A 74-year-old male presented to a rural emergency department with an acute onset of right groin pain and dizziness. The patient’s chronic medical conditions included primary hypertension controlled with lisinopril, Vitamin D deficiency treated with ergocalciferol, and obesity with a BMI of 33.39. The patient reported a 35-year history of chewing tobacco use with cessation 22 years prior. The patient denied alcohol or recreational drug use. Physical exam was positive for tachypnea, hypotension, tachycardia, and bilateral lower extremity edema. Laboratory testing demonstrated toxic metabolic encephalopathy, lactic acidosis, acute kidney injury, hypomagnesemia, hyponatremia, hypochloremia, hypocalcemia, and leukocytosis. On presentation, an axial computed tomography scan of the abdomen and pelvis was also obtained, which demonstrated an abscess in the right adductor compartment measuring 9.1 × 5.8 cm and an abscess between the gluteus medius and maximus measuring 5.6 × 12.8 cm (). An X-ray of the right hip and lumbar spine was also obtained (). Initial laboratory results showed a serum C-reactive protein of 43 mg/L, erythrocyte sedimentation rate of 68 mm/h, white blood cell count of 24,000 cells/μL, and a D-dimer of 2.15 μg fibrinogen equivalent units/mL. After initial evaluation in the rural emergency department, the patient was transferred to a larger hospital for consultation by orthopedic surgery. The patient underwent several aspirations of the right hip at both the outside hospital and tertiary center. Aspirates grew methicillin-sensitive Staphylococcus aureus (MSSA) on culture with a segmented neutrophil count of 96% and a total nucleated count of 564,000/μL. These findings met the major criteria for PJI according to guidelines from the Musculoskeletal Infection Society []. At the outside hospital, the patient was started on parenteral vancomycin and meropenem after diagnosis of MSSA PJI and bacteremia. The patient underwent an urgent but limited debridement of the right hip joint space with the placement of calcium sulfate antibiotic beads. This hospitalization was complicated by lung atelectasis, ileus, anasarca, and severe electrolyte imbalance. Eight days after admission, the patient was transported to our tertiary care facility for further orthopedic evaluation. On arrival, consideration was given to performing an exchange arthroplasty. Despite improvements noted in the patient’s overall medical status as compared to the initial presentation, the patient remained medically frail with leukocytosis (ASA 4). A shared discussion was held with the patient and family regarding the risks and benefits of exchange arthroplasty versus DAIR. Based on this informed discussion, the decision was made to proceed with DAIR. On day 4 of admission to our tertiary hospital, the patient underwent DAIR. At our institution, the DAIR protocol involved complete synovectomy, followed by exhaustive debridement of residual synovial tissue. Tissue samples were collected aseptically for culture. Next, an antiseptic solution of povidone-iodine was used to copiously irrigate the wound. The sterile field was replaced with a clean setup. Then, we performed an aseptic exchange of the modular components--including the femoral head and acetabular liner. Calcium sulfate antibiotic beads were loaded with 1 g vancomycin and 240 mg gentamicin and inserted into the right hip joint for local delivery (). The patient was noted to have a metal-on-metal bearing joint with no metallosis. The wound was closed, and negative pressure wound therapy was applied due to concerns of delayed healing. There were no intraoperative complications. However, the patient developed a right foot drop immediately following the procedure. Once stabilized by day 18 of admission, the patient was transferred to an in-patient rehabilitation facility for daily physical and occupational therapy. Within a week, the patient’s laboratory results demonstrated up-trending leukocytosis. The patient became febrile, had worsening of a sacral decubitus ulcer, and developed warmth and redness of the rip hip surgical site, prompting readmission to the hospital for an infection workup. On readmission, the patient was diagnosed with cellulitis of the abscess drainage site in the right adductor compartment. The patient also developed vancomycin-resistant Enterococcus faecium infection of a sacral wound. Parenteral cefepime was added to the patient’s antibiotic regimen for 1 week. This readmission was complicated by anemia requiring transfusion and an acute episode of pain and edema of the right hand, concerning septic arthritis. Arthrocentesis with crystal analysis of the fluid demonstrated calcium pyrophosphate dihydrate crystal accumulation, suggestive of pseudogout due to hypomagnesemia. On day 9 of hospital readmission, pelvic imaging demonstrated repeat abscess formation in the right medial thigh. Interventional radiology removed 33 mL of purulent fluid from the right medial thigh and placed a pigtail drain. Parenteral nafcillin and oral rifampin were added to the patient’s antibiotic regiment by infectious disease consult. On day 11 of hospital readmission, the patient was discharged to another in-patient rehabilitation center with orders to receive continued parenteral antibiotic treatment and daily therapy. The pigtail drain in the right adductor compartment was removed 22 days after placement once imaging showed the resolution of the periarticular abscesses (). After regaining the ability to perform activities of daily living, the patient was discharged home at 15 weeks post-DAIR. The patient continued oral doxycycline and rifampin daily. At 6 months after the final surgery, the patient was decreased to oral doxycycline daily. At 10 months after the final surgery, infectious disease discontinued chronic antimicrobial suppression. Over the course of treatment, the patient showed normalization of inflammatory markers. The patient is ambulatory without assistance and has returned to some of their previous activities. The patient’s right foot drop persists along with atrophy and dysesthesias of the anterior lower leg. Possible etiologies of sciatic nerve injury during posterior hip exposures include direct injury, ischemia, traction, compression, and heat, among other causes. Special consideration should be taken to optimize limb placement and padding during surgery. In addition, retraction around the acetabulum must be carefully performed to reduce mechanical stress on the nerve, thus lowering the risk of iatrogenic nerve injury. The patient utilizes an ankle-foot orthosis as needed. The patient is being monitored for signs of reinfection following cessation of antibiotic therapy.