Case note review

Careful consideration of clinical details is essential for determining the overall benefit of a lesser procedure in a septic elderly patient.

Case details: An 83-year-old female presented to a peripheral hospital after falling from a toilet seat at home. She had multiple comorbidities including cardiovascular disease, diabetes and obesity. She had previously undergone a left total hip replacement, which used a long stem femoral component, cerclage wires and a greater trochanteric plate. X-rays performed on admission showed a dislocated hip replacement and loosening and dislodgement of a cup cage construct. Five days after presentation she was diagnosed as having Staphylococcus aureus bacteraemia. End-of-life care was discussed with the family at the peripheral hospital, but 16 days after her fall the patient was transferred to a tertiary hospital for ongoing care. After appropriate investigation and planning she was taken to theatre for a one-stage washout, debridement and revision of the total hip replacement. The infected components (cup cage construct, wires, greater trochanteric plate and femoral head but not stem) were removed and the acetabulum stabilised using a Trabecular MetalTM augment. After the procedure, the patient had a prolonged period of hypotension and was transferred to the intensive care unit (ICU) for inotropic support. She was in ICU for seven days with extensive efforts made to improve her condition. On day 11 post-surgery, she had a gastrointestinal bleed. By day 20, she was described as having peripheral shut down. The patient died on day 22 post-surgery. Assessment of the medical records revealed extensive anaesthetic assessment and preparation before the major operation was undertaken at the tertiary hospital. The operation was performed in the middle of the day with a consultant surgeon and anaesthetist involved. The operation was performed within three hours and proceeded without incident. Clinical lessons: A question was raised regarding the decision to perform a revision total hip replacement in an elderly patient with septicaemia. A lesser procedure of drainage and debridement pending clinical improvement before a one- or two-stage revision may have led to a different outcome. There were some important decisions to be made in the care of this patient, who previously had extensive revision surgery to her left hip. She presented with an infection and a dislocated hip with a dislodged cup cage construct. She was appropriately investigated and treated to reduce the effects of the bacteraemia. A one-stage procedure was decided on when she was not toxic. There was no occasion where a simple washout would have provided sufficient benefit to this patient. To have washed out the hip and left her with a dislocated prosthesis would have prolonged her suffering and was unlikely to have improved her chance of survival. In these circumstances, the decision to perform a one-stage washout, debridement and revision was appropriate. The surgery was performed at an appropriate time, by senior staff, in an expeditious manner to give this patient the best chance of survival.

Although there may be a role for a simple washout in sick, toxic patients with prosthetic infections, in this case, the decision to proceed with a one-stage revision was appropriate. 

Professor Guy Maddern, Surgical Director of Research and Evaluation incorporating ASERNIP-S

RECOMMENDED READING

Argenson JN, Arndt M, Babis G, et al. Hip and Knee Section, Treatment, Debridement and Retention of Implant: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty. 2019;34(2S): S399-S419. doi: 10.1016/j.arth.2018.09.025

Please note: these cases are edited from ANZASM first- or second-line assessments that have been generated by expert surgeons in the field.