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20 December 2001
Infected Compartment Syndrome After Acupuncture
Competing interests NONE declared by the authors.
Nasir Hussain Shah AFRCS, FRCSI Senior House Officer in Trauma & Orthopaedic Surgery Norfolk & Norwich University Hospital, Brunswick Road, Norwich NR1 3SR Tel: + 44 1603 286286 Email: firstname.lastname@example.org
Caroline Hing MSc, FRCS Research Registrar Institute Of Orthopaedics Norfolk & Norwich University Hospital, Brunswick Road, Norwich NR1 3SR
J Keith Tucker FRCS Consultant Orthopaedic Surgeon Institute Of Orthopaedics Norfolk & Norwich University Hospital, Brunswick Road, Norwich NR1 3SR
Robert J Crawford FRCS Consultant Orthopaedic Surgeon Institute Of Orthopaedics Norfolk & Norwich University Hospital, Brunswick Road, Norwich NR1 3SR
Infected Compartment Syndrome After Acupuncture
Editor – White et al reported that no serious complication was found in their survey 1. We wish to report here a case of infected compartment syndrome, which was almost certainly caused by an acupuncture needle.
A 37-year-old diabetic male presented to his General Practitioner with pain in his lower calf after doing some DIY (Do It Yourself). A diagnosis of Achilles Tendonitis was made and he was treated with acupuncture to the calf and Diclofenac sodium tablets. Later that evening his calf pain became worse and he was referred to Accident & Emergency department where a provisional diagnosis of deep venous thrombosis was made. Low molecular weight heparin was given and arrangement made for the ultrasound scan of the calf the next morning. When seen the next day, he was tachycardic, hypotensive, hypothermic, hypoxic and clammy, with a tender and grossly swollen right calf measuring 20 cm more in circumference than the left. A clinical diagnosis of unidentified sepsis and deep venous thrombosis was made. He was started on anticoagulant and antibiotic therapy.
An ultrasound scan of the calf did not confirm the presence of a deep venous thrombosis. The diagnosis was then revised to infected compartment syndrome and he was taken immediately to operating theatre where fasciotomy was carried out. A swab of fluid from within the muscle compartment was sent for urgent microscopy and revealed gram-positive cocci. Post operatively he required inotropic support to maintain his blood pressure therefore he was admitted to the Intensive Therapy Unit where he remained for 9 days. Streptococcus Group A was subsequently grown from his blood culture. Closure of the wound was carried out on the 17th day. He was discharged from the hospital 19 days after his presentation.
He subsequently developed a contracture of the flexor hallucis longus muscle for which he had a lengthening operation. It was noted at this stage that he had swelling on the Achilles tendon, which was felt to represent an area of degenerative Achilles tendonitis. We presume that his original problem was degenerative tendonitis aggravated by unaccustomed exertion.
Compartment syndrome and fatal cases of septicaemia have been described in the literature after acupuncture2, 3, but not together in same patient. We suspect that this severe complication of acupuncture occurred as a result of inoculation of the organism from the skin into the calf musculature. Ernst and White have described other adverse events associated with acupuncture 4. We would re-emphasise that the procedure is not without risk.
1. White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001; 323:485-486
2. Smith DL, Walczyk MH. Campbell S. Acupuncture-needle-induced compartment syndrome. Western Journal of Medicine 1986; 144 (4): 478-479,
3. Onizuka T, Oishi K, Ikeda T, Watanabe K et al. A fatal case of streptococcal toxic shock-like syndrome probably caused by acupuncture. Kansenshogaku Zassi 1998; 72:776-780
4. Ernst E, White A. Life – threatening adverse reactions after acupuncture? A systemic review. Pain. 1997; 71:12-126
Competing interests: None declared
Norfolk and Norwich University Hospital
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24 September 2001
EDITOR - White et al.(1) and MacPherson et al.(2) reported prospective surveys conducted with statistically sufficient sample size. We also conducted the same kind of survey at a Japanese national college clinic(3). Interestingly, the incidences of "significant" (but actually minor) adverse events were similar: 14 per 10000 treatment sessions in medical acupuncture(1), 13 in traditional acupuncture(2), and 14 in Japanese acupuncture(3). Although some under-reported cases may have existed, these studies demonstrate that acupuncture is relatively safe in "standard practice" regardless of schools or modes of practice.
On the other hand, in "non-standard practice", many serious adverse events have been reported in medical literature(4). Therefore, education and rigorous qualification of acupuncture practitioners are important. Apart from ignorance, therapists' negligence and patients' reaction should be discussed separately, as we already proposed(3). After conducting a prospective survey on the incidence of acupuncture adverse reactions that seem essentially unavoidable in standard practice(5), we have been tackling the problem of how to reduce negligent cases, which should be prevented.
At our clinic where approximately 30 acupuncturists practise, all incidents which occur during and after acupuncture treatment must be reported to the acupuncture office. We define "incident" not only as adverse event which actually occurred, but also event which nearly occurred. Regarding forgotten needles, 27 related incidents were reported during April and September 2000. In monthly meetings since April 2000, we started informing all the acupuncturists of how the incidents occurred, based on analyses of collected incident reports. For example, we discussed and made demonstrations of the following factors: forgotten needles tend to be recognised mainly in the lower extremities or the head where the needles are hidden by a towel or the hair; many of the acupuncturists who were involved in forgotten needles were acting on behalf of the acupuncturist who had inserted the needles; the incidence was remarkably higher during treatments while the acupuncturists were conducting clinical instruction for their students. Although there has been a recent decrease in the total number of treatment sessions per month, the occurrence of incidents regarding forgotten needles seems to have decreased somewhat since we started the feedback system. (Table)
After demonstrating that acupuncture is inherently safe, we should proceed to focusing on how to reduce the risk of negligence in acupuncture treatments. As shown above, even a simple system of incident reporting and constant feedback in a group setting might be used to achieve this aim.
No competing interests.
1 White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32000 consultations with doctors and physiotherapists. BMJ 2001;323:485-6.
2 MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety study: prospective survey of 34000 treatments by traditional acupuncturists. BMJ 2001;323:486-7.
3 Yamashita H, Tsukayama H, Tanno Y, Nishijo K. Adverse events in acupuncture and moxibustion treatemnt: a six-year survey at a national clinic in Japan. J Altern Complement Med 2001;5:229-36.
4 Rampes H, Peuker E. Adverse effects of acupuncture. In: Ernst E and White A, ed. Acupuncture a scientific appraisal. Oxford: Butterworth- Heinemann, 1999:128-52.
5 Yamashita H, Tsukayama H, Hori N, Kimura T, Tanno Y. Incidence of adverse reactions associated with acupuncture. J Altern Complement Med 2000;6:345-50.
Table Incident of forgotten needles which occurred at Tsukuba College of Technology Clinic Month/year No. of Total no. of Incidence (%) incidents treatment sessions April/2000 3 857 0.35 May 5 871 0.57 June 6 921 0.65 July 1 934 0.11 August 2 926 0.22 September 10 903 1.11 October 3 952 0.32 November 3 880 0.34 December 1 899 0.11 January/2001 1 766 0.13 February 3 784 0.38 March 0 744 0.00 April 1 704 0.14 May 1 786 0.13 June 4 788 0.51 July 3 786 0.38 August 2 789 0.25
Competing interests: TableIncident of forgotten needles which occurred at Tsukuba College of Technology ClinicMonth/year No. of Total no. of Incidence (%)incidents treatment sessionsApril/2000 3 857 0.35May 5 871 0.57June 6 921 0.65July 1 934 0.11August 2 926 0.22September 10 903 1.11October 3 952 0.32November 3 880 0.34December 1 899 0.11January/2001 1 766 0.13February 3 784 0.38March 0 744 0.00April 1 704 0.14May 1 786 0.13June 4 788 0.51July 3 786 0.38August 2 789 0.25
Tsukuba College of Technology Clinic
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