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Rovere G, De Mauro D, D'Orio M, Fulchignoni C, Matrangolo MR, Perisano C, Ziranu A, Pataia E. Use of muscular flaps for the treatment of hip prosthetic joint infection: a systematic review. BMC Musculoskelet Disord 2021; 22:1059. [PMID: 34949162 PMCID: PMC8705100 DOI: 10.1186/s12891-021-04945-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Deep periprosthetic infection after total hip arthroplasty (THA) is a serious and challenging complication for the orthopedic surgeon. Muscular flaps may represent a valid management option for the treatment of this condition. We present a systematic literature review about the use of muscular flaps for the treatment of hip prosthetic joint infection. METHODS The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventy-seven articles, out of 279 titles, were considered eligible for the full-text analysis. Finally 15 studies that met inclusion criteria were included in this review. RESULTS Overall, 210 patients (49% males, 48.6% females and 2.4% not reported) suffering from THA infection treated with muscular flaps were collected. The mean age was 69.6 years. Mean follow-up, reported in all studies, was 3.3 years. The results presented by the different authors, highlight the effectiveness of muscular flaps for the treatment of periprosthetic infection, in terms of function, limb salvage, prevention of the recurrences, cost-effectiveness, and quality of life postoperatively. CONCLUSIONS Muscle flaps provide an excellent management option for patients with persistent infection after total hip arthroplasty.
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Affiliation(s)
- Giuseppe Rovere
- Department of Orthopedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica Del Sacro Cuore, Largo Agostino Gemelli 8, 06168, Roma, Italy
| | - Domenico De Mauro
- Department of Orthopedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica Del Sacro Cuore, Largo Agostino Gemelli 8, 06168, Roma, Italy
| | - Marco D'Orio
- Department of Orthopedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica Del Sacro Cuore, Largo Agostino Gemelli 8, 06168, Roma, Italy
| | - Camillo Fulchignoni
- Department of Orthopedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica Del Sacro Cuore, Largo Agostino Gemelli 8, 06168, Roma, Italy
| | - Maria Rosaria Matrangolo
- Department of Orthopedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica Del Sacro Cuore, Largo Agostino Gemelli 8, 06168, Roma, Italy
| | - Carlo Perisano
- Department of Orthopedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica Del Sacro Cuore, Largo Agostino Gemelli 8, 06168, Roma, Italy
| | - Antonio Ziranu
- Department of Orthopedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica Del Sacro Cuore, Largo Agostino Gemelli 8, 06168, Roma, Italy
| | - Elisabetta Pataia
- Department of Orthopedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica Del Sacro Cuore, Largo Agostino Gemelli 8, 06168, Roma, Italy.
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Liu YB, Pan H, Chen L, Ye HN, Wu CC, Wu P, Chen L. Total hip revision with custom-made spacer and prosthesis: A case report. World J Clin Cases 2021; 9:7605-7613. [PMID: 34616833 PMCID: PMC8464474 DOI: 10.12998/wjcc.v9.i25.7605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/16/2021] [Accepted: 07/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Both periprosthetic joint infections (PJIs) and severe femoral segmental defects are catastrophic complications of total hip arthroplasty (THA), and both present a significant challenge in revisional surgery. There are limited data available to guide clinical decision making when both occur concurrently.
CASE SUMMARY A 61-year-old woman presented with a 6-mo history of a sinus tract at the site of her original THA incision. Radiological imaging revealed a total hip joint implant with an ipsilateral segmental femoral defect. Based on histological, radiological, laboratory, and clinical features, a diagnosis of concurrent chronic PJI and segmental femoral defect (Type IIIB, Paprosky classification) was made. After multidisciplinary team discussion, three-dimensional (3D)-printed, custom-made antibiotic spacers were created that could be used to mold antibiotic-loaded cement spacer. These were placed following PJI debridement in the first stage of revision surgery. After the PJI was eliminated, a 3D-printed, custom-made, femoral prosthesis was created to repair the considerable femoral defect. After 20-mo follow-up, the patient had excellent functional outcomes with a near-normal range of hip movement. So far, neither evidence of recurrent infection nor loosening of the prosthesis has been observed.
CONCLUSION We describe a case of “two-stage, custom-made” total hip revision to treat PJI with a concurrent segmental femoral defect. Use of a personalized, 3D-printed spacer and proximal femoral prosthesis led to satisfactory hip function and no early postoperative complications. Use of a customized implant provides surgeons with an alternative option for patients where no suitable spacer or implant is available. However, the long-term function, longevity, and cost-effectiveness of the use of custom-made prostheses have yet to be fully explored.
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Affiliation(s)
- Yang-Bo Liu
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Hao Pan
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Li Chen
- Orthopaedics Unit, St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy VIC 3065, Australia
| | - Hao-Nan Ye
- First School of Clinical Medicine, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Cong-Cong Wu
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Peng Wu
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Lei Chen
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
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Total Hip Arthroplasty for Ankylosis Requiring Rotational Rectus Femoris Flap and Skin Graft for Wound Closure. Arthroplast Today 2020; 6:141-145. [PMID: 32346585 PMCID: PMC7183003 DOI: 10.1016/j.artd.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/01/2020] [Accepted: 03/04/2020] [Indexed: 11/22/2022] Open
Abstract
We present a case report of a 51-year-old Ghanaian immigrant who underwent total hip arthroplasty in the setting of spontaneous ankylosis of unknown etiology. The increase in offset of the patient's limb through reconstruction, in combination with severe soft-tissue atrophy of the lower extremity, resulted in a soft-tissue defect that could not be closed primarily. This ultimately required a rectus femoris rotational flap and skin grafting for coverage. We describe the surgical technique used for conversion of an ankylosed hip to total hip arthroplasty, as well as the technique for management of a large proximal thigh soft-tissue defect with rectus femoris muscle flap coverage.
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Singh R, Wadhwani J, Rohilla RK, Kaur K. Proximal femoral resection and Tensor Fascia Lata flap for recalcitrant trochanteric pressure ulcers. Spinal Cord Ser Cases 2019; 5:15. [PMID: 30729039 PMCID: PMC6363780 DOI: 10.1038/s41394-019-0157-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 01/04/2023] Open
Abstract
Introduction Trochanteric pressure ulcers (PrUs) are difficult to treat and are often complicated by infection spreading to the hip joint. We review three cases from India where proximal femoral resection and pedicled Tensor Fascia Lata (TFL) flapping was used in the management of infected deep trochanteric ulcers communicating to the hip joint. Case presentation Three patients had a total of four trochanteric PrUs communicating to the hip joint. Proximal femoral resection along with radical debridement of the pressure ulcer (PrU) was the first step in our surgical protocol. Serial debridements were performed to make the resulting cavity healthier and ready for the subsequent flap surgery. TFL flapping was done to cover the raw area of the PrU and the donor site was closed either primarily or with a split skin graft. All patients were males with AIS A spinal cord injury (SCI) and stage 4 PrUs in the trochanteric region. One patient had bilateral trochanteric ulcers. There was complete healing of all PrUs with improvement in wheelchair mobility, and general health. Discussion PrUs are a common complication of patients with SCI and are often considered one of the most neglected issues of health care delivery in India. Proximal femoral resection with pedicled TFL muscle flap is a versatile and reliable procedure for the coverage of recalcitrant trochanteric PrU with hip joint involvement. Minimal donor site morbidity occurs.
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Affiliation(s)
- Roop Singh
- Department of Orthopaedic Surgery, Paraplegia & Rehabilitation, Pt. B.D. Sharma PGIMS, Rohtak-124001 Haryana, India
| | - Jitendra Wadhwani
- Department of Orthopaedic Surgery, Paraplegia & Rehabilitation, Pt. B.D. Sharma PGIMS, Rohtak-124001 Haryana, India
| | - Rajesh Kumar Rohilla
- Department of Orthopaedic Surgery, Paraplegia & Rehabilitation, Pt. B.D. Sharma PGIMS, Rohtak-124001 Haryana, India
| | - Kiranpreet Kaur
- Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma PGIMS, Rohtak-124001 Haryana, India
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Faenza M, Pieretti G, Lamberti R, Di Costanzo P, Napoletano A, Di Martino M, Casale F, Ferraro GA, Nicoletti GF. Limberg fasciocutaneous transposition flap for the coverage of an exposed hip implant in a patient affected by ewing sarcoma. Int J Surg Case Rep 2018; 41:516-519. [PMID: 29546030 PMCID: PMC5723282 DOI: 10.1016/j.ijscr.2017.11.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 11/20/2022] Open
Abstract
Hemipelvectomy with immediate reconstruction with prosthetic devices for the surgical treatment of malignant tumors is an invasive procedure. The treatment of an exposed hip implant in these cluster of patient is extremely challenging and the literature shows how negative pressure wound therapy and myocutaneous, both pedicled and free, flaps are workhorses in these situations. The literature shows that the gold standard in the coverage of exposed prosthetic devices and in the treatment of infected non healing wounds is represented by muscular or myocutaneous flap. In this paper we report a successful coverage of exposed prosthetic hip implant with a local fasciocutaneous flap in a patient in which any other kind of reconstruction was not feasible. Introduction Hemipelvectomy with immediate reconstruction with prosthetic devices for the surgical treatment of malignant tumors is an invasive procedure with many possible complications such as wound breakdown, seroma, hematoma and infection. The treatment of an exposed hip implant in these cluster of patient is extremely challenging and the literature shows how negative pressure wound therapy and myocutaneous, both pedicled and free, flaps are workhorses in these situations. Case report In this paper we report a successful coverage of exposed prosthetic hip implant with a local fasciocutaneous flap in a patient in which any other kind of reconstruction was not feasible. Discussion Fasciocutaneous flaps can be considered as an easily performed and minimally invasive surgical procedure, particularly reliable even in patients in poor general conditions, with preservation of future flap options.
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Affiliation(s)
- Mario Faenza
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Piazza Luigi Miraglia, 1-80138 Naples, Italy; Traslational Medicine of Development and Active Aging, Università degli Studi di Salerno, Via Giovanni Paolo II, 132-84084, Fisciano (Salerno), Italy.
| | - Gorizio Pieretti
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Piazza Luigi Miraglia, 1-80138 Naples, Italy
| | - Rossella Lamberti
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Piazza Luigi Miraglia, 1-80138 Naples, Italy
| | - Pasquale Di Costanzo
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Piazza Luigi Miraglia, 1-80138 Naples, Italy
| | - Antonio Napoletano
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Piazza Luigi Miraglia, 1-80138 Naples, Italy
| | - Martina Di Martino
- Department of Women, Child and General and Specialist Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Paediatric Oncology Unit, Vico Luigi De Crecchio, 2-80138 Naples, Italy
| | - Fiorina Casale
- Department of Women, Child and General and Specialist Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Paediatric Oncology Unit, Vico Luigi De Crecchio, 2-80138 Naples, Italy
| | - Giuseppe A Ferraro
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Piazza Luigi Miraglia, 1-80138 Naples, Italy
| | - Giovanni F Nicoletti
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Piazza Luigi Miraglia, 1-80138 Naples, Italy
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The Modified Girdlestone Procedure With Muscle Flap for Management of Pressure Ulcers and Heterotopic Ossification of the Hip Region in Spinal Injury Patients: A 15-Year Review With Long-term Follow-up. Ann Plast Surg 2017; 77:645-652. [PMID: 26808772 DOI: 10.1097/sap.0000000000000706] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pressure ulceration, pyogenic arthritis, and hip heterotopic ossification are complications encountered in spinal cord injury patients. The Girdlestone procedure has been established as an effective treatment modality for hip pathology in this population and is particularly efficacious when a muscle flap is used to fill the femoral resection defect. We previously reported its use as a 3-stage procedure. Through time, experience was gained, and consequently, our technique has evolved to a 1-stage procedure. METHODS A retrospective analysis of all spinal cord injury patients who had undergone Girdlestone arthroplasty or excision of heterotopic ossification by the pressure ulcer management team at Rancho Los Amigos National Rehabilitation Center between 1991 and 2005 was performed. A description of our management, operative protocol, outcome, and complication is given. RESULTS Over 15 years (between 1991 and 2005), 295 patients underwent 330 procedures. Hips were operated for infection, heterotopic ossification, pressure ulceration, dislocation, femoral head necrosis, or fracture or a combination of the above. Twenty-five cases (7.6%) required surgical revision for wound breakdown in the immediate postoperative period. Average follow-up was 40.3 months; 43.6% of patients developed recurrence of ulceration requiring surgery. The average time until recurrence was 27.3 months. CONCLUSIONS The Girdlestone arthroplasty is an effective modality to treat hip infection, ankylosis, heterotopic ossification, dislocation, or other pathology associated with the spinal cord injury patient. Long-term follow-up of a large patient population reveals the efficacy of the procedure in preventing recurrence and improving patient quality of life.
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Risk assessment and usefulness of musculocutaneous flap transposition for recurrent septic arthritis of the hip in adults. Hip Int 2016; 26:503-507. [PMID: 27132529 DOI: 10.5301/hipint.5000369] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Septic arthritis of the hip joint in adults often progresses to recurrent infections that require repeated surgeries for treatment. The purpose of the present study was to assess the risk of a recalcitrant hip infection and the usefulness of musculocutaneous flap transposition. METHODS 15 adult patients who underwent surgeries for the treatment of hip infections were retrospectively analysed. Patients who recovered from infection by undergoing arthroscopy, open irrigation, debridement, continuous irrigation, resection arthroplasty, and/or the placement of antibiotic-loaded acrylic cement were classified into Group A (n = 10). Patients who showed residual infection after multiple surgeries and ultimately recovered after undergoing musculocutaneous flap transposition were classified into Group B (n = 5). The age at onset, sex, incidence of multi-drug-resistant organisms, incidence of infection at other sites, compromising factors, peak preoperative C-reactive protein level, and period from onset to initial surgery were compared between groups. RESULTS There was a statistically significant difference in the period from onset to initial surgery (p = 0.024). The infections remained chronic after multiple surgeries in most patients who had complications and/or a poor general or local condition. All of the patients recovered after musculocutaneous flap transposition without the need for additional surgery and did not experience recurrence during the follow-up period in Group B. CONCLUSIONS Delayed diagnosis and/or treatment and compromised host caused recurrent septic arthritis of the hip in adults. Musculocutaneous flap transposition may be a useful method for the treatment of recalcitrant hip infection.
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[Treatment of a recalcitrant hip infection with a vastus lateralis muscle flap]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013; 56:439-43. [PMID: 23594941 DOI: 10.1016/j.recot.2012.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 07/11/2012] [Accepted: 07/16/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Recalcitrant hip infection after arthroplasty presents a reconstructive challenge to orthopedic surgeons. The aim of this study is to evaluate the results with a vastus lateralis muscle flap used to treat these recalcitrant hip infections in our Department. MATERIAL AND METHODS A retrospective descriptive study was conducted on five patients with deep hip infections by transposition of the vastus lateralis muscle flap. Average age: 70.5 years. Mean follow-up: 30 months (range, 25-34 months). All patients had previously undergone other major surgical procedures (mean of 3.7 previous procedures). All had multiple microbial infections before surgery. The pathogens involved using cultures of the fistula, the outcome of the wound and laboratory results, including C-reactive protein (CRP), were analysed. RESULTS Healing was achieved in the five patients who underwent surgery without requiring any further procedures or inflammatory signs of infection. CRP returned to normal one month after surgery, and there was no morbidity or mortality related to surgical technique. CONCLUSION In our experience, the vastus lateralis muscle flap as a treatment for recalcitrant deep infection after arthroplasty has presented good results, provided there is appropriate antibiotic therapy and surgical debridement, thus achieving wound healing and a return to normal of the CRP.
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Rodríguez-Rosales G, Cebrián-Parra J, Francés-Borrego A, Marco-Martínez F, López-Durán Stern L. Treatment of a recalcitrant hip infection with a vastus lateralis muscle flap. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012. [DOI: 10.1016/j.recote.2012.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Suda AJ, Heppert V. Vastus lateralis muscle flap for infected hips after resection arthroplasty. ACTA ACUST UNITED AC 2010; 92:1654-8. [PMID: 21119170 DOI: 10.1302/0301-620x.92b12.25212] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We evaluated the potential of a vastus lateralis muscle flap in controlling infection after resection arthroplasty of the hip. We retrospectively reviewed 119 patients with 120 chronic infections after resection arthroplasty treated with this procedure. The flap was fixed with Mitek anchors in the acetabular cavity. The mean duration of infection after resection before the muscle flap procedure was 6.5 months (2 to 13). The patients had previously undergone a mean of 4.9 operations (2 to 25). In all patients the infected cavity was the origin of the persistent infection. The mean follow-up was for 2.6 years (1.0 to 4.7). No patient had recurrent infection post-operatively and all had an improvement in the pain and better quality of life.
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Affiliation(s)
- A J Suda
- Department Septic Surgery, Bone, Joint and Prostheses Infections, BG Trauma Centre, Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen, Germany.
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Tan KJ, Lim CT, Lim AYT. The use of muscle flaps in the salvage of infected exposed implants for internal fixation. ACTA ACUST UNITED AC 2010; 92:401-5. [PMID: 20190312 DOI: 10.1302/0301-620x.92b3.22115] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The treatment of infected exposed implants which have been used for internal fixation usually involves debridement and removal of the implant. This can result in an unstable fracture or spinal column. Muscle flaps may be used to salvage these implants since they provide soft-tissue cover and fresh vascularity. However, there have been few reports concerning their use and these have concentrated on the eradication of the infection and successful soft-tissue cover as the endpoint. There is no information on the factors which may influence the successful salvage of the implant using muscle flaps. We studied the results and factors affecting outcome in nine pedicled muscle flaps used in the treatment of exposed metal internal fixation with salvage of the implant as the primary endpoint. This was achieved in four cases. Factors predicting success were age < 30 years, the absence of comorbid conditions and a favourable microbiological profile. The growth of multiple organisms, a history of smoking and the presence of methicillin-resistant Staphylococcus aureus on wound cultures indicated a poor outcome. The use of antibiotic beads, vacuum-assisted closure and dressing, the surgical site, the type of flap performed and the time from primary surgery to flap cover were not predictive of outcome.
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Affiliation(s)
- K-J Tan
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Hospital, Young Loo Lin School of Medicine, National University of Singapore, National University Health System, 5 Lower Kent Ridge Road, Singapore
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Tiemann AH, Homagk L, Diefenbeck M, Mückley T, Hofmann GO. [Preservation of hip prosthesis with local surgical revision and creation of a fistula persistens : an option for palliative treatment of periprosthetic infection in old, polymorbid patients?]. Unfallchirurg 2009; 110:1021-9. [PMID: 18060337 DOI: 10.1007/s00113-007-1367-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of implanted hip prostheses is increasing constantly. At the same time the patients are becoming older and older. Thus, also patients with periprosthetic infections are older and therefore sicker. Uniform guidelines for the treatment of infected arthroplasties are controversial. Empirical studies show that the explantation of the original prosthesis and implantation of a revision may be the option with the greatest chance of success. These very aggressive procedures may overburden the old, polymorbid patient. The aim of this study was to ascertain whether or not keeping the hip prosthesis in combination with local debridement, formation of a permanent fistula and long-term administration of antibiotics is a possible option for the treatment of infected hip prostheses in old and polymorbid patients. PATIENTS Between 01.01.2004 and 28.01.2007, 12 patients with periprosthetic infection after hip arthroplasty (PIH) were treated. Their average age was 79.8 years. Eleven patients were rated ASA III preoperatively. The prostheses were on average 23.8 weeks old when the first signs of infection occurred. In 10 cases the infection was caused by Staphylococcus (MRSA 3x). The main comorbidities were hypertension, diabetes, coronary heart disease and thyroid malfunction. RESULTS After a mean 8.83 months, six patients were deceased (average age 85.50 years). In five of the remaining six patients the fistula worked without any problem. In one case the fistula was occluded. None of the patients showed any sign of acute infection. All were able to walk with full weight-bearing on the affected hip. CONCLUSION Restricting the indication to old, polymorbid patients, preservation of the arthroplasty in combination with local surgical debridement, permanent fistula and long-term systemic administration of antibiotics seems to be an alternative to explantation of the prosthesis with consecutive revision arthroplasty or resection arthroplasty.
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Affiliation(s)
- A H Tiemann
- Abteilung für Septische und Rekonstruktive Chirurgie, Klinik für Unfall- und Wiederherstellungschirurgie,BG-Kliniken Bergmannstrost, Merseburger Strasse 165, 06112, Halle Saale, Deutschland.
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Rudelli S, Uip D, Honda E, Lima ALLM. One-stage revision of infected total hip arthroplasty with bone graft. J Arthroplasty 2008; 23:1165-77. [PMID: 18534510 DOI: 10.1016/j.arth.2007.08.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 08/08/2007] [Indexed: 02/01/2023] Open
Abstract
There are many different opinions in the literature regarding the best procedure for revision of infected hip arthroplasty and hence in achieving long-term stabilization of a new implant. Thirty-two patients with 32 loose and infected total hip arthroplasties underwent revision with a bone graft in a 1-stage procedure. The bone graft was used in the acetabulum and femur in 25 patients, in the acetabulum alone in 4 patients and in the femur alone in 3 patients. A metal mesh was necessary in 15 patients to contain the morselized bone graft. At the time of surgical revision, 9 patients had a draining sinus, 6 had a closed sinus, and 17 had never had sinuses in the surgical wound. Antibiotic therapy was administered intravenously and orally for 6 months. Mean follow-up was 103 months (range, 63-183 months), and infection recurred in 2 (6.2%) cases. Further studies are necessary, and continuation of this method is justified.
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Affiliation(s)
- Sergio Rudelli
- Department of Orthopaedic Surgery, Santa Casa Medical School, São Paulo, Brazil
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Acartürk TO. Treatment of large ischial ulcers communicating with the hip joint with proximal femoral resection and reconstruction with a combined vastus lateralis, vastus intermedius and rectus femoris musculocutaneous flap. J Plast Reconstr Aesthet Surg 2008; 62:1497-502. [PMID: 18718837 DOI: 10.1016/j.bjps.2008.04.063] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Revised: 04/16/2008] [Accepted: 04/19/2008] [Indexed: 02/07/2023]
Abstract
Pressure ulcers which communicate with the hip joint are very difficult to treat. Often, the hip joint is infected with osteomyelitis of the proximal femur resulting in bouts of sepsis and flap failure. These patients require proximal femoral resection and wide debridement in order to eradicate the infection, which in turn results in large and deep cavities. Reconstruction requires either a muscle flap or even a total thigh flap if the defect is very large and the pelvis is involved. In a series of six ischial or ischio-trochanteric pressure sores communicating with the hip joint, following multiple serial debridements, the vastus lateralis, vastus intermedius and rectus femoris muscles were raised as a single musculocutaneous flap ('three muscle flap'), based on the descending branch of the lateral femoral circumflex artery, and transposed into the defect. All patients were paraplegics and had signs of sepsis during admission. Two patients had prior failed reconstructions within 3 months of admission and the others had not been operated on before. The external skin defect of the ulcers ranged from 7 x 5 cm to 30 x 12 cm. After 12 months follow up there was no recurrence of pressure sores or sepsis. The 'three muscle flap' offers the advantage of providing large bulk to fill deep cavities, while preserving the rest of the thigh. The flap elevation is fast and safe and the vascular pedicle is reliable. This technique is not for simple pressure sores, but should be reserved for large pressure sores complicated with large cavities created after resection of the proximal femur.
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Affiliation(s)
- Tahsin Oguz Acartürk
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University School of Medicine, Adana 01330, Turkey.
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Shieh SJ, Jou IM. Management of Intractable Hip Infection after Resectional Arthroplasty Using a Vastus Lateralis Muscle Flap and Secondary Total Hip Arthroplasty. Plast Reconstr Surg 2007; 120:202-207. [PMID: 17572564 DOI: 10.1097/01.prs.0000264067.68714.a6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Shyh-Jou Shieh
- Tainan, Taiwan From the Division of Plastic and Reconstructive Surgery, Department of Surgery, and the Department of Orthopedics, College of Medicine, National Cheng Kung University Medical Center
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16
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Vastus lateralis muscle flap for infected hip defects: a report of four cases. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2006. [DOI: 10.1007/s00590-006-0120-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Gusenoff JA, Hungerford DS, Orlando JC, Nahabedian MY. Outcome and management of infected wounds after total hip arthroplasty. Ann Plast Surg 2002; 49:587-92. [PMID: 12461440 DOI: 10.1097/00000637-200212000-00006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Infected wounds after total hip arthroplasty can be limb threatening. Management strategies are designed to eradicate infection, to obtain stable wound coverage, and to preserve the prosthesis. However, there is no general consensus for optimal management. The authors reviewed their 7-year combined orthopaedic and plastic surgical experience to provide a protocol for management. Ten patients (six women and four men) with a mean age of 60 years (range, 41-82 years) were studied. Primary hip diagnoses included arthritis (n = 8) and avascular necrosis (n = 2). Wound analysis included the size, depth, and infection as well as exposure of bone, joint capsule, and prosthetic components. Follow-up ranged from 1 to 6 years (mean, 3.9). Primary plastic surgical operations included a pedicle muscle flap (n = 4), debridement and local wound care (n = 3), and delayed wound closure (n = 3). Salvage of the total hip arthroplasty was achieved in 6 of 10 patients. Complete wound healing was achieved in 9 of 10 patients. The authors conclude that salvage of the infected hip prosthesis is accomplished best via early recognition, irrigation, debridement, and plastic surgery consultation. Management strategies include muscle flap coverage for complex wounds associated with exposure of prosthetic components, bone, or hardware; debridement with delayed closure or skin graft for large superficial wounds without deep structure involvement; and local wound care for small superficial wounds, poor surgical candidates with clean wounds, and when surgical options are not possible.
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Affiliation(s)
- Jeffrey A Gusenoff
- Division of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
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18
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Ikeda K, Matsuda M, Yamauchi D, Tomita K. Infection of the inguinal region treated by musculocutaneous flaps. J Orthop Surg (Hong Kong) 2001; 9:51-56. [PMID: 12468844 DOI: 10.1177/230949900100900110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study documented the treatment of the inguinal dead space with chronic infection using musculocutaneous flaps. The average age of the patients (5 males and 2 females) was 50.0 years. Six cases of reconstruction after malignant tumor resection and one case after total hip arthoroplasty were treated. Six rectus abdominis flaps and 2 vastus lateralis flaps were used. Previous radiation therapy had been performed on five patients. The duration of chronic infection averaged 2.3 months, excluding a 4- year long case. All flaps survived and the average follow-up period was 2.8 years. Five cases had no relapse of the infection but two cases relapsed 18 months and 2 years respectively after the surgery. These two did not have tumor prostheses removed prior to the surgery.
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Affiliation(s)
- Kazuo Ikeda
- Department of Orthopaedic Surgery, School of Medicine, Kanazawa University, Kanazawa, Japan
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19
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Therapeutic Angiogenesis in Surgery and Oncology. Angiogenesis 1994. [DOI: 10.1007/978-1-4757-9188-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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20
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Benito-Ruiz J, Baena-Montilla P, Mena-Yago A, Miguel I, Montanana-Vizcaino J. A complicated trochanteric pressure sore: what is the best surgical management? Case report. PARAPLEGIA 1993; 31:119-24. [PMID: 8446456 DOI: 10.1038/sc.1993.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Pressure sores are a common complication after spinal cord injury. But great advances in their management (nursing care, prevention and surgery) have been made in the last four decades. Neglected pressure ulcers may affect the adjacent joint, leading to septic arthritis. We report a paraplegic patient with a large trochanteric sore with hip arthritis, in whom we performed an upper femoral resection and acetabular curettage (Girdlestone's technique) and coverage with the homolateral vastus lateralis muscle flap in one stage. Some questions pertaining to this operation are discussed and there is a comparison with other ways of management described in the literature. We conclude that a successful outcome with the management of such large sores depends on a radical, aggressive operation to remove all of the affected tissue, and ensure a safe coverage with a reliable, viable muscle flap. The collaboration and the positive attitude of the patient towards the procedure and the result obtained are decisive in preventing recurrences.
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Affiliation(s)
- J Benito-Ruiz
- Department of Plastic and Reconstructive Surgery, Hospital La Fe, Valencia, Spain
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