Thigh Abscess Secondary to Continuous Popliteal Nerve Catheter: A Rare Complication
1
Abstract Introduction Residents, 1 Cleveland Clinic/Healthspan and 2 Cleveland Clinic/Mercy Regional Medical Center Thigh Abscess Secondary to Continuous Popliteal Nerve Catheter: A Rare Complication Jennifer Gerres, DPM 1 ; Megan Oltmann, DPM 2 ; Michael Wheeler, DPM 2 Case Study Case Study References The continuous popliteal nerve catheter (CPNC) is an increasingly popular adjuvant therapy to reduce postoperative pain in lower extremity surgery. It has few noted complications in the literature with serious infectious complications reported at 0.25% to 0.75%. We present the rare case of a posterior thigh abscess secondary to a CPNC, which requires multiple surgical debridements and long-term IV antibiotic use. The literature review highlights complications of the continuous popliteal nerve catheter with special emphasis upon infection risk factors. Discussion Discussion Figure 3 Figure 4 Figure 5 A continuous popliteal nerve catheter (CPNC) comprises the percutaneous insertion of a catheter adjacent to the sciatic nerve with a local anesthetic infusion, which offers anesthesia and analgesia for multiple days. 1 Unlike a single bolus injection, which would last 8 to 24 hours, the CPNC is desirable when a prolonged neural blockade would provide relief. Using a continuous infusion, the need for general anesthesia is reduced 2 as well as lessens the patient’s postoperative opioid requirements. 2-5 Furthermore, the CPNC is associated with lower postoperative pain scores and reduced breakthrough pain; and less nausea and vomiting, urinary retention, opioid-related side effects, and sleep disturbances. 1,2 Complications are rare in reported literature with catheter dislodgement, catheter obstruction, or neuropathy the most common. Local infection of peripheral nerve catheters ranges from 0 to 3% in the literature and serious infection less than 1%. The benefits of CPNC are well documented in the literature with lower patient reported postoperative pain scores and decreased patient need for postoperative opioids most significant. Singelyn et al. 4 compared the CPNC to intramuscular injection of opioids and to IV PCA morphine in the postoperative setting. Only 8% of those with the CPNC required supplemental opioids; whereas, those with IM opioids and IV PCA morphine required 91% and 100% supplementation respectively. The patients with CPNC also reported less nausea and vomiting. In the study by White et al., 6 a prospective, randomized, placebo-controlled study of continuous infusion of bupivacaine versus normal saline via a popliteal catheter after a single bolus of bupivacaine, after 48 hours, a significant reduction in pain scores, opioid use, and anti-emetic use was noted in the treatment group. This is further supported by a similar study conducted by Elliot and colleagues 2 who observed that after 72 hours while the overall pain scores in both groups were low, those in the CPNC group had significantly lower pain scores with a considerably less requirement for supplemental opioids. Complications of peripheral nerve catheters include catheter dislodgement or obstruction, leaking of infusate at catheter site, peri-catheter hematoma, 1 and vascular rupture. 7 Borgeat and colleagues 8 reported 2 cases of inflammation at the catheter site in 1001 patients that underwent a continuous popliteal nerve catheter. No incidences of infection or neuropathy were noted. When observed, the neuropathy is transient in nature 9 with 41% of patients experiencing some paresthesia, 10 but persistent sensory deficit is reported at 1.91%. 11 Localized inflammation of the peripheral nerve catheter varies between 0 to 13.7%, with localized infection between 0 to 3%. 9 However, bacterial colonization of the indwelling catheter is high, 6 to 57%, depending on the location of the catheter. 9,12 If colonization of the catheter occurs, it is most likely Staphylococcus epidermidis 12 ; however, if abscess or infection occurs, the mostly like organism is Staphylococcus aureus. 13 Our patient’s infective organism was Methicillin-resistant Staphylococcus aureus. Interestingly, Capdevila and colleagues 12 reported no abscess, local infection, or colonization of 167 CPNCs with Staphylococcus aureus. Of those 112 CPNCs that were colonized, 77.3% were colonized with coagulase-negative Staphylococcus and 18.1% with gram-negative bacillus. None of the colonized catheters resulted in abscess or infection. Staphylococcus aureus, specifically Methicillin-resistant S. Aureus, was the infective agent in two reported cases of CPNC abscess. 14-16 One case, described by Compère et al., 14,15 of MRSA abscess occurred in a study of 400 patients with CPNCs 15 days after the catheter was removed. In that patient, the duration of the CPNC was 5 days. The patient required surgical debridement and IV vancomycin for 1 month. Tucker et al. 16 described the case of posterior thigh abscess secondary to MRSA infection, which presented 4 days after CPNC insertion. Like our case, the catheter was removed, but symptoms worsened and a CT demonstrated an abscess to the popliteal fossa. Not only was the duration of the CPNC similar to our case, but poor pain control despite continuous infusion of local anesthetic and opioids may have been an early sign of infection for a change in local pH can reduce anesthetic efficacy. It is imperative under those circumstances to inspect the catheter site for dislodgement, obstruction, or infection. Risk factors for CPNC infection include postoperative intensive care stay, catheter duration of greater than 72 hours, absence of antibiotic prophylaxis 13 and poor aseptic technique. 14 Other risk factors that have been described are male sex, trauma, and contaminated local anesthetic solution. Of the risk factors defined, our patient’s CPNC remained for 4 days. Pre-existing surgical site infection has not been shown to increase risk of indwelling catheter infection. 9,17 While lack of antibiotic prophylaxis is a risk factor for infection, in multiple studies antibiotics were not routinely given and no infection was reported. 9,11 Lastly, to reduce the potential of CPNC infection one must adhere to strict aseptic technique, use protective barriers and skin disinfectants with an alcohol base, and remove the CPNC within 72 hours of insertion. In conclusion, while colonization of indwelling peripheral nerve catheters are common, infections are rare with infection of CPNCs less than 1%. While it is important to recognize the infectious potential of an indwelling catheter, our case is the exception and the literature supports the use of CPNCs as a safe and beneficial method of analgesia. 1. Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011; 113(4):904-25. 2. Elliot R, Pearc CJ, Seifert C, Calder JDF. Continuous infusion versus single bolus popliteal block following major ankle and hindfoot surgery: a prospective, randomized trial. Foot Ankle Int. 2010; 31(12):1043-7. 3. Liu SS, Salinas FV. Continuous plexus and peripheral nerve blocks for postoperative analgesia. Anesth Analg. 2003; 96:263-72. 4. Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal sciatic nerve block: an original technique to provide postoperative analgesia after foot surgery. Anesth Analg. 1997; 83:383-6. 5. Gallardo J, Lagos L, Bastias C, Henríquez H, Carcuro G, Paleo M. Continuous popliteal block for postoperative analgesia in total ankle arthroplasty. Foot Ankle Int. 2012; 33:208-12. 6. White PF, Issioui T, Skrivanek GD, Early JS, Wakefield C. The use of a continuous popliteal sciatic nerve block after surgery involving the foot and ankle: does it improve the quality of recovery? Anesth Analg. 2003; 97:1303-9. 7. Wiegel M, Gottschaldt U, Hennebach R, Hirschberg T, Reske A. Complications and adverse effects associated with continuous peripheral nerve blocks in orthopedic patients. Anesth Analg. 2007; 104(6):1578-82. 8. Borgeat A, Blumenthal S, Lambert M, Theodorou P, Vienne P. The feasibility and complications of the continuous popliteal nerve block: a 1001-case survey. Anesth Analg. 2006: 103(1):229-33. 9. Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anaesth. 2010; 105 Suppl 1:i97-107. 10. Hajek V, Dussart C, Klack F, Lamy A, Martinez AY, Lainé P, et al. Neuropathic complications after 157 procedures of continuous popliteal nerve block for hallux valgus surgery. A retrospective study. Orthop Traumatol Surg Res. 2012; 98(3):327-33. 11. Gartke K, Portner O, Taljaard M. Neuropathic symptoms following continuous popliteal block after foot and ankle surgery. Foot Ankle Int. 2012; 33(4):267-74. 12. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery. Anesthesiology. 2005; 103;1035-45. 13. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology. 2009; 110:182-8. 14. Compère V, Rey N, Baert O, et al. Major complications after 400 continuous popliteal sciatic nerve blocks for post-operative analgesia. Acta Anaesthesiol Scand. 2009; 53:339-345. 15. Compère V, Cornet C, Fourdrinier V, et al. Thigh abscess as a complication of continuous popliteal sciatic nerve block. Br J Anaesth. 2005; 95(2):255-6. 16. Tucker CJ, Kirk KL, Ficke JR. Posterior thigh abscess as a complication of continuous popliteal nerve catheter. Am J Orthop. 2010; 39(3):E25-E27. 17. Gasparini JR, Mello SS, Marques RS, Saraiva RA. Postoperative continuous plexular analgesia. A study on the side effects and risk factors of catheter infection. Rev Bras Anestesiol. 2008; 58:608-13. A 53-year-old non-diabetic female underwent open reduction with internal fixation of a left trimalleolar fracture. Prior to surgery, a CPNC was inserted for postoperative pain management (0.2% ropivicaine at 10ml/h), and the patient received 1g cefazolin IV pre-and postoperatively. Despite the use of oral opioids, the patient could not be weaned from the CPNC and remained in hospital. Upon postoperative day 3, the patient began to complain of generalized left thigh pain. Vital signs demonstrated a pulse of 100 and oral temperature of 101°F. Physical exam of the surgical incision did not elicit malodor or purulence with the wound well-coapted. Peri-catheter erythema was noted, but without induration or pain to the catheter site. Lab work revealed a white count of 14.6, and urine and blood cultures were negative for growth. Ultrasound of bilateral lower extremities was negative for deep vein thrombosis; however, enlarged lymph nodes in the left groin were observed. With continued fever and no other infectious source determined, on postoperative day 4, the CPNC was removed without note of purulence or induration at the catheter site. Erythema was still observed peri-catheter without improvement or worsening since postoperative day 3. Despite CPNC removal, the patient continued to exhibit fever and complained of chills, sweats, and increasing left posterior thigh pain, specifically to the area of the catheter insertion. On physical exam, inspection of the surgical wound did not reveal signs of infection; however, upon assessment of the popliteal nerve catheter site it was found to be erythematous and painful to touch with frank induration. No crepitus, fluctuance, or purulence was elicited. Lymph nodes of the left groin were palpable. Computed tomography demonstrated abscess (Figure 1) within the soft tissue adjacent to the former CPNC site. The primary team performed an incision and drainage of the CPNC site. Two, 2cm incisions were made over the site and 5cc of purulent material was expressed and sent for culture and sensitivity. No undermining or tracking of the tissue was noted. The patient began empiric therapy of 1g vancomycin IV q12h and 3.375g piperacillin- tazobactam IV q6h until definitive cultures. Cultures demonstrated Methicillin-resistant Staphylococcus aureus, and piperacillin-tazobactam was discontinued and rifampin 600mg PO q24h was added as adjuvant therapy. However, 3 days after the incision and drainage with initiation of antibiotic therapy, fever and leukocytosis persisted, and now on physical exam, the entirety of the posterior thigh—from the popliteal fossa to the ischial tuberosity—was erythematous and indurated. Magnetic resonance imaging showed widespread multiloculated abscess (Figure 2) and diffuse edema to the left posterior thigh compartment (Figures 3, 4, & 5). The patient underwent emergency radical debridement of the left thigh. A serpentine incision extended from the ischial tuberosity to the proximal calf of the posterior thigh. Two-thirds of the posterior compartment as well as the medial and lateral heads of the gastrocnemius were involved and debrided or excised. Significant phlegmon was noted along the course of the sciatic nerve. The popliteal fossa was explored and the knee joint was not breached. Negative wound pressure therapy was applied to the wound until primary closure could be performed. The patient experienced hypovolemic shock and spent three days in surgical intensive care where she received 6 units PRBCs and 2 units FFP. Post radical debridement, the patient remained afebrile and the leukocytosis resolved. She underwent two negative pressure therapy dressing changes with further debridement of non-viable tissue until the wound was primarily closed. Rifampin was discontinued due to patient intolerance. Thirty-one days after initial admission for the ORIF of the left trimalleolar ankle fracture the patient was discharged to a rehabilitation center on a 6-week course of 1g vancomycin IV q12h. She underwent 9 months (3 months within an acute rehab setting) of extensive physical and occupational therapy. At one year, the patient continued to have discomfort when sitting for long periods, and ambulated without difficulty or assistance. Radiographs of the trimalleolar fracture demonstrated a well-healed fracture without periosteal reaction or loosening of fixation.
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Transcript of Thigh Abscess Secondary to Continuous Popliteal Nerve Catheter: A Rare Complication
Abstract
Introduction
Residents, 1Cleveland Clinic/Healthspan and 2Cleveland Clinic/Mercy Regional Medical Center
Thigh Abscess Secondary to Continuous Popliteal Nerve Catheter: A Rare Complication Jennifer Gerres, DPM1; Megan Oltmann, DPM2; Michael Wheeler, DPM2
Case Study
Case Study
References
The continuous popliteal nerve catheter (CPNC) is an increasingly popular adjuvant therapy to reduce postoperative pain in lower extremity surgery. It has few noted complications in the literature with serious infectious complications reported at 0.25% to 0.75%. We present the rare case of a posterior thigh abscess secondary to a CPNC, which requires multiple surgical debridements and long-term IV antibiotic use. The literature review highlights complications of the continuous popliteal nerve catheter with special emphasis upon infection risk factors.
Discussion
Discussion
Figure 3
Figure 4 Figure 5
A continuous popliteal nerve catheter (CPNC) comprises the percutaneous insertion of a catheter adjacent to the sciatic nerve with a local anesthetic infusion, which offers anesthesia and analgesia for multiple days.1 Unlike a single bolus injection, which would last 8 to 24 hours, the CPNC is desirable when a prolonged neural blockade would provide relief. Using a continuous infusion, the need for general anesthesia is reduced2 as well as lessens the patient’s postoperative opioid requirements.2-5 Furthermore, the CPNC is associated with lower postoperative pain scores and reduced breakthrough pain; and less nausea and vomiting, urinary retention, opioid-related side effects, and sleep disturbances.1,2
Complications are rare in reported literature with catheter dislodgement, catheter obstruction, or neuropathy the most common. Local infection of peripheral nerve catheters ranges from 0 to 3% in the literature and serious infection less than 1%.
The benefits of CPNC are well documented in the literature with lower patient reported postoperative pain scores and decreased patient need for postoperative opioids most significant. Singelyn et al.4 compared the CPNC to intramuscular injection of opioids and to IV PCA morphine in the postoperative setting. Only 8% of those with the CPNC required supplemental opioids; whereas, those with IM opioids and IV PCA morphine required 91% and 100% supplementation respectively. The patients with CPNC also reported less nausea and vomiting. In the study by White et al.,6 a prospective, randomized, placebo-controlled study of continuous infusion of bupivacaine versus normal saline via a popliteal catheter after a single bolus of bupivacaine, after 48 hours, a significant reduction in pain scores, opioid use, and anti-emetic use was noted in the treatment group. This is further supported by a similar study conducted by Elliot and colleagues2 who observed that after 72 hours while the overall pain scores in both groups were low, those in the CPNC group had significantly lower pain scores with a considerably less requirement for supplemental opioids.
Complications of peripheral nerve catheters include catheter dislodgement or obstruction, leaking of infusate at catheter site, peri-catheter hematoma,1 and vascular rupture.7 Borgeat and colleagues8 reported 2 cases of inflammation at the catheter site in 1001 patients that underwent a continuous popliteal nerve catheter. No incidences of infection or neuropathy were noted. When observed, the neuropathy is transient in nature9 with 41% of patients experiencing some paresthesia,10 but persistent sensory deficit is reported at 1.91%.11
Localized inflammation of the peripheral nerve catheter varies between 0 to 13.7%, with localized infection between 0 to 3%.9 However, bacterial colonization of the indwelling catheter is high, 6 to 57%, depending on the location of the catheter.9,12 If colonization of the catheter occurs, it is most likely Staphylococcus epidermidis12; however, if abscess or infection occurs, the mostly like organism is Staphylococcus aureus.13 Our patient’s infective organism was Methicillin-resistant Staphylococcus aureus.
Interestingly, Capdevila and colleagues12 reported no abscess, local infection, or colonization of 167 CPNCs with Staphylococcus aureus. Of those 112 CPNCs that were colonized, 77.3% were colonized with coagulase-negative Staphylococcus and 18.1% with gram-negative bacillus. None of the colonized catheters resulted in abscess or infection. Staphylococcus aureus, specifically Methicillin-resistant S. Aureus, was the infective agent in two reported cases of CPNC abscess.14-16 One case, described by Compère et al.,14,15 of MRSA abscess occurred in a study of 400 patients with CPNCs 15 days after the catheter was removed. In that patient, the duration of the CPNC was 5 days. The patient required surgical debridement and IV vancomycin for 1 month. Tucker et al.16 described the case of posterior thigh abscess secondary to MRSA infection, which presented 4 days after CPNC insertion. Like our case, the catheter was removed, but symptoms worsened and a CT demonstrated an abscess to the popliteal fossa. Not only was the duration of the CPNC similar to our case, but poor pain control despite continuous infusion of local anesthetic and opioids may have been an early sign of infection for a change in local pH can reduce anesthetic efficacy. It is imperative under those circumstances to inspect the catheter site for dislodgement, obstruction, or infection.
Risk factors for CPNC infection include postoperative intensive care stay, catheter duration of greater than 72 hours, absence of antibiotic prophylaxis13 and poor aseptic technique.14 Other risk factors that have been described are male sex, trauma, and contaminated local anesthetic solution. Of the risk factors defined, our patient’s CPNC remained for 4 days. Pre-existing surgical site infection has not been shown to increase risk of indwelling catheter infection.9,17 While lack of antibiotic prophylaxis is a risk factor for infection, in multiple studies antibiotics were not routinely given and no infection was reported.9,11 Lastly, to reduce the potential of CPNC infection one must adhere to strict aseptic technique, use protective barriers and skin disinfectants with an alcohol base, and remove the CPNC within 72 hours of insertion.
In conclusion, while colonization of indwelling peripheral nerve catheters are common, infections are rare with infection of CPNCs less than 1%. While it is important to recognize the infectious potential of an indwelling catheter, our case is the exception and the literature supports the use of CPNCs as a safe and beneficial method of analgesia.
1. Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011; 113(4):904-25.2. Elliot R, Pearc CJ, Seifert C, Calder JDF. Continuous infusion versus single bolus popliteal block following major ankle and hindfoot surgery: a prospective, randomized trial. Foot Ankle Int. 2010; 31(12):1043-7.3. Liu SS, Salinas FV. Continuous plexus and peripheral nerve blocks for postoperative analgesia. Anesth Analg. 2003; 96:263-72. 4. Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal sciatic nerve block: an original technique to provide postoperative analgesia after foot surgery. Anesth Analg. 1997; 83:383-6.5. Gallardo J, Lagos L, Bastias C, Henríquez H, Carcuro G, Paleo M. Continuous popliteal block for postoperative analgesia in total ankle arthroplasty. Foot Ankle Int. 2012; 33:208-12. 6. White PF, Issioui T, Skrivanek GD, Early JS, Wakefield C. The use of a continuous popliteal sciatic nerve block after surgery involving the foot and ankle: does it improve the quality of recovery? Anesth Analg. 2003; 97:1303-9. 7. Wiegel M, Gottschaldt U, Hennebach R, Hirschberg T, Reske A. Complications and adverse effects associated with continuous peripheral nerve blocks in orthopedic patients. Anesth Analg. 2007; 104(6):1578-82. 8. Borgeat A, Blumenthal S, Lambert M, Theodorou P, Vienne P. The feasibility and complications of the continuous popliteal nerve block: a 1001-case survey. Anesth Analg. 2006: 103(1):229-33.9. Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anaesth. 2010; 105 Suppl 1:i97-107.10. Hajek V, Dussart C, Klack F, Lamy A, Martinez AY, Lainé P, et al. Neuropathic complications after 157 procedures of continuous popliteal nerve block for hallux valgus surgery. A retrospective study. Orthop Traumatol Surg Res. 2012; 98(3):327-33. 11. Gartke K, Portner O, Taljaard M. Neuropathic symptoms following continuous popliteal block after foot and ankle surgery. Foot Ankle Int. 2012; 33(4):267-74.12. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery. Anesthesiology. 2005; 103;1035-45.13. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology. 2009; 110:182-8. 14. Compère V, Rey N, Baert O, et al. Major complications after 400 continuous popliteal sciatic nerve blocks for post-operative analgesia. Acta Anaesthesiol Scand. 2009; 53:339-345. 15. Compère V, Cornet C, Fourdrinier V, et al. Thigh abscess as a complication of continuous popliteal sciatic nerve block. Br J Anaesth. 2005; 95(2):255-6. 16. Tucker CJ, Kirk KL, Ficke JR. Posterior thigh abscess as a complication of continuous popliteal nerve catheter. Am J Orthop. 2010; 39(3):E25-E27. 17. Gasparini JR, Mello SS, Marques RS, Saraiva RA. Postoperative continuous plexular analgesia. A study on the side effects and risk factors of catheter infection. Rev Bras Anestesiol. 2008; 58:608-13.
A 53-year-old non-diabetic female underwent open reduction with internal fixation of a left trimalleolar fracture. Prior to surgery, a CPNC was inserted for postoperative pain management (0.2% ropivicaine at 10ml/h), and the patient received 1g cefazolin IV pre-and postoperatively. Despite the use of oral opioids, the patient could not be weaned from the CPNC and remained in hospital. Upon postoperative day 3, the patient began to complain of generalized left thigh pain. Vital signs demonstrated a pulse of 100 and oral temperature of 101°F. Physical exam of the surgical incision did not elicit malodor or purulence with the wound well-coapted. Peri-catheter erythema was noted, but without induration or pain to the catheter site. Lab work revealed a white count of 14.6, and urine and blood cultures were negative for growth. Ultrasound of bilateral lower extremities was negative for deep vein thrombosis; however, enlarged lymph nodes in the left groin were observed.
With continued fever and no other infectious source determined, on postoperative day 4, the CPNC was removed without note of purulence or induration at the catheter site. Erythema was still observed peri-catheter without improvement or worsening since postoperative day 3.
Despite CPNC removal, the patient continued to exhibit fever and complained of chills, sweats, and increasing left posterior thigh pain, specifically to the area of the catheter insertion. On physical exam, inspection of the surgical wound did not reveal signs of infection; however, upon assessment of the popliteal nerve catheter site it was found to be erythematous and painful to touch with frank induration. No crepitus, fluctuance, or purulence was elicited. Lymph nodes of the left groin were palpable. Computed tomography demonstrated abscess (Figure 1) within the soft tissue adjacent to the former CPNC site. The primary team performed an incision and drainage of the CPNC site. Two, 2cm incisions were made over the site and 5cc of purulent material was expressed and sent for culture and sensitivity. No undermining or tracking of the tissue was noted. The patient began empiric therapy of 1g vancomycin IV q12h and 3.375g piperacillin-tazobactam IV q6h until definitive cultures. Cultures demonstrated Methicillin-resistant Staphylococcus aureus, and piperacillin-tazobactam was discontinued and rifampin 600mg PO q24h was added as adjuvant therapy.
However, 3 days after the incision and drainage with initiation of antibiotic therapy, fever and leukocytosis persisted, and now on physical exam, the entirety of the posterior thigh—from the popliteal fossa to the ischial tuberosity—was erythematous and indurated. Magnetic resonance imaging showed widespread multiloculated abscess (Figure 2) and diffuse edema to the left posterior thigh compartment (Figures 3, 4, & 5). The patient underwent emergency radical debridement of the left thigh. A serpentine incision extended from the ischial tuberosity to the proximal calf of the posterior thigh. Two-thirds of the posterior compartment as well as the medial and lateral heads of the gastrocnemius were involved and debrided or excised. Significant phlegmon was noted along the course of the sciatic nerve. The popliteal fossa was explored and the knee joint was not breached. Negative wound pressure therapy was applied to the wound until primary closure could be performed. The patient experienced hypovolemic shock and spent three days in surgical intensive care where she received 6 units PRBCs and 2 units FFP. Post radical debridement, the patient remained afebrile and the leukocytosis resolved. She underwent two negative pressure therapy dressing changes with further debridement of non-viable tissue until the wound was primarily closed. Rifampin was discontinued due to patient intolerance. Thirty-one days after initial admission for the ORIF of the left trimalleolar ankle fracture the patient was discharged to a rehabilitation center on a 6-week course of 1g vancomycin IV q12h. She underwent 9 months (3 months within an acute rehab setting) of extensive physical and occupational therapy. At one year, the patient continued to have discomfort when sitting for long periods, and ambulated without difficulty or assistance. Radiographs of the trimalleolar fracture demonstrated a well-healed fracture without periosteal reaction or loosening of fixation.
