Short-term Success in Treatment of an Acute Hematogenous Periprosthetic Hip Joint Infection with Debridement, Antibiotics, and Implant Retention

Abstract

Introduction: Periprosthetic joint infection (PJI) is an unfortunate but frequent complication following total hip arthroplasty, with an incidence of 1%. Debridement, antibiotics, and implant retention is a treatment option for acute hematogenous PJI, with success rates reported up to 70%. Here, we present a case demonstrating short-term success using this treatment approach in a 74-year-old medically infirm patient.

Case report: The patient - a 74-year-old male with well-functioning bilateral total hip arthroplasties performed 14 years prior - presented to a rural emergency department with an acute onset of right groin pain and dizziness. The patient was found to have sepsis, a right hip joint effusion, and periarticular abscesses on assessment. Synovial fluid aspiration from the right hip grew methicillin-sensitive Staphylococcus aureus. The patient was transferred to an outside hospital for limited debridement of the right hip joint, followed by transfer to our tertiary hospital. On arrival, consideration was given to performing an exchange arthroplasty. However, given the patient's medical frailty, it was felt that the risks were prohibitive, as supported by the presence of ileus, severe electrolyte imbalance, anemia requiring transfusion, anasarca, and vancomycin-resistant Enterococcus faecium infection of a sacral wound. The patient underwent surgery utilizing an established protocol of aggressive debridement and cleaning of the hip space, exchange of the modular arthroplasty components, and placement of antibiotic calcium sulfate beads for local delivery. The patient was treated with parenteral antibiotics followed by chronic oral antimicrobial suppression for 10 months after the final surgery. During treatment, the patient's inflammatory markers have normalized. The patient is ambulatory without assistive devices but uses an ankle orthosis due to a post-operative foot drop that did not resolve. The patient has regained satisfactory mobility with an Oxford hip score of 27.

Conclusion: This case demonstrates short-term success in the treatment of acute hematogenous PJI in a medically infirm patient utilizing debridement, antibiotics, and implant retention and may serve to inform future patient counseling.

Keywords: Joint infection; and implant retention; antibiotics; debridement; revision arthroplasty; total hip arthroplasty.

Figure 1

An axial computed tomography slice from the date of admission, highlighting abscess formation within the right thigh adductor musculature.

Figure 2

Radiographs and clinical images: AP pelvis radiographs taken on the date of hospital admission before surgery.

Figure 3

Radiographs and clinical images: AP pelvis radiograph following debridement, antibiotics, and implant retention (note the calcium sulfate beads present within the joint space).

Figure 4

Radiographs and clinical images: AP pelvis radiograph 6 weeks post-debridement, antibiotics, and implant retention.