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545
Technical
Aspiration of the Hip in Patients Arth ropla sty J. Shannon
Swan,1
Ethan
M. Braunstein,2
and
William
Treated
fluoroscopy
table,
acetabulum
and the resected
sufficient
Technique If the patient has not had recent plain radiographs, we obtain an anteroposterior scout film to evaluate postoperative anatomy and to evidence
of infection.
Suspicious
findings
include
periostitis or poorly defined destruction of the resected femoral head or acetabulum. The patient is placed supine on a fluoroscopy table. The resection arthroplasty site is observed under image intensification,
and
the preferred
location
for puncture
is marked
with
marking pen or other method. The area is thoroughly draped. A needle is placed just above the approximate line
drawn
between
localization
than
one
the
is important,
may
suspect
greater
and
because
because
lesser
the
trochanters
amthroplasty
of the
site
previous
a suitable
cleansed and midpoint of a (Fig.
1). This
is more
cranial
resection
of the
femoral head and neck. The position of the femoral vessels also should be noted so that they can be avoided along with other possible complicating
structures,
such as renal transplants
and stomas.
Local anesthesia is administered. A 20-gauge spinal needle is then inserted from an anterior approach, essentially perpendicular to the
Received September 24, 1990; accepted after revision October 30, 1990. I Department of Radiology. University of Wisconsin Health Sciences Center,
depth
intervening
if needle
obtain
Medical
Center,
Room
depth
cartilaginous
placement
a single
document
spot
intraarticular
area
between
may
be
is
after
apparent
is contacted, tissue
the
is attempted
when
but often
present.
One
no may
of the needle. If no fluid is returned,
5-10
is correct.
A small
amount
of
contrast
film
after
a low-volume
placement
contrast
injection
to
of the needle (Fig. 2).
Discussion In the past 2 years, eight patients have been referred to us for preoperative evaluation. Seven men and one woman were studied; ages ranged from 38 to 70 years. All had been previously treated for infected total hip prostheses with Gimdlestone procedures followed by appropriate antibiotic regimens. We have aspirated various locations above the intertrochanteric line, because fluid return was difficult to obtain in our first few patients. We found only one location that gave consistent and sufficient fluid return, namely, the midpoint of
600 Highland
Ave.,
of Orthopedic
563-0545
Suitable
to the
Aspiration
material may be injected also. Contrast material should flow away from the needle easily. The pseudocapsule tends to have a rather linear configuration roughly paralleling the acetabular margins. We
Department
University
directed
femur.
ml of nonbacteriostatic sterile saline may be injected and aspiration repeated. Injection of saline should be accomplished with little resis-
3
Indiana
or
done with slow withdrawal
of Radiology, Indiana University Medical Center, 926 W. Michigan St., Indianapolis, Surgery,
needle
detect resistance from scar tissue only when the needle is advanced. In such cases, the proper depth must be estimated and aspiration
Department
March 1991 0361-803X/91/1
the
wall of the acetabulum osseous
2
AJR 156:545-546,
with
is achieved.
the posterior
tance
for radiologic
with Girdlestone
CapeIlo3
Aspiration of any postoperative hip may be difficult, but in a joint in which infection has occurred and arthroplasty components have been removed, obtaining fluid for culture is particularly challenging. Hips treated with Girdlestone or mesection arthroplasty should be reassessed for residual infection before revision, because the results of aspiration will influence the surgeon’s approach to the patient. We describe a technique for gaining access to the resection arthroplasty site that has been successful in our patients.
search
Note
600, 541 Clinical
© American Roentgen Ray Society
Madison,
WI 53792.
Address
IN 46202. Dr., Indianapolis,
IN 46202.
reprint
requests
to J. S. Swan.
546
SWAN
ET AL.
AJR:156,
Fig. 1.-Radiograph
of patient
March
1991
who underwent
Downloaded from www.ajronline.org by 58.49.53.28 on 11/05/15 from IP address 58.49.53.28. Copyright ARRS. For personal use only; all rights reserved
a typical modified Girdlestone arthroplasty after removal of total hip prosthesis and antibiotic treatment. Spinal needle has been placed above a point approximately bisecting intertrochanteric line (arrows).
Fig. 2.-Radiograph
shows linear appearance
of pseudocapsule after low-volume contrast injection (arrows). Flow of contrast material away from needle tip shows placement of needle in pseudocapsule.
the intertrochanteric line. Adequate fluid for bacteriologic study was obtained in all eight patients. The fluid return was always serosanguinous. Thus far, saline injection and measpiration have not been necessary. Seven patients had negative cultures at aspiration and underwent revision arthroplasty. One patient has not had a revision arthroplasty yet, but his cultures and aspiration were negative, and he has had no clinical signs of infection. When total hip arthmoplasties fail, the cause is usually related to infection or aseptic loosening. Of greater clinical concern is infection, which can be quite difficult to eradicate. Ultimate control of infection usually requires removal of the prosthetic components [1 ]. The resection arthmoplasty or Girdlestone procedure is often done as a salvage operation in these circumstances [21. The acetabulum and resected femur are allowed to articulate with one another after being rounded off at the time of component removal. In some patients this is the final treatment, assuming infection is controlled. For optimal hip function, however, a second total hip arthroplasty is necessary. Patients who are possible candidates for revision undergo a modified Girdlestone procedure in which no rounding off of the bones is done when the
components are removed [3]. Criteria for revision of the Girdlestone arthmoplasty with a second total hip arthroplasty include: freedom from infection for at least 3-6 months, initial infection by a Gram-positive organism of low virulence, and negative Gram stains at surgery [3]. In the patient with an infected total hip prosthesis, the dilemma facing the surgeon is the presence of residual infection. The radiologist plays an important mole in patients’ treatment by performing an accurate diagnostic aspiration, potentially making a diagnosis of infection without subjecting the patient to unnecessary surgery. We recommend this simple technique as an initial approach to aspiration of the hip in patients who have undergone Gimdlestone arthmoplasty.
REFERENCES 1 . Anderson
LD, Meyer
FN. Management
of infected
implants.
In: Chapman
MW, ed. Operative orthopedics. Philadelphia: Lippincott, 1988:876-882 2. Grauer JD, Amstutz HC, O’Carroll PF, Dorey FJ. Resection arthroplasty of the hips. J Bone Joint Surg [Am]
3. Colandruccio operative
RA. Arthroplasty
orthopedics.
St. Louis:
1989;71
-A: 669-678
of hips. In: Crenshaw Mosby,
1987:1456
AH. ed. Campbell’s
545
Technical
Aspiration of the Hip in Patients Arth ropla sty J. Shannon
Swan,1
Ethan
M. Braunstein,2
and
William
Treated
fluoroscopy
table,
acetabulum
and the resected
sufficient
Technique If the patient has not had recent plain radiographs, we obtain an anteroposterior scout film to evaluate postoperative anatomy and to evidence
of infection.
Suspicious
findings
include
periostitis or poorly defined destruction of the resected femoral head or acetabulum. The patient is placed supine on a fluoroscopy table. The resection arthroplasty site is observed under image intensification,
and
the preferred
location
for puncture
is marked
with
marking pen or other method. The area is thoroughly draped. A needle is placed just above the approximate line
drawn
between
localization
than
one
the
is important,
may
suspect
greater
and
because
because
lesser
the
trochanters
amthroplasty
of the
site
previous
a suitable
cleansed and midpoint of a (Fig.
1). This
is more
cranial
resection
of the
femoral head and neck. The position of the femoral vessels also should be noted so that they can be avoided along with other possible complicating
structures,
such as renal transplants
and stomas.
Local anesthesia is administered. A 20-gauge spinal needle is then inserted from an anterior approach, essentially perpendicular to the
Received September 24, 1990; accepted after revision October 30, 1990. I Department of Radiology. University of Wisconsin Health Sciences Center,
depth
intervening
if needle
obtain
Medical
Center,
Room
depth
cartilaginous
placement
a single
document
spot
intraarticular
area
between
may
be
is
after
apparent
is contacted, tissue
the
is attempted
when
but often
present.
One
no may
of the needle. If no fluid is returned,
5-10
is correct.
A small
amount
of
contrast
film
after
a low-volume
placement
contrast
injection
to
of the needle (Fig. 2).
Discussion In the past 2 years, eight patients have been referred to us for preoperative evaluation. Seven men and one woman were studied; ages ranged from 38 to 70 years. All had been previously treated for infected total hip prostheses with Gimdlestone procedures followed by appropriate antibiotic regimens. We have aspirated various locations above the intertrochanteric line, because fluid return was difficult to obtain in our first few patients. We found only one location that gave consistent and sufficient fluid return, namely, the midpoint of
600 Highland
Ave.,
of Orthopedic
563-0545
Suitable
to the
Aspiration
material may be injected also. Contrast material should flow away from the needle easily. The pseudocapsule tends to have a rather linear configuration roughly paralleling the acetabular margins. We
Department
University
directed
femur.
ml of nonbacteriostatic sterile saline may be injected and aspiration repeated. Injection of saline should be accomplished with little resis-
3
Indiana
or
done with slow withdrawal
of Radiology, Indiana University Medical Center, 926 W. Michigan St., Indianapolis, Surgery,
needle
detect resistance from scar tissue only when the needle is advanced. In such cases, the proper depth must be estimated and aspiration
Department
March 1991 0361-803X/91/1
the
wall of the acetabulum osseous
2
AJR 156:545-546,
with
is achieved.
the posterior
tance
for radiologic
with Girdlestone
CapeIlo3
Aspiration of any postoperative hip may be difficult, but in a joint in which infection has occurred and arthroplasty components have been removed, obtaining fluid for culture is particularly challenging. Hips treated with Girdlestone or mesection arthroplasty should be reassessed for residual infection before revision, because the results of aspiration will influence the surgeon’s approach to the patient. We describe a technique for gaining access to the resection arthroplasty site that has been successful in our patients.
search
Note
600, 541 Clinical
© American Roentgen Ray Society
Madison,
WI 53792.
Address
IN 46202. Dr., Indianapolis,
IN 46202.
reprint
requests
to J. S. Swan.
546
SWAN
ET AL.
AJR:156,
Fig. 1.-Radiograph
of patient
March
1991
who underwent
Downloaded from www.ajronline.org by 58.49.53.28 on 11/05/15 from IP address 58.49.53.28. Copyright ARRS. For personal use only; all rights reserved
a typical modified Girdlestone arthroplasty after removal of total hip prosthesis and antibiotic treatment. Spinal needle has been placed above a point approximately bisecting intertrochanteric line (arrows).
Fig. 2.-Radiograph
shows linear appearance
of pseudocapsule after low-volume contrast injection (arrows). Flow of contrast material away from needle tip shows placement of needle in pseudocapsule.
the intertrochanteric line. Adequate fluid for bacteriologic study was obtained in all eight patients. The fluid return was always serosanguinous. Thus far, saline injection and measpiration have not been necessary. Seven patients had negative cultures at aspiration and underwent revision arthroplasty. One patient has not had a revision arthroplasty yet, but his cultures and aspiration were negative, and he has had no clinical signs of infection. When total hip arthmoplasties fail, the cause is usually related to infection or aseptic loosening. Of greater clinical concern is infection, which can be quite difficult to eradicate. Ultimate control of infection usually requires removal of the prosthetic components [1 ]. The resection arthmoplasty or Girdlestone procedure is often done as a salvage operation in these circumstances [21. The acetabulum and resected femur are allowed to articulate with one another after being rounded off at the time of component removal. In some patients this is the final treatment, assuming infection is controlled. For optimal hip function, however, a second total hip arthroplasty is necessary. Patients who are possible candidates for revision undergo a modified Girdlestone procedure in which no rounding off of the bones is done when the
components are removed [3]. Criteria for revision of the Girdlestone arthmoplasty with a second total hip arthroplasty include: freedom from infection for at least 3-6 months, initial infection by a Gram-positive organism of low virulence, and negative Gram stains at surgery [3]. In the patient with an infected total hip prosthesis, the dilemma facing the surgeon is the presence of residual infection. The radiologist plays an important mole in patients’ treatment by performing an accurate diagnostic aspiration, potentially making a diagnosis of infection without subjecting the patient to unnecessary surgery. We recommend this simple technique as an initial approach to aspiration of the hip in patients who have undergone Gimdlestone arthmoplasty.
REFERENCES 1 . Anderson
LD, Meyer
FN. Management
of infected
implants.
In: Chapman
MW, ed. Operative orthopedics. Philadelphia: Lippincott, 1988:876-882 2. Grauer JD, Amstutz HC, O’Carroll PF, Dorey FJ. Resection arthroplasty of the hips. J Bone Joint Surg [Am]
3. Colandruccio operative
RA. Arthroplasty
orthopedics.
St. Louis:
1989;71
-A: 669-678
of hips. In: Crenshaw Mosby,
1987:1456
AH. ed. Campbell’s
