Clinical History, Examination and Blood Test Results

  • Discussion case 5 is a 68-year old female whose presenting complaint was pain in her right hip.

  • This presentation was on a background of a primary hip replacement one-year earlier due to a fractured neck of femur.

  • She underwent a hip aspiration initially to rule out infection – This was negative.

  • She required a revision procedure to her right total hip replacement.


Imaging Results

PRE-OP RADIOGRAPH

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The pre-operative radiograph demonstrates an uncemented total hip replacement with cerclage wiring. There is an unhealed previous lesser trochanteric fracture. A zone of lucency can be seen surrounding the femoral stem which reaches a maximum of 5mm at the medial distal aspect. This lucent zone is in keeping with loosening of the implant.

 

Diagnosis

  • Loosening of a right total hip arthroplasty requiring revision surgery.


Treatment

  • One stage revision of loose total hip replacement

  • This patient required an extensive pre-operative work up with cardiology, haematology and anaesthetics due to a complex past medical history

    • Posterior approach with extensive dissection to reach the joint

    • Fracture had healed so the plate was removed

    • Stem was loose but the cup was fixed

    • Reclaim stem

      • 15mm + 24mm body + 1mm ceramic 32mm head

    • Intra-operative check demonstrated a stable leg with equal lengths

    • Local anaesthetic infiltrated

    • Wash ++

    • Vicryl, monocryl and glue to close


Imaging Outcomes

POST-OP RADIOGRAPHS

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Revision right total hip replacement in situ. Cerclage wiring has been removed. There is no evidence of any periprosthetic fracture or metalwork fracture/slippage.

 

Clinical history continued

  • Samples taken at the time of her first revision grew Staphylococcus epidermidis and Staphylococcus warneri.

  • She received post-operative Vancomycin.

  • Her CRP remained raised at 89mg/L.


Diagnosis Two

  • Infection of a right total hip arthroplasty requiring a two stage revision


Treatment two Stage 1

  • Stage 1 was as follows;

    • Procedure 2-weeks after initial revision

    • Posterior approach through old incision

    • Samples were taken for microbiology

    • Both components were firmly fixed and explanted

    • Synovectomy completed

    • Brush for the femur

    • Savlon and wash ++

    • Cemented cup and stem spacer

      • Cement containing vancomycin and gentamycin

      • Long c-stem used

    • This was stable

    • Vicryl and monocryl used to close

  • Post-operatively the patient was started on clexane with the aim to review immediately.


Imaging Outcomes Stage 1

POST-OP RADIOGRAPHS

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This post-operative series of radiographs demonstrates the spacer components in situ. There is a lucent line running from the proximal medial femoral endocortical surface to the cortical surface, suggesting a periprothetic fracture compared to the previous radiograph.

 

Clinical history continued

  • Samples taken at the time of the first stage of the procedure grew Staphylococcus epidermidis resistant to Rifampicin.

  • She was started on a 6-week course of Daptomycin.

  • Her CRP fell to 20mg/L.

  • In clinic, there was no erythema or sinuses around the wound, with it reported as being clean.


Treatment two stage 2

  • She underwent revision of the spacer with a reclaim stem and a titanium cup.

  • Vancomycin and Gentamycin infused cement was used.

  • Post-operatively she required Vancyomycin, Tazocin and Amikacin.


Imaging outcomes stage 2

POST-OP RADIOGRAPHS

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3-MONTHS POST-OP RADIOGRAPHS

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The post-operative radiographs from stage 2 are shown above. This shows the new revision total hip arthroplasty. There is a breech in the ilio-ischial and ilio-pectineal lines suggesting a fracture of the anterior and posterior columns of the acetabulum on the right side. Note also how the distal femoral stem is in contact with the anterior femoral endocortex.

These post-operative radiographs taken at three months are stable in position compared to the previous radiographs. This radiograph is unchanged.

 

15-MONTHS POST-OP RADIOGRAPHS

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These post-operative radiographs were taken at 15-months post-op. The implant remains in a good position. There is ossification of the acetabular fracture noted in the post-operative radiograph.

 

Clinical Outcomes

  • Samples taken from the hip capsule during the second stage of the revision procedure didn’t grow anything. Her CRP reduced to 7mg/L one month after stage 2.

  • This patient returned to clinic 15-months after her procedure (due to other ongoing complex medical issues).

  • At this time examination of her hip was satisfactory. She felt her right leg was longer than the left, so EOS imaging was arranged to quantify this to produce a shoe raise.


Learning Points

  • Short stems remain controversial as primary hip replacement, especially for treating hip fractures.

  • Conservative treatment for periprosthetic hip fracture does not work.

  • Hip aspiration can produce false negative cultures.

  • Microbiological cultures that show multiple organisms needs microbiological advice.

  • Microbiological advice to do a 2 stage revision after a 1 stage revision because of the microbiological culture results is hard for the patient and surgeon but is sometimes the only way forward for a good long term result.