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When An Allergic Reaction To A Topical Antibiotic Complicates Post-Op Healing After A TAR

Total ankle arthroplasty cases are often challenging but post-op complications can lead the course in an even more complicated direction. The authors offer key insights from a case involving post-op abscesses and wounds after inappropriate application of a topical antibiotic.

End-stage arthritis of the talotibial joint presents many issues for patients and surgeons alike. Common causes of destruction to the ankle joint include post-traumatic changes, primary osteoarthritis and end-stage findings of other conditions such as rheumatoid arthritis.1 Researchers have also found that the majority of cases of post-traumatic arthritis in the ankle follow previous rotational injuries whereas idiopathic osteoarthritis is more common in the knee and hip joints.1

Surgical options for the treatment of severe ankle arthritis vary from arthroscopic synovectomy to total joint arthroplasty. In recent years, total ankle arthroplasty has gained popularity but also has potential challenges including wound infections and delayed wound healing due to incisions over the anterior ankle, where motion can slow wound healing.2 Many times, post-TAR patients we see in our facility will be discharged to sub-acute rehabilitation before returning home.

With this in mind, we present a case involving total ankle arthroplasty for a patient who had wound healing complications following an allergic reaction during the postoperative course.

Addressing Post-Op Abscesses Over Incision For TAR

A 63-year-old female presented to our clinic with persistent right ankle pain after injury in a 2008 auto accident. She had undergone four previous surgeries to the right ankle, including a subtalar joint arthrodesis by a previous physician. Subsequent radiographs showed severe arthritis of the right ankle with retained hardware from the previously mentioned subtalar joint arthrodesis (see first image above). One of the implanted metallic screws was within the subchondral plate of the talus. Magnetic resonance imaging (MRI) revealed subtalar joint fusion with severe ankle joint arthritis and a large talar dome lesion surrounding the retained surgical hardware (see second image above).

We decided to perform a total ankle arthroplasty and performed the procedure in January 2017 (see third image above). The patient was discharged to sub-acute rehabilitation three days later, non-weightbearing with a below-knee fiberglass cast on the right lower extremity. She presented to the clinic on postoperative day 10 for cast removal and evaluation. The surgical incision was well-coapted with adequate progression toward healing. After we applied a dry, sterile dressing to the surgical site, the patient returned to the sub-acute rehab facility. We provided explicit written directions to the patient and facility for the dressing to remain clean, dry and intact until the next follow-up appointment. We also informed the facility of the patient’s multiple allergies including bacitracin-neomycin-polymyxin b topical ointment (Neosporin).

The patient returned to the clinic 10 days later on a semi-emergent basis with abscesses along the distal aspect of incision. She stated that a nurse at the sub-acute rehab facility had removed the dressing against orders and applied bacitracin-neomycin-polymyxin b ointment over the surgical incision. We drained the abscesses, obtained cultures and started the patient on amoxicillin/clavulanic acid (Augmentin) 875 mg twice daily prophylactically. Cultures of the abscess fluid later revealed no bacterial growth.

The patient returned to the clinic on postoperative day 41 with a 1.2 cm x 2.7 cm x 0.3 cm ulceration overlying the surgical incision. Additionally, a visit on postoperative day 53 revealed another abscess on the dorsal right foot (see fourth image above). At this time, we were concerned that the patient could develop a septic ankle joint due to a compromised soft tissue envelope. After sharp excisional wound debridement we applied a cryopreserved placental membrane graft the next day. The wound was debrided to the level of extensor hallucis longus tendon with no overt signs of infection noted.

The patient returned to the clinic six days after the most recent procedure with a postoperative hematoma measuring 2.1 cm x 4.2 cm and exposure of the extensor hallucis longus tendon (see fifth image above). We employed negative pressure wound therapy (NPWT) 67 days after the original procedure and continued until postoperative day 130. We noted full healing of the surgical site in early August 2017, approximately seven months after we had performed the total ankle replacement (see sixth image above).

What You Should Know About Perioperative Topical Antibiotics

Total ankle replacement can be a viable treatment option for patients with articular degeneration of the ankle joint but this procedure is not without challenges. This case demonstrates an avoidable complication secondary to application of bacitracin-neomycin-polymyxin b to the surgical site despite a known allergy. Neomycin reportedly causes allergic contact dermatitis in seven to 13 percent of patients.3 Researchers have also found that prolonged use of topical antibiotics on impaired skin increases the likelihood of allergic contact dermatitis.4 Additionally, Trookman and colleagues have shown that bacitracin and polymyxin b decrease cell proliferation of fibroblasts and reduce the number of keratinocytes, both of which are important to wound healing.3

Based on the current literature, practitioners need to be cognizant of the potential complications of topical antibiotics, especially in the presence of compromised skin. This case demonstrates an unforeseen complication following an inherently risky surgical procedure. It also highlights the need for clear and concise communication and discharge instructions when patients will be discharged to a sub-acute rehabilitation facility in the postoperative period.

Dr. Brown is a second-year resident at Providence-Providence Park Hospital in Southfield, Mich.

Dr. Pupp is board-certified by the American Board of Foot and Ankle Surgery. He is in private practice in Southfield, Mich.

 

Online Exclusives
By Michael Brown, DPM, and Guy Pupp, DPM, FACFAS

References
  1. Saltzman CL, Salamon ML, Blanchard GM, et al. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005;25:44-46.
  2. Clough TM, Alvi F, Majeed H. Total ankle arthroplasty: what are the risks?: a guide to surgical consent and a review of the literature. Bone Joint J. 2018;100-B(10):1352-1358.
  3. Trookman NS, Rizer RL, Weber T. Irrigation and allergy patch test analysis of topical treatments commonly used in wound care: evaluation on normal and compromised skin. J Am Acad of Dermatol. 2011;64(3):S16-S22.
  4. Burkemper NM. Contact dermatitis, patch testing, and allergen avoidance. Mo Med. 2015;112(4):296-300.
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