A previously healthy, fifty-three-year-old woman whose only known comorbidity was a one-pack-per-day smoking history presented with a six-month history of progressive right shoulder pain and weakness despite nonsurgical treatments including physical therapy and corticosteroid injections. Radiographs made at another institution revealed narrowing of the acromiohumeral distance and associated bone-spur formation. A rotator cuff tear was confirmed with magnetic resonance imaging. She underwent an uncomplicated routine open rotator cuff repair and acromioplasty, which lasted approximately two hours. The combined procedures were performed on an outpatient basis in a hospital setting, and the patient received a single dose of clindamycin preoperatively for prophylactic antibiotic coverage because she was allergic to penicillin. Important findings during the operation included a full-thickness rotator cuff tear involving a small portion of the infraspinatus and supraspinatus tendons. According to the operative notes, the tear was approximately 1.5 cm from the insertion of the greater tuberosity; however, tendon-to-tendon repair was considered difficult. The tear was closed with figure-of-eight, number-0 Ethibond sutures (Ethicon, Johnson and Johnson, Somerville, New Jersey).
On the fifth postoperative day, the patient had fever as well as pain and redness at the operative site and was brought to the emergency room by her daughter. An in-depth history revealed that the patient had experienced increasing weakness during the previous two days along with multiple episodes of falling. In the emergency room, the patient was noted to have a temperature of 103°F (39.4°C), a pulse of 120 beats/min, and a blood pressure of 100/50 mm Hg. Physical examination showed erythema, tenderness, and edema at the operative site. Initial abnormal laboratory values included a total white blood-cell count of 18,400/mm3 (18.4 × 109/L), a D-dimer level of >5000 ng/mL (>5000 µg/L), a fibrin split product level of >80 µg/mL (>80 mg/L), a fibrinogen level of 698 g/L, a serum sodium level of 125 mEq/L (125 mmol/L), a blood glucose level of 195 mg/dL (10.8 mmol/L), a serum calcium level of 7.3 mg/dL (1.8 mmol/L), a serum magnesium level of 0.9 mmol/L, an international normalized ratio of 1.3, and a serum albumin level of 2.5 g/L. Additional laboratory values were normal, including hemoglobin and hematocrit levels, platelet count, the remaining electrolyte values from the chemistry panel, and liver function tests. Swab wound cultures and two sets of blood cultures were obtained in the emergency room, with initial findings of gram-positive cocci by Gram stain.
The patient was initially treated with vancomycin and gentamicin in the emergency room. She was taken to the operating room within six hours of admission. The original surgical wound was opened, and inspection revealed a deep infection involving the deltoid musculature. There was necrosis of the upper quarter of the pectoralis major muscle, the subfascial tissue, and approximately the anterior two-thirds of the deltoid muscle. Additional necrosis was found along the insertion of the trapezius muscle and extended to its insertion in the lateral aspect of the posterior triangle of the neck, and necrotic fat was found in the suprascapular notch. There appeared to be thrombosis of the external jugular vein, and several subcutaneous nerves in the suprascapular fossa were identified and appeared nonviable. Intraoperative tissue biopsies and wound cultures from the shoulder and pectoralis major muscle revealed gram-positive cocci. The patient underwent wide débridement of the upper chest wall, the right shoulder area, and the upper arm, with resection and takedown of the rotator cuff repair. The patient was kept intubated postoperatively due to a diagnosis of postoperative respiratory failure. She was initially taken to the intensive care unit and then transferred to a regional medical center for hyperbaric oxygen therapy.
Following transfer, antibiotic coverage was changed to vancomycin, clindamycin, and ciprofloxacin on the recommendation of an infectious disease specialist. Due to a high suspicion that a group-A streptococcus was the pathogen, intravenous immune globulin therapy was also initiated. The patient underwent the first of seven hyperbaric oxygen therapy treatments on postoperative day 14. On postoperative day 3, the final pathologic diagnosis of necrotizing fasciitis was made when histological analysis of a biopsy specimen of tissue obtained from the right shoulder showed necrotic fat and fascia with hemorrhage. Additionally, the initial wound and blood cultures demonstrated growth of methicillin-sensitive Staphylococcus aureus. Streptococcus was never identified as an infecting organism. Antibiotic coverage was changed to clindamycin alone. On postoperative day 9 after the initial débridement, the patient underwent pectoralis muscle-flap coverage of the exposed humeral head and distal part of the acromion5 (Figs. 1-A and 1-B). The pectoralis major muscle was detached from the humerus and elevated from lateral to medial, with care taken to leave the pectoralis minor muscle intact. The muscle flap was rotated to cover the exposed bone and sutured into place. The patient tolerated this procedure well and subsequently underwent split-thickness skin grafting of the right shoulder with use of donor skin from the right thigh. She was discharged to a skilled nursing facility twenty-six days after admission and underwent upper-extremity physiotherapy. At the time of the latest follow-up visit at one year, she was found to have good shoulder shrug to resistance with grade-4 (of 5) strength. Passive shoulder flexion (forward elevation of the upper extremity) was possible to 120°. Active shoulder flexion to 50° with grade-3 (of 5) strength was noted; this movement was noted to elicit elbow flexion. She was able to actively abduct the right upper extremity to approximately 30° and had grade-3 (of 5) strength with approximately 30° of both internal and external rotation. The muscle flap and skin graft were well incorporated, and the donor site was epithelialized. The patient was not able to return to work due to chronic pain associated with the course of rehabilitation. The patient was able to perform activities of daily living, many of which she accomplished with the contralateral extremity.