OLD SEPTIC HIP AND CONVERSION TO TOTAL HIP REPLACEMENT

Abstract

Patients with a history of septic arthritis or tuberculosis (TB) of the hip frequently develop secondary osteoarthritis (OA). These patients present a challenge for having joint replacement because of abnormal bone development, the possibility of re-infection, soft tissue problems and their life-style (more active than patients with old age arthritis). We retrospectively review a decent group of 55 cases where one stage cemented total hip arthroplasty was performed with history of old hip infection by a team of surgeons at Wrightington Hospital, Lancashire, UK from 1970 to 2008. The purpose of this study is to find the survival analysis with revision (for infection) as the end stage. There are 33 females and 22 males aged from 25 to 75 yrs (mean 52 years). 21 patients had proven or probable tuberculous infection, 29 had the past history of old septic hip, and the remaining 5 had recent septic hip (i.e., less than 5 years). The patients are followed for between 1 to 23 years (mean 10 years). Pre-operatively, 25 patients had arthrodesis while 24 patients had moderate to severe secondary OA. 3 patients had dysplastic acetabulum, 2 patients had shallow acetabulum and 1 had Avascular Necrosis (AVN). In 33 cases, intra-operative tissue samples didn’t grow any organism, 2 samples grew Staphylococcus aureus, 2 samples grew Coagulase Negative Staphylococcus (CNS), 1 grew pseudomonas, samples were not sent in 9 cases, laboratory did not process the sample in 1 case and no documentation found in 3 cases. Cement with antibiotics was used in 45 patients (Gentamicin alone in 37 cases, Gentamicin and Vancomycin in 3 cases, Gentamicin, Fucidic Acid and Eryth-romycin in 2 patients, Gentamicin, Vacncomycin and Streptomycin in 1 patient, Gentamicin and Streptomycin in 1 case and Gentamicin, Vacncomycin and Amoxycillin in 1 patient). Mostly intravenous antibiotics (3 doses of Cefuroxime) were given, but in few cases with old TB, anti-tuberculous treatment was started pre-operatively and continued for 3 months post-op. In 16 patients either antibiotics were not given or not documented to be given. Failure happened in 2 cases of positive intra-op sample culture with Staphylococcus aureus, 1 patient with pre-op aspiration which showed pseudomonas and in 2 cases where tissue sample showed no growth. 8 patients had revision of at least one of the components for aseptic loosening. The 2 failed cases with positive culture with Staphylococcus aureus had post operative antibiotics and extra antibiotics in cement. Both cases had early wound healing issues.

Conclusion: We can conclude that total hip arthroplasty is safe in old cases of septic or tuberculous hips, provided appropriate antibiotic cover. We have some evidence that total hip replacement can be carried out in cases of recent infection of hip but level of evidence is not very great as we don’t have a large sample of such patients.