Infected Primary Total Knee Arthroplasty Due To Aeromonas Hydrophilia. Case Report And Literature Review.
J Chow, R Freihaut
aeromonas hydrophilia, arthroplasty, infection, knee replacement
J Chow, R Freihaut. Infected Primary Total Knee Arthroplasty Due To Aeromonas Hydrophilia. Case Report And Literature Review.. The Internet Journal of Orthopedic Surgery. 2012 Volume 19 Number 2.
Wound infections by
A literature review was completed on September 9, 2011 with PubMed, Medline, EmBase and Google Scholar. The keywords
In this report we describe an unusual case of a primary total knee arthroplasty infection caused by
A 60-year-old Anglo-Saxon male with medial compartment osteoarthritis had initially consulted the orthopaedic surgeon in September 2008. He had advanced osteoarthritis on x-ray however he was not symptomatic enough for warrant a total knee arthroplasty initially. In September 2010, he returned with increasing pain, a decreased range of motion and the ability to walk only 100m. A diagnostic arthroscopy was performed and showed grade 2 changes in the patella-femoral joint, grade 4 medial compartment changes, grade 3 changes in the lateral compartment along with a torn medial meniscus. The patient was then booked for a total knee replacement in March 2011.
The patient was an active individual of average height and weigh whom sold tractors for a living. He was fit and well with nil significant past medical history and not taking any regular medications. However he was a smoker with a 30 pack year history.
The total knee arthroplasty was preformed with normal sterile precautions in regards to prepping, draping and surgical hoods. One gram of intravenous Cephazaolin was given prior to the tourniquet being inflated. A medial incision with a medial parapatella approach, standards cuts and jigs were used along with the patella not being resurfaced. A Zimmer CR flex with an uncemented femur, cemented tibia and cross-linked poly was placed. The Knee was closed with vicryl for the capsule and subcutaneous layer and staples were used for the skin. One drain was placed under the capsular layer and left for 24 hours and removed. Cephazaolin antibiotic prophylaxis for 24 hours was commenced along with Clexane as DVT prophylaxis. The patient was discharged on 100mg of aspirin and to have the dressing changed and staples to be removed by the community nurse two weeks after the surgery and to follow-up with the orthopaedic surgeon at six weeks.
When the community nurse removed the staples, an ooze on the proximal aspect of the wound was noted and a smaller dressing was placed. The patient continued to mobilise and had regular physiotherapy. He also began taking showers and baths with the dressing removed and started going into his swimming pool in his backyard immediately after the staples were removed. His home’s water supply was tank water and his pool was a salt-water swimming pool, however the water was chlorinated.
At three weeks post total knee replacement the patient noted a continual discharge from the proximal aspect of the wound, redness, swelling and fever. He presented to a peripheral hospital where swabs were taken of the discharge and he was commenced on intravenous cephazaolin 1g and told to present to Lismore Base Hospital the next day. On review by the orthopaedic team the knee was noted to be swollen with anterior cellulitis, a continual discharge from the proximal aspect of the wound and the patient had a CRP of 200 and a white cell count of 14. He was immediately taken to theatres for an open washout, synovectomy and change of the poly liner. The procedure was done under tourniquet with a longitudinal midline incision using the old scar. All the suture material was removed and frank pus was found in the superficial layers and haemoserous fluid was found in the deep layer. The specimens were sent for microbiology and thorough debridement was carried out from the superficial to the deep layer. The wound was washed out with peroxide, pulse lavage of 10 liters of normal saline and 1 liter of normal saline with Gentamicin. Gloves and drapes were then changed and using clean instruments a new poly liner was inserted. PDS was used to close the deep and superficial layers and prolene for skin. Furthermore, two drains were placed and sterile dressing was applied. He was then commenced on Cephazaolin 1g intravenous qid and ciprofloxacin 750ml intravenous bd. A PICC line was inserted with regular CRP’s commenced. The drains were removed two days post washout.
With the patients permissions samples of water were taken from the patient’s home, which included the bathroom sink tap, showerhead, and bathtub tap along with the outdoor swimming pool. The samples were then sent to the microbiology department at Lismore Base Hospital and
Only one article pertaining to
We recommend that patients should continue to dress their wounds with sterile dressings until they have completely sealed over and healed. Furthermore, due to the many households in the area using tank water, patients should avoid having baths and continue to shower with waterproof dressings until their wound has completely healed and not until 4-6 weeks after the operation should patient begin to swim in pools. Further research should be done on the safety of home water for surgical wounds because it was noted that the organisms
In conclusion, prosthesis infection is an unfortunate risk associated with primary knee arthroplasty11-13. A lot of precautions are taken preoperatively, intraoperative to prevent infection. This includes good pre-operative assessment, skin checks, sterile technique, hoods and prophylactic antibiotics12,13. However, post-operatively while the wound still is not healed precautions are left to the patient whom may not be compliant or not understand the consequences of infection. Patients should continue to dress their wounds with waterproof dressings until completely healed and not swim or soak the wound until so. Furthermore, they should also be warned about the signs of infection11 and to present to the hospital immediately so samples can be taken if infected and in this case due to the rapid and destructive nature of the organism1,2 have an early debridement and washout and be commenced on the appropriate antibiotic14 in order to have the best possible outcome in a bad situation.