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Introduction: Periprosthetic joint infection (PJI) is an unfortunate but frequent complication following total hip arthroplasty, with an incidence of 1%. Debridement, antibiotics, and implant retention is a treatment option for acute hematogenous PJI, with success rates reported up to 70%. Here, we present a case demonstrating short-term success using this treatment approach in a 74-year-old medically infirm patient. Case Report: The patient - a 74-year-old male with well-functioning bilateral total hip arthroplasties performed 14 years prior - presented to a rural emergency department with an acute onset of right groin pain and dizziness. The patient was found to have sepsis, a right hip joint effusion, and periarticular abscesses on assessment. Synovial fluid aspiration from the right hip grew methicillin-sensitive Staphylococcus aureus. The patient was transferred to an outside hospital for limited debridement of the right hip joint, followed by transfer to our tertiary hospital. On arrival, consideration was given to performing an exchange arthroplasty. However, given the patient's medical frailty, 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. The patient underwent surgery utilizing an established protocol of 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 was treated with parenteral antibiotics followed by chronic oral antimicrobial suppression for 10 months after the final surgery. During treatment, the patient's inflammatory markers have normalized. The patient is ambulatory without assistive devices but uses an ankle orthosis due to a post-operative foot drop that did not resolve. The patient has regained satisfactory mobility with an Oxford hip score of 27. Conclusion: This case demonstrates short-term success in the treatment of acute hematogenous PJI in a medically infirm patient utilizing debridement, antibiotics, and implant retention and may serve to inform future patient counseling.
RESUMEN
OBJECTIVE: Medial epicondyle fractures are a common pediatric injury. When operative, cannulated partially threaded screws, with or without a washer, are commonly utilized. These implants may need to be removed after full healing if symptomatic. There is mixed evidence regarding the influence of a washer on rates of implant removal, and the influence of screw size has not been studied. We aim to determine the rate of symptomatic deep implant removal for each fixation type and identify factors associated with the need for removal. METHODS: This was an IRB-reviewed, retrospective, case-cohort study. Patients treated at our institution between January 1, 2004 and December 31, 2019, age 18 years old or younger, with a medial epicondyle fracture managed operatively with 4.0 or 4.5 mm cannulated screws with or without washers were included. Patients with multiple operative ipsilateral elbow fractures and those who underwent implant removal for reasons other than pain or irritation were excluded. Removal rates were compared between screw sizes (4.0 vs 4.5 mm), as well as with and without a washer using a Cox proportional hazards model. RESULTS: In total, 151 patients met the inclusion criteria, 54 with symptomatic hardware removed and 97 without symptomatic hardware removed. A significantly higher number of patients treated with 4.5 mm screws compared with 4.0 mm screws underwent removal of symptomatic deep implants (50% vs 30%, P = 0.033). In a multivariable Cox regression model adjusting for age and ulnar nerve status, when no washer was used, the hazard ratio (HR) for symptomatic hardware removal for 4.5 mm screws was 2.92 times the HR for 4.0 mm screws (95% CI: 1.35-6.29). When a 4.0 mm screw was used, the HR for symptomatic hardware removal for a washer was 3.24 times the HR without a washer (95% CI: 1.53-6.84). CONCLUSION: Implant removal rates are influenced by screw size and the use of a washer. These results may help guide implant choice and counsel families regarding the rate of symptomatic implant removal. LEVEL OF EVIDENCE: Level III-therapeutic level, case-control study.