{"id":33857,"date":"2020-08-21T08:49:34","date_gmt":"2020-08-21T14:49:34","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=33857"},"modified":"2023-08-23T10:25:01","modified_gmt":"2023-08-23T16:25:01","slug":"hip-revision-surgery-solves-infection","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/hip-revision-surgery-solves-infection\/","title":{"rendered":"With hip revision surgery, second time\u2019s a charm."},"content":{"rendered":"
<\/div>
\"black
Blake Learned rides his mountain bike near Moab, Utah, in 2019. The prosthetic hip that enabled such adventures would, after a nasty fall and subsequent infection, need replacing. Photo courtesy of Blake Learned<\/figcaption><\/figure>\n

He had been up and down ladders thousands of times over the half century he had climbed the ladder of the construction business. Blake Learned had long since run his own construction company when, in June 2019, he climbed up to the roof of a custom home in progress.<\/p>\n

\u201cI made a stupid mistake and the ladder slipped,\u201d he recalled.<\/p>\n

Gravity took full advantage, yanking him down through 10 feet of fresh air with no regard for what lay beneath. Learned\u2019s right hip smashed down onto a stone ridge. The trochanter<\/a> \u2013 what most of us would call the hipbone \u2013 shattered and the skin over it tore open.<\/p>\n

That would be bad news for anyone. But with Learned, a complication would beget complications. Learned\u2019s right hip had been replaced two years before.<\/p>\n

Learned, then 70, had always been active in work and play. Running and hiking had been big parts of his life since he was a young man, and, with time, he added road and mountain biking to the mix. By 2017, he had worn out his original hip to the point that even a short hike became unbearable. He had had the hip replaced at a metro-Denver community hospital. Like most hip replacements, the surgery and recovery had gone smoothly.<\/p>\n

Infection crept into the hip<\/strong><\/h3>\n

The fall from the ladder hadn\u2019t damaged the hip replacement itself \u2013 a testament to just how solid these replacements are. Surgeons reassembled the trochanter and affixed it to the femur with two long screws. That might have been the end of the story, but the open fracture had welcomed bacteria normally locked outside the skin\u2019s protective edifice. Despite all the flushing out and the antibiotics, the hip got infected. Learned was back in the hospital a couple of weeks later. Providers drained and cleaned out the hip and put him on intravenous antibiotics for three months.<\/p>\n

\"an
An X-ray of the spacer hip. Photo courtesy Dr. Craig Hogan<\/figcaption><\/figure>\n

Learned stayed active, or tried to. But he felt more tired, especially as he worked to get back into shape on his road bike. The question of whether the problem was a recurrence of the infection got an answer in December. He spiked a fever that required a short course of antibiotics. A surgeon suggested another procedure to clean out the hip, with the caveat that it had a 50-50 chance of success.<\/p>\n

Learned decided to look elsewhere. A physician friend suggested Dr. Craig Hogan<\/a>, a University of Colorado School of Medicine and UCHealth orthopedic surgeon at UCHealth University of Colorado Hospital<\/a> on the Anschutz Medical Campus<\/a> (UCH). In clinic, Hogan told Learned that no amount of cleaning could ensure that the infection would go away.<\/p>\n

\u201cThis is textbook,\u201d he told his patient. \u201cYou have an infection, and you need to have the old hip taken out and replaced.\u201d<\/p>\n

Hip revision surgery<\/strong><\/h3>\n

It wouldn\u2019t be as straightforward as the first time around, Hogan added. As Learned well knew, getting rid of such an entrenched infection wouldn\u2019t be a matter of popping a few antibiotics.<\/p>\n

\u201cThis is like treating cancer,\u201d Hogan told Learned. \u201cWe have very good treatments. Sometimes they work; sometimes they don\u2019t.\u201d<\/p>\n

At issue was the behavior of bacteria on the metal of a prosthetic joint. After that fall off the ladder, bacteria entered the open wound and made their way to the replacement hip\u2019s titanium, where they colonized. Over time, the microbes formed a slimy layer \u2013 a biofilm \u2013 that repelled antibiotics.<\/p>\n

\u201cIn layman\u2019s terms, it\u2019s like a forcefield,\u201d Hogan explained. \u201cThe bacteria replicate then lay dormant. For some patients, the only symptom is pain.\u201d<\/p>\n

So it was for Learned. He was dubious of the prospect of major hip revision surgery. But he relented in early 2020, and hip revision surgery was scheduled for Monday, Feb. 10.<\/p>\n

\"the
It\u2019s no accident that fully 30% of Dr. Craig Hogan\u2019s joint-replacement surgeries are revisions.<\/figcaption><\/figure>\n

Hip revision surgery is tough work<\/strong><\/h3>\n

The term \u201crevision\u201d is, in the context of joint replacements, euphemistic. Over time, bones fuse into prosthetic joints, further cementing them in place \u2013 a great thing until they have to come out. Exchanging an existing prosthetic joint for a replacement is akin to having an old silver filling replaced with a modern enamel-imitating composite, but on a much larger and more invasive scale. Just as a dentist must carve into the surrounding tooth to ensure a firm hold for the new filling, a joint-replacement specialist must ream out strong, healthy femur and hip socket to ensure a solid base for the second replacement. That costs bone.<\/p>\n

Hip revision surgeries are challenging even without an infection. Learned\u2019s infection raised the stakes because the first revision offers the best chance of clearing the infection. Failure to do so, Hogan says, and \u201ca patient can be left in a situation where they\u2019re facing life without a hip joint \u2013 or even an amputation.\u201d<\/p>\n

Given the difficulty and the downside risks of such surgeries, a surgeon such as Hogan who specializes in them is an extreme rarity: fully 30% of the 550 or so surgeries he does each year are joint-replacement revisions.<\/p>\n

\u201cThese are patients who are in dire straits,\u201d Hogan said. \u201cThere are not a lot of options, and not a lot of physicians want to engage in difficult surgeries like this.\u201d<\/p>\n

Septic surprise before surgery<\/strong><\/h3>\n

By the Friday before the surgery, pain was no longer Learned\u2019s only symptom. As if the microbes decided to go out with a flourish, they ventured out of their biofilm-protected home in the hip\u2019s titanium and infected their host\u2019s blood. That triggered a high fever and chills that soon had Learned bundled into a thick down parka. This was a dangerous turn of events: sepsis and septic shock, as such infections are known, kill anywhere from<\/a> 20% to 50% of those they strike.<\/p>\n

Learned was admitted to UCH days earlier and in a far more precarious state than had been the plan.<\/p>\n

UCHealth infectious disease specialists identified the offending bacteria as Staphylococcus aureus<\/em> and started Learned on intravenous antibiotics. He had stabilized, but was still very sick, when Hogan and colleagues went to work on Feb. 10.<\/p>\n

The surgery involved roughly four hours of debridement and joint-replacement preparation. Learned lost about 2.5 liters of blood, about half the volume that had been in his body before the surgery (blood and blood-product donations backfilled it all). In place of the plastic-and-titanium hip from the original 2017 surgery, Hogan installed something called a hip spacer.<\/p>\n

This was a temporary hip joint made of stainless steel coated with antibiotic cement containing 12 times as much antibiotic as a typical intravenous dose \u2013 which Learned would also take for six solid weeks in an effort to stamp out the infection for good.<\/p>\n

Learned\u2019s hip revision involved, in fact, two surgeries.<\/p>\n

\u2018Linked for life\u2019<\/strong><\/h3>\n

The first removed his old prosthesis, cleaned out the hip, prepared the femur and hip socket for the arrival of the new hip prosthesis, and installed the hip spacer. The second, to be done three months later, would replace the spacer with a permanent titanium hip.<\/p>\n

Learned spent eight days at UCH recovering from surgery and sepsis.<\/p>\n

\u201cI\u2019ve never been so sick, and I\u2019ve never felt so just totally dependent on the care as I did when I was in there after my surgery,\u201d Learned said. \u201cThey were incredible, and they were so competent about what was going on with me.\u201d<\/p>\n

\"An
An X-ray after the hip revision surgery. Photo courtesy Dr. Craig Hogan.<\/figcaption><\/figure>\n

As it happened, the three-month wait spanned UCHealth\u2019s COVID-19 shutdown. During that time, Learned was to be at most 50% weight-bearing on his right leg, and he wasn\u2019t allowed to drive. On May 16, Hogan and his team performed the second surgery at UCHealth Broomfield Hospital<\/a>, where many UCHealth joint-replacement procedures were and are being done to minimize COVID-19 risk.<\/p>\n

That surgery was far easier on both patient and surgeon: out came the spacer and in went the new joint in a matter of a couple of hours. At two weeks, Learned was walking two miles; a month after surgery, he could walk gentle mountain trails. By early July, Hogan cleared him to ride a road bike, which Learned takes for spins on the Cherry Creek and South Platte River trails.<\/p>\n

There\u2019s still infection risk, Hogan says \u2013 up to 30% of patients such as Learned end up with reinfection, often from new bacteria that take advantage of heavy antibiotics\u2019 clearing of competing strains. The surgeon will follow Learned closely for a year and keep tabs on him for longer still.<\/p>\n

\u201cWe\u2019re basically linked for life,\u201d Hogan said. \u201cThe long-term goal is for him to have no restrictions, and to get him back to his really active lifestyle.\u201d<\/p>\n

That lifestyle won\u2019t include climbing ladders. Learned is retiring when the weather cools off again. He\u2019ll have all the more time to enjoy the roads and trails with his second new hip.<\/p>\n","protected":false},"excerpt":{"rendered":"

He had been up and down ladders thousands of times over the half century he had climbed the ladder of the construction business. Blake Learned had long since run his own construction company when, in June 2019, he climbed up to the roof of a custom home in progress. \u201cI made a stupid mistake and […]<\/p>\n","protected":false},"author":23,"featured_media":33861,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[6],"tags":[162,3063,183,9187,9167],"class_list":["post-33857","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-healthy-living","tag-infectious-diseases","tag-orthopedic-joint-replacement-preservation","tag-orthopedics","tag-readysetco","tag-specialized-services"],"acf":[],"yoast_head":"\nWith hip revision surgery, second time\u2019s a charm. - UCHealth Today<\/title>\n<meta name=\"description\" content=\"A hard fall triggered what surgeon Dr. Craig Hogan described as a joint-repair process akin to a cancer fight. 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