Management of the Recalcitrant Total-Hip Arthroplasty Wound

Meland-N-Bradly. Arnold-Phillip-G. Weiss-Helmut-C. From the Section of Plastic and Reconstructive Surgery at the Mayo Clinic and Mayo Foundation. Received for publication May 24, 1990. Revised October 12, 1990. Plastic and Reconstructive Surgery. 1991 Oct. 88(4). pp 681-685. The infection rate for total-hip arthroplasty is around 1 percent. This small group is usually managed by complete removal of the prosthesis and the cement and closure over suction catheters to "collapse" the wound and eventually achieve a girdlestone arthroplasty. Occasionally, there are patients who have a persistent draining wound after this treatment and repeated efforts at wound closure. We present 27 patients who had recalcitrant, noncollapsible wounds of the hip that were present for many months to years. Twenty-eight cases of infected total-hip arthroplasties that did not respond to removal of the prosthesis and cement and closure were seen by the authors between January of 1977 and December of 1988. One patient had bilateral involvement. Average age was 64 years (range 33 to 79 years). There was an average of 4.2 previous surgical attempts at closure (range 1 to 21). Staphylococcus aureus was the most common organism, but the infections were virtually all multiple. Thirty-three muscles were utilized in 27 patients. The rectus femoris was used in 23 cases, the vastus lateralis in 8, tensor fasciae latae in 1, and combined latissimus dorsi-serratus anterior free-tissue transfers were carried out in 2. Multiple combinations of transpositions and free flaps were utilized. Follow-up ranged from 1 to 10 years, with an average of 6.4 years. Eighteen patients were ambulatory with minor degrees of pain, five ambulated with a cane, seven ambulated with a walker, six ambulated with crutches, and four ambulated unassisted, all of whom had reimplantation of their hip arthroplasty at least 12 months following the muscle flap procedure. Three did not ambulate, and in two, the ambulatory status could not be determined. All patients went on to develop a healed, noncomplicated wound. We conclude that muscle, either by direct transposition or free-tissue transfer, is an ideal choice for obliteration of this chronic, debilitating, painful wound.