Rhea Kohli, BS
Medical Student
Burrell College of Osteopathic Medicine
Apple Valley, Minnesota, United States
Wound dehiscence and infection in a 75-year-old Venezuelan woman with Rheumatoid arthritis, persisting two decades after Achilles tendon surgical repair.
Case Description:
We present the case of a 75-year-old female with Rheumatoid arthritis (RA), who underwent surgical repair of the right Achilles tendon twenty years ago in Venezuela, experiencing repeat incision site dehiscence and infection. Perioperatively, the patient remained on immunosuppressive medications and continued smoking. For twenty years following, she experienced repeat complications with no re-intervention. She presented on exam with gross ulceration, purulent drainage and aggravating pain from the incision site. Wound culture revealed staphylococcal infection, and ankle x-ray showed no articular disturbance. She received wound care and a course of antibiotics, pending follow-up.
Discussions:
Rheumatoid arthritis is an established independent risk factor for complications after orthopedic procedures. However, the question of how to manage perioperative treatment with immunosuppressive agents, while minimizing complications and disease flares remains unanswered. In an analysis of first-line RA drugs, current data suggest mixed evidence on perioperative use. Methotrexate has been determined safe with fewer disease flares. Leflunomide, a drug in the same class, has shown a significantly increased risk for infection and articular disturbances. Studies on biologics have shown some as safe, while others increase the risk for bleeding and dehiscence. The use of corticosteroids in combination with other RA drugs produce complications including necrotic eschars, prolonged drainage and delayed healing.
Conclusions:
This case illustrates the complexity of managing acute treatment when chronic, systemic inflammatory disease is present. Our patient's continued use of immunosuppressive RA agents while smoking has contributed to her timeline of exacerbations. The lessons learned from this case demonstrate the importance of evaluating medication regimen with risk factors perioperatively, to optimize conditions for healing. The mixed evidence surrounding these agents highlights the need for additional studies to provide guidance on treating this patient population.
