Issue link: https://viewer.e-digitaledition.com/i/556451
CASE STUDY A 66-YEAR- OLD FEMALE first presents to us with pain in her buttock, groin and thigh. Eleven years earlier, she underwent a staged bilateral hip replacement. An infection in her left hip occurred one year after that surgery and required revision surgery (two-stage re-implantation) and at least one subsequent debridement. She was pain free until 2010 (6 years after the revision). She reports being minimally ambulatory since 2011 and essentially non- ambulatory over the past year. She uses a walker or wheelchair for most activities. She has been told that if she weightbears she might fracture her femur, as her stem has been protruding. She has been advised against further surgery. X-rays are obtained, showing the presence of a right, uncemented total hip without compromise, and a loose left total hip fixed in hybrid fashion. There is significant osteolytic change and loosening of both femoral and acetabular components. There is fracture of the central wall of the acetabulum; there is a broad radiolucency around the whole component. The femoral stem is a calcar-style cemented stem, which has subsided anteriorly and distally. Radiographs show marked thinning of the cortex posteriorly near the tip of the stem with a portion of the remaining cement in the canal; she has marked proximal femoral thinning. Laboratory tests are inconclusive as regards to residual infection (mixed results). Pre- operative diagnosis: grossly loosened left total hip arthroplasty status post removal and two-stage re-implantation for infection, possibly due to infection. Surgical treatment involves radical debridement around the upper femur to remove fragmented cement laterally and exuberant membrane, and vig- orous debridement behind the shell, along with multiple sampling of tissue for infection. When no infection is identified, acetabular and femoral revi- sion is performed. The patient begins ambulation on POD #1 (postoperative day 1) and is sufficiently independent, per PT protocol, to be discharged POD #2. She is discharged to her home with in-home physical therapy. Three months post-op she reports that she is pain-free, weight bearing with crutches and is gaining the confidence to move off of her crutches. whether or not the revision surgery can help accomplish that," says Geizer. "We also make sure they understand the restrictions they may have after surgery for the first six weeks. This really helps with compliance." Diet is discussed and protein supple- ments are given a week or two before surgery and after surgery, as well, to help with wound healing and muscle building. Patients are also instructed to visit their dentists prior to surgery to verify there are no underlying sources of infection in their teeth or gums. If post-operative bracing is needed, that's arranged ahead of time, as well, so patients can be fitted with a brace and educated about its use before surgery takes place. "Discharge is also planned ahead," say s G ei z er. "Even a f ter re v ision surger y, patients can be discharged directly to their homes if they have a support system there and the home is safe for them to function in. If the patient needs a short-term skilled nurs- ing facility, St. Vincent's case managers help with that." "Ma ria nne's job, a nd that of our entire consolidated team, is getting the patients and their families/sup- port people through the entire process predictably and expeditiously," says Dr. Stulberg. "Our goal is to get them back on their feet and back to their referring physician, hopefully within six to 12 weeks. And that takes a team." He points out that patients benefit from an organized approach to revision surgery. "Not all environments are built to be organized around joint replace- ment and revision, like St. Vincent's Spine and Orthopedic Institute is," Dr. Stulberg says. "I think our consoli- dated team approach and experience with knee and hip revisions make all the difference. Hopefully, we'll continue to get better and better." F o r m o r e i n f o r m a t i o n a b o u t St. V incent C har it y Medical Center Spine and Or thopedic Instit ute, visit stvincentcharity.com/spine-ortho. To refer a patient, call 888-709-9007. ■ IMAGES COURTESY OF BERNARD STULBERG, MD PRE-OP POST-OP 2 0 1 5 S E P T E M B E R /O C T O B E R ■ M D N E W S . CO M ■ MD NEWS Cleveland/Akron/Canton | 1 7