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Clinical Focus
14 MARCH 2025 ausdoc . com . au
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Case Report
Corticosteroid caution
A patient ’ s devastating complication after a total hip replacement shows the potential danger of corticosteroid injections done in the lead-up to joint arthroplasty .
Dr Michael O ’ Sullivan Orthopaedic surgeon with an interest in primary and revision hip and knee replacement and hip arthroscopic surgery , Sydney , NSW .
A
SIXTY-five-year-old man , with no medical comorbidities , has a painful right hip that is being investigated by his GP . An MRI shows severe hip joint osteoarthritis with a large effusion and significant inflammatory changes . The radiologist , in the report , suggests the patient may benefit from an intra-articular cortisone injection . This is arranged by a locum GP , who is not aware that the patient ’ s usual GP has referred him to an orthopaedic surgeon for a surgical opinion .
The corticosteroid injection is uncomplicated , but when the patient later sees the surgeon , he does not mention he had the injection . An uncomplicated total hip arthroplasty is performed about six weeks after the injection .
On day four postop , the patient develops a haemoserous ooze from his wound .
Subsequent investigations show a large peri-articular collection and significantly elevated WCC and CRP . A washout with a liner and head exchange is performed ( that is , debridement and implant retention ). A methicillin-sensitive Staphylococcus aureus is grown from multiple cultures taken at the time of surgery . Postoperatively , this requires two months of IV antibiotics followed by oral therapy .
Discussion
Periprosthetic joint infection ( PJI ) following total knee or hip arthroplasty is a rare but devastating complication that occurs in a very small percentage of patients post-surgery . The rate of PJI within 90 days postoperatively is up to 1.3 % for total knee replacements ( TKRs ), and 1.1 % for total hip replacements . 1
According to the Australian Orthopaedic Association National Joint Replacement Registry , PJI accounts for 23.3 % of primary total hip replacement ( THR ) revisions and 27.3 % of primary TKR revisions . 2 PJI therefore remains a considerable concern for surgeons who perform joint replacement surgery .
The factors that place a patient at a higher risk of developing a PJI have been exhaustively studied . Identifying risk factors and defining and clarifying the most appropriate
diagnostic and therapeutic measures are top priorities for orthopaedic surgeons globally .
Recognised risk factors for PJI include a number of comorbid diseases ( such as poorly controlled diabetes , obesity , malignancy ,
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