Sepsis of the hip due to pressure sore in spinal cord injured patients: advocacy for a one-stage surgical procedure

Abstract

Study design: Retrospective study reporting characteristics and management of septic arthritis of the hip due to pressure sores in spinal cord-injured patients. Objectives: To describe clinical and biological data of septic arthritis of the hip and its treating management. Setting: The database of the regional SCI referral center, Nantes, France. Methods: We retrospectively collected data from 33 cases of septic arthritis of the hip in the medical files of 26 patients. Results: We analyzed 33 cases of septic arthritis of the hip treated in one French referent center for spinal cord-injured patients from January 1988 to December 2009. Most patients had a thoracic complete paraplegia and nearly two-third (17 out of 26) had no systematic follow-up. In 25 out of 33 cases, the septic arthritis of the hip was due to a trochanteric pressure sore. The causal pressure sore was most frequently associated with a persistent drainage. The standard radiological examination led to the diagnosis in 30 cases and, in 7 questionable cases, magnetic resonance imaging was more contributory. Surgery always consisted of a wide carcinologicallike excision and of a subtrochanteric proximal femoral resection including both greater and lesser trochanters. A musculocutaneous flap was realized for all cases and the choice of the muscle depended on the localization of the causal pressure sore but also of the remaining choices, as most of the patients had already undergone a prior surgery. An antibiotic treatment was adapted to multiple samples during surgery. Conclusion: We do advocate for a one-stage procedure including a subtrochanteric proximal femoral resection and a musculocutaneous flap.

Should treatment decisions in septic arthritis of the native hip joint be based on the route of infection?

“…Patients with SA of the native hip due to CS pose the biggest challenge. If the patient is non-ambulatory a singlestage procedure (definitive Girdlestone) is advocated, which consists of proximal femur resection, filling of the dead space with a muscle flap (typically vastus lateralis) and potentially a hip-bridging external fixator for several weeks (Le Fort et al, 2015;Suda and Heppert, 2010). If the patient is ambulatory, this treatment can be combined with a spacer followed by reimplantation of a THA after the first stage appears successful.…”

External Locking Plate Fixation for Femoral Subtrochanteric Fractures

“…7 The presence of a hip bedsore could be an risk factor of septic contamination in the surrounding bone structure. Le Fort et al 26 retrospectively analysed 33 spinal cord-injured cases with septic hip arthritis and revealed that 25 (75.8%) were caused by a trochanteric pressure sore. Darouiche et al 27 evaluated 36 patients with pressure sore and six were diagnosed as osteomyelitis by pathologic examination of bone tissue.…”

Ischial and Sacral Pressure Ulcers

“…The use of prophylactic antibiotics has been debated 36,37) . The microorganisms found in pressure ulcers or during pressure ulcer surgery [38][39][40] were, in order of predominance, Staphylococcus aureus (50%), Enterococci, gram-negative bacilli like Escherichia coli and Proteus mirabilis, and anaerobic bacteria such as the Bacteroides species 17) .…”