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A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?

Trunnionosis is a type of corrosion and wear at the head-neck taper junction of the femoral implant, and it can be a slow and silent catastrophe. Simultaneous prosthetic joint infection (PJI) is occasionally possible based on the fulfillment of a few of the minor criteria from the Musculoskeletal In...

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Autor principal: Jagadale, Vivek
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Cureus 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819065/
https://www.ncbi.nlm.nih.gov/pubmed/31687316
http://dx.doi.org/10.7759/cureus.5544
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author Jagadale, Vivek
author_facet Jagadale, Vivek
author_sort Jagadale, Vivek
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description Trunnionosis is a type of corrosion and wear at the head-neck taper junction of the femoral implant, and it can be a slow and silent catastrophe. Simultaneous prosthetic joint infection (PJI) is occasionally possible based on the fulfillment of a few of the minor criteria from the Musculoskeletal Infection Society (MSIS), but the existing literature lacks adequate evidence to support that the infection actually exists. We are presenting a case of an 82-year-old man with right total hip arthroplasty performed over a decade prior to presenting to the emergency room with a sudden-onset pop followed by groin pain and difficulty in walking. Radiographs showed a dissociated femoral implant at the level of trunnion with malalignment and heterotopic ossification. Metal Artifact Reduction Sequence MRI of the right hip showed mixed type-two and type-three pseudotumors, and atrophy of surrounding abductor muscles. The erythrocyte sedimentation rate was within normal limits, C-reactive protein was borderline raised, and serum cobalt-chromium levels were elevated without any signs of systemic metal toxicity. Hip joint aspirate revealed blood-stained fluid flooded with red blood cells, leukocytes and neutrophils, and a positive alpha-defensin assay. These findings were interpreted as positive for prosthetic joint infection. Intraoperatively, there was severe wear of the inferomedial aspect of the femoral head-neck junction and extensive metallosis throughout the right hip. Tissue and fluid specimens were sent for cultures, sensitivities, and histopathology for pseudotumor and infection evaluation. An articulating antibiotic spacer was then placed with the intent to perform a staged reconstruction of the femur and right acetabulum. Final synovial, bone, and soft tissue cultures, as well as histopathological photomicrograph of the tissue slides, were negative for infection. This case demonstrates the striking features of metallosis associated with trunnion failure of a metal-on-polyethylene total hip joint prosthesis that was simultaneously showing signs of prosthetic infection by satisfying the minor criteria according to the latest guidelines by the MSIS with a strikingly high cell count of red blood cells in the synovial fluid exam, indicating inflamed hyper-vascular pseudotumors vs. hemarthrosis vs. bloody tap. Diagnostic dilemma led by positive synovial fluid alpha defensin, high synovial neutrophil and white cell count results with negative final cultures or infection on histological slides raises concern that infection was not present and two-stage revision arthroplasty with six weeks of antibiotics was not necessary along with increased risk of morbidity, mortality as well as cost of care.
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spelling pubmed-68190652019-11-04 A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist? Jagadale, Vivek Cureus Infectious Disease Trunnionosis is a type of corrosion and wear at the head-neck taper junction of the femoral implant, and it can be a slow and silent catastrophe. Simultaneous prosthetic joint infection (PJI) is occasionally possible based on the fulfillment of a few of the minor criteria from the Musculoskeletal Infection Society (MSIS), but the existing literature lacks adequate evidence to support that the infection actually exists. We are presenting a case of an 82-year-old man with right total hip arthroplasty performed over a decade prior to presenting to the emergency room with a sudden-onset pop followed by groin pain and difficulty in walking. Radiographs showed a dissociated femoral implant at the level of trunnion with malalignment and heterotopic ossification. Metal Artifact Reduction Sequence MRI of the right hip showed mixed type-two and type-three pseudotumors, and atrophy of surrounding abductor muscles. The erythrocyte sedimentation rate was within normal limits, C-reactive protein was borderline raised, and serum cobalt-chromium levels were elevated without any signs of systemic metal toxicity. Hip joint aspirate revealed blood-stained fluid flooded with red blood cells, leukocytes and neutrophils, and a positive alpha-defensin assay. These findings were interpreted as positive for prosthetic joint infection. Intraoperatively, there was severe wear of the inferomedial aspect of the femoral head-neck junction and extensive metallosis throughout the right hip. Tissue and fluid specimens were sent for cultures, sensitivities, and histopathology for pseudotumor and infection evaluation. An articulating antibiotic spacer was then placed with the intent to perform a staged reconstruction of the femur and right acetabulum. Final synovial, bone, and soft tissue cultures, as well as histopathological photomicrograph of the tissue slides, were negative for infection. This case demonstrates the striking features of metallosis associated with trunnion failure of a metal-on-polyethylene total hip joint prosthesis that was simultaneously showing signs of prosthetic infection by satisfying the minor criteria according to the latest guidelines by the MSIS with a strikingly high cell count of red blood cells in the synovial fluid exam, indicating inflamed hyper-vascular pseudotumors vs. hemarthrosis vs. bloody tap. Diagnostic dilemma led by positive synovial fluid alpha defensin, high synovial neutrophil and white cell count results with negative final cultures or infection on histological slides raises concern that infection was not present and two-stage revision arthroplasty with six weeks of antibiotics was not necessary along with increased risk of morbidity, mortality as well as cost of care. Cureus 2019-08-31 /pmc/articles/PMC6819065/ /pubmed/31687316 http://dx.doi.org/10.7759/cureus.5544 Text en Copyright © 2019, Jagadale et al. http://creativecommons.org/licenses/by/3.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Infectious Disease
Jagadale, Vivek
A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?
title A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?
title_full A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?
title_fullStr A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?
title_full_unstemmed A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?
title_short A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?
title_sort case report and literature review to aid in the management of trunnion failure in hip arthroplasty patients: can trunnionosis and prosthetic joint infection co-exist?
topic Infectious Disease
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819065/
https://www.ncbi.nlm.nih.gov/pubmed/31687316
http://dx.doi.org/10.7759/cureus.5544
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