathology. New York: Churchill Livingstone, 1983. p. 739—96. 16. Rubery PT, Smith MD, Cammisa FP, et al. Mycotic aortic aneurysm in patients who have lumbar vertebral osteomyelitis. J Bone Joint Surg 1995;77-A(11):1729—32. 17. Vasilakis A, Jackson RJ, Rozar Jr FE, et al. Revascularization of a symptomatic pseudoaneurysm of the anterior tibial artery. Am Surg 1990;56:209—13.