What is the diagnosis for a patient with gas bubbles in the tissue after undergoing hip arthroplasty (hip replacement surgery)?

From the Guidelines

If you're experiencing gas bubbles after hip replacement surgery, this could be a sign of a serious infection called gas gangrene, which requires immediate medical attention, and treatment typically involves aggressive surgical debridement and high-dose intravenous antibiotics, such as penicillin G and clindamycin, as recommended by the Infectious Diseases Society of America 1.

Key Considerations

• Gas gangrene is a life-threatening condition that can rapidly spread and cause tissue death, sepsis, and other serious complications.
• Prompt treatment is essential to prevent these complications and improve patient outcomes.
• The diagnosis of prosthetic joint infection (PJI) can be difficult and may require a combination of clinical findings, laboratory tests, and imaging studies, as outlined in the American College of Radiology guidelines 1.
• The management of PJI often necessitates surgical interventions and prolonged courses of intravenous and oral antimicrobial therapy, as recommended by the Infectious Diseases Society of America 1.

Treatment Options

• Aggressive surgical debridement to remove infected tissue
• High-dose intravenous antibiotics, such as penicillin G at 20 million units IV q24 h or clindamycin 600-900 mg IV q8 h, as recommended by the Infectious Diseases Society of America 1
• Possibly hyperbaric oxygen therapy

Important Notes

• Don't attempt to treat this at home or delay seeking care.
• Early symptoms include severe pain around the surgical site, swelling, skin discoloration, and a crackling sensation when touching the skin.
• The bacteria thrive in low-oxygen environments and can enter through surgical wounds, making post-operative patients particularly vulnerable.
• The American Academy of Orthopaedic Surgeons (AAOS) guidelines strongly recommend the use of ESR, CRP, and serum interleukin-6 testing for patients being assessed for peri-prosthetic joint infection 1.

From the Research

Infection with Gas Bubbles after Hip Replacement Surgery

• Infection with gas bubbles after hip replacement surgery can be a serious complication, as seen in a case study from 2 where a 78-year-old woman presented with a painful total hip arthroplasty five years postoperation and was found to have air in the hip joint, which led to the discovery of a ruptured diverticulum that decompressed into the total hip arthroplasty.
• The presence of air or gas shadows in a painful total hip arthroplasty is an ominous finding and can indicate either joint sepsis with a gas-forming bacteria or communication of the joint with a hollow viscus and sepsis, as concluded by the authors of 2.
• Treatment options for periprosthetic infection after total hip replacement include single-stage exchange and two-stage exchange, with single-stage exchange being successful in eradicating periprosthetic infection and resulting in excellent functional and satisfaction scores, as seen in the study by 3.
• The use of topical vancomycin has been investigated as a means to prevent periprosthetic joint infection in hip and knee arthroplasty, with some studies suggesting its effectiveness, such as 4, while others have found it ineffective, as seen in the systematic review by 5.
• Postoperative fever after hip prosthesis implantation is a common phenomenon, but its etiological background and relation to wound infections is still unclear, as discussed in the study by 6, which found that postoperative fever is only a minor predictive factor of wound infections and that absence of fever does not mean absence of septic complications.

Prevention and Treatment

• The use of intrawound vancomycin in primary hip and knee arthroplasty has been shown to be a safe and cost-effective means to decrease early periprosthetic joint infection, as seen in the study by 4.
• The study by 4 found that the vancomycin cohort demonstrated decreased overall infection rate and PJI rate compared with the untreated group, with no statistical difference in incidence of ototoxicity or acute kidney injury.
• The cost to prevent 1 infection with the addition of intrawound vancomycin was calculated to be $816, based on the cost of vancomycin powder and calculated number needed to treat, as seen in the study by 4.