5,557

Long Head of Biceps Tendon Pathology in Rotator Cuff Tears: Review of Incidence, Pathology and Current Trends of Management

Anestis Iossifidis1, Georgios Togias1, Liam Rose1, John Adamu Tiifu1

1 Department of Trauma and Orthopaedic Surgery, Shoulder Unit, Croydon University Hospital, London,UK.

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Anestis Iossifidis, MD, FRCS Ed, FRCS Ed (orth.), Senior Trauma & Orthopaedic Surgeon, Croydon University Hospital, 530 London Road, Croydon, London, CR7 7YE, the United Kingdom.
Telephone: +0044 (0) 7802404708
Email: anestis.iossifidis@gmail.com

Received: February 13, 2022
Revised: February 15, 2022
Accepted: February 16 2022
Published online: February 28, 2022

ABSTRACT

Necrotising soft-tissue infection is a life-threatening infection that requires a high index of suspicion for diagnosis. Treatment of this condition is an urgent and aggressive surgical debridement of all necrotic tissues within 12hours of presentation, high-dose broad-spectrum antimicrobial therapy and critical care support. It is a surgical emergency and requires a multidisciplinary team coordination between the surgeons, critical care and microbiology specialists. This approach has now been shown to reduce by 50% the high mortality of this condition. We present a rare case of upper limb Necrotising soft-tissue infection and review the current management of this surgical emergency.

Key words: Necrotising soft-tissue infection; Necrotising fasciitis; upper limb infections; Group A Streptococcus

© 2022 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Iossifidis A, Owusu EA, Tiifu JA, Iossifidis N. Necrotising Soft-Tissue Infection of the Upper Limb: A Case Report and Review of Current Management. International Journal of Orthopaedics 2022; 9(1): 1603-1607 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/3265

INTRODUCTION

Necrotising soft-tissue infection (NSTI) is uncommon but life-threatening, and rapidly spreading infection, involving various layers of the skin, subcutaneous tissue, deeper fascia and muscle. Delay in diagnosis and/or treatment increases the rates of morbidity and mortality. It is a surgical emergency and requires early surgical debridement within 12 hours of presentation.

It has been described as early as the 5th century BC by Hippocrates as a rapidly expanding infection with extensive necrosis and liquefaction of all soft tissues, associated with high mortality[1,2]. The modern term of “necrotising fasciitis” was first used by Wilson (1952) to describe this rapidly progressing fascial necrosis.[3]. The current terminology of this condition is “Necrotising soft-tissue infection” (NSTI)[4]. We present a rare case of upper limb NSTI and review the current diagnosis and management of this surgical emergency.

CASE REPORT

A 57year-old man had noticed a small spot on the dorsal part of the right mid forearm, just below his tattoo, 48 hours prior to presentation and a picture was taken with his phone (Figure 1). The wound had grown rapidly in size and he presented with a very painful, swollen and infected wound on the posterolateral aspect of the right forearm. There was no history of insect bites or injury. He felt well in himself with no fever. Associated comorbidities included 27 years of intravenous heroin addiction which was terminated 2 years prior, and smoking with mild chronic obstructive pulmonary disease.

Examination showed slight tachycardia (pulse 107) and a respiratory rate of 16. Blood pressure was within normal limits (133/78). There was a 12 x 8 cm wound over the dorsal aspect of right mid-distal forearm, with necrotic centre, surrounded by erythema and swelling up to the elbow proximally and the wrist distally (area marked) (Figure 2). Radiographs were normal. Initial bloods tests showed a C reactive protein (CRP) of 113, white cell count (WCC) of 13. The clinical impression was that of a rapidly spreading NSTI and the patient was taken to theatre for emergency debridement within 3 hours from presentation. Wound swab and blood cultures were taken Intravenous fluids and high-dose broad spectrum antibiotics were given (clindamycin, piperacillin/tazobactam, gentamicin and teicoplanin) following discussion with the microbiologist.

Surgery involved debridement of all necrotic tissues down to the deep fascia and an area of 2 cm swollen tissue circumferentially up to healthy bleeding tissues (Figure 3). The wound was washed with 6L of saline solution and a vacuum dressing was applied. The wound was clean when re-explored 24h later and no further debridement was necessary. The patient was then referred to plastic surgeons for skin grafting. The patient made an uneventful recovery. His vitals improved within 12 hours with a heart rate of 79 and a respiratory rate of 11. Blood test results showed a CRP of 74, and a WCC of 11. Four days later the CRP decreased to 7 and the WCC to 6. Microbiology results showed heavy growth of ß -haemolytic Group A Streptococcus (GAS).

Figure 1 Photograph taken by the patient 48 hours prior to admission.

Figure 2 Photograph taken 48 hours later during hospital presentation.

Figure 3 Photograph following surgical debridement.

DISCUSSION

NSTI is a rare surgical emergency with an incidence of 0.4 and 0.5 cases per 100,000 population and 500 cases per year in the UK[5-7]. It mainly affects the extremities but can occur in any part of the body. Risk factors include: intravenous drug use, alcohol dependence, diabetes mellitus, over 50 years of age, hypertension, and obesity[7,8].

Causal organisms of NSTI

(1) May include the following pathogens: Gram positive bacteria: (Mainly ß haemolytic Group A streptococci (GAS), and less often Group B streptococci, Enterococci, Coagulase negative staphylococci, Staphylococcus aureus, Bacillus species).Gram negative bacteria: (Escherichia coli, Pseudomonas aeruginosa, Proteus species, Serratia species). Anaerobic bacteria: (Bacteroides species, Clostridium species, Pepto-streptococcus species). Fungi: (Zygomycetes, Aspergillus, Candida). Other: Aeromonas hydrophila, Vibrio species.

(2) Classification of NSTI

Type 1: Is a polymicrobial infection mostly in immunocompromised individuals and includes anaerobes, Gram-negative and Gram-positive organisms. It is the most common type (70%) and occurs in the trunk and perineum. Affects patients with several comorbidities, (intravenous drug use, diabetes mellitus, cardiovascular)[7,9]. Type 2: Is mainly due to Group A streptococcus (GAS) with or without Staphylococcus aureus. Typically occurs in the limbs, with a history of usually minor injury. (20-30%)[7,9,10].

Less common types: Type 3: Is a monomicrobial necrotising fasciitis, which can be caused by water exposure with Aeromonas hydrophila, or Vibrio vulnificus, and is more common in Asia. Type 4: Caused by fungal pathogens particularly in immunocompromised patients[9].

The predominant organism in Type 2 necrotising fasciitis is GAS, which is common in UK based studies. The human pathogen Streptococcus pyogenes or group A Streptococcus (GAS), accounts for over 600 million infections globally per year with a high level of morbidity and mortality. New evidence suggests that invasive GAS (iGAS) is becoming more virulent. Recent epidemiological evidence points to a rapid emergence of the GAS genotype emm 89 as a leading cause of disease in the United Kingdom and other parts of the world. The new emergent clade variant was unexpectedly genetically acapsular, and exhibited enhanced production of the toxins[11].

Pathophysiology

Bacteria can invade soft tissues mainly through a break in the skin barrier or more rarely through haematogenous spread. Bacteria proliferate and release toxins, causing local tissue damage with subsequent inflammatory responses. Infection extends rapidly along fascial planes beyond the area of overlying cellulitis[12,13]. Some toxins produce vascular thrombosis and ischemic necrosis of all tissue layers. Toxins are responsible for systemic signs such as fever, hypotension, tachycardia, tachypnoea and altered mental status. Toxins may also activate T cells and macrophages resulting in a massive release of cytokines with an uncontrolled systemic inflammatory response that can lead to multi-organ failure and septic shock[13].

Diagnosis of NSTI

It is a clinical diagnosis and NSTI requires a high index of suspicion. The early presentation is that of swelling, with severe pain and cellulitis. However, a rapidly progressive soft-tissue infection should always be suspected as a necrotising infection. There is severe pain disproportionate to the visible skin changes, and the oedema extends beyond the erythema area. Often there is an area of hypoesthesia over the site of infection. Necrotic skin, blisters, and systemic signs of infection (fever, tachycardia, hypotension and increased respiratory rate) may be late signs. Lymphangitis and lymphadenopathy are rare due to thrombosis of the vessels. The clinical picture may worsen very quickly within a few hours. Necrotising fasciitis is primarily a clinical diagnosis. However, investigations can support the diagnosis if this is unclear. Laboratory findings include rising inflammatory markers, WCC, and elevated serum creatinine kinase levels. Magnetic resonance imaging and Ultrasound scan have high accuracy rates but may be difficult to perform under emergency conditions[14,15].

The ‘finger test’ is a surgical method that can be performed under local anaesthesia at the bedside for the diagnosis of necrotising fasciitis. It involves making a 2 cm incision down to the deep fascia. Findings that suggest necrotising fasciitis following incision include: minimal resistance to finger dissection (a ‘positive’ finger test), absence of bleeding and pus, presence of necrotic tissue and murky or greyish ‘dishwater’ fluid[16,17].

Severity assessment of NSTI

(1) Laboratory Risk Indicator for Necrotising infection (LRINEC) score

Wong et al (2004) proposed the use of the Laboratory Risk Indicator for Necrotising infection (LRINEC) in order to predict the presence of NSTI[18]. It scores six independent variables: serum C-reactive protein level, white blood cell count, haemoglobin level, serum sodium level, serum creatinine level, and serum glucose level. A systematic review by Bechar et al (2017) concluded that the LRINEC score was useful in the diagnosis of necrotizing fasciitis[19]. However, a more recent meta-analysis of 5982 cases by Fernando et al (2018) showed that the LRINEC score had a low sensitivity of 68.2% and specificity of 84.8%, and should not be used to rule-out NSTI[20].

(2) Quick Sepsis-related Organ Failure Assessment score. (qSOFA score)

The third international consensus definitions for sepsis and septic shock (Sepsis-3) by Singer et al (2016) suggested that in hospital settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria: respiratory rate of 22/min or greater, altered Glasgow coma scale, or systolic blood pressure of 100 mm Hg or less. These criteria constitute a new bedside clinical score termed the quick Sepsis-related Organ Failure Assessment (qSOFA) score. An increase in the of 2 points or more, is associated with an in-hospital mortality greater than 10%[21].

Mortality rate variation of NSTI

The progression of the infection is often rapid, and prognosis depends on quick diagnosis and appropriate treatment. The presenting signs of NSTI can be quite similar to those of other common soft tissue infections, such as cellulitis, making early diagnosis challenging.  A high index of suspicion for NSTI is crucial to early recognition and intervention without delay. A recent review showed that 71.4% of the NSTIs are misdiagnosed on initial evaluation[22]. Delay in diagnosis and surgical debridement lead to an increased mortality rate.

Nawijn et al (2020) comparing mortality rates before and after 2000 in the Netherlands, reported a significant reduction in mortality from 28.3% to 20.6%. However, average mortality rates reported remained constant around 20% over the past 20 years[23].

Mortality rates for NSTI are considered high, and vary between 14% and 33% depending on the country of the study. Germany 32.8%[24], France 23.7%[25], Netherlands 21%[23], USA 14%[26]. Neilly et al (2019) reported the UK experience with an NSTI mortality of 17% and an amputation rate of 14%. The amputation cohort had a 50% mortality[7].

The mortality rates also vary according to surgical timing. Gelbard et al (2018) pooled the results from six studies and found that surgery within 12 h compared to surgery after 12 h from presentation had reduced mortality rates 13% vs 26% respectively[27].

A recent systematic review and meta-analysis of 109 studies by Nawijn et al (2020) showed a similar reduction in mortality if the initial surgery is performed within 12 h after presentation (19% vs. 34%) and demonstrated that early surgical debridement, lowers the mortality rate for NSTI by almost 50%[23].

Multidisciplinary team Managenent

A multidisciplinary team (MDT) is mandatory for the management of this condition and requires coordination between the surgeons, critical care and microbiology specialists. The gold standard for treating NSTI is an early diagnosis, urgent surgical debridement of necrotic tissues, antimicrobial therapy, and haemodynamic support. The bacteria causing NSTI can spread rapidly along the fascial planes. The goal of the initial surgical procedure is therefore to prevent further spreading of the infection by aggressive debridement of all the infected and necrotic tissues until healthy viable tissue is seen. [17] In patients with a high suspicion for necrotizing infection, surgical debridement within the first 12 h after admission, is of paramount importance. Surgical debridement should be repeated as necessary every 12-24 h, until the patient has no necrotic tissue remaining[26].

Adjunctive antibiotic therapy and supportive care is crucial. Intravenous empirical antibiotics start after having obtained blood cultures. Until microbial identification and sensitivities are known, high-dose broad-spectrum antibiotics should be administered that cover the most common aetiologies for NSTI, according to local antimicrobial guidelines. In our hospital that includes: clindamycin, piperacillin/tazobactam, gentamicin and teicoplanin. Once culture results are available, therapy is tailored accordingly[17,28].

Conclusion

Necrotising fasciitis is a life-threatening soft-tissue infection that requires a high index of suspicion for diagnosis. The gold standard management of NSTI includes an early diagnosis, urgent and aggressive surgical debridement of necrotic tissues within 12hours after presentation, high-dose broad-spectrum antimicrobial therapy and critical care support. NSTI is a life-threatening surgical emergency and requires a multidisciplinary team coordination between the surgeons, critical care and microbiology specialists. This approach has now been shown to reduce by 50% the high mortality of this condition.

REFERENCES

1. Descamps V, Aitken J, Lee MG.Hippocrates on necrotising fasciitis. Lancet 1994; 344: 556. [PMID: 7914656]; [DOI: 10.1016/s0140-6736(94)91956-9]

2. Hippocrates. Epidemics: (translated by WHS Jones). Vol I. London: Heinemann, for Harvard University Press, 1957: 24-43.

3. Wilson B. Necrotizing fasciitis. Am Surg 1952; 18(4): 416-431. [PMID: 14915014]

4. Howell GM, Rosengart MR. Necrotizing soft tissue infections. Surg Infect. 2011; 12: 185-90 [PMID: 21767158]; [DOI: 10.1089/sur.2011.032]

5. Hasham S, Matteucci P, Stanley PR, Hart NB. Necrotising fasciitis. BMJ 2005; 330(7495): 830-833. [PMID: 15817551]; [PMCID: PMC556077]; [DOI: 10.1136/bmj.330.7495.830]

6. Angoules AG, Kontakis G, Drakoulakis E,Vrentzos G,Granick MS,Giannoudis PV. Necrotising fasciitis of upper and lower limb: a systematic review. Injury 2007; 38(Suppl 5): S19-S26. [PMID: 18048033]; [DOI: 10.1016/j.injury.2007.10.030]

7. Neilly DW, Smith M, Woo A, Bateman V,Stevenson I. Necrotising fasciitis in the North East of Scotland: a 10-year retrospective review. Ann R Coll Surg Engl. 2019 May; 101(5): 363-72. [PMID: 30855976]; [PMCID: PMC6513372]; [DOI: 10.1308/rcsann.2019.0013]

8. Francis KR, Lamaute HR, Davis JM, Pizzi WF. Implications of risk factors in necrotizing fasciitis. Am Surg 1993; 59(5): 304-308. [PMID: 8489099]

9. Morgan MS. Diagnosis and management of necrotising fasciitis: a multiparametric approach. J Hosp Infect 2010; 75(4): 249-257 [PMID: 20542593]; [DOI: 10.1016/j.jhin.2010.01.028]

10. Weiss KA, Laverdière M. Group A Streptococcus invasive infections: a review. Can JSurg 1997; 40: 18-25. [PMID: 9030079]; [PMCID: PMC3949874]

11. Turner CE, Abbott J, Lamagni T,Holden MTG,David S,Jones MD,Gama L,Efstratiou A,Sriskandan S. Emergence of a new highly successful acapsular group A Streptococcus clade of genotype emm89 in the United Kingdom. MBIO 2015; 6(4): e00622-15. [PMID: 26173696]; [PMCID: PMC4502227]; [DOI: 10.1128/mBio.00622-15]

12. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009; 208(2): 279-88. [PMID: 19228540]; [DOI: 10.1016/j.jamcollsurg.2008.10.032]

13. Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med. 2017; 377: 2253-65. [PMID: 29211672]; [DOI: 10.1056/NEJMra1600673]

14. Kim KT, Kim YJ, Won Lee J, Kim YJ, Park SW, Lim MK, Suh CH. Can necrotizing infectious fasciitis be differentiated from non-necrotizing infectious fasciitis with MR imaging? Radiology. 2011; 259: 816-24. [PMID: 21406630]; [DOI: 10.1148/radiol.11101164]

15. Yen ZS, Wang HP, Ma HM, Chen SC, Chen WJ. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med. 2002; 9: 1448-51 [PMID: 12460854]; [DOI: 10.1111/j.1553-2712.2002.tb01619.x]

16. Andreasen TJ, Green SD, Childers BJ. Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plast Reconstr Surg. 2001; 107: 1025-35. [PMID: 11252099]; [DOI: 10.1097/00006534-200104010-00019]

17. Sartelli M, Guirao X, Hardcastle TC. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg. 2018 Dec 14; 13: 58. [PMID: 30564282]; [PMCID: PMC6295010]; [DOI: 10.1186/s13017-018-0219-9]

18. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (laboratory risk indicator for necrotizing fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004; 32: 1535. [PMID: 15241098]; [DOI: 10.1097/01.ccm.0000129486.35458.7d]

19. Bechar J, Sepehripour S, Hardwicke J, Filobbos G. Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: a systematic review of the literature. Ann R Coll Surg Engl. 2017; 99: 341-6. [PMID: 28462647]; [PMCID: PMC5449710]; [DOI: 10.1308/rcsann.2017.0053]

20. Fernando SM, Tran A, Cheng W, Rochwerg B, Kyeremanteng K, Seely AJE, Inaba K,Perry JJ. Necrotizing soft tissue infection: diagnostic accuracy of physical examination, imaging, and LRINEC score: a systematic review and meta-analysis. Ann Surg. 2018. [PMID: 29672405]; [DOI: 10.1097/SLA.0000000000002774]

21. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016; 315: 801-10 [PMID: 26903338]; [PMCID: PMC4968574]; [DOI: 10.1001/jama.2016.0287]

22. Goh T, Goh L, Ang C, Wong C. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014; 101: e119-125. [PMID: 24338771]; [DOI: 10.1002/bjs.9371]

23. Nawijn F, Smeeing DPJ, Houwert RM, Leenen LPH, Hietbrink F. Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg. 2020; 15: 4. [PMID: 31921330]; [PMCID: PMC6950871]; [DOI: 10.1186/s13017-019-0286-6]

24. Krieg A, Dizdar L, Verde PE, Knoefel WT. Predictors of mortality for necrotizing soft-tissue infections: a retrospective analysis of 64 cases. Langenbeck’s Arch Surg. 2014; 399(3): 333-41. [PMID: 24413760]; [DOI: 10.1007/s00423-014-1162-1]

25. Audureau E, Hua C, de Prost N, Hemery F, Decousser JW, Bosc R,Lepeule R,Chosidow O,Sbidian E. Mortality of necrotizing fasciitis: relative influence of individual and hospitallevel factors, a nationwide multilevel study, France, 2007-12. Br J Dermatol. 2017; 177(6): 1575-82. [PMID: 28452064]; [DOI: 10.1111/bjd.15615]

26. Okoye O, Talving P, Lam L, Smith J, Teixeira PG, Inaba K, Koronakis N, Demetriades D. Timing of re-debridement after initial source control impacts survival in necrotizing soft tissue infection. Am Surg. 2013; 79: 1081-5. [PMID: 24160803]

27. Gelbard RB, Ferrada P, Yeh DD, Williams BH, Loor M, Yon J,Mentzer C,Khwaja K, Kohli A,Bulger E, Robinson BRH. Optimal timing of initial debridement for necrotizing soft tissue infection: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018; 85(1): 208-14 [PMID: 29485428]; [DOI: 10.1097/TA.0000000000001857]

28. BMJ. Necrotising fasciitis. BMJ Best Practice.Available from: URL: https://bestpractice.bmj.com/topics/en-gb/3000241

Refbacks

  • There are currently no refbacks.


Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.