Case summary
Male, 49 years old, had a total hip arthroplasty in a hospital in Hebei 2 years ago due to a fracture of the right femoral neck, after the operation, the wound did not heal, local sinus tracts formed, pus continued to flow, and the temperature increased from time to time.
15 days ago, he suddenly developed chills, high fever, and pain and discomfort in the right hip, after his temperature returned to normal with oral antipyretics. When standing, he suddenly developed pain in the right lateral thigh, sinus tract formation and continuous flow of coffee-like fluid.
X-ray examination of the right hip and right femur suggested septic osteomyelitis (whole femur), loose prosthesis and periprosthetic fracture, and was admitted to our department for treatment.
Past history
Past history: He has been suffering from alcoholic cirrhosis for many years, and his current liver function status is Child-pugh modified liver function classification, grade B.
He has been suffering from “peptic ulcer” for many years and has been regularly treated with omeprazole with average effect.
Six months ago, he underwent a repair of gastric perforation at the People’s Hospital of Jingfu County, Hebei Province, and recovered well after the operation.
Physical examination
Vital signs are stable and body temperature is normal.
The right lower limb was shortened by 75px, externally rotated by 45°, swelling of the right thigh and knee joint was obvious, a small amount of skin pigmentation on the right thigh, a sinus tract of about 50px in length could be seen on the right hip lateral side, and coffee-like fluid was continuously flowing, about 200ml/day.
right knee joint in flexion position with pain in the right knee joint during passive movement.
Increased body surface temperature of the right lower extremity, impaired active movement of the right hip, and severe pain on passive movement.
The active and passive activities of the affected foot and toes were normal, the dorsal right foot artery pulsation was present, and the peripheral blood flow, sensation and activities of the right lower limb were still good.
Auxiliary examination
X-ray of the right hip and knee (2014-9-30) : After right hip arthroplasty, the prosthesis was loose, the screw was broken, contact bone destruction at the end of the prosthetic stem, gas shadowing within the soft tissue of the distal femur was seen, and focal dead bone formation, consistent with the imaging of chronic septic osteomyelitis of the whole femur.
Drainage drug sensitivity report form (2014-9-21, a county people’s hospital in Hebei province): suggestive of Citrobacter yangensis, Enterobacter aerogenes (active Klebsiella). Resistant to most cephalosporin antibiotics (but sensitive to ceftazidime), sensitive to β-lactam antibiotics such as Penan class, and sensitive to quinolones.
First preoperative film
Treatment options
The first major challenge: should systemic antibiotics be applied to patients who are admitted without signs of systemic infection (normal blood picture but high CRP and sedimentation)? Can we apply local antibiotics alone?
Second challenge: considering the patient’s hepatic insufficiency (Tbil:30.4umol/L, Alb:24.2g/L, ALP:216.1U/L, GGT:145.8U/L, abnormal coagulation), what antibiotics to choose?
The third major challenge: how to unify the treatment of revision surgery and control of chronic osteomyelitis of the whole femur?
Antibiotic selection
Selection of ceftazidime for injection, 0.5g/dose, 2g/dose, ivgtt, q12h, according to the drug sensitivity results.
Medication for 1 month.
Later changed to cefprozil tablets, 0.25g/tablet, 0.5g/dose, bid;
Significant decrease in CRP, close to normal levels.
Several pus negative, but one month later first intraoperative deep tissue culture of ESBL-producing Escherichia coli.
Is it reasonable?
Surgical management
Basic principle: debridement and drainage.
For post-arthroplasty wound infection with pus, early drainage and effective antibiotics should be administered.
Deep infections generally require removal of the prosthesis, excision of the lesion, irrigation of the wound, and retention of a drainage tube with continuous negative pressure drainage using sterile saline or antibiotic saline.
If the prosthesis does not loosen after debridement and bone resorption is not obvious on X-ray, the prosthesis can be retained and the systemic application of effective antibiotics and continuous negative pressure drainage with irrigation can be continued.
Revision of artificial hip joint
Chronic osteomyelitis after hip arthroplasty with debridement, prosthesis removal, dead bone removal, irrigation and negative pressure drainage?
After debridement, placement of bone cement mixed with antibiotics in an extended stem appliance?
Continuous irrigation and negative pressure drainage after debridement combined with temporary fixation with an external fixation brace?
How is the bone defect caused by extensive debridement filled, with bone cement, allograft, artificial bone, or autologous bone?
Is a total femoral prosthesis suitable?
What is the treatment of choice?
First surgical plan
2014-11-27 Artificial total hip arthroplasty + bone cement placeholder with gentamicin + negative pressure drainage was performed under general anesthesia
Postoperative continuation of ceftazidime for injection, 0.5g/stem, 2g/dose, ivgtt, q12h; 2 weeks course.
No local indication of infection in the wound.
The blood picture and CRPS were basically normal, but WBC, Neut, Plt and RBC were significantly lower than normal after 2 weeks. After taking ricegrine for 1 month, the three blood lines still did not rise to normal, but after the second revision surgery (changed to levofloxacin injection) the three lines gradually rose to normal level, why?
First postoperative radiograph
Second surgical plan
2015-1-16 Under general anesthesia, right cemented occupant removal + total hip revision (Link lubinus polyethylene socket cup + Link MP femoral prosthesis stem with gentamicin bone cement, 16mm diameter, 250mm length).
Levofloxacin injection, 0.5g/dose, 0.5g/dose, ivgtt, qd; 2 weeks course.
Blood picture was normal, CRP: 10.0 mg/L, and wound exudate was negative for common bacterial culture.
The patient was able to stand on the floor and walk with the assistance of a walker and was discharged 2 weeks after surgery.
Second postoperative radiograph
Follow up situation
Good general physical condition with no fever.
Good local healing of the wound without redness, swelling, pressure pain and subcutaneous fluctuation.
Hip and knee function at 3 months postoperatively
Hip Harris score: 86
HSS score of knee joint: 82
Summary of experience
1. the key is to select effective antibiotics according to the drug sensitivity results.
2. Emphasis on local anti-infection treatment and surgical management.
3. deep infections present after hip replacement should be treated promptly with debridement (especially in patients with systemic systemic diseases and low resistance); conservative treatment often leads to prolonged infection and even causes chronic osteomyelitis.
4. Bone cement containing antibiotics can effectively treat chronic osteomyelitis and shorten the duration of systemic antibiotics after surgery.