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Case Report
Sonographic Detection of a Stitch Abscess
Tsz-Ching Hsu, MD,1 Chung-Li Wang, MD, PhD,2 Tyng-Guey Wang, MD,1 Fon-Jou Shieh, MD3
1
Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7,
Chung-Shan South Road, Taipei, Taiwan
2
Department of Orthopedic Surgery, College of Medicine, National Taiwan University, 7, Chung-Shan South
Road, Taipei, Taiwan
3
Department of Diagnostic Ultrasound, College of Medicine, National Taiwan University Hospital, 7,
Chung-Shan South Road, Taipei, Taiwan
Received 18 March 1997; accepted 30 September 1997
ABSTRACT: A 28-year-old man with a ruptured right
Achilles tendon underwent primary end-to-end suture
immediately after injury. Painful swelling developed 6
months later, and a lump with discharge from a sinus
was observed during physical assessment. Sonographic examination with a 10-MHz linear-array transducer demonstrated a hypoechoic mass, 8 × 6 mm,
within which were 2 markedly echogenic dots. A stitch
abscess was strongly suspected and was confirmed
surgically. © 1998 John Wiley & Sons, Inc. J Clin Ultrasound 26:225–227, 1998.
Keywords: stitch abscess; ultrasonography; Achilles
tendon
T
he incidence of infection after suturing of a
ruptured Achilles tendon is 12%.1 Detection
of the infection, especially an abscess, is critical
because it indicates the need for surgical management.2 Physical examination, however, is not always sufficient for diagnosis. High-resolution
real-time sonography has become an increasingly
popular imaging modality in the evaluation of
various soft-tissue masses because it can localize
and determine the content of the mass accurately
and noninvasively.3–8 We report a case of sonographic detection and localization of an infected
retained suture in the Achilles tendon that could
not be diagnosed on conventional radiographs.
don. Six months earlier, he had experienced a
rupture of the right Achilles tendon as a result of
direct contusion, and immediate repair with endto-end sutures was performed at a local hospital.
Recovery was uneventful until 5 months after suturing, when the symptoms above began. Physical
examination 1 month later revealed a tender
lump 4 cm proximal to the insertion of the Achilles tendon at the right calcaneus. The overlying
skin was erythematous with discharge from a sinus. Bacterial culture of material obtained from
the sinus grew Staphylococcus aureus. Thompson’s test was negative, and a radiograph of the
right ankle showed no abnormalities.
Sonographic examination with a 10-MHz linear-array transducer (Diasonic VST Master series, Santa Clara, CA) demonstrated a swollen
Achilles tendon with good continuity. An 8 × 6
mm hypoechoic mass with 2 markedly echogenic
dots was observed at the level of the tender lump.
The white dots had a prominent acoustic shadow
(Figure 1).
At debridement, a stitch of 0-size nylon surrounded by infected granulation tissue was found
at the site of the Achilles tendon repair (Figure 2).
The stitch was removed (Figure 3), and the infected tissue was debrided. The wound healed
rapidly, and the symptoms disappeared completely.
CASE REPORT
A 28-year-old man presented with painful swelling and intractable pain in the right Achilles tenCorrespondence to: C.-L. Wang
© 1998 John Wiley & Sons, Inc.
CCC 0091-2751/98/040225-03
DISCUSSION
Redaelli et al1 reported that the incidence of infection after repair of the Achilles tendon is 12%.
Using nonabsorbable sutures increases the
chance of infection because they react with the
225
HSU ET AL
FIGURE 1. Longitudinal sonogram obtained with a stand-off pad showing a hypoechoic mass (long arrow) at the posterior surface of the Achilles
tendon (black arrowheads). Two echogenic dots (short arrow) with subtle acoustic shadows can be seen within the mass.
FIGURE 2. Infected granulation tissue (black arrow) over the posterior
surface of the intact Achilles tendon.
connective tissue, causing adhesions around the
tenorrhaphy.9
Radiographs are of little use in the assessment
of most soft-tissue masses and nonradiopaque foreign bodies.3,7 CT shows abnormal soft-tissue
masses only if their radiodensity is significantly
different from that of neighboring tissues or if
they are large enough to disrupt normal tissue
planes. Several studies have confirmed that sonography is more accurate than CT in estimating
the size, shape, and anatomic relationships of
soft-tissue masses—information essential for
making a diagnosis and planning treatment.10–12
It is believed that MRI, with its superior contrast resolution, provides better tissue characterization than other imaging modalities do. MRI is
also sensitive in depicting nonradiopaque foreign
bodies such as wood splinters.13,14 However, it is
considerably more expensive and less widely
226
FIGURE 3. A stitch of 0-size nylon removed from the infected granulation tissue. The stitch node (black arrow) was seen as hyperechoic
dots with acoustic shadows on the sonograms.
available than sonography is, and bodies with a
metallic content give rise to significant artifacts
on MRI.15
Sonography, like MRI, does not expose the patient to ionizing radiation, but unlike MRI, sonography is safe to use in patients who have ferromagnetic implants. 1 3 , 1 6 Sonography can
determine the liquid and solid content of a softtissue mass, and the extent of a mass, its size, and
its relationships with adjacent structures can be
DETECTION OF STITCH ABSCESS
ascertained.8 Therefore, sonographically guided
diagnostic aspiration is a safe and accurate
method for differentiating an abscess from other
types of collections.
Foreign bodies associated with inflammatory
masses often appear sonographically as hyperreflective foci with an acoustic shadow and a surrounding hypoechoic halo.17 The 2 echogenic dots
with acoustic shadows in this case strongly suggested foreign bodies. Stitch abscess, though less
common today than in the past, was suspected
preoperatively based on the sonographic findings
and was proved during surgery.
REFERENCES
1. Redaelli C, Niederhauser U, Carrel T, et al: Rupture of the Achilles tendon: fibrin gluing or suture
[in German]. Chirurg 1992;63:572.
2. Goodenough RD, Molnar JA, Burke JF: Surgical
infection. In Hardy JD, ed: Hardy Textbook of Surgery, 2nd edn. Philadelphia, Lippincott, 1988, p.
123.
3. Fornage BD, Schernberg FL: Sonographic preoperative localization of a foreign body in the hand. J
Ultrasound Med 1987;6:217.
4. Lange TA, Austin CW, Seibert JJ, et al: Ultrasound imaging as a screening study for malignant
soft-tissue tumors. J Bone Joint Surg Am 1987;69:
100.
5. Yamagauchi M, Takeuchi S, Matsuo S: Ultrasonic
evaluation of pediatric superficial masses. J Clin
Ultrasound 1987;15:107.
6. Yeh HC: Ultrasonography of orthopedics and soft
tissues of extremities. In Sanders RC, Hill MC, eds:
Ultrasound Annual. New York, Raven Press, 1985,
p. 87.
7. Fornage BD, Schernberg FL: Sonographic diagnosis of foreign bodies of the distal extremities. AJR
Am J Roentgenol 1986;147:567.
8. Fornage BD, Rifkin MD: Ultrasound examination
of the hand and foot. Radiol Clin North Am 1988;
26:109.
9. Minta P: Experimental studies on the usefulness of
Dexon (polyglycolic acid) and our known modified
method for suturing after tendon severing [in German]. Zeitschrift fur Experimentelle Chirurgie
1980;13:59.
10. De Flaviis L, Nessi R, DelBo P, et al: High resolution ultrasonography of wrist ganglia. J Clin Ultrasound 1987;15:17.
11. Harcke HT, Grissom LE, Finkelstein MS: Evaluation of the musculoskeletal system with sonography. Am J Roentgenol 1988;150:1253.
12. Kaplan PA, Motamoros A, Anderson JC: Sonography of the musculoskeletal system. Am J Roentgenol 1990;155:237.
13. Stein RA, Clarke S: Foreign bodies in the foot. J
Am Podiatr Med Assoc 1993;66:284.
14. Mizel MS, Steinmetz ND, Trepman E: Detection of
wooden foreign bodies in muscle tissue: experimental comparison of computed tomography, magnetic
resonance imaging, and ultrasonography. Foot
Ankle Int 1994;15:437.
15. Oikarinen KS, Nieminen TM, Makarainen H, et al:
Visibility of foreign bodies in soft tissue in plain
radiographs, computed tomography, magnetic
resonance imaging, and ultrasound. An in vitro
study. Int J Oral Maxillofac Surg 1993;22:119.
16. Johnstone AJ, Beggs I: Ultrasound imaging of softtissue masses in the extremities. J Bone Joint Surg
Br 1994;76-B:688.
17. Gooding AW: Foreign bodies. In Fornage BD, ed:
Musculoskeletal Ultrasound. New York, Churchill
Livingstone, 1995, p. 99.
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