2014 Jul 23 4(3):e60.Ĭoumarin-derivative-induced skin necrosis involving the breast was reported as early as 1943. Warfarin-induced skin necrosis after total knee arthroplasty: a case report. Reference: Wang J, Giordani M, Pereira G. The patient was stabilized and discharged home on postoperative day fifty-five. This occurred on postoperative day fifty-two (Fig. Additional treatment options were discussed with the patient after the surgery, and he elected to proceed with a transfemoral amputation. The extensor mechanism (the patellar tendon, the patella, and the quadriceps tendon) was necrotic as well. The skin and soft-tissue necrosis was extensive, and flap coverage with use of the gastrocnemius was deemed nonviable. The patient was taken to the operating room on postoperative day forty-eight both orthopaedic and plastic surgeons were present for the irrigation and debridement. Protein C, protein S, antithrombin III, and factor-V Leiden studies were all normal. On postoperative day forty-five, the patient was transferred to a tertiary center. At the second debridement, the area of necrosis was estimated to be 40 cm in length and 25 cm circumferentially, with involvement of the joint capsule. Debridement was carried down to the fascia. A small area of skin in the popliteal region appeared viable. At the first debridement, the necrosis was noted to be circumferential, starting from just above the patella to 7 cm distal to the patella. Plans were made to take him to the operating room for surgical debridement at a later date.Įxcisional debridement of the wound and eschars was performed on postoperative days forty-one and forty-three. The skin and soft-tissue necrosis stabilized, and the patient was discharged on postoperative day twenty-two. Ultrasound studies were negative for deep vein thrombosis or arterial stenosis. Cryoglobulin, antinuclear antibody, neutrophil cytoplasmic antibody, and lupus anticoagulant studies were negative. Knee joint fluid, blood, and urine cultures were negative for infection. The hemoglobin remained stable and the platelet count was normal to elevated during the hospitalization. D-dimer and fibrinogen levels were both elevated. Several specialists were consulted, including hematologists and oncologists, and a full workup was initiated. The skin and soft tissues, however, continued to deteriorate until there was circumferential full-thickness necrosis around the knee (Fig. The blisters kept enlarging for two more days before they appeared to stabilize on postoperative day eleven. Figure 1 shows the appearance of the knee at this time. The patient was given fresh-frozen plasma and began enoxaparin therapy. The INR steadily declined to normal values over the next five days. On postoperative day eight, the INR peaked at 2.4 and the warfarin was discontinued. On postoperative day seven, new blisters were noted posteriorly, and the skin beneath the old blisters appeared darker. After more blisters were evident the following day, they were drained at the bedside. ![]() On postoperative day five, blisters were noted on the anteromedial side of the knee. The knee was swollen and mildly erythematous and had some new hemorrhagic blisters. On postoperative day four, the patient presented to the emergency room because of increased pain and inability to mobilize, and he was admitted to the hospital. On postoperative day three, the skin around the incision appeared slightly swollen and ecchymotic but was within normal expectations, and the patient was discharged home. After surgery, the patient was treated with enoxaparin while hospitalized, and warfarin therapy was resumed. ![]() In the five months prior to stopping the warfarin, the international normalized ratio (INR) ranged from 1.7 to 2.1. Preoperatively, the patient had been on chronic warfarin therapy for the atrial fibrillation, but the warfarin had been stopped for six days before the procedure. There were no perioperative complications. A tourniquet was used only during the cementing portion. An eighty-three-year-old man with multiple medical comorbidities, including atrial fibrillation, underwent a primary right total knee arthroplasty.
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