What is the step-by-step procedure for total hip replacement in a patient requiring wound debridement?

Total Hip Replacement with Wound Debridement: Step-by-Step Procedure

Total hip replacement in a patient requiring wound debridement should follow a structured approach that prioritizes infection control, proper wound management, and successful implantation of the prosthesis.

Pre-operative Assessment and Planning

• Evaluate patient risk factors for infection and delayed healing:
  • Diabetes mellitus, inflammatory arthritis, immunosuppressant therapy 1
  • Advanced age, poor nutritional status 2
• Review wound characteristics:
  • Duration of drainage (>5 days suggests potential deep infection) 1
  • Presence of sinus tract (pathognomonic of prosthetic joint infection) 1
• Obtain appropriate cultures:
  • Avoid superficial swabs as they are often misleading 1
  • Collect deep tissue specimens (minimum of three) 1

Surgical Approach for Infected Total Hip Replacement with Debridement

Step 1: Patient Positioning and Preparation

• Position patient in lateral decubitus or supine position depending on surgical approach
• Prepare and drape the surgical site with antiseptic solution
• Administer appropriate prophylactic antibiotics

Step 2: Initial Incision and Exposure

• Make incision along previous surgical scar if present
• Extend incision as needed to provide adequate exposure
• Carefully dissect through subcutaneous tissues
• Identify and protect neurovascular structures

Step 3: Wound Assessment and Debridement

• Thoroughly inspect the wound for:
  • Extent of infection
  • Involvement of deeper structures
  • Quality of surrounding tissues
• Perform radical debridement of all infected and necrotic tissues 1
• Collect multiple tissue samples (minimum of three) for culture and sensitivity 1
• Copiously irrigate the wound with antiseptic solution

Step 4: Prosthesis Management Decision

Based on infection assessment, choose one of the following approaches:

Option A: Debridement and Implant Retention (DAIR)

• Indicated for acute infections within 30 days of implantation or <3 weeks of symptom onset 1
• Perform thorough debridement around the prosthesis
• Exchange removable components (polyethylene liner, modular femoral head) 1
• Irrigate with antiseptic solution

Option B: One-Stage Exchange (for selected cases)

• Consider for total hip arthroplasty with:
  • Good soft tissue envelope
  • Known pathogen identity preoperatively
  • Pathogens susceptible to oral antibiotics with excellent bioavailability 1
• Remove infected prosthesis completely (including cement if present)
• Perform thorough debridement of infected tissues
• Reimplant new prosthesis during same procedure
• Consider antibiotic-impregnated bone graft to fill voids 3

Option C: Two-Stage Exchange (most common in US)

• Indicated for patients not suitable for one-stage exchange 1
• First stage:
  • Remove infected prosthesis completely
  • Perform thorough debridement
  • Insert antibiotic-impregnated cement spacer
  • Close wound in layers
• Second stage (after 2-6 weeks of antibiotic therapy):
  • Confirm infection eradication (pre-revision sedimentation rate and CRP) 1
  • Remove spacer
  • Reimplant definitive prosthesis

Step 5: Wound Closure

• Ensure meticulous hemostasis
• Close wound in layers with appropriate suture material
• Consider muscle flap coverage for complex wounds with exposure of prosthetic components 4
• Apply sterile dressing

Post-operative Management

Antibiotic Therapy

• For staphylococcal prosthetic joint infections:
  • 2-6 weeks of pathogen-specific intravenous antimicrobial therapy
  • Combined with rifampin 300-450 mg orally twice daily
  • Followed by rifampin plus companion oral drug for a total of 3 months 1

Wound Care

• Monitor wound for signs of infection or dehiscence
• Maintain wound dressing for appropriate duration
• Assess wound healing at approximately 14 days 2
• Consider delayed suture removal (14+ days) for patients with risk factors for delayed healing 2

Rehabilitation

• Begin appropriate physical therapy based on surgical procedure performed
• Adjust weight-bearing status according to procedure and implant stability

Management of Complications

Superficial Wound Dehiscence

• Perform superficial irrigation and debridement 5
• Continue appropriate antibiotic therapy
• Consider local wound care for small superficial wounds 4
• Consider delayed closure or skin graft for large superficial wounds 4

Deep Infection

• For persistent infection despite initial management:
  • Consider permanent resection arthroplasty for:
    • Non-ambulatory patients
    • Limited bone stock
    • Poor soft tissue coverage
    • Highly resistant organisms
    • Multiple failed previous exchanges 1
  • Consider amputation as last resort in selected cases 1

Follow-up

• Regular clinical and radiological assessment
• Monitor inflammatory markers (ESR, CRP)
• Evaluate for signs of infection recurrence
• Assess functional outcomes using standardized scores

By following this structured approach, the surgeon can optimize outcomes for patients requiring total hip replacement with wound debridement, prioritizing infection control while maintaining joint function and quality of life.