CASE 18: Revision surgery for an infected and well-fixed hip, using a modular taper fluted stem
The Story
“The patient was a 79-year old gentlemen who presented to his GP with an actively discharging right hip wound with no systemic symptoms.
This was on the background of a chronic right hip infection following a total hip arthroplasty. This infection had been ongoing for over 9 years and was being suppressed with QDS Flucloxacillin and BD Fucidin.
He was referred to our service, by which time the wound had been discharging for 6-weeks, however, it had started to improve. On examination in clinic, a sinus was seen over the right hip. There was no tenderness over the hip with an adequate range of movement compared to the left side.
This patient was discussed in our infection MDT and the decision was made to perform an off antibiotics aspiration of the right hip. At this stage his CRP was 3mg/L and his ESR 9mm/H.
He remained clinically stable while off antibiotics, so the decision was made not to restart them.
The hip aspiration grew Staphylococcus aureus and there was frank pus within the joint. When he returned to clinic to discuss the results, his CRP had risen to 69mg/L.
A further discussion in the infection MDT concluded that this patient would be suitable for a single stage revision of the right hip with antibiotic cement (Vancomycin and Gentamycin) in conjunction with systemic Teicoplanin, Amikacin and Ceftriaxone.”
The Investigation
Pre-operative radiographs explored the current situation.
The Evidence
The pre-operative radiographs were relatively unremarkable, demonstrating some degenerative change in the left joint.
The Diagnosis
This patient was diagnosed with a chronically infected right total hip replacement, requiring a single stage revision to treat the infection.
The Operation
Single stage revision for an infected right total hip replacement;
Posterior approach through the old wound with the sinus excised
4 stay sutures
5 samples sent for culture
Components were well fixed
Femoral stem explanted with flexible osteotomes and midus rex
Acetabular cup was easily explanted
60mm titanium cup implanted with 3 screws for fixation
Dual mobility liner used
Reclaim stem 15mm + 65mm
28mm ceramic head
Good reduction with a stable joint
Wash ++ with savlon and saline
Closed with vicryl, monocryl and glue
Post-op the patient was started on broad spectrum antibiotics with the aim of completing a 12-week course – Teicoplanin, Amikacin and Ceftriaxone.
The Outcome
This series of post-operative radiographs demonstrate the revision right total hip arthroplasty in situ. Some degenerative changes can be seen in the contralateral hip.
Samples taken at the time of surgery grew Staphylococcus aureus which was sensitive to Flucloxacillin, Ciprofloxacin and Rifampicin. The patient was switched to Ciprofloxacin 500mg BD and Rifampicin 450mg BD to complete a 12-week course.
At 3-weeks post-op the wound had healed well and the patient was able to walk partially weight bearing with crutches. On examination he was able to straight leg raise and had a good range of motion. His CRP had fallen to 39mg/L.
At 6-weeks post-op his CRP had fallen further to 13mg/L.
At 9-months post-op the wound had healed well and the patient was able to mobilise independently.
These two post-operative radiographs were taken at 9-months post-op. They show no change compared to the original post-operative radiographs.
The Verdict
“Infection free status of a total hip arthroplasty is defined as a well-healed wound with no evidence of component loosening on a radiograph and a clinically well-functioning hip 12-months after the operation. There are no tests that can confirm this unless clinical symptoms are present.”
