Abstract
Prosthetic joint infection is an unfortunate though well-recognized complication of total joint arthroplasty. An iliacus and/or iliopsoas muscle abscess is a rarely documented presentation of hip prosthetic joint infection. It is thought an unrecognized retroperitoneal nidus of infection can be a source of continual seeding of the prosthetic hip joint, prolonging attempts to eradicate infection despite aggressive debridement and explant attempts. The current study presents five cases demonstrating this clinical scenario, and discusses various treatment challenges.In each case we report the patient's clinical history, pertinent imaging, management and outcome. Diagnosis of the iliacus muscle abscess was made using computed tomography imaging. In brief, the mean number of total drainage procedures (open and percutaneous) per patient was 4.2, and outcomes consisted of one patient with a hip girdlestone, two patients with delayed revisions, and two patients with retained prosthesis. All patients ended with functional pain and on oral antibiotic suppression with an average follow up of 18 months.This article highlights an iliacus muscle abscess as an unrecognized source of infection to a prosthetic hip. It demonstrates resilience to standard treatment protocols for prosthetic hip infection, and is associated with poor patient outcomes. Aggressive surgical debridement appears to remain critical to treatment success, and early retroperitoneal debridement of the abscess should be considered.
Highlights
Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty with a reported incidence of 1-3%1, 2
In the setting of hip PJI, a more unusual factor influencing treatment success is the presence of an infectious source not managed by standard debridement, such as an iliacus muscle abscess (IMA)
Computed tomography (CT) or magnetic resonance imaging (MRI) is required for diagnosis, though neither are routinely recommended by MSIS consensus guidelines in the diagnosis of PJI14
Summary
Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty with a reported incidence of 1-3%1, 2. A CT scan of the pelvis revealed a right IMA (Fig. 1A) She underwent a retroperitoneal debridement of the iliacus muscle and a hip I&D followed by an explant of all hardware. Repeat CT imaging at six weeks following antibiotic treatment revealed persistent abscess (Fig. 2B), and he underwent retroperitoneal debridement of the iliacus muscle. Due to elevated clinical suspicion, a CT scan was obtained, revealing a fluid collection in the right iliacus muscle (Fig. 3A, 3B) He underwent a spacer exchange where gross purulence was noted down into the anterior pelvic brim where the iliopsoas tendon crossed over the anterior hip capsule – decompressed thru an extra-pelvic approach. A CT scan of the pelvis revealed bilateral iliacus muscle abscesses extending into iliopsoas bursa (Fig. 5A-C) He underwent a bilateral hip prosthesis femoral head/liner exchange – intraoperative cultures grew Bacteroides fragilis. He was placed on IV antibiotics and remains on high dose oral antibiotic suppression thereafter at nine months post-op
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