A Baseball Bruise and a Battle for Limb Salvage - Part 3

Part three of a four-part series about an athlete’s fight to beat a leg infection and save his leg. In parts one and two, JH, age 62, was hit in the shin by a baseball. Treatment included three surgeries to open and drain the contusion, another to remove necrotic tissue and a third to graft a vein, artery and skin from his thigh to the wound. Nearly healed, JH was preparing to get back to baseball when a curve ball came his way.)

Managing a busy life with what JH called a hoagie roll on his lower leg, presented its own set of challenges. The hoagie roll created an environment to feed the wound area with blood and enable it to heal, covering what had been exposed bone with viable tissue. Despite the new appendage, he could see the end game, with full healing on the horizon and with a return to the routine of family, work, and sports. Sutures out and the wound healing, the hoagie roll was unattractive and in the way of socks and trouser legs, but it was to be surgically reduced in a few weeks.

After a morning shower 10 days after returning home, JH noticed some orange-tinted, clear fluid oozing from the incision line. Peeling back one of the many butterfly bandages to take a look, the wound opened up along the incision line, releasing more fluid. In the wound, he saw something moving. Then he noticed a handful of somethings disappearing into the wound and returning to the surface again and again. Maggots and hundreds of small, oval white maggot eggs filled the wound.

JH sent a picture while simultaneously calling his physician. In denial, his physician said, “It can’t be.” A Friday, JH was to see the doctor the following Tuesday. He was told to wipe the incision line clean and keep the Tuesday appointment. But, the doctor said, it would also be fine for him to go to an emergency department for evaluation if he would be more comfortable with that.

Horrified both with what he was seeing on his leg and what he was hearing from his doctor, JH headed back to Philadelphia.

On examination, the physician assistant exclaimed, “There are maggots in there!” For the first time in weeks, JH expressed dismay with the resident and became animated – an understatement at best, belying weeks of frustration. He shouted, “I told you – and you wanted me to wait five days to be seen?”

When it occurs, maggot infestation, known as Myiasis, is considered to represent a breakdown in standards of care. As a result, there are few statistics on the frequency of these occurrences [Myiasis: maggot infestation]. Myiasis typically results when a common female housefly lands on a wound or wound dressing to feed and lays eggs there. One fly can lay between 50-300 eggs at one time. The eggs hatch within 12 hours and are fully grown within 60 hours. Shortly thereafter, they migrate to drier feeding territory.

While conceptually a thoroughly disgusting situation, maggots have been historically used to facilitate wound healing. Prior to antibiotics, maggots were intentionally introduced to some wounds and were found to promote healing by eating only necrotic—not viable—tissue, increasing exudate, digesting some forms of bacteria and secreting certain enzymes to break down necrotic tissue [Myiasis: maggot infestation].

While myiasis would resolve itself within weeks as maggots seek other environments, both patients and caregivers typically find the wait intolerable and removal is necessary. In JH’s case, waiting was not a consideration [Myiasis: maggot infestation].  

Immediately rushed back into surgery for the fourth time, the surgeons tried to clean the wound of infection again, and to remove necrotic tissue, maggots, and larvae. Remarkably, there was still no infection in the bones, but new tissue cultures revealed the infection was now caused primarily by E. coli; it’s unclear whether this was a polymicrobial infection from the start, or if the prior antibiotic therapy had been effective against Staphylococcus and now a new infection had been introduced.  Common in the digestive tracts of healthy individuals, E. coli in an infection can typically be treated with antibiotics.

During this latest surgery, twenty antibiotic beads were placed into the wound. Antibiotic beads were developed for use with joint replacement surgery to reduce the potential for infection in patients undergoing hip replacements [Tiny antibiotic beads fight infections after joint replacement]. The beads release antibiotics slowly over a period of up to six weeks. JH’s wound remained undressed for three days while it was watched closely for indications of healing from the deep parts of the wound towards the skin, and, of course, for signs of a new infection.

A fifth surgery later closed the wound. JH’s leg was cast, and he was sent home with instructions to return in 10 days to remove both the cast and sutures. The cast was an ultraconservative measure intended to prevent any chance of additional infection or infestation.

(In the final segment of this series, JH will face additional surgeries and learn whether he will ever return to his busy and athletic life or whether the infection will enter his bone and bloodstream.)

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