Endoprosthesis of the hip joint | Sport-Med Kraków
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Endoprosthesis of the hip joint
The incidence of postoperative infection after ACL reconstruction is reported to be 0.4 to 0.9%,. Early debridement and complete removal of the artificial implant have been reported to be very important for complete recovery from postoperative infection after ACL reconstruction. A case of prolonged infection at the tibial bone tunnel caused by residual artificial materials after ACL reconstruction is reported.
Endoprosthesis for reestablishment of knee joint …
A 24-year-old man, who had poorly managed severe atopic dermatitis, underwent double-bundle ACL reconstruction of his right knee with hybrid grafts using autologous hamstrings tendon and artificial ligaments at the age of 17 years at a local hospital. Endo-button CL® was used to fix the graft at the femoral side, and interference screws and staples were used at the tibial side. After the first surgery, severe knee pain and swelling developed suddenly, and turbid synovial fluid was obtained by joint puncture on postoperative day 17. Postoperative suppurative knee arthritis was suspected, and arthroscopic debridement was performed immediately. After the debridement, the swelling and pain of the right knee joint decreased immediately; however, wound redness and swelling subsequently developed at the right proximal lower leg where the grafts were fixed by staples and interference screws. Surgical site infection was suspected, and wound debridement with staple removal was performed 10 weeks after surgery, but the interference screws were not removed at that time. was isolated on wound culture and treated with antibiotics after the surgery. However, the wound did not heal, and a fistula eventually formed. One year after the primary surgery, second wound debridement with interference screw removal was performed, but wound infection was prolonged, and a fistula formed again. The condition was left untreated for six years, and the patient was referred to our hospital at his family’s request. At the initial visit to our hospital, a purulent discharge was observed from the fistula at the right proximal lower leg (). There were no inflammatory signs at the knee joint, and range of motion was unrestricted. There was no instability, and he did not feel any knee pain or giving way. Laboratory data showed mild elevation of C-reactive protein (CRP) at 0.32 mg/dL (). On magnetic resonance imaging (MRI), iso-intensity to the muscle on T1-weighted imaging (WI) and high intensity on T2WI were observed within the widened tibial bone tunnel, and linear-shaped low intensity areas on both T1 and T2WI were found within this area. In addition, low intensity on T1WI and high intensity on T2WI with fat-suppression were observed over an extensive area in the bone marrow at the proximal tibia surrounding the bone tunnel, but there was no area of low intensity on T2WI within the bone marrow (). These imaging findings indicated abscess formation with necrotic tissue within the tibial bone tunnel and widespread inflammation at the proximal tibia. For this reason, surgery was planned as follows: first, debridement of the tibial bone tunnel where abscess and necrotic tissue were definitively present;and second, additional extensive debridement approaching from the bone tunnel to the proximal tibia as appropriate if intraoperative findings showed spread of infection beyond the bone tunnel to the proximal tibia. Prior to the surgery, the patient was admitted to our hospital for two weeks to treat his atopic dermatitis and improve his skin condition. During the surgery, a fistula was found connected to the tibial bone tunnel, and pus was observed within the bone tunnel. When debridement was advanced further, a portion of the artificial ligament and non-absorbable suture were extracted along with the pus from the bone tunnel (). Further observation of the bone tunnel with an endoscope showed osteosclerosis of the bone tunnel wall without destruction, and no obvious communication to the surrounding bone marrow was observed. Moreover, no obvious communication between the bone tunnel and joint was also observed, which indicated that the reconstructed ligament was conserved in the joint. Bone cement mixed with vancomycin was formed into a rod shape and loaded into the bone tunnel. Skin and subcutaneous tissue around the fistula were excised, while still allowing for primary closure. The patient was treated with an antibiotic (cefazolin 6 g/day) intravenously. Since was isolated from intraoperative tissue culture, cefazolin was administered for two weeks postoperatively, and then levofloxacin was administered orally for three months. Signs of infection were not observed at the surgical site, and healing of the surgical site was achieved on postoperative day 7. CRP also rapidly returned to normal levels on postoperative day 14. The bone cement was removed at eight weeks postoperatively. On MRI, the extensive bone marrow edema at the proximal tibia had disappeared () at three months after surgery. One year after the surgery, there were no signs of infection at the surgical site and the knee joint. There was no instability, and the patient had no subjective symptoms such as pain or “giving way”. He had no limitations in activities of daily living and returned to normal activities.
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