What is the appropriate management for a patient with increased swelling in the right thigh femur area after right hip resection arthroplasty (Girdlestone procedure)?

Management of Increased Right Thigh Swelling After Girdlestone Procedure

Immediate evaluation with ultrasound or MRI without IV contrast is essential to differentiate between hematoma, abscess, or deep infection, followed by urgent image-guided aspiration if fluid collection is identified, as infection after hip resection arthroplasty requires aggressive early intervention to prevent treatment failure and systemic complications. 1

Initial Diagnostic Approach

Clinical Assessment Priority

• Evaluate for signs of deep infection immediately: fever, wound drainage, erythema extending beyond the surgical site, and systemic inflammatory markers (elevated WBC, CRP, ESR). 1
• Assess neurovascular status of the limb to exclude compartment syndrome or vascular compromise, which can present as progressive swelling. 1
• Measure limb circumference at standardized points to quantify and track swelling progression. 2

Imaging Strategy

• Ultrasound is the first-line imaging modality for detecting fluid collections, joint effusion, and sinus tracts with 100% specificity when intraarticular effusion extends extraarticularly in the setting of infection. 1
• MRI without IV contrast (rating 7-9) is usually appropriate if ultrasound is inconclusive, as it demonstrates soft tissue edema (86.7% sensitivity), fluid collections, and can distinguish infection from hematoma. 1
• MRI features highly suggestive of infection include: intramuscular edema (86-91% accuracy), periosteal reaction, capsular edema, and enlarged lymph nodes (80% sensitivity, 86.7% specificity). 1

Definitive Diagnosis

Image-Guided Aspiration

• Joint/fluid collection aspiration is the most useful test (rating 9) for confirming or excluding infection and identifying the causative organism, with 96.4% specificity. 1
• Perform aspiration under ultrasound, fluoroscopic, or CT guidance to maximize yield and safety. 1
• Send aspirate for: cell count with differential, Gram stain, aerobic and anaerobic cultures, and consider alpha-defensin testing. 1

Management Based on Diagnosis

If Infection is Confirmed

• Early aggressive surgical debridement is mandatory within the first 2 weeks of symptom onset, as delays beyond 14 days result in universal treatment failure in chronic infections. 3
• The Girdlestone procedure effectively eradicates sepsis in 95.5% of cases when combined with thorough joint debridement, complete removal of any retained cement fragments, and prolonged IV antibiotics (4-6 weeks). 4, 5
• Surgical technique must include: copious saline irrigation, meticulous hemostasis, consideration of muscle flap (hamstring or vastus lateralis) to obliterate dead space, and placement of drains with suction irrigation until wound healing. 6, 4
• Intravenous antibiotics for 4-6 weeks are essential, tailored to culture results. 4

If Hematoma Without Infection

• Small hematomas can be managed conservatively with limb elevation, compression, and close monitoring. 1
• Large or expanding hematomas require surgical evacuation to prevent infection, compartment syndrome, or delayed wound healing. 1
• Ensure adequate hemostasis was achieved initially and check coagulation parameters, especially if patient was on anticoagulation (aspirin, clopidogrel, warfarin). 1

If Seroma or Lymphatic Fluid

• Conservative management with compression and monitoring is appropriate for small seromas. 1
• Aspiration may be required for large symptomatic collections, but carries risk of introducing infection. 1

Critical Postoperative Considerations

Fluid Management

• Hypovolemia is common postoperatively and requires prompt correction with IV fluids or encouragement of early oral intake. 1, 7
• Monitor for signs of hypovolemia: tachycardia, hypotension, decreased urine output, which can contribute to wound complications. 1, 7

Immobilization and Traction

• Maintain limb traction for 2-4 weeks postoperatively to allow soft tissue healing and prevent proximal femoral migration. 5
• Delayed mobilization (after 4 weeks) with progressive weight-bearing reduces risk of wound breakdown and recurrent infection. 5

Monitoring for Complications

• Recurrence of infection occurs in 10% of cases requiring repeat surgery, often with hyperbaric oxygen therapy. 4
• Long-term follow-up reveals 43.6% develop recurrent ulceration at average 27.3 months, necessitating ongoing surveillance. 8
• Wound breakdown occurs in 7.6% in immediate postoperative period and 30% may fail to heal requiring reoperation. 4, 8

Common Pitfalls to Avoid

• Do not delay intervention beyond 2 weeks if infection is suspected, as this universally results in treatment failure. 3
• Do not attempt component retention in the setting of chronic infection after Girdlestone procedure—this approach fails 100% of the time. 3
• Do not leave retained cement fragments in infected cases, as complete removal is necessary for infection control. 5
• Do not underestimate fluid requirements—cardiac output-guided fluid administration improves outcomes and reduces hospital stay. 1, 7