Difficult Revision THA in a Patient with a Suspected Infection

    Dr. Charles Nelson presents the case of 62-year-old woman who had a revision procedure more than 20 years ago. She has had worsening pain for a year, and lab tests are suggestive of an infection.

    Revision total hip arthroplasty (THA) procedures are typically performed when the primary hip fails due to aseptic loosening, instability, infection, osteolysis and wear, and periprosthetic fracture.

    As the number of primary THAs increases, particularly in younger patients it makes sense that the number of revision procedures will increase as well. Over the next 2 decades, joint replacement surgeons are looking at a triple-digit increase in revision THAs.

    At ICJR’s Annual Modern Trends in Joint Replacement meeting, Charles L. Nelson, MD, from the University of Pennsylvania in Philadelphia, shared a surgical video of a difficult revision procedure he had done on a patient with a suspected infection.

    The patient in this video is a 62-year-old woman who had undergone a primary THA of the left hip in 1975 and a revision for dislocation in 1992.

    When she was referred to Dr. Nelson, she had experienced worsening hip pain for approximately a year, with pain worsening with activity and weight-bearing. She reported having a childhood hip condition, most likely hip dysplasia, for which she was in a body cast until age 2.

    On examination, she had shortening of her left leg, an abductor lurch, and positive Trendelenburg and Stinchfield tests. She had pain with hip flexion and internal rotation.

    Laboratory testing done at another facility indicated elevated erythrocyte sedimentation rate and C-reactive protein levels; these were confirmed at Dr. Nelson’s lab.

    Dr. Nelson aspirated 10 mL of cloudy, purulent yellow synovial fluid that was tested and found to have 24,375 white blood cells/mcL (97% segmented neutrophils and 2-plus leukocyte esterase) and 1,700 red blood cells/mcL.

    Final cultures had no growth, but because of a strong suspicion of infection, Dr. Nelson was not willing to do a single-stage revision. The patient underwent a 2-stage revision.

    The video (below) covers the key points of the case, and is narrated by Dr. Nelson.