1. staged revision hip arthroplasty, left 2. placement of antibiotic cement hip spacer. 3. Irrigation and debridement bone, muscle 4. fluoroscopy 5. incisional wound VAC 6. Femoral Osteotomy
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Pre-Op Diagnosis Code: Pre-op Diagnosis
* Infection associated with internal left hip prosthesis, initial encounter (CMS/HCC) [T84.52XA]
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Post-Op Diagnosis Code: Post-op Diagnosis
* Infection associated with internal left hip prosthesis, initial encounter (CMS/HCC) [T84.52XA]
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Findings:
Purulent fluid around prosthesis and soft tissues.
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Indications: The patient is a 66-year-old woman who has a history of acute myeloid leukemia secondary to MDS. She is post bone marrow transplant and has relapsed. She has pancytopenia due to relapse of disease and recent chemotherapy requiring blood product support. She developed Klebsiella sepsis with growth from her blood, urine, and most recently from an aspiration of the left hip joint. Alternatives risks and benefits were discussed with the patient and with her hematology team and the recommendation was to proceed with surgery to remove her infected hip prosthesis and replace it with an antibiotic spacer in an attempt to eradicate her infection. She understood and wished to proceed with the surgery.
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Procedure Details
The patient was brought to the operating room and placed in a supine position on the operating table. General anesthetic was induced by the anesthesiologist. The patient was already on IV antibiotic therapy. She was rolled into a lateral position and secured with a hip positioner and axillary roll. The left hindquarter was prepped with DuraPrep and draped in the usual sterile fashion for arthroplasty. I first used the patient’s previous scar which was about 15 cm centered on the greater trochanter and I dissected down through dense fibrous scar tissue. I opened the gluteus maximus fascia and revealed dark brownish slightly purulent looking fluid which was consistent with the fluid that I had aspirated from her hip last week. The fluid was in the gluteus maximus and tracked up into the buttock and also was around the posterior aspect of the prosthesis as the posterior capsular and piriformis repair had torn and there was open communication with the hip joint in the space. I evacuated the fluid and cultured it. We dislocated the hip. I removed the metal femoral head. I then debrided the soft tissues sharply with a rongeur and excised yellowish fibrinous tissue from around the prosthesis and around the hip joint. The patient also had bone on the lesser trochanter that had disintegrated and I remove these areas of fragmented bone.
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Turned our attention to extraction of the femoral stem. He uses cement removal osteotomes and try to loosen the interval between the prosthesis and the native bone. She had a bone ingrowth stem in place. With multiple attempts I was unable to extract the femoral device with a slap hammer. Therefore I opted to perform a femoral osteotomy. I had to extend the incision proximally an additional 10 cm and distally an additional 16 cm down the thigh in order to perform the osteotomy. He is a C-arm image and performed an extended osteotomy including the greater trochanter and the lateral half of the femur for 15 centimeters. I remove the lateral half of the femur maintaining the abductor attachment on the greater trochanter. I then used osteotome to extract the press-fit stem from the anterior half of the femur and was able to finally extracted.
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We then turned our attention to the acetabular side. I remove the acetabular polyethylene liner with a osteotome. We removed 3 acetabular screws. I then replaced the acetabular liner and use the centralizing curved osteotome device to loosen the interface between the metal bone ingrowth shell and the patient’s native bone around the acetabulum circumferentially. I was then able to extract the acetabular shell.
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The entire proximal femur acetabulum and soft tissues were debrided excising infected tissue. I then copiously irrigated with pulsatile lavage 9 L of solution last 3 L containing bacitracin.
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After change of gloves and new drape we then proceeded with placement of a nonabsorbable drug delivery antibiotic spacer. Based on my preoperative discussions with infectious disease team and the pharmacist and the patient’s cultures with Klebsiella with sensitivities to amikacin, we selected amikacin. I placed 2 g of amikacin per package of cement and we created using the Biomet system for femoral antibiotic spacer a femoral cement spacer and a femoral head cement spacer. I placed the femoral stem cement spacer in position in the anterior half of the osteotomized femur. I then placed the lateral half of the osteotomy including greater trochanter over this and placed to Dall-Miles cables in position around the osteotomy and tensioned these and crimped them in position. I then placed the cement femoral head and reduce the hip into the acetabulum. I then packed into the bone defect and around the femoral neck some additional antibiotic cement in the proximal femur.
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Fluoroscopy confirmed good position of the cement spacer and good fixation of the and reduction of the femoral osteotomy.
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I then attempted to close the posterior capsule with 0 PDS. I closed the vastus lateralis. I placed a deep 15 French drain and closed the IT band and gluteus maximus fascia over the drain. I closed the deep subcutaneous layers which are fibrosed with 0 PDS and subcutaneous layers with 2-0 PDS and skin was closed with staples.
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I then placed a customizable incisional wound VAC 41 cm onto the incision and attached the adhesive and suction tubing and confirmed good function of the wound VAC with no leak. I placed a sterile dressing over the Jackson-Pratt drain entry site. We placed an abduction pillow on the patient.