Presentations

Abstract

Introduction:

Periprosthetic joint infection (PJI) is an established complication following total hip arthroplasty, with an incidence of one percent. Debridement, antibiotics and implant retention (DAIR) is an initial treatment option for acute hematogenous PJI, though it has reported failure rates up to 84%. Here we present a case demonstrating early success using this treatment approach in a 74 year old medically infirm patient.

Case Information:

The patient in question-a 74 year old male with well-functioning bilateral total hip arthroplasties performed 14 years prior-presented to a rural emergency department with acute onset of right groin pain and hypotension. The patient was found to have sepsis and periarticular abscesses on assessment. Synovial fluid from the right hip grew methicillin-sensitive Staphylococcus aureus after consecutive cultures. The patient underwent debridement of the right hip joint at the initial hospital followed by transfer to our tertiary hospital. Upon arrival, consideration was given to performing a two-stage exchange arthroplasty. However, given his medical complexity (ASA 4), 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. As such, the patient underwent surgery utilizing an established DAIR protocol with 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 developed a foot drop following the surgery. The patient was treated with parenteral antibiotics and remained on chronic oral antimicrobial suppression until ten months after the final surgery. During the treatment course, the patient's inflammatory markers have normalized and his function has improved. He is ambulatory without assistive devices but uses an ankle orthosis as needed. He has regained satisfactory mobility and has an Oxford hip score of 27.

Discussion/Clinical Findings:

High failure rates of DAIR may encourage the utilization of other surgical treatment options for acute PJI including one or two-stage exchange arthroplasty. Two-stage exchange arthroplasty has been found to control infection at 89% for first revisions but poses risks of massive blood loss and increased mortality in comparison to DAIR. Such risks were deemed insufferable in this patient's case, thus the less invasive treatment option of DAIR was preferred. At one year postoperatively, the patient remains infection free.

Conclusion:

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