A 77-year-old man presented to the outpatient department with hip pain after falling. Two years earlier, he underwent an uncomplicated primary hip replacement (MY cup and stem, Protetim Ltd., Hungary). Initial radiographs were negative, and the patient was discharged, with the advice of rest and a further follow-up. 6 months later, he presented again, with constant pain in his right hip and had a four day history of high temperature and a swollen lump in the inguinal area, apparently an abscess. The aspiration of the abscess grew Salmonella Enteridis. Laboratory findings included a positive salmonella O antibody titer (1:400), a very high erythrocyte sedimentation rate (120 mms/h), hypalbuminaemia and anaemia. Radiographs showed osteomyelitis and periosteal reaction around both components, in the acetabulum and in the femur.
Because of the patient's advanced age and poor medical condition, before proceeding with treatment of the infection, the patient needed a temporary pacemaker. Although a two-stage revision would have been the ideal procedure for the patient, considering his cardiovascular status, upon consulting with the anaesthetic team, a one-stage procedure was chosen to decrease perioperative stress, and to provide an immediately weight bearing limb, with earlier mobility. From an anterolateral approach, the abscess was drained, the walls of the abscess were excised, and a cemented cup and cemented revision stem (MY cup and stem, Protetim Ltd., Hungary) were implanted in one sitting. The patient was started on intravenous antibiotics according to the susceptibility pattern of the microorganism. The Kirby Bauer disc diffusion test was used for susceptibility testing (non-automated). In the initial 72 hrs 3 × 400 mgs of ciprofloxacin was given, which was switched to oral ciprofloxacin for a further six weeks, in the dose of 2 × 500 mgs. Although the organism was not sensitive to gentamicin we used our routine gentamicin containing bone cement to fix both components, as this was the only antibiotic loaden bone cement available to us at that time. By the second postoperative day the patient had a normal temperature and a subsequent haemoculture, urine samples and a wound swab were all negative. The patient was discharged on the 13th day. The Salmonella antibody titer was down to 1:100. The patient was symptom and complication free for a further 6 and half years, and died of unrelated causes at the age of 84.
A 61-year-old male patient had bilateral uncemented hip replacements (MY uncemented cup and stem, Protetim Ltd., Hungary) because of avascular necrosis of the both femoral heads. A year later the right hip was revised because of a fracture of the ceramic head. For the next six years the patient was asymptomatic. Seven years after initial surgery, he presented with dislocation of the right hip prosthesis which occurred after a fall. The hip was reduced and the patient was discharged three days later. One day after discharge he was admitted to a medical ward with tachypnea, atrial fibrillation and fluid in the lungs. Laboratory findings included normal anion gap, elevated chlorine level, metabolic acidosis, deteriorated kidney and liver functions, jaundice and severe thrombocytopenia. Despite receiving oxygen, his oxygen saturation did not rise above 95% indicating potential parenchymal lung damage. Massive pulmonary embolism was clinically excluded. The working diagnosis was of ARDS caused by sepsis. The patient was transferred to the intensive care unit and was intubated because of progressive respiratory insufficiency. In the medical ward an empirical combination of intravenous antibiotics was initiated, which included cefotaxime 3 × 2 grs, supplemented by metronidazole 3 × 500 mgs daily as the initial working diagnosis was gastrointestinal infection with jaundice. Because of the imminent multiple organ failure the antibiotic treatment was changed in the intensive care unit to 3 × 4.5 grs of piperacillin.
After some improvement in his general condition a more thorough search for the cause of infection was carried out including an autolog leukocyte scintigraphy. The results showed increased uptake in both lungs, in the spleen, and in the soft tissues around the right hip. His general condition did not allow any surgical intervention at that stage. During the next ten days several haemoculture samples were taken and they were all negative. The only positive finding was a pharynx swab showing Candida albicans, which was felt to have no clinical significance. Then an ultrasound guided aspiration of the right hip was performed, gaining sufficient samples for microbiology. Samples showed a mixed flora of Salmonella cholerae-suis, and Acinetobacter haemolyticus.
As per the susceptibility of the organism intensive, intravenous, combined antibiotic treatment of 3 × 600 mgs of clindamycin and 3 × 400 mgs of ciprofloxacin was initiated for the first 72 hrs, and oral ciprofloxacin was given for a further 6 weeks, in the dose of 2 × 500 mgs. The patient's condition improved enough to perform a revision of the right total hip replacement. Both components were found to be stable, however they were removed along with a thorough debridement of the abscess. For the removal of the stable stem, it was necessary to open a cortical window on the femur. This was fixed with three cerclage wires. A spacer containing Gentamicin was inserted into the femur and the acetabulum. The intra-operative cultures, a haemoculture sample and the surgical drain were all returned negative for microorganisms.
C reactive protein and ESR values returned to the physiological threshold after three months. However, there was a further month of delay before the second stage reimplantation could be performed because of extensive sacral and calcaneal pressure sores suffered in the initial three weeks of intensive care.
An uncemented revision hip replacement was performed using a Duraloc cup and AML stem (DePuy, Warsaw, In.). Just four months after the reimplantation, the patient went back to his original occupation and at latest follow-up, five years post-operatively he is asymptomatic and there has been no sign of recurrent infection.