The patient presented himself in our orthopedic clinic 4 years after the implantation of a right hip total prosthesis. The patient was 78 years old, with a history of Stage IIIA B cell Lymphoma in remission. He has been limping with severe pain for about 2 months, walking with crutches, about two cm difference in the lower limbs. X-rays and CT scans showed signs of loosening of the prosthesis towards the pelvis. Pic 1
Before performing a revision, we decided to make a sterile puncture in the operating room under C-arm fluoroscopic control. While waiting for the result of the antibiogram, the patient was treated with an empirical antibiotic therapy and then, after finding the presence of E. Coli, with Cefotaxim 2g three times per day.
Therefore, after adequate antibiotic therapy, we decided to remove the implanted prosthesis and to substitute with Antibiotic Impregnated Cement Spacers (Gentamycin and Vancomycin). The femoral stem, the acetabular component and swabs of the muscular fascia and synovial joint fluid were sent to microbiological further analysis that did not show the growth of any germ. For this reason, after an adequate monitorization of the patient's general condition, he was discharged with an oral antibiotic therapy and full weight bearing, as tolerated by pain. Pic 2
According to guidelines, the patient should have had the implantation of the final prosthesis after 6 weeks. However, during the same period, the Covid-19 pandemic occurred and therefore, in order to plan the definitive operation, it was necessary to contact the hospital's Task Force, which allowed it only nine weeks after the spacer. (3, 6, 8)
After the implantation of the final prosthesis (Acetabular Component 62, Delta TT Company Lima Corporate and two screws 6.5, Stem 12 LCU Company Link, small head 36mm Ceramic), the postoperative course was normal, the patient was always asymptomatic, except for a mild anemia, treated with Ferric sodium gluconate for one week. The postoperative prophylaxis of the infection included a double antibiotic with Cefotaxim 2g three times per day and Rifampicin 600mg once in the evening for the following 8 weeks. Pic 3
During his second hospitalization, there were performed two pharyngeal swabs for Covid-19, both negative. The patient was asymptomatic throughout the following week. However, after a sudden worsening of the respiratory symptoms with low saturation (SpO2 87%) and severe respiratory distress, it was performed an urgent chest X-ray and then a CT scan, without evidence of pulmonary embolism but with multiple areas of ground-glass opacification patterns Pic 4. We decided to perform a Covid-19 rapid test, that resulted positive for the Covid-19 IgM and therefore the patient was transferred to the Covid observation ward, waiting for further swabs. The next two swabs were negative and therefore the patient was transferred to the Covid ward reserved for patients with negative swabs but with clinical symptoms for further treatment and one week later, after the resolution of the pulmonary symptoms, discharged at home.
Subsequent check-ups were carried out at six and ten weeks after surgery, the first one also with X-rays. In both examinations, the patient did not refer pain, the wound was dry and clean, the mobility was good and the radiography demonstrated an excellent position of the prosthesis without signs of detachment. Blood tests were always normal with regularization of CRP values.