Hi, my name is Chris Michael, and I'm going to be presenting on septic tenosynovitis and rupture of the tibialis anterior tendon as a case report and a review of the literature. So a brief introduction, tibialis anterior injury itself is rare, it's the third most common tendon rupture in the lower extremity following Achilles and patellar tendon injuries. The mechanism typically involves plantar flexion and eversion or open or direct trauma to the tendon itself, and it's usually managed surgically or non-surgically, it can be directly repaired, you can do a tendon transfer, autograft and allograft are also possible, but regarding the specific case that we're presenting today, it's on tibialis anterior rupture as a complication from septic tenosynovitis, which has not been previously described in the literature. So the case, it's a 46-year-old female with a past medical history of HIV, hepatitis C, diabetes, medication noncompliance, as well as current IV drug abuse. She's coming in with a chief complaint of right ankle pain, two days in duration with associated fevers, chills, diaphoresis, nausea, and vomiting. On exam, there was signs of direct heroin injection in her right lower extremity, and based on these clinical findings, as well as a concern for a deep self-tissue infection, a CAT scan was ordered of her right lower extremity. So you can see here on this axial cut of the CT scan, at the level of the ankle joint, the arrow demonstrates an area of rim-enhancing fluid, which is existing within the tendon sheath of the tibialis anterior tendon up at the top of the screen. On the sagittal cut, similar findings are demonstrated. The arrow demonstrates a rim-enhancing fluid collection within the tendon sheath once again. So incision and drainage was performed at the bedside when this patient first presented. She was started thereafter on IV vancomycin. She failed to improve after two days of IV vancomycin therapy, and subsequently, she underwent MRI of her right lower extremity with and without contrast, based on her lack of improvement. So axial MRI sequences of the right lower extremity at the level of the ankle joint demonstrate again a rim-enhancing fluid collection within the tendon sheath of the tibialis anterior tendon, as well as a high-grade partial tear of the tendon itself, as demonstrated by the green arrow. So she was taken to the operating room for repeat incision and drainage. Based on these MRI findings, wound cultures were taken, and her antibiotic regimen was then broadened to include the persilin and tezobactam. Finally, she went back to the operating room a third time for primary closure of the wound. Her wound cultures grew out methicillin-sensitive staphylococcus aureus, resistant to clindamycin. She was then subsequently discharged on Bactrim. So a brief discussion, septic kinesinovitis is an infection of the potential space which exists in tendon sheaths. The space creates a walled-off environment ideal for pathogens to grow in isolation from host defenses. Inoculation of the tendon sheath can occur from direct trauma or hematogenous spread, and commonly isolated organisms most common are streptococci and staphylococcus aureus. It occurs in three distinct stages. First involves distension of the inflamed tendon sheath with exudative fluid, followed by distension of the tendon sheath with purulent fluid, and lastly septic necrosis of the tendon sheath and surrounding structures. Some factors which are involved with poor prognosis include age over 43, diabetes, subcutaneous purulence, digital ischemia, which is more to do with the hand and foot, and then polymicrobial infections. And then, as we saw in our case, common imaging modalities which are used for diagnosis include CT and MRI without contrast, as well as ultrasound. Typically medical management involves systemic antibiotics, and surgical is typically irrigation and treatment, and it usually occurs in serial fashion. Just to summarize the topic in our case, septic tenosynovitis is a pretty common consult which you can see in the emergency room, but when it leads to tendon rupture of the tibialis anterior tendon, it's a unique case which has not been previously described in the literature. The bottom line is if this is recognized and treated early, it is possible to avoid potentially devastating complications like amputation or any further morbidity. Thank you for your time. Thank you.

video presentation

septic tenosynovitis

rupture

tibialis anterior tendon

complication