S Boulis, A Wee, M Bowditch
loosening &, periprosthetic infection, salmonella, two-staged revision
S Boulis, A Wee, M Bowditch. A Case Report Of Salmonella Infection Of A Total Knee Replacement Following Gastrointestinal Sepsis. The Internet Journal of Orthopedic Surgery. 2005 Volume 3 Number 2.
Salmonella infection of a joint prosthesis is extremely rare. We present a case of delayed diagnosis of Salmonella enteritidis infection of a knee replacement. The infection spread to the joint during a previous episode of sepsis through haematogenous route in the absence of immunosupression.
Early recognition of haematogeous spread and early aggressive treatment are crucial to prevent development of significant loosening and joint destruction. The patient underwent a two-stage revision arthroplasty. No signs of re-infection have appeared 18 months after surgery.
Periprosthetic infection is a devastating complication in joint replacement surgery and develops in 0.5% - 2% of cases (1).
We present a case of delayed diagnosis of Salmonella infection of a knee replacement leading to prosthetic loosening and joint destruction and requiring a 2-stage revision surgery.
A 66-year-old lady with an original diagnosis of medial compartment osteoarthritis of the knee had numerous previous procedures including tibial osteotomies and a unicondylar knee replacement in 1988. The latter failed after 3 years and in 1991 she underwent a cemented knee replacement.
In April 2002 the patient was admitted as an emergency with acute upper abdominal pain, sepsis and profuse diarrhoea. Her inflammatory markers were WCC of 46, ESR of 60 and CRP of 120. Her blood and stool cultures, abdominal ultrasound and CT scans were negative. She underwent an emergency laparotomy that did not reveal a clear source of sepsis. The episode resolved post-operatively with delayed treatment with intravenous followed by oral ciprofloxacin.
In May 2002, following recovery from the abdominal sepsis, her knee started to swell and became hot especially towards the end of the day. The possibility of haematogenous spread during the previous abdominal sepsis to the knee resulting in a significant deep infection was not recognised. She was referred to our clinic in September 2004.
She presented to our clinic with severe knee pain which made her wheelchair bound. On examination, she had a sinus over the antero-medial aspect of the knee. There was a marked varus deformity of the knee.
The radiographs shown in Figure 1 reveal a loose implant with bone loss on the medial side of the femur and tibia resulting in severe mal-alignment. Previous radiographs of the knee in 2001 did not show evidence of loosening.
The inflammatory markers were raised ESR at 30 and CRP at 60. The isotope bone scan revealed increased activity. In light of these findings, she underwent a two-stage revision knee replacement. The first stage in November 2004 involved excision of the prosthesis, thorough soft tissue debridement, and insertion of articulating cement spacer. Microbiological culture of the implant and specimens were positive for
Salmonellosis may present as one of several syndromes including gastroenteritis, enteric fever or septicaemia. Most patients infected with
A prosthetic joint is at risk of bacterial infection during a period of bacteraemia through haematogenous spread of infection. This was not recognised at the time of presentation with knee problems. The cost of the delayed diagnosis from lack of early recognition and early aggressive treatment was significant loosening and joint destruction.
Although no organisms were cultured in this case in 2002, clinical improvement occurred with ciprofloxacin.
Previous case reports had described