With hip revision surgery, second time’s a charm.

Hip replacements usually last decades; when infection struck, a second, complex surgery saved the joint.
August 21st, 2020
black on his bike in in Moab after his first hip replacement.
Blake Learned rides his mountain bike near Moab, Utah, in 2019. The prosthetic hip that enabled such adventures would, after a nasty fall and subsequent infection, need replacing. Photo courtesy of Blake Learned

He had been up and down ladders thousands of times over the half century he had climbed the ladder of the construction business. Blake Learned had long since run his own construction company when, in June 2019, he climbed up to the roof of a custom home in progress.

“I made a stupid mistake and the ladder slipped,” he recalled.

Gravity took full advantage, yanking him down through 10 feet of fresh air with no regard for what lay beneath. Learned’s right hip smashed down onto a stone ridge. The trochanter – what most of us would call the hipbone – shattered and the skin over it tore open.

That would be bad news for anyone. But with Learned, a complication would beget complications. Learned’s right hip had been replaced two years before.

Learned, then 70, had always been active in work and play. Running and hiking had been big parts of his life since he was a young man, and, with time, he added road and mountain biking to the mix. By 2017, he had worn out his original hip to the point that even a short hike became unbearable. He had had the hip replaced at a metro-Denver community hospital. Like most hip replacements, the surgery and recovery had gone smoothly.

Infection crept into the hip

The fall from the ladder hadn’t damaged the hip replacement itself – a testament to just how solid these replacements are. Surgeons reassembled the trochanter and affixed it to the femur with two long screws. That might have been the end of the story, but the open fracture had welcomed bacteria normally locked outside the skin’s protective edifice. Despite all the flushing out and the antibiotics, the hip got infected. Learned was back in the hospital a couple of weeks later. Providers drained and cleaned out the hip and put him on intravenous antibiotics for three months.

an xray of the spacer hip
An X-ray of the spacer hip. Photo courtesy Dr. Craig Hogan

Learned stayed active, or tried to. But he felt more tired, especially as he worked to get back into shape on his road bike. The question of whether the problem was a recurrence of the infection got an answer in December. He spiked a fever that required a short course of antibiotics. A surgeon suggested another procedure to clean out the hip, with the caveat that it had a 50-50 chance of success.

Learned decided to look elsewhere. A physician friend suggested Dr. Craig Hogan, a University of Colorado School of Medicine and UCHealth orthopedic surgeon at UCHealth University of Colorado Hospital on the Anschutz Medical Campus (UCH). In clinic, Hogan told Learned that no amount of cleaning could ensure that the infection would go away.

“This is textbook,” he told his patient. “You have an infection, and you need to have the old hip taken out and replaced.”

Hip revision surgery

It wouldn’t be as straightforward as the first time around, Hogan added. As Learned well knew, getting rid of such an entrenched infection wouldn’t be a matter of popping a few antibiotics.

“This is like treating cancer,” Hogan told Learned. “We have very good treatments. Sometimes they work; sometimes they don’t.”

At issue was the behavior of bacteria on the metal of a prosthetic joint. After that fall off the ladder, bacteria entered the open wound and made their way to the replacement hip’s titanium, where they colonized. Over time, the microbes formed a slimy layer – a biofilm – that repelled antibiotics.

“In layman’s terms, it’s like a forcefield,” Hogan explained. “The bacteria replicate then lay dormant. For some patients, the only symptom is pain.”

So it was for Learned. He was dubious of the prospect of major hip revision surgery. But he relented in early 2020, and hip revision surgery was scheduled for Monday, Feb. 10.

the doctor that performed the hip revision surgery
It’s no accident that fully 30% of Dr. Craig Hogan’s joint-replacement surgeries are revisions.

Hip revision surgery is tough work

The term “revision” is, in the context of joint replacements, euphemistic. Over time, bones fuse into prosthetic joints, further cementing them in place – a great thing until they have to come out. Exchanging an existing prosthetic joint for a replacement is akin to having an old silver filling replaced with a modern enamel-imitating composite, but on a much larger and more invasive scale. Just as a dentist must carve into the surrounding tooth to ensure a firm hold for the new filling, a joint-replacement specialist must ream out strong, healthy femur and hip socket to ensure a solid base for the second replacement. That costs bone.

Hip revision surgeries are challenging even without an infection. Learned’s infection raised the stakes because the first revision offers the best chance of clearing the infection. Failure to do so, Hogan says, and “a patient can be left in a situation where they’re facing life without a hip joint – or even an amputation.”

Given the difficulty and the downside risks of such surgeries, a surgeon such as Hogan who specializes in them is an extreme rarity: fully 30% of the 550 or so surgeries he does each year are joint-replacement revisions.

“These are patients who are in dire straits,” Hogan said. “There are not a lot of options, and not a lot of physicians want to engage in difficult surgeries like this.”

Septic surprise before surgery

By the Friday before the surgery, pain was no longer Learned’s only symptom. As if the microbes decided to go out with a flourish, they ventured out of their biofilm-protected home in the hip’s titanium and infected their host’s blood. That triggered a high fever and chills that soon had Learned bundled into a thick down parka. This was a dangerous turn of events: sepsis and septic shock, as such infections are known, kill anywhere from 20% to 50% of those they strike.

Learned was admitted to UCH days earlier and in a far more precarious state than had been the plan.

UCHealth infectious disease specialists identified the offending bacteria as Staphylococcus aureus and started Learned on intravenous antibiotics. He had stabilized, but was still very sick, when Hogan and colleagues went to work on Feb. 10.

The surgery involved roughly four hours of debridement and joint-replacement preparation. Learned lost about 2.5 liters of blood, about half the volume that had been in his body before the surgery (blood and blood-product donations backfilled it all). In place of the plastic-and-titanium hip from the original 2017 surgery, Hogan installed something called a hip spacer.

This was a temporary hip joint made of stainless steel coated with antibiotic cement containing 12 times as much antibiotic as a typical intravenous dose – which Learned would also take for six solid weeks in an effort to stamp out the infection for good.

Learned’s hip revision involved, in fact, two surgeries.

‘Linked for life’

The first removed his old prosthesis, cleaned out the hip, prepared the femur and hip socket for the arrival of the new hip prosthesis, and installed the hip spacer. The second, to be done three months later, would replace the spacer with a permanent titanium hip.

Learned spent eight days at UCH recovering from surgery and sepsis.

“I’ve never been so sick, and I’ve never felt so just totally dependent on the care as I did when I was in there after my surgery,” Learned said. “They were incredible, and they were so competent about what was going on with me.”

An X-ray after the hip revision surgery
An X-ray after the hip revision surgery. Photo courtesy Dr. Craig Hogan.

As it happened, the three-month wait spanned UCHealth’s COVID-19 shutdown. During that time, Learned was to be at most 50% weight-bearing on his right leg, and he wasn’t allowed to drive. On May 16, Hogan and his team performed the second surgery at UCHealth Broomfield Hospital, where many UCHealth joint-replacement procedures were and are being done to minimize COVID-19 risk.

That surgery was far easier on both patient and surgeon: out came the spacer and in went the new joint in a matter of a couple of hours. At two weeks, Learned was walking two miles; a month after surgery, he could walk gentle mountain trails. By early July, Hogan cleared him to ride a road bike, which Learned takes for spins on the Cherry Creek and South Platte River trails.

There’s still infection risk, Hogan says – up to 30% of patients such as Learned end up with reinfection, often from new bacteria that take advantage of heavy antibiotics’ clearing of competing strains. The surgeon will follow Learned closely for a year and keep tabs on him for longer still.

“We’re basically linked for life,” Hogan said. “The long-term goal is for him to have no restrictions, and to get him back to his really active lifestyle.”

That lifestyle won’t include climbing ladders. Learned is retiring when the weather cools off again. He’ll have all the more time to enjoy the roads and trails with his second new hip.

 

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About the author

Since 2008, Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado. He was a 2007-2008 Ted Scripps Fellowship recipient in Environmental Journalism at CU.

His latest book, "The Laser That’s Changing the World," tells the story of the inventors and innovators who saw, and ultimately realized, the potential of lidar to help solve problems ranging from smokestack-pollution detection, ice-sheet mapping, disaster recovery, and, ultimately, autonomous-vehicle guidance, among many other uses. His first book, "From Jars to the Stars," recounts how Ball Aerospace evolved from an Indiana jar company - and a group of students in a University of Colorado basement - to an organization that managed to blast a sizable crater in the comet 9P/Tempel 1. "Jars" won the Colorado Book Award for History in 2012.

Todd graduated with a business degree from the University of Michigan, where he played soccer, and with a master’s degree from the Fletcher School of Law and Diplomacy at Tufts University. Before becoming a journalist at the turn of the millennium, he was an IT and strategy consultant. He once spoke fluent Japanese and still speaks fluent German.

When not writing, he spends time with teenage daughters and wife Carol, plays soccer, and allows himself to be bullied by a puggle he outweighs by a factor of seven.