The patient presented himself in our orthopedic clinic 4 years after the implantation of a right hip total prosthesis. The patient was 78 years old, with a history of stage IIIA B cell lymphoma in remission. He had been limping with severe pain for about 2 months, walking with crutches, with an about 2-cm difference in the lower limbs. Blood tests showed 11.4 × 1000/μL leukocytes, CRP at 7.53 mg/dL and ESR at 84 mm/1 h. X-rays and CT scans showed signs of loosening of the prosthesis towards the pelvis. (Fig. 1).
Before performing a revision, we decided to make a sterile puncture in the operating room under C-arm fluoroscopic control. While waiting for the result of the antibiogram, the patient was treated with an empirical antibiotic therapy. After finding the presence of E. coli, the patient was treated with Cefotaxim 2 g three times per day for 6 weeks.
Then, we decided to remove the implanted prosthesis and to substitute with antibiotic-impregnated cement spacers (Gentamycin and Vancomycin). The femoral stem, the acetabular component and swabs of the muscular fascia and synovial joint fluid were sent to microbiological laboratory for further analysis and the test did not reveal growth of any germ. For this reason, after adequate monitoring of the patient’s general condition, he was discharged with an oral antibiotic therapy prescribed and full weight bearing, since the pain was tolerable. (Fig. 2).
According to guidelines, the patient should have received the implantation of the final prosthesis after 6 weeks. However, during the same period, the COVID-19 pandemic occurred and, therefore, in order to plan the definitive operation, it was necessary to contact the hospital’s Task Force, which allowed it only 9 weeks after the spacer placement [2,3,4].
After implantation of the final prosthesis (Acetabular Component 62, Delta TT Company Lima Corporate and two screws 6.5 mm, Stem 12 LCU Company Link, small head 36 mm Ceramic), the postoperative course was uneventful, and the patient remained asymptomatic, except for a mild anemia, which was treated with Ferric sodium gluconate for 1 week. The postoperative prophylaxis of the infection included a double antibiotic protocol with Cefotaxim 2 g three times per day and Rifampicin 600 mg once in the evening for the following 8 weeks. (Fig. 3).
During his second hospital stay, two nasal-pharyngeal swab tests were performed for COVID-19, both being negative. The patient was asymptomatic for the first postoperative week. However, while the patient was in our department on the eighth postoperative day, after a sudden worsening of the respiratory symptoms with low oxygen saturation (SpO2 87%) and severe respiratory distress, an emergency chest X-ray and then a CT scan were performed, and they showed no evidence of pulmonary embolism but revealed multiple areas of ground-glass opacification (GGO) (Fig. 4).
The wound looked normal without signs of infections or dehiscence and there was no swelling or hematoma on the operated hip. We decided to perform a COVID-19 rapid test, which showed that patient was positive for COVID-19 IgM.
According to the literature [5, 6], there are no defined radiological criteria to distinguish between a pulmonary embolism and a Sars Cov-2 Infection. Moreover, pulmonary embolism (PE) is seen in a high frequency in hospital-treated patients with COVID-19, with an incidence of 30%.
At this time, we had to decide where we had to transfer our patients. As part of a Health Care Company made by 7 Hospitals, the designated Task Force decided to divide the Patients into two subtypes:
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1.
Patient who tested positive for COVID-19 (Swab test) and had clinical symptoms and/or radiological evidence of COVID-19 Disease;
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2.
Patient whose results of COVID-19 Swabs were negative but had clinical symptoms or radiological evidence for COVID-19 Disease.
The two different groups were treated similarly but in different isolation departments.
Therefore, the patient was transferred to the second one, waiting for further swab tests and further treatment. One week later, after the resolution of the pulmonary symptoms, the patient was finally discharged home.
Two subsequent check-ups were carried out 6 and 10 weeks after surgery, with the first one including X-ray examination. In both examinations, the patient did not report pain, the wound was dry and clean, the mobility was good and the radiography demonstrated an excellent position of the prosthesis without signs of detachment. Blood tests were consistently normal, with stable CRP level.
