77-year-old female with a prior left total hip replacement presented with chronically draining sinuses in the groin crease and at the greater trochanter. The patient suffered from extreme hip pain for 14 months but avoided orthopaedic consultation due to fear of surgery. An acute injury occurred warranting immediate surgical intervention. Irrigation and debridement were performed and culture swabs from both sinuses revealed infection to be Staphylococcus aureus. A two-stage revision was planned due to the presence of the two chronic sinuses and virulent bacteria.
Treatment - Stage 1
All implants were removed. The well-bonded femoral implant was explanted with difficulty through an extended trochanteric osteotomy. A temporary intramedullary (IM) nail covered with vancomycin paste was placed to maintain the lumen of the fractured shaft. A thorough debridement and splaying/excision of the sinuses was performed. 20cc STIMULAN beads mixed with antibiotic was used to treat the bacterial infection at the acetabulum, along the tract of the groin crease sinus and along the entire tract length of the lateral thigh sinus. I.V. antibiotics were administered for 6 weeks after surgery, followed by a 2 week antibiotic-free time period. The CRP returned to normal limits within 4 weeks and remained low after the antibiotic holiday.
Treatment - Stage 2
At 10 weeks, revision surgery was performed with removal of the temporary IM nail and placement of a diaphyseal fitting modular femoral stem and multi-hole titanium cup.
Outcome
3 weeks after stage 1 treatment, both sinuses had healed. At 8 weeks, CRP levels returned to normal and infection was eradicated with complete absorption of STIMULAN. At 24 months, the patient lives independently, ambulates without gait aids and remains pain and infection free. Note: See STIMULAN page for regulatory statements. MA0363R1
