Case Report: Arthroscopic Treatment of Psoas Abscess Concurrent with Septic Arthritis of the Hip Joint

Transcription

1 Case Report: Arthroscopic Treatment of Psoas Abscess Concurrent with Septic Arthritis of the Hip Joint Pil Whan Yoon, MD*, Jeong Joon Yoo, MD, Hee Joong Kim, MD, and Kang Sup Yoon, MD* Department of Orthopedic Surgery, *Seoul National University Boramae Hospital, Seoul, South Korea, Seoul National University Hospital, Seoul, South Korea

2 Financial Disclosure No benefits in any form have been received from a commercial party related directly or indirectly.

3 Introduction Psoas abscess 1. Primary psoas abscess The cause is often unknown: trauma, distant source of infection Male : Female = 3:1 Most common in developing countries (Ricci et al. World J Surg, 1986) Most common pathogen: Staphylococcus aureus 2. Secondary psoas abscess Direct extension from an adjacent retroperitoneal or intra-abdominal infection Pathogens: often mixed E. coli and bacteroides spp (most common)

4 Purpose of This Study To describe the first case of a primary psoas abscess concurrent with septic arthritis of the hip joint treated with hip arthroscopy

5 Case Report A 62-year-old man with diabetes mellitus presented with a 3-day history of the left hip pain, rigors, and general myalgia. Fever of 38.1 C WBC count of 10,850/μL C-reactive protein of mg/dl MRI with contrast left psoas muscle swelling and lobulating cystic lesion with peripheral enhancement, and the fluid collection tracked into the left hip joint Muscle swelling Abscess tracked into the hip joint Psoas abscess Hip joint fluid collection

6 Arthroscopic Surgery Hip arthroscopic surgery on the 5 day of illness Access to the peripheral compartment w/o traction, 45 hip flexion High-volume irrigation using > 30L of normal saline and debridement of the proliferative synovial membrane and granulation tissue Anterior capsuloctomy to gain access to the iliopsoas bursa Drainage tube was placed in the hip joint and the iliopsas bursa through the defect on the anterior hip capsule. Opening at anterior capsule Access to the iliopsoas bursa Drainage tube insertion after capsulotomy Granulation tissues Femoral head

7 Postoperative Management 1. The etiologic agent: Staphylococcus aureus (from hip joint aspiration) 2. Antibiotics: Intravenous piperacillin/tazobactam for 6 weeks Oral moxifloxacin for 1 week Psoas abscess Air bubbles spreaded along psoas bursa during hip arthroscopy Decreased muscle swelling No abscess PreOp Contrast CT Contrast CT at immediate postop Contrast CT at postop 2 weeks

8 Results Hematologic and biochemical tests: normalized at 4 weeks after surgery. 12-month Follow-up The ROM in the hip joint was unrestricted and the patient did not have any particular complaint. Modified Harris hip score: 90.2 Nonarthritic hip score: PreOp X-ray PostOp 12 months

9 Discussion Management of psoas abscess Antibiotics treatment accompanied by abscess drainage CT-guided percutaneous drainage or open surgical drainage Psoas abscess concurrent with septic arthritis of the hip Joint 5 similar case reports in previous literatures Author (Journal, Year) Beredjiklian et al (Am J Orthop, 2001) Talbot et al (Injury, 2004) Treatment Emergent open I&D of the hip joint + percutaneous drainage of the prevertebral abscess Open I&D Second stage total hip arthroplasty due to pathologic hip fracture Kumagai et al (J Orthop Sci, 2005) Open I&D of both hip joint and psoas abscess Compain et al (Joint Bone Spine, 2008) Open I&D Second stage total hip arthroplasty Dala-Ali et al (J Orthop Surg Res, 2010) IV antibioitics + oral antibiotics

10 Discussion Communication of iliopsoas bursa with the hip joint The iliopsoas bursa is located near the most vulnerable portion of the anterior capsule of the hip; therefore, a defect in the anterior capsule leads to communication between the bursa and the hip joint. The hypothesized pathological mechanisms: friction from the overlying iliopsoas tendon, increased intra-articular pressure from overproduction of synovial fluid, and a weakening of the capsule resulting from wear with age or inflammatory or degenerative joint disease. Wunderbaldinger et al (Eur Radiol, 2002) A communication between this bursa and the hip joint is present in about 15% of healthy adults

11 Conclusion This is the first case of a primary psoas abscess concurrent with septic arthritis of the hip joint treated with hip arthroscopy. Arthroscopic surgery is an effective and less invasive technique for treating psoas abscess with septic arthritis of the hip joint.

12 References 1. Beredjiklian PK, Adler L, Wong K, Katz M, Yeh GL, Garino JP. Prevertebral abscess with extension into the hip joint. Am J Orthop (Belle Mead NJ) Jul;30(7): Talbot NJ, Costa S, Giles NC. Pathological hip fracture following intracapsular spread of a psoas abscess. Injury Sep;35(9): Dala-Ali BM, Lloyd MA, Janipireddy SB, Atkinson HD. A case report of a septic hip secondary to a psoas abscess. J Orthop Surg Res Sep 16;5: Kumagai K, Ushiyama T, Kawasaki T, Matsusue Y. Extension of lumbar spine infection into osteoarthritic hip through psoas abscess. J Orthop Sci. 2005;10(1): Compain C, Michou L, Orcel P, Hannouche D, Richette P. Septic arthritis of the hip with psoas abscess caused by Non-typhi Salmonella infection in an immunocompetent patient. Joint Bone Spine Jan;75(1): Toohey AK, LaSalle TL, Martinez S, Polisson RP. Iliopsoas bursitis: clinical features, radiographic findings, and disease associations. Semin Arthritis Rheum Aug;20(1): Wunderbaldinger P, Bremer C, Schellenberger E, Cejna M, Turetschek K, Kainberger F. Imaging features of iliopsoas bursitis. Eur Radiol Feb;12(2):