‘How to deal with this, that and the other?’ An orthopaedic surgeon's unexpected encounter with a trio of problems in an elderly man

• Published in: BMJ case reports Vol. 2014; p. bcr2014206274
• Main Authors: Chen, Yongsheng, Singh, Amritpal, Long, Yiling Angeline, Chee, Yu Han
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 09.11.2014; BMJ Publishing Group
• Series: Case Report
• Subjects: 80 Years; Abscesses; Aged, 80 and over; Antibiotics; Arthroplasty, Replacement, Hip; Asia; Bacteremia - diagnosis; Bacteremia - microbiology; C-Reactive Protein - analysis; Cement; Chinese; Femoral Neck Fractures - surgery; Fractures; Hip joint; Humans; Joint surgery; Male; Orthopedics; Osteoporotic Fractures - surgery; Pain; Psoas Abscess - diagnosis; Psoas Abscess - microbiology; Staphylococcal Infections - diagnosis; Unusual Presentation of More Common Disease/Injury; Urinary tract infections; Urogenital system
• ISSN: 1757-790X; 1757-790X
• DOI: 10.1136/bcr-2014-206274

This is the first clinical report of a psoas abscess encountered during a routine hemiarthroplasty surgery for a femoral neck fracture in a man with a recent urinary tract infection. There were no prior symptoms to suggest a psoas abscess, which was present on the same side as the hip fracture, apart from a history of recurrent urinary tract infection. The surgery had to be altered intraoperatively to that of an excision arthroplasty of the displaced non-viable femoral head along with insertion of an antibiotic-impregnated cement spacer into the hip joint. Relevant microbiological studies confirmed a methicillin-sensitive Staphylococcus aureus psoas abscess with bacteraemia in addition to Staphylococcus bacteriuria, so 6 weeks of intravenous antibiotics were started. A planned second-stage hemiarthroplasty was undertaken and the patient recovered fully without complications. Primary infection of the urinary tract by S. aureus is rare. This case serves to remind clinicians that caution must be exercised in patients with recurrent infections, especially when such infections affect organs or areas close to the intended surgery site. This warrants thorough evaluation for an occult source of infection. A psoas abscess is an unusual cause of hip pain and accurate diagnosis relies on a high index of suspicion. The antibiotic-impregnated articulating cement spacer is a useful surgical adjunct after excision arthroplasty, it not only elutes a high concentration of antibiotics in the infected field, but also facilitates second-stage arthroplasty surgery by preventing muscle and soft tissue contractures from developing.