Two stage revision knee arthroplasty for infection with massive bone loss. A technique to achieve spacer stability (original) (raw)
Related papers
Antibiotic-impregnated articulating cement spacer for infected total knee arthroplasty
Indian Journal of Orthopaedics, 2011
Background: Standard treatment of chronic infected total knee arthroplasty (TKA) is a two-stage revision, the first step being placement of an antibiotic-impregnated cement spacer. Here we describe the results of a new technique (modification of the Goldstien's technique) for intraoperative manufacture of a customized articulating spacer at minimal cost and with relatively good conformity and longevity. Materials and Methods: Thirty-six infected knees underwent this procedure from June 2002 to May 2007. The technique consists of using the freshened femur and tibia interface as molds wrapped in a tin foil for manufacturing the two components of the spacer with antibiotic-impregnated methyl methycrylate cement. We used the spacer and the femoral component of the trial set of a TKA system to mold them to perfect articulation. We also reinforced the spacer with a K-wire scaffold to prevent fracture of the cement mantle in the last 21 cases. Results: All 36 knees showed excellent results in terms of infection control, mobility, and stability. There was significant improvement in the WOMAC and Knee Society Scores (20 and 39 points respectively). There were two fractures of the spacers in the initial 15 cases that did not have K-wire scaffolding but none in the last 21 that had reinforcement. Conclusion: This technique provides a more conforming spacer, with good range of motion and stability. The reinforcement helps in preventing the fracture of the cement mantle and is cost effective.
Two-stage reimplantation, with interval antibiotic-impregnated cement spacer, is the preferred treatment of prosthetic knee joint infections. In medically compromised hosts with prior failed surgeries, the outcomes are poor. Articulating spacers in such patients render the knee unstable; static spacers have risks of dislocation and extensor mechanism injury. We examined 58 infected total knee arthroplasties with extensive bone and soft tissue loss, treated with resection arthroplasty and intramedullary tibiofemoral rod and antibiotic-laden cement spacer. Thirty-seven patients underwent delayed reimplantation. Most patients (83.8%) were free from recurrent infection at mean follow-up of 29.4 months. Reinfection occurred in 16.2%, which required debridement. Twenty-one patients with poor operative risks remained with the spacer for 11.4 months. All patients, during spacer phase, had brace-free ambulation with simulated tibiofemoral fusion, without bone loss or loss of limb length
The Knee, 2010
Polymethyl methacrylate spacers are commonly used during staged revision knee arthroplasty for infection. In cases with extensive bone loss and ligament instability, such spacers may not preserve limb length, joint stability and motion. We report a retrospective case series of 19 consecutive patients using a custom-made cobalt chrome hinged spacer with antibiotic-loaded cement. The "SMILES spacer" was used at first-stage revision knee arthroplasty for chronic infection associated with a significant bone loss due to failed revision total knee replacement in 11 patients (58%), tumour endoprosthesis in four patients (21%), primary knee replacement in two patients (11%) and infected metalwork following fracture or osteotomy in a further two patients (11%). Mean follow-up was 38 months (range 24-70). In 12 (63%) patients, infection was eradicated, three patients (16%) had persistent infection and four (21%) developed further infection after initially successful second-stage surgery. Above knee amputation for persistent infection was performed in two patients. In this particularly difficult to treat population, the SMILES spacer two-stage technique has demonstrated encouraging results and presents an attractive alternative to arthrodesis or amputation.
Two-stage total infected knee arthroplasty treatment with articulating cement spacer
Archives of Orthopaedic and Trauma Surgery, 2010
Introduction The treatment of infected total knee arthroplasty (TKA) is controversial and various. Two-stage prolonged reimplantation and 6-week systemic antibiotics use have been a gold standard of treatment in recent years. Patients Seventeen knees of 17 patients, who underwent primary TKA and subsequently developed infections, were implanted articulating antibiotic-loaded cement spacer through two-stage reimplantation. In the postoperative period, parenteral antibiotic treatment targeting the specific microorganism detected in each patient was started and continued with oral administration. The mean total (parenteral and oral) antibiotic treatment time was 6.8 weeks (6–10). The spacer remained in its location until complete soft tissue recovery and normal values for laboratory parameters were achieved. The mean time interval between spacer implantation and reimplantation was 4.2 months (3–6). Results In the last follow-up examinations of the patients, conditions requiring reoperation were detected in 3 patients (17.6%). In 2 of these patients (11.7%), infection developed after a mean 1-year interval. The joint motion ranges of the patients were measured in the preoperative period, during spacer use, and following reimplantation. The mean joint motion range of the patients was 58º (12–90) in the preoperative period; in the presence of spacer between the two stages, 69º (15–100); and in the last follow-up examination after reimplantation, 95º (10–120). Conclusion Use of articulating cement spacer in the treatment of infected TKA is efficient and reliable.
The Journal of Bone and Joint Surgery (American), 2007
March 13, 2010 Supplementary Material http://www.ejbjs.org/cgi/content/full/89/4/871/DC1 Supplementary Material http://www.ejbjs.org/cgi/content/full/89/4/871/DC2 Reprints and Permissions Permissions] link. and click on the [Reprints and jbjs.org article, or locate the article citation on to use material from this order reprints or request permission Click here to ➤ Infection at the site of a total joint arthroplasty can be classified into four basic categories: Type I (early postoperative), Type II (late chronic), Type III (acute hematogenous), and Type IV (positive intraoperative cultures with clinically unapparent infection).
The use of spacers (static and mobile) in infection knee arthroplasty
Current Reviews in Musculoskeletal Medicine, 2015
Revision total knee arthroplasty (TKA) is the treatment of choice in patients with periprosthetic joint infection. It may be performed in either a single stage or two stages. In the latter option, between stages, an antibiotic-loaded spacer may be used to maintain a certain amount of joint stability and mobility after the infected implant is removed, adding an intra-articular concentration of antibiotics. There are two types of antibiotic-loaded cement spacers: static and dynamic. Static spacers basically create a temporary arthrodesis with antibiotic-loaded cement and usually are handmade within the surgical field. Dynamic spacers can be created intraoperatively by using different tools or may be prepackaged by the manufacturer; they allow range of motion between stages. In this article, the authors review the indications, surgical techniques, and results for static and dynamic spacers in two-stage revision TKA.
The Journal of Bone and Joint Surgery. British volume, 2012
Antibiotic impregnated articulating spacers are used in two-stage revision total knee arthroplasty to deliver local antibiotic therapy while preserving function. We have observed infection control in greater than 95% of cases with functional outcomes approaching those seen in revision for aseptic loosening. Higher failure has been observed with methicillin resistant organisms.
Indian Journal of Orthopaedics, 2009
Background: The routine use of antibiotic-loaded bone cement (ABLC) during primary or uninfected revision arthroplasty remains controversial. Many studies quote the total joint arthroplasty (TJA) infection rate to be less than 1%. Total knee arthroplasty (TKA) has a higher infection rate than total hip arthroplasty (THA). Based on both animal and human studies in the past, ABLC has been found effective in reducing the risk of infection in primary TJA. We are presenting retrospective analysis of results in terms of infection rate in 659 TKA performed by a single surgeon under similar conditions during 2004-2007 using CMW1 (Depuy, Leeds, UK) with premixed 1 g of gentamicin. Patients and Methods: We did primary TKA in 659 knees of 379 patients during 2004-2007 using CMW1 (Depuy, Leeds, UK) cement containing 1 g of gentamicin in 40 g of cement in a premixed form. Standard OT conditions were maintained using laminar air flow, isolation suits for the operating team, pulse lavage and disposable drapes in each patients. Midvastus approach was used in all the patients to expose the knee joint. A systemic antibiotic (third-generation cephalosporin and aminoglycoside) was used preoperatively and 48 h postoperatively. We observed the patients in terms of infection in the high-risk and low-risk group till the recent follow-up with a mean of 20.6 months (9-38 months). Results: We had deep infection in six knees in six patients and all of them required two-stage revision surgery later in the highrisk group. Infection occurred at a mean of 20.5 months after surgery earliest at 9 months and latest at 36 months after surgery. The infection rate in our study was 0.91% which is comparatively less than the reported incidence of 1-2% in reported studies. Conclusion: We conclude that the use of antibiotic loaded bone cement is one of the effective means in preventing infection in primary TJA.
Acta Scientific Orthopaedics
Background: Two stage revision for periprosthetic joint infection after total knee arthroplasty is the golden standard of treatment, but it has a large number of reinfections and outcomes of re-implantations are far from optimal. Many patients after spacer implantation are not being reimplanted during the first 6 months due to multiple reasons. Method: In this prospective study 160 patients (160 joints) who underwent two stage revision for septic knee arthroplasty were included. In all cases articulating spacers with primary metal femoral component and armed intramedullary spacers (dowels) were implanted. 4 patients were lost to follow-up within a year after the spacer implantation with confirmed infection sedation at the first follow up in 3 months after spacer implantation and were excluded from the study. Out of the rest 156 cases in 81 case liner of bone cement was used. In 75 cases we used polyethylene liner. Medical comorbidities, type of knee replacement (primary vs. revision), culture results, serum hemoglobin level, erythrocyte sedimentation rate, Knee Society Score, knee range of motion, were all recorded before the first spacer implantation, in 3 months and at the last follow-up in average 56.35±18.77 months after reimplantation or spacer with poly liner implantation. Results: After the first stage infection relapsed in 33% (N = 27) of the cases in cement liner group and in 8% (N = 6: 4 during the first 6 months after the 1 st spacer implantation and 2 later) of cases in poly liner group. At the last follow-up control over infection with functioning articulating knee was achieved in 85% and 94.7% of cases, respectively. Clinical and functional results in poly liner group were significantly better than in cement liner group at all periods of follow-up (p ≤ 0,05). Conclusion: superior results of poly liner spacers over cement liner spacers made us completely abandon cement liner spacer technique and broaden the indications for so called temporary-permanent spacers with polyethylene liner in cases of infection in the knee with possibility to achieve knee stability with non-constrained spacer. Success of temporary-permanent spacers implantation may lead us towards wider use of one stage revisions in "high risk" deep infection after knee arthroplasty.
Treatment of Infected Total Knee Arthroplasty Using an Articulating Spacer
Clinical Orthopaedics & Related Research, 2005
The primary aim of treating infected knee joints after total knee arthroplasty is to eradicate the infection, but this is difficult to achieve. We reviewed the treatment of infections that occurred after total knee arthroplasty in patients with rheumatoid arthritis. The subjects were 14 patients with rheumatoid arthritis (3 men, 11 women; ages 38-81 years) who had 14 infected knee joints. The outcome was preservation of the implant in two cases, revision arthroplasty in six cases, arthrodesis in three cases, resection arthroplasty in one case, amputation in one case, and death in one case. If there is no loosening, preservation of the implant should be attempted. If preservation is impossible, revision arthroplasty is the next best option considering the effect on daily activities in patients with the disease affecting multiple joints.