Infected hip replacement after procedures Roy Rubht, M.D.,’ Eduardo A. Salvati, M.D.,*+ Robert Lewis, D.D.S.,‘** New York, N. Y. THE
HOSPITBL
HOSPITAGCORNELL
FOR
SPECIAL UNIVERSITY
SURGERY, MEDICAL
AFFILIATED
and WITH
THE
NEW
YORK
COLLEGE
Three cases are reported in which there was a worrisome association between dental work and an infected total hip replacement. The patients had long asymptomatic: intervals subsequent to implantation of prosthetic hip joints. After dental procedures, infections became apparent in these hips. Such infections carry an enormous and crippling morbidity. The potential complications of transient bacteremia in the patient with a cardiac valvular prosthesis are appreciated and the importance of prophylactic antibodies for dental work in such patients is well known. Although we emphasize that, there is no proof that the infections in our patients were metastatic from the mouth, the sequence of events is suggestive. We recommend prophylarsrtir, antibiotics for dental work in the patient with a total hip replacement.
S
ince RushtonI first emphasized the association between the bacteremias of dental origin and bacterial endocarditis, an extensive literature on this phenomenon has continued to accumulate. 2-11 The potential complications of transient bacteremia to the patient with a cardiac lesion or cardiovascular prosthesis are appreciated. The importance of prophylactic antibiotics for such patients undergoing dental procedures is apparently well established. We report an association between dental procedures and infection in a noncardiovascular prosthesis in three patients under our care. Total hip replacement (THR) is an orthopedic procedure offered to selected patients with severe disease of the hip. The hip joint is resected and replaced by a prosthesis con“Resident, Orthopedic Surgery; Instructor of Surgery (Orthopedics), Cornell University Medical College. **Acting Chief, Hip Clinic; Associate Attending Orthopedic Surgeon, The Hospital for Special Surgery; Associate Professor of Orthopedic Surgery, Cornell University Medkaal College. ***Attending Prosthodontist, North Shore University Hospital and Long Island Jew&h Hillside Medical Center. Assistant Clinical Professor, State University of New York-Stony Brook.
18
Volume Number
41 1
Infected
total
hip replacement
Fig. 1. Total hip replacement prostheses. A, McKee-Farrar type used reported on. A metallic femoral component implanted in the shaft of the with a metallic acetabular component fixed to the pelvis. Both components with acrylic cement. B, Another type of prosthesis in current use employs weight polyethylene plastic acetabular component with the metallic femoral
19
in two patients femur articulates are held in place a high molecular component.
of two components: (1) a socket or acetabular portion placed in the pelvis and (2) a head or femoral portion placed in the proximal end of the femur (Figs. 1 and 2). The components are most often fixed in position with the use of polymethylmethacrylate cement. Thousands of these procedures have been performed in recent years (more than 2,500 at our center alone), and increasing numbers of patients with hip prostheses are surely being seen by dentists. One information service has reported to us that 49,000 total hip units have been sold by manufacturers in the past year alone.I2 How many of these have actually been placed in patients is unknown. Amon,0‘ the many complications possible after THR, infection is by far one of the most serious.l” sisting
CASE CASE
REPORTS 1
A (X-year-old woman underwent a right THR (cemented McKee-Farrar prosthesis) on Aug. 19, 1969, because of severe osteoarthritis, The procedure was carried out uneventfully without antibiotic prophylaxis. She did well for the next 31$ years until she had an accident and dislocated the hip. Reduction was accomplished under spinal anesthesia without difficulty. The joint was aspirated and bacterial cultures showed no growth. For the next 8 months the patient did well, but then she dislocated the hip again on Aug. 16, 1974. Reduction was achieved by manipulation as before, and the patient remained asymptomatic thereafter. In September, 1974, she began a 3-month program of dental work that consisted of restorative dentistry and the endodontic treatment of a nonvital tooth. Root canal therapy was accomplished in three viiits, without any sign of purulent substance. The last dental visit was for a final prophylaxis and scaling. At the inception of dental treatment a complete medical history was obtained. The decision made after consultation with an orthopedist was that prophylacic antibiotic therapy was not necessary. On Jan. 6, 1975, 4 weeks after the last dental work, and 5% years after
20
Rubin,
Salvati,
and Lewis
Oral January,
Surg. 1976
Fig. d. a, Case 1, Roentgenogram showing THR in place. In this case, the acrylic cemrnt had radiopaque barium sulfate in it, which allows visualization of it on the roentgenogram around the femoral stem and acetabular component. The wires on the lateral side are used to fix the greater trochanter back in place after detachment for insertion of the prosthesis. R, Roentgenogram after removal of the prosthesis Ileeause of infection. A flail, unstable hip results, with a shortened lower extremity. The patient is able t,o ambulate in this condition but only with a limp requiring the use of a walker or bilateral crutches. THR, the p:ltient, expericncrd acute pain in the right hip, and fever. She was admitted to an affiliated hospital with :I temperature of 38.8” C. and a white blood cell count of 17,300. Despite extreme pain on motion of the right hip, the roentgenograms did not reveal a dislocation. Aspiration of the hip joint yielded pus which cultured StaphyZococc~s aurcus, coagulase positive. The same organism was cultured from the blood. The patient did not improve on intensive intravenous antibiotic therapy and was transferred to The Hospital for Special Surgery. On Jan. 20, 1975, she underwent incision and drainage of the hip, complete removal of the prosthesis and cement, and dkl)ridement of infected tissue. At operation, a :Ihour procedure, approximately 1,000 C.C. of pus was encountered. The patient required transfusion of nineteen units of blood. Postoperative treatment consisted of intravenous antibiotics for 6 weeks and tracation to the leg, via a tibia1 pin, for 4 weeks. The wound healed but continued to drain from two small openings; cultured first from the drainage was Staphylococcus nureus, congulasc positive, and then Proteus mirabilis. With intensive physical therapy, the patient. became ambulatory with a walker. Sixty-two days postoperatively, the patient was able to return home. She had a flail hip and a still-draining wound. The services of a visiting nurse and close follow-up KIIXJ \vere needed. The patient’s hospital bill for the second admission was $18,390.00. At followup, 3 months post-operatively, the wound had ceased draining and the patient was free of pain. She was able to ambulate short distances indoors, with the use of a walker. CASE
2
A 5%year-old woman underwent a left THR (cemented McKee-Farrar type) on Feb. 25, 1970, for the sequelat% of juvenile rheumatoid arthritis. She received prophylactic antibiotics (oxacillin and dicloxacillin) intra- and postoperatively for ti days. Cultures of tissue from the hip joint at operation were negative. Seventeen days postoperatively the patient required operation for advanced periodontitis with abscesses. Lincomyein coverage was provided. Cultures of the abscesses grew Streptococcus and nonpathogenic Neisseria, 1)oth sensitive to lincomycin. For the next 5 years the patient was well. In 1974, she had multiple tooth extractions. Three weeks prior to readmission she had a filling removed and replaced. Two days prior to rradmis-
Volume Number
41 1
Infected
total
hiI)
replacewed
21
xion the patient had acute pain in the left hip, and chills. She was readmitted to The Hospital for Sptqial Surgery on Feb. 3, 1975, with a temperature of 39.6” C. and a very tender left hip. Cult,ures of blood and hip aspirate grew Staphylococc~ts cl~rre~s, coagulase positive. The patient was treated with high doses of intravenous oxacillin (12 Gm. per day) for 3 weeks, but her response was not satisfactory. Incision and drainage, dbbridement, and removal of the prosthesis and cement were required on Feb. 25, 1975. This was a 4-hour procedure and required transfusion of xix units of lllood. The wound healed without complications. With intensive therapy, the patient started ambulation 3 weeks postoperatively. She was discharged after 85 days in the hospital, walking with crutches: Her hospital bill for the second admission was $18,720.00. CASE
3
A 62-year-old man underwent a left THR (Ring type, uncemented) on June 25, 1970, because of painful osteoarthritis. Four and one-half years previously, he had undergone an intrrtrochanteric osteotomy to the left hip because of the same condition. This latter procedure was covered preoperatively and postoperatively with a total of 2 weeks of nafcillin. At the time of the left THR, microbial cultures of the hip were negative. The patient received antibiotics for 3 weeks after the THR. He remained intermittently febrile, with a temperature always below 38.0” C., for 15 days postoperatively but was then afebrile. The wound healed well and the patient was discharged, free of pain. Worth noting is the fact that the patient underwent a right hip osteotomy in January, 1967, 1 year after the left hip osteotomy, and a right THR (Ring type, uncemented) in February, 19i0, 4 months prior to the left THR. The postopeative courses were benign. In March, 1972, 22 months after the left THR, root canal surgery was required I)ecnuse of an abscess. After this operation the patient received oral penicillin G for 4 days. The abscess was not cultured. Eight months later, in November and December, 1972, the patient had six additional dental sessions, one of which was covered with an antibiotic. At this time he began to have an aching pain in the left hip. He was not disabled and remained ambulatory until May 7, 1973, when he experienced severe pain in the left hip, fever, chills, and myalgias. Hr was admitted to The Hospital for Special Surgery with a temperature of 39.5” C. and a very tender left hip. Cultures of blood, sputum, urine, and hip aspirate grew het:i-hemolytie streptococcus, group G. The patient was treated with intravenous penicillin but developed pulmonary edema, and septic shock. This was controlled, but 1 week later he bled from a strf,sx ulcer and required transfusion of eleven units of blood. He then had a myocardial infarction. After :L stormy S-week course of intensive treatment, the patient became afebrile and went hornet’, on oral penicillin V. Six months later, in January, 1974, he was again admitted for removal of the loose, infected, and painful left THR, but the operation was cancelled bccause of poor cardiac status. The patient required transfer to an affiliated hospital for coronary artery bypass surgery 11crxuse of intractable angina pectoris. He improved and at recent followup is stable and afebrile, off antibiotics. He has pain in the left hip and ambulates with crutches.
DISCUSSION
These three case reports emphasize the seriousnessand crippling morbidity of an infected total hip replacement. In orthopedics, considerable efforts are being made to understand and minimize such infections.i2-13 Studies are ongoing concerning parameters such as peri-operative prophylactic antibioticP and filtered, controlled air flow in the operating room.‘“, *Ii Follow-up studies of hip endoprostheses have shown two types of deep infection: an early “acute” presentation within a few weeks or months of operation ; and a late “latent” presentation that is manifest after months or years of an apparently benign course.l”, Ii In the latter situation, the infecting organism presumably lies dormant or smoulders subclinically until activated by unknown factors.
22
Rubin,
Salvati,
Owl surg.
and Lewis
Jxnu:wy,
1976
There is certainly no proof that the three casesof infection presented in this report were caused by dental work. Surely hundreds of patients with THR’s have had dental work without known complications. Also, once infection is established, there is no way of definitely distinguishing between a metastatic and a latent type. Each case, especially Cases2 and 3 in which no aspiration was done prior to overt, symptoms of infection, may represent a latent infection acquired at the time of the original operation. Furthermore, in Case 3, only one of the bilateral THR’s became infected. However, becauseof the very long asymptomatic intervals after operation in all cases,the circumstantial association with dental work is a worrisome factor. There have been several reports of infections at sites remote from the hip, such as the kidneys, lungs, gastrointestinal tract, and teeth, causing bacteremia with possible seeding of a hip prosthesis.1s-23Metastatic infection from the urinary tract to a total knee prosthesis has been reported.‘4 If such seeding of a prosthetic implant can occur from transient bacteremia, what is the role of antibiotic prophylaxis in preventing such seeding? Should patients with a total joint replacement who are undergoing dental work be treated with antibiotics as are patients with cardiac lesions or prosthetic valves? To our knowledge, sufficient data do not exist to answer these questions definitively. Confusing the issue is the fart that, although it is standard procedure to provide antibiotic coverage for certain cardiac patients undergoing dental work, the entire concept has been called into question. In. ?(:“Adequate” antibotic coverage may be ineffetive in preventing endocarditis.” In spite of these problems, wc think that metastatic infection of a THR is a definite possibility. We believe that the morbidity of an infected THR is so devastating that the risks of antibiotic prophylaxis for dental work seemsmall in comparison. Whether future studies may show such treatment to be unnecessary and/or ineffective remains to be seen. At present, we advise our patients to inform their dentists of their total hip prostheses, and we suggest antibiotic chemoprophylaxis for dental procedures. We are grateful private cases, and
to Dr. P. D. Wilson, Jr., and Dr. B. Jacobs for to Mary Ellen Sleeman for technical assistance.
permission
to publish
their
REFERENCES 1. Rushton,
M. A. : Subacute Bacterial Endocarditis Following the Extraction of Teeth, GUY’S Hosp. Rep. 80: 39-44, 1930. 2. Archard, H. O., and Roberts, W. C.: Bacterial Endocarditis After Dental Procedures in Patients With Aortic Valve Prostheses, J. Am. Dent. Assoc. 72: 648-652, 1966. 3. Cutcher, L., Goldberg, of Bacteremia Associated With R., Lilly, E., and Jones, C.: Control Extraction of Teeth, ORAL SURG. 31: 602-605, 1971. 4. Jones, J. C., Cutcher, J. L., Goldberg, J. R., and Lilly, G. E.: Control of Bacteremia ASsociated With Extraction of Teeth, ORAL SURG. 30: 454-459, 1970. 5. Rise, E., Smith, J., and Bell, J.: Reduction of Bacteremia After Oral Manipulations, Arch. Otolaryngol. 90: 198-201, 1969. 6. Robinson, L., Kraus, F. W., Lazansky, J. P., Wheeler, R. E., Gordon, S., ant1 Johnson, V.: Bacteremias of Dental Origin. I. Revlew of the Literature, ORAL SURG. 3: 519-531, 1950. 7. Robinson, Wheeler, R. E., Gordon, S., and Johnson, L., Kraus, F. W., Lazansky, J. P., V.: Rxcteremias of Dental Origin. II. A Study of Factors Influencing Occurrence and Detection, ORAL BURG. 3: 923-936, 1950, 8. Sconyers, Relationship of Bacteremia to J. R:, Crawford, J. J., and Moriarty, J. D.: Toothhrushing rn Patients With Periodontitis, J. Am. Dent. Assoc. 87: 616-622, 1973. 9. Scopp, I. W., and Orvieto, Degerming by Povidone-Iodine Irrigation : L. D.: Gingival
Infected
10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.
total
hip replacement
23
Bacteremia Reduction in Extraction Procedures, J. Am. Dent. Assoc. 83: 1294-1296, 1971. Scopp, I. W.: Transient Bacteremia Following Dental Manipulation, Am. J. Dis. Child. 126: 270. 1973. Wiesenbangh, J. M.: Comparison of Oral Penicillin G and Clindamycin as Prophylactic Antibiotics in Oral Snraerv. ORAL BURG. 31: 302-311. 1971. Wilson. P. D.. Jr.. SalGat”i: E. A.. and Blumenfeld: E. L.: Infection in HiD Renlacement Arthroplasty. ‘Symhosium on Sur&cal Infections aid Antibiotics, Snrg. Cl&. dorth Am. 55: 1431-1437, 1975. Wilson, P. D., Jr., Salvati, E. A., Aglietti, P., and Kntner, L. T.: The Problem of Infection in Endowosthetic Snwerv of the HiD Joint. Clin. OrthoD. 96: 213-221. 1973. Rangno,LR. E. : The Rxti&ale of Aniibiotic ‘Prophylaxis >n Total Hip heplacement Arthroplasty, Clin. Orthop. 96: 206-209, 1973. Aglietti, P., Salvati, E. A.. Wilson. P. D., Jr., and Kutner. L.: Effect of a Surgical Horizontal ~nihirection&l Filtkred Ai; Flow U&t on Wou& Bacterial Contamination and Wound Healing, Clin. Orthop. 101: 99-104, 1974. Wiley, A., and Barnett, M.: Clean Surgeons and Clean Air, Clin. Orthop. 96: 168, 1973. Roles, N. C.: Infection in Total Prosthetic Replacement of the Hip and Knee Joints, Proc. R. Sot. Med. 64: 10-12, 1971. Artz, T. D., Macys, J., Salvati, E. A., Jacobs, B., and Wilson, P. D., Jr.: Hematogenons Infection of Total Hip Replacements: A Report of Four Cases, presentation to American Academy of Orthopedic Surgeons, San Francisco, California, March 2, 1975. Crness, R. L., Bickel, W. S., and von Kessler, K. L.: Infections in Total Hips Secondary to a Primary Source Elsewhere, Clin. Orthop. 106: 99-101, 1975. of Genitonrinary Tract Irvine, R., Johnson, B. L., and Amstntz, H. C.: The Relationship Procedures and Deep Sepsis After Total Hip Replacement, Burg. Gynecol. Obstet. 139: 701-706, 1974. Langenskiold, A., and Risks, E. B.: Haematogenons Salmonella Infection Around a Metal Hip Endoprosthesis, Acta. Orthop. &and. 38: 220-225, 1967. Mallory, T. H.: Sepsis in Total Hip Replacement Following Pnenmococcal Pneumonia, J. Bone Joint Snrg. [Am.] 55: 1753-1754, 1973. Parsons, D. W.: Discussion of paper: Influence of Antibiotic Therapy on Wound Inflammation and Sepsis Associated With Orthopaedic Implants: A Long-term Survey by J. T. Scales, Proc. R. Sot. Med. 64: 639-640, 1971. Hall, A. J.: Late Infection About a Total Knee Prosthesis, J. Bone Joint Snrg. [Br.] 56: 144-147. 1974. Stang, ‘J. M.: Chemoprophylaxis for Bacterial Endocarditis. Correspondence, N. Engl. J. Med. 292: 427, 1975. Weinstein, L. : Chemoproplylaxis for Bacterial Endocarditis. Correspondence, N. Engl. J. Med. 292: 427-428. 1975. Duraclf, D. T., and Littler, W. A.: Failure of “Adequate” Penicillin Therapy to Prevent Bacterial Endocarditis After Tooth Extraction, Lancet 2: 846-847, 1974.
Reprint requests to : Dr. Ednardo A. Salvati The Hospital for Special 535 East 70th St. New York, N. Y. 10021
Surgery
HOSPITBL
HOSPITAGCORNELL
FOR
SPECIAL UNIVERSITY
SURGERY, MEDICAL
AFFILIATED
and WITH
THE
NEW
YORK
COLLEGE
Three cases are reported in which there was a worrisome association between dental work and an infected total hip replacement. The patients had long asymptomatic: intervals subsequent to implantation of prosthetic hip joints. After dental procedures, infections became apparent in these hips. Such infections carry an enormous and crippling morbidity. The potential complications of transient bacteremia in the patient with a cardiac valvular prosthesis are appreciated and the importance of prophylactic antibodies for dental work in such patients is well known. Although we emphasize that, there is no proof that the infections in our patients were metastatic from the mouth, the sequence of events is suggestive. We recommend prophylarsrtir, antibiotics for dental work in the patient with a total hip replacement.
S
ince RushtonI first emphasized the association between the bacteremias of dental origin and bacterial endocarditis, an extensive literature on this phenomenon has continued to accumulate. 2-11 The potential complications of transient bacteremia to the patient with a cardiac lesion or cardiovascular prosthesis are appreciated. The importance of prophylactic antibiotics for such patients undergoing dental procedures is apparently well established. We report an association between dental procedures and infection in a noncardiovascular prosthesis in three patients under our care. Total hip replacement (THR) is an orthopedic procedure offered to selected patients with severe disease of the hip. The hip joint is resected and replaced by a prosthesis con“Resident, Orthopedic Surgery; Instructor of Surgery (Orthopedics), Cornell University Medical College. **Acting Chief, Hip Clinic; Associate Attending Orthopedic Surgeon, The Hospital for Special Surgery; Associate Professor of Orthopedic Surgery, Cornell University Medkaal College. ***Attending Prosthodontist, North Shore University Hospital and Long Island Jew&h Hillside Medical Center. Assistant Clinical Professor, State University of New York-Stony Brook.
18
Volume Number
41 1
Infected
total
hip replacement
Fig. 1. Total hip replacement prostheses. A, McKee-Farrar type used reported on. A metallic femoral component implanted in the shaft of the with a metallic acetabular component fixed to the pelvis. Both components with acrylic cement. B, Another type of prosthesis in current use employs weight polyethylene plastic acetabular component with the metallic femoral
19
in two patients femur articulates are held in place a high molecular component.
of two components: (1) a socket or acetabular portion placed in the pelvis and (2) a head or femoral portion placed in the proximal end of the femur (Figs. 1 and 2). The components are most often fixed in position with the use of polymethylmethacrylate cement. Thousands of these procedures have been performed in recent years (more than 2,500 at our center alone), and increasing numbers of patients with hip prostheses are surely being seen by dentists. One information service has reported to us that 49,000 total hip units have been sold by manufacturers in the past year alone.I2 How many of these have actually been placed in patients is unknown. Amon,0‘ the many complications possible after THR, infection is by far one of the most serious.l” sisting
CASE CASE
REPORTS 1
A (X-year-old woman underwent a right THR (cemented McKee-Farrar prosthesis) on Aug. 19, 1969, because of severe osteoarthritis, The procedure was carried out uneventfully without antibiotic prophylaxis. She did well for the next 31$ years until she had an accident and dislocated the hip. Reduction was accomplished under spinal anesthesia without difficulty. The joint was aspirated and bacterial cultures showed no growth. For the next 8 months the patient did well, but then she dislocated the hip again on Aug. 16, 1974. Reduction was achieved by manipulation as before, and the patient remained asymptomatic thereafter. In September, 1974, she began a 3-month program of dental work that consisted of restorative dentistry and the endodontic treatment of a nonvital tooth. Root canal therapy was accomplished in three viiits, without any sign of purulent substance. The last dental visit was for a final prophylaxis and scaling. At the inception of dental treatment a complete medical history was obtained. The decision made after consultation with an orthopedist was that prophylacic antibiotic therapy was not necessary. On Jan. 6, 1975, 4 weeks after the last dental work, and 5% years after
20
Rubin,
Salvati,
and Lewis
Oral January,
Surg. 1976
Fig. d. a, Case 1, Roentgenogram showing THR in place. In this case, the acrylic cemrnt had radiopaque barium sulfate in it, which allows visualization of it on the roentgenogram around the femoral stem and acetabular component. The wires on the lateral side are used to fix the greater trochanter back in place after detachment for insertion of the prosthesis. R, Roentgenogram after removal of the prosthesis Ileeause of infection. A flail, unstable hip results, with a shortened lower extremity. The patient is able t,o ambulate in this condition but only with a limp requiring the use of a walker or bilateral crutches. THR, the p:ltient, expericncrd acute pain in the right hip, and fever. She was admitted to an affiliated hospital with :I temperature of 38.8” C. and a white blood cell count of 17,300. Despite extreme pain on motion of the right hip, the roentgenograms did not reveal a dislocation. Aspiration of the hip joint yielded pus which cultured StaphyZococc~s aurcus, coagulase positive. The same organism was cultured from the blood. The patient did not improve on intensive intravenous antibiotic therapy and was transferred to The Hospital for Special Surgery. On Jan. 20, 1975, she underwent incision and drainage of the hip, complete removal of the prosthesis and cement, and dkl)ridement of infected tissue. At operation, a :Ihour procedure, approximately 1,000 C.C. of pus was encountered. The patient required transfusion of nineteen units of blood. Postoperative treatment consisted of intravenous antibiotics for 6 weeks and tracation to the leg, via a tibia1 pin, for 4 weeks. The wound healed but continued to drain from two small openings; cultured first from the drainage was Staphylococcus nureus, congulasc positive, and then Proteus mirabilis. With intensive physical therapy, the patient. became ambulatory with a walker. Sixty-two days postoperatively, the patient was able to return home. She had a flail hip and a still-draining wound. The services of a visiting nurse and close follow-up KIIXJ \vere needed. The patient’s hospital bill for the second admission was $18,390.00. At followup, 3 months post-operatively, the wound had ceased draining and the patient was free of pain. She was able to ambulate short distances indoors, with the use of a walker. CASE
2
A 5%year-old woman underwent a left THR (cemented McKee-Farrar type) on Feb. 25, 1970, for the sequelat% of juvenile rheumatoid arthritis. She received prophylactic antibiotics (oxacillin and dicloxacillin) intra- and postoperatively for ti days. Cultures of tissue from the hip joint at operation were negative. Seventeen days postoperatively the patient required operation for advanced periodontitis with abscesses. Lincomyein coverage was provided. Cultures of the abscesses grew Streptococcus and nonpathogenic Neisseria, 1)oth sensitive to lincomycin. For the next 5 years the patient was well. In 1974, she had multiple tooth extractions. Three weeks prior to readmission she had a filling removed and replaced. Two days prior to rradmis-
Volume Number
41 1
Infected
total
hiI)
replacewed
21
xion the patient had acute pain in the left hip, and chills. She was readmitted to The Hospital for Sptqial Surgery on Feb. 3, 1975, with a temperature of 39.6” C. and a very tender left hip. Cult,ures of blood and hip aspirate grew Staphylococc~ts cl~rre~s, coagulase positive. The patient was treated with high doses of intravenous oxacillin (12 Gm. per day) for 3 weeks, but her response was not satisfactory. Incision and drainage, dbbridement, and removal of the prosthesis and cement were required on Feb. 25, 1975. This was a 4-hour procedure and required transfusion of xix units of lllood. The wound healed without complications. With intensive therapy, the patient started ambulation 3 weeks postoperatively. She was discharged after 85 days in the hospital, walking with crutches: Her hospital bill for the second admission was $18,720.00. CASE
3
A 62-year-old man underwent a left THR (Ring type, uncemented) on June 25, 1970, because of painful osteoarthritis. Four and one-half years previously, he had undergone an intrrtrochanteric osteotomy to the left hip because of the same condition. This latter procedure was covered preoperatively and postoperatively with a total of 2 weeks of nafcillin. At the time of the left THR, microbial cultures of the hip were negative. The patient received antibiotics for 3 weeks after the THR. He remained intermittently febrile, with a temperature always below 38.0” C., for 15 days postoperatively but was then afebrile. The wound healed well and the patient was discharged, free of pain. Worth noting is the fact that the patient underwent a right hip osteotomy in January, 1967, 1 year after the left hip osteotomy, and a right THR (Ring type, uncemented) in February, 19i0, 4 months prior to the left THR. The postopeative courses were benign. In March, 1972, 22 months after the left THR, root canal surgery was required I)ecnuse of an abscess. After this operation the patient received oral penicillin G for 4 days. The abscess was not cultured. Eight months later, in November and December, 1972, the patient had six additional dental sessions, one of which was covered with an antibiotic. At this time he began to have an aching pain in the left hip. He was not disabled and remained ambulatory until May 7, 1973, when he experienced severe pain in the left hip, fever, chills, and myalgias. Hr was admitted to The Hospital for Special Surgery with a temperature of 39.5” C. and a very tender left hip. Cultures of blood, sputum, urine, and hip aspirate grew het:i-hemolytie streptococcus, group G. The patient was treated with intravenous penicillin but developed pulmonary edema, and septic shock. This was controlled, but 1 week later he bled from a strf,sx ulcer and required transfusion of eleven units of blood. He then had a myocardial infarction. After :L stormy S-week course of intensive treatment, the patient became afebrile and went hornet’, on oral penicillin V. Six months later, in January, 1974, he was again admitted for removal of the loose, infected, and painful left THR, but the operation was cancelled bccause of poor cardiac status. The patient required transfer to an affiliated hospital for coronary artery bypass surgery 11crxuse of intractable angina pectoris. He improved and at recent followup is stable and afebrile, off antibiotics. He has pain in the left hip and ambulates with crutches.
DISCUSSION
These three case reports emphasize the seriousnessand crippling morbidity of an infected total hip replacement. In orthopedics, considerable efforts are being made to understand and minimize such infections.i2-13 Studies are ongoing concerning parameters such as peri-operative prophylactic antibioticP and filtered, controlled air flow in the operating room.‘“, *Ii Follow-up studies of hip endoprostheses have shown two types of deep infection: an early “acute” presentation within a few weeks or months of operation ; and a late “latent” presentation that is manifest after months or years of an apparently benign course.l”, Ii In the latter situation, the infecting organism presumably lies dormant or smoulders subclinically until activated by unknown factors.
22
Rubin,
Salvati,
Owl surg.
and Lewis
Jxnu:wy,
1976
There is certainly no proof that the three casesof infection presented in this report were caused by dental work. Surely hundreds of patients with THR’s have had dental work without known complications. Also, once infection is established, there is no way of definitely distinguishing between a metastatic and a latent type. Each case, especially Cases2 and 3 in which no aspiration was done prior to overt, symptoms of infection, may represent a latent infection acquired at the time of the original operation. Furthermore, in Case 3, only one of the bilateral THR’s became infected. However, becauseof the very long asymptomatic intervals after operation in all cases,the circumstantial association with dental work is a worrisome factor. There have been several reports of infections at sites remote from the hip, such as the kidneys, lungs, gastrointestinal tract, and teeth, causing bacteremia with possible seeding of a hip prosthesis.1s-23Metastatic infection from the urinary tract to a total knee prosthesis has been reported.‘4 If such seeding of a prosthetic implant can occur from transient bacteremia, what is the role of antibiotic prophylaxis in preventing such seeding? Should patients with a total joint replacement who are undergoing dental work be treated with antibiotics as are patients with cardiac lesions or prosthetic valves? To our knowledge, sufficient data do not exist to answer these questions definitively. Confusing the issue is the fart that, although it is standard procedure to provide antibiotic coverage for certain cardiac patients undergoing dental work, the entire concept has been called into question. In. ?(:“Adequate” antibotic coverage may be ineffetive in preventing endocarditis.” In spite of these problems, wc think that metastatic infection of a THR is a definite possibility. We believe that the morbidity of an infected THR is so devastating that the risks of antibiotic prophylaxis for dental work seemsmall in comparison. Whether future studies may show such treatment to be unnecessary and/or ineffective remains to be seen. At present, we advise our patients to inform their dentists of their total hip prostheses, and we suggest antibiotic chemoprophylaxis for dental procedures. We are grateful private cases, and
to Dr. P. D. Wilson, Jr., and Dr. B. Jacobs for to Mary Ellen Sleeman for technical assistance.
permission
to publish
their
REFERENCES 1. Rushton,
M. A. : Subacute Bacterial Endocarditis Following the Extraction of Teeth, GUY’S Hosp. Rep. 80: 39-44, 1930. 2. Archard, H. O., and Roberts, W. C.: Bacterial Endocarditis After Dental Procedures in Patients With Aortic Valve Prostheses, J. Am. Dent. Assoc. 72: 648-652, 1966. 3. Cutcher, L., Goldberg, of Bacteremia Associated With R., Lilly, E., and Jones, C.: Control Extraction of Teeth, ORAL SURG. 31: 602-605, 1971. 4. Jones, J. C., Cutcher, J. L., Goldberg, J. R., and Lilly, G. E.: Control of Bacteremia ASsociated With Extraction of Teeth, ORAL SURG. 30: 454-459, 1970. 5. Rise, E., Smith, J., and Bell, J.: Reduction of Bacteremia After Oral Manipulations, Arch. Otolaryngol. 90: 198-201, 1969. 6. Robinson, L., Kraus, F. W., Lazansky, J. P., Wheeler, R. E., Gordon, S., ant1 Johnson, V.: Bacteremias of Dental Origin. I. Revlew of the Literature, ORAL SURG. 3: 519-531, 1950. 7. Robinson, Wheeler, R. E., Gordon, S., and Johnson, L., Kraus, F. W., Lazansky, J. P., V.: Rxcteremias of Dental Origin. II. A Study of Factors Influencing Occurrence and Detection, ORAL BURG. 3: 923-936, 1950, 8. Sconyers, Relationship of Bacteremia to J. R:, Crawford, J. J., and Moriarty, J. D.: Toothhrushing rn Patients With Periodontitis, J. Am. Dent. Assoc. 87: 616-622, 1973. 9. Scopp, I. W., and Orvieto, Degerming by Povidone-Iodine Irrigation : L. D.: Gingival
Infected
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hip replacement
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Bacteremia Reduction in Extraction Procedures, J. Am. Dent. Assoc. 83: 1294-1296, 1971. Scopp, I. W.: Transient Bacteremia Following Dental Manipulation, Am. J. Dis. Child. 126: 270. 1973. Wiesenbangh, J. M.: Comparison of Oral Penicillin G and Clindamycin as Prophylactic Antibiotics in Oral Snraerv. ORAL BURG. 31: 302-311. 1971. Wilson. P. D.. Jr.. SalGat”i: E. A.. and Blumenfeld: E. L.: Infection in HiD Renlacement Arthroplasty. ‘Symhosium on Sur&cal Infections aid Antibiotics, Snrg. Cl&. dorth Am. 55: 1431-1437, 1975. Wilson, P. D., Jr., Salvati, E. A., Aglietti, P., and Kntner, L. T.: The Problem of Infection in Endowosthetic Snwerv of the HiD Joint. Clin. OrthoD. 96: 213-221. 1973. Rangno,LR. E. : The Rxti&ale of Aniibiotic ‘Prophylaxis >n Total Hip heplacement Arthroplasty, Clin. Orthop. 96: 206-209, 1973. Aglietti, P., Salvati, E. A.. Wilson. P. D., Jr., and Kutner. L.: Effect of a Surgical Horizontal ~nihirection&l Filtkred Ai; Flow U&t on Wou& Bacterial Contamination and Wound Healing, Clin. Orthop. 101: 99-104, 1974. Wiley, A., and Barnett, M.: Clean Surgeons and Clean Air, Clin. Orthop. 96: 168, 1973. Roles, N. C.: Infection in Total Prosthetic Replacement of the Hip and Knee Joints, Proc. R. Sot. Med. 64: 10-12, 1971. Artz, T. D., Macys, J., Salvati, E. A., Jacobs, B., and Wilson, P. D., Jr.: Hematogenons Infection of Total Hip Replacements: A Report of Four Cases, presentation to American Academy of Orthopedic Surgeons, San Francisco, California, March 2, 1975. Crness, R. L., Bickel, W. S., and von Kessler, K. L.: Infections in Total Hips Secondary to a Primary Source Elsewhere, Clin. Orthop. 106: 99-101, 1975. of Genitonrinary Tract Irvine, R., Johnson, B. L., and Amstntz, H. C.: The Relationship Procedures and Deep Sepsis After Total Hip Replacement, Burg. Gynecol. Obstet. 139: 701-706, 1974. Langenskiold, A., and Risks, E. B.: Haematogenons Salmonella Infection Around a Metal Hip Endoprosthesis, Acta. Orthop. &and. 38: 220-225, 1967. Mallory, T. H.: Sepsis in Total Hip Replacement Following Pnenmococcal Pneumonia, J. Bone Joint Snrg. [Am.] 55: 1753-1754, 1973. Parsons, D. W.: Discussion of paper: Influence of Antibiotic Therapy on Wound Inflammation and Sepsis Associated With Orthopaedic Implants: A Long-term Survey by J. T. Scales, Proc. R. Sot. Med. 64: 639-640, 1971. Hall, A. J.: Late Infection About a Total Knee Prosthesis, J. Bone Joint Snrg. [Br.] 56: 144-147. 1974. Stang, ‘J. M.: Chemoprophylaxis for Bacterial Endocarditis. Correspondence, N. Engl. J. Med. 292: 427, 1975. Weinstein, L. : Chemoproplylaxis for Bacterial Endocarditis. Correspondence, N. Engl. J. Med. 292: 427-428. 1975. Duraclf, D. T., and Littler, W. A.: Failure of “Adequate” Penicillin Therapy to Prevent Bacterial Endocarditis After Tooth Extraction, Lancet 2: 846-847, 1974.
Reprint requests to : Dr. Ednardo A. Salvati The Hospital for Special 535 East 70th St. New York, N. Y. 10021
Surgery
