Palliative Wound Care Case #9: Chronic Knee Infection in an Elderly Man

Palliative Wound Care Case #9: Chronic Knee Infection in an Elderly Man

This is an 82-year-old male developed a chronic draining wound in the incision line from his surgery of the left total knee arthroplasty. Upon further investigation and after following the patient for approximately 4 weeks it was determined that he had infected hardware in the left knee. The patient is an otherwise active 82-year-old who was left with a difficult wound and a coincident hardware infection.

The original surgery occurred 3 months prior to presentation to our wound center. Two weeks after the operation he was readmitted to the hospital for a methicillin-resistant staph aureus and Group G Streptococcus infection of the knee and was placed on intravenous vancomycin for six weeks. 5 weeks after the initial operation the orthopedic surgeon performed incision and drainage with a complete irrigation of the wound and hardware. He was continued on oral doxycycline 100 mg by mouth twice a day along with rifampin; at all times he was followed by an infectious disease specialist. Upon initial presentation to the wound center two months after the surgery he presented with a large eschar over an extended wound. He also had some edema of the left lower extremity all the way up to and including the knee.

We treated the patient conservatively using serial debridements (both surgical and selective) in the wound center. We also utilized compression stockings to minimize the edema of the lower extremity and allow the tension on the wound edges to relax.

This represents the initial presentation of the wound with eschar and peri-wound swelling.
After 6 weeks of therapy with decompression with bandages, chronic administration of antibiotics and serial debridements patient is left with a much smaller but persistently draining wound at the 12 o’clock position.

Palliative Discussion

At age 82, the patient is left in a difficult situation along with other medical problems that include congestive heart failure, hypertension, and hypothyroidism. The patient is left with a much smaller, chronically draining wound that will require long-term antibiotic suppression. The tunneling goes down to visible hardware. He is left with 3 options at this time. First, would be long-term antibiotic suppression of what is presumed to be infected hardware with a persistent wound. Second, explantation of the hardware with antibiotic spacer and then an attempt to place a new artificial knee. Third, would be an above-the-knee amputation.

From a palliative perspective continuing to discuss his options and simplifying [sic] the choices to the above 3 options is part of our treatment plan. The patient is now getting information from four separate medical sources: his primary care doctor, the orthopedic surgeon, infectious disease specialist and the wound care specialist. We have to presume that while we may be suggesting the same choices that we might have different preferences and the ability to communicate a clear picture to the patient is challenging. For all of us who practice, we know that patients accept information in a biased manner which results in confusing communication loops. Likewise, as professionals we have our own biases as we make suggestions to patients, based upon our experience, or lack thereof.

For right now, the patient has chosen to continue on oral antibiotics long-term for suppression of the infection. He has a functional knee which is not painful for him. The risks of amputation (the actual surgery and the postoperative recuperation) are significant. Patient was also not excited about explantation of the knee as it would considerably curtail his general well-being and current activity.

What would you do?

The general discussion of the patient above is truthful. Identifiable data had been modified in order to make sure that the patient cannot be identified so modifications of age, gender, and other details were modified that do not affect the overall discussion.

© 2016 Scott Matthew Bolhack MD MBA CMD CWS FACP FAAP

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