Patient: 30-year-old male

History:

• Left distal femoral fracture at age 10 with underlying monostotic fibrous dysplasia (FD). Treated with osteosynthesis and bone graft.

• Pathological left femoral neck fracture at age 20. Treated with intramedullary femoral nail in another hospital.

• Developed septic arthritis 6 weeks later, treated with removal of nail, femoral head resection, and antibiotics.

• Debridement of femoral metaphysis and total hip arthroplasty (THA) with uncemented prosthesis at age 21.

• Developed PJI 3 years later, treated with debridement, removal of prosthesis, and placement of gentamicin spacer followed by cemented THA.

• Developed lymphedema and recurrent PJI 1 year later (treated with debridement and antibiotics).

• Deep vein thrombosis (DVT) of right axillary vein 6 months later (treated with anticoagulation). Diagnosed with antiphospholipid syndrome and thoracic outlet syndrome.

• Experienced two episodes of femoral component displacement within a month (reduced closed).

• Developed another PJI with draining fistulas, leading to transfer to our hospital.

Presentation:

• Pain and decreased range of motion in left hip

• Leukocytosis and elevated C-reactive protein (CRP)

• Radiographs showed osteolytic zones around prosthetic components and femoral deformity

• Two draining fistulas in left thigh

Intervention:

• Two-stage revision hip arthroplasty:

  • Stage 1: Removal of prosthesis, implantation of antibiotic spacer, debridement, and resection of fistulas.

  • Stage 2: Not performed due to severe bone defects.

• Antibiotic therapy with oxacillin followed by ciprofloxacin

Outcome:

• Improved pain and mobility

• Normalized CRP

• Persistent left leg edema

• No active fistulas

• Walking with two crutches and partial weight-bearing on left leg at 1 year follow-up

Microbiology:

• Staphylococcus aureus (resistant only to trimethoprim-sulfamethoxazole) isolated from periprosthetic tissue

Discussion:

This case highlights the challenges of managing recurrent PJI in a young patient with underlying bone pathology (FD). Despite aggressive surgical debridement and antibiotic therapy, the patient continues to experience complications. Future management options may need to be considered based on ongoing clinical status and potential for further bone reconstruction.