Native Adult Hip with Bacterial Septic Arthritis

Clinical characteristics and long-term outcomes of septic arthritis of the native hip joint: a 20-year retrospective review

BACKGROUND

The primary purpose of this retrospective case series was to describe the prevalence and outcomes of single-stage hip arthroplasty in patients who were previously treated for septic arthritis of the native hip at our institution over a 20-year period. This study also examined rates of persistent or recurrent infection, reoperation, and mortality for septic arthritis of the native hip.

METHODS

Adult patients treated for septic arthritis of the native hip at our institution from 1995 to 2015 were retrospectively identified. Exclusion criteria included age <18 years, missing or incomplete medical records, treatment at an outside institution, and prior surgery of the hip.

RESULTS

97 patients were included in this study. 3 patients (3.1%) who were previously treated for septic arthritis of the native hip underwent single-stage hip arthroplasty an average of 40 ± 25 months from the date of infection. 3 of the 18 (16.7%) patients who were treated with resection arthroplasty underwent second-stage joint reconstruction. There were no cases of periprosthetic joint infection (PJI). 1 patient who underwent single-stage arthroplasty experienced implant-induced metallosis, necessitating removal of the implant. There were no other cases of revision arthroplasty.

CONCLUSIONS

The prevalence of single-stage hip arthroplasty in patients with a history of septic arthritis of the native hip joint was 3.1%, which is higher than the prevalence of hip arthroplasty in the United States general population, suggesting that a history of septic arthritis may increase the risk of requiring hip arthroplasty. In the small number of patients who went on to receive a hip replacement, there were no reported cases of PJI. This study suggests that hip arthroplasty is a viable option for patients with symptomatic osteoarthritis and a history of septic arthritis of their hip.

Advanced imaging shows extra-articular abscesses in two out of three adult patients with septic arthritis of the native hip joint

Background: Septic arthritis (SA) of the native adult hip is a rare orthopaedic emergency requiring prompt diagnosis and treatment. As clinical presentation and laboratory findings are frequently atypical, advanced imaging is often requested. This retrospective study aimed to investigate the prevalence and pattern of extra-articular infectious manifestations and their implications for pre-operative advanced imaging in patients with proven SA of the native hip joint. Methods: Out of 41 patients treated surgically for SA of the native hip during a 16-year period at our tertiary referral hospital, 25 received advanced imaging (computed tomography (CT), magnetic resonance imaging (MRI), or fluorodeoxyglucose positron emission tomography (FDG PET-CT)) prior to initial intervention. For each investigation, a specific set of variables was systematically interpreted, and the most suitable surgical approach was determined. The prognostic value was evaluated by comparing specific outcome measures and the extent of extra-articular involvement. Results: It was found that 32 % of patients had an abscess in one anatomical region, 32 % of patients had abscesses in multiple anatomical regions, and only 36 % of patients had no substantial abscess. Gluteal abscesses were especially common in patients with SA due to contiguous spread. Abscesses in the iliopsoas region were more common in patients with SA due to hematogenous seeding. A combination of several different surgical approaches was deemed necessary to adequately deal with the various presentations. No significant prognostic factors could be identified. Conclusion: We recommend performing advanced imaging in patients with suspected or proven septic arthritis of the native hip joint, as extra-articular abscesses are present in 64 % and might require varying anatomical approaches.

Medullary-Sparing Antibiotic Cement Articulating Spacer Reduces the Rate of Mechanical Complications in Advanced Septic Hip Arthritis: A Retrospective Cohort Study

Antibiotic cement articulating spacers eradicate infection during a two-stage revision for advanced septic hip arthritis (ASHA); however, mechanical complications have been reported. We hypothesized that the rate of mechanical complications would be lower in medullary-sparing (MS) than in non-medullary-sparing (n-MS) articulating spacers. A retrospective study of ASHA using n-MS or MS spacers was conducted between 1999 and 2019. The rate of mechanical complications and reoperation and risk factors for mechanical complications were analyzed. The cohort included 71 n-MS and 36 MS spacers. All patients were followed up for 2 years. The rate of spacer dislocation was lower in MS (0%) than in n-MS spacers (14.1%; p = 0.014). The reoperation rate for mechanical complications was lower in MS (0%) than in n-MS spacers (12.7%; p = 0.019). The rate of a diaphyseal stem during reimplantation was lower in MS (0%) than in n-MS spacers (19.4%; p = 0.002). The identified risk factors for n-MS spacer dislocation were postoperative under-restored femoral head diameter ≥3 mm, femoral offset ≥3 mm, and surgical volume (≤6 resection arthroplasties per year). Both spacers controlled infection. However, MS spacers had a lower spacer dislocation and reoperation rate and avoided the diaphyseal stem during reimplantation. We recommend using MS spacers to restore native femoral head diameter and femoral offset when ASHA is treated by surgeons with lower surgical volumes.

Should treatment decisions in septic arthritis of the native hip joint be based on the route of infection?

Background: Surgical management of septic arthritis (SA) of the hip aims at treating the infection by either preserving, resecting or replacing the joint. In some cases, joint preservation should be attempted, whereas other cases would benefit from immediate joint resection or replacement. Prognostic factors have been proposed to guide decision-making. We hypothesized that most of these factors can be simplified to three subgroups based on the route of infection: contiguous spreading, direct inoculation or hematogenous seeding. Methods: A total of 41 patients have been treated surgically for SA of the native hip at our tertiary hospital during the last 16 years. Medical records were studied, and various patient and disease characteristics were collated. Results: Significant differences between (1) level of fitness, (2) condition of the hip joint, (3) micro-organisms and (4) chance of femoral head preservation were found for patients with SA of the native hip resulting from the three aforementioned subgroups. Femoral head resection was necessary at one point in 85 % of patients. Patients with hematogenous infections of undamaged hips had a reasonable chance (53 %) of avoiding joint resection or replacement. Hip arthroplasty was performed on 46.3 % of patients, with an infection rate of 10.5 %. Conclusion: Patients with SA of the native hip resulting from contiguous spreading, hematogenous seeding or direct inoculation differ significantly and should be considered distinct clinical entities. Route of infection is directly related to the chance of femoral head preservation and should, therefore, guide decision-making. Only patients with hematogenous infection to a previously healthy hip had the possibility of femoral head preservation.

ACUTE DESTRUCTIVE HIP SEPTIC ARTHRITIS IN A YOUNG ADULT PATIENT: CASE REPORT (v2)

The Authors describe a case of rapid right hip destructive septic arthritis in a 50-year-old male patient with no previous noteworthy medical history. Patient arrived to our attention following a one week history of right hip pain. Laboratory markers and imaging at presentation were negative. However, on a follow-up examination significant joint effusion was noted and joint tap was performed. Despite wide spectrum antibiotic therapy institution, significant joint damage was observed. This required surgical femoral head excision with antibiotic loaded spacer, followed by hip arthroplasty surgery 12 weeks afterwards. Complete healing of the infection and recovery of pain-free joint motion was noted at 1 year follow-up.

Bilateral Erosive Septic Hip Arthritis Following Pregnancy

We report on a 34-year-old female whose normal spontaneous vaginal delivery was complicated by Group B streptococcus (GBS) colonization. She developed postpartum, bilateral, rapidly destructive septic hip arthritis. She was treated with bilateral articulating, antibiotic-impregnated spacers, 6 weeks of parenteral antibiotics, and subsequent conversion to total hip arthroplasties. In pregnant women, GBS can result in bacteremia, urinary tract infection, endometritis, and pneumonia. Less commonly, GBS can lead to endocarditis, sacroiliitis, or septic arthritis. Septic arthritis of the hip following pregnancy has been described in a limited number of case reports, yet none, to our knowledge, with rapid bilateral destruction requiring two-staged conversion to total hip replacement.

Efficacy and safety of arthroscopic treatment for native acute septic arthritis of the hip joint in adult patients

Background

As septic arthritis is time-dependent and has a propensity for irreversible joint damage, early diagnosis and treatment are needed. Frequently, adult patients with septic arthritis cannot undergo invasive surgery because of comorbidities and a weakened immune system. Hip arthroscopic irrigation and debridement for native acute septic arthritis of the hip joint have been performed as the first choice of treatment for patients of all ages. This study aimed to assess the efficacy and safety of arthroscopic management for native acute septic arthritis of the hip joint in adult patients.

Methods

Five adult patients (mean age, 46.2 years; all male) were retrospectively reviewed. Immediately after diagnosis, all patients underwent hip arthroscopic irrigation, debridement with synovectomy, and drainage. Partial weight-bearing was permitted once the C-reactive protein level normalised to < 1.0 mg/dl. Preoperative comorbidities, bacterial culture results, surgical complications, duration of hospital stay, time-to-confirmed normalisation of the C-reactive protein level, and recurrence incidence were evaluated.

Results

All patients had comorbidities, and the cultured microorganisms differed among cases. There were no complications related to arthroscopic surgery. All patients achieved confirmed C-reactive protein normalisation within an average of 69.8 days, and there was no recurrence during the follow-up period (mean, 40.2 months; range, 16–60 months).

Conclusion

Arthroscopic management for native acute septic arthritis of the hip joint is a safe and effective procedure in adult patients.

Tractionless Hip Arthroscopy for Septic Arthritis in Children

Surgical management of septic arthritis in young children is traditionally performed with open techniques, although arthroscopic approaches are commonly used in the knee and shoulder. Hip arthroscopy is technically demanding in small children and requires modification from traditional hip arthroscopy. The purpose of this study is to describe a safe technique to perform hip arthroscopy without traction in the pediatric hip and, secondarily, to report short-term results of a case series. Pediatric hip arthroscopy can be safely performed without traction on a radiolucent table and allows joint irrigation and debridement including drain placement through the use of 1 or 2 portals. Hip arthroscopy is a safe, valuable, minimally invasive technique in the treatment of children with septic arthritis of the hip.

Two-Stage Primary Arthroplasty of Native Hips and Knees That Had Previously Failed Treatment for Septic Arthritis: A Single-Center Experience

Background

Patients with a history of degenerative joint disease secondary to an acute or remote episode of septic arthritis of the native knee or hip present a unique challenge for the orthopaedic surgeon. This study describes our experience with two-stage primary arthroplasty for such patients.

Methods

We reviewed 42 patients with a history of septic arthritis treated with two-stage primary arthroplasty between 2008 and 2018. Patients were evaluated using modified Harris Hip Score, Knee Society Score (KSS), and KSS functional component (KSSF). Paired t-tests were used to compare changes for continuous variables within cohorts. Multivariate linear and logistic regression models were constructed to determine predictors of outcomes and complications.

Results

At a mean of 3.3-year follow-up, there were 14 (33.3%) complications and the infection cure rate was 95.2%. On average, patients improved in the modified Harris Hip Score (42.9 ± 11.8 vs 83.3 ± 11.1, P < .001), KSS (35.9 ± 16.9 vs 80.1 ± 16.6, P < .001), KSSF (38.0 ± 15.1 vs 71.5 ± 24.0, P < .001), knee flexion (90.9 ± 14.9 vs 100.5 ± 17.1), and hip flexion (73.8 ± 21.2 vs 102.1 ± 11.8, P < .001). Age (β: -0.78, P = .004) was independently associated with lower Harris Hip Score in the hip cohort. There were no independent predictors of the KSS or KSSF. The erythrocyte sedimentation rate (odds ratio: 1.07, P = .043) and C-reactive protein (odds ratio: 1.43, P = .018) at stage 2 were independently associated with a higher likelihood of complications at the final follow-up.

Conclusion

Patients with a history of native septic arthritis of the hip and knee, and secondary end-stage degenerative joint disease, showed significant postoperative improvements and a high rate of complications after two-stage primary total joint arthroplasty. Despite improvements, some patients may necessitate a third operation because of the incidence of reinfection and spacer exchange. This information should be used to counsel patients who present with this challenging clinical scenario.

Rapidly Progressive Osteoarthritis and Acetabular Bone Loss Outcomes for Patients Undergoing Primary Total Hip Replacement

Rapidly progressive osteoarthritis (RPO) is a rare condition which is poorly understood. Limited published literature is available. Reported here is a cohort of patients with RPO and acetabular bone loss who underwent primary THA. Risk factors, degree of acetabular bone loss and outcomes are presented. A typical case of RPO is described and investigations discussed. A retrospective audit was undertaken. 49 patients over an 18-year period were included. RPO patients were significantly older (P < 0.01) and had a lower BMI (P = 0.03). The mean acetabular bone loss in this cohort was 10.0 mm. Pathogenesis and risk factors for developing RPO remain unclear and future research is necessary. Repeat imaging in patients with deteriorating symptoms is important and urgent surgery is required maintain bone stock.