Antibiotic-impregnated Spacer Research Articles

Impact of Antibiotic-Impregnated Spacer Design in the Treatment of Periprosthetic Hip Infection.

Although 2-stage exchange arthroplasty, consisting of temporary insertion of an antibiotic-impregnated cement spacer (AICS), is considered the standard of care for chronic periprosthetic joint infection (PJI) in total hip arthroplasty (THA), a consensus on the AICS design has not yet been established. Ceramic-on-polyethylene AICSs (Poly-AICS) are theorized to cause less pain and better function than cement-on-bone AICS (CemB-AICS) but use non-antibiotic-impregnated components that may harbor bacteria. This study evaluates the impact of spacer design on infection-free survivorship following THA reimplantation as well as pain and function during the interim AICS stage. A retrospective review was performed of all cases of THA PJI treated with either Poly-AICS or CemB-AICS at a single high-volume academic center. Data were collected until the final follow-up after THA reimplantation with an average follow-up duration of 2.6 years. The primary outcome was infection-free survivorship after the final reimplantation. Secondary outcomes included postoperative pain scores, opioid use, time to ambulation, length of stay, complications, and discharge disposition. A total of 99 cases (67 CemB-AICS; 32 Poly-AICS) were included. There were no baseline differences between the 2 groups. There were no differences in infection-free survivorship after reimplantation in survivorship curve comparisons (P= .122) and no differences in postoperative inpatient pain scores, opioid use, length of stay, time to ambulation, complications, or discharge disposition during the AICS stage. Patients with THA PJI treated with Poly-AICS did not have worse infection-related outcomes despite the use of non-antibiotic-impregnated components but also did not appear to have less pain or improved function during the early AICS stage.

Tibiotalar arthrodesis as treatment for septic distal tibia osteomyelitis using bone transport with a monoplanar external fixator and flap coverage. A case report

This article describes a complex case where an open tibial pilon fracture in a 39-year-old male resulted in septic pseudoarthrosis with articular involvement and skin necrosis. The infection was managed through a debridement with extended margins and an obliteration of the defect with an antibiotic-impregnated spacer. Once the infection was treated, the bone defect was filled by a bone transport procedure combined with a tibiotalar arthrodesis. The soft tissues were covered by means of a propeller flap. Although the final result of the case was satisfactory several lessons were learned, among them the need to always suspect an infection when treating open fractures in the distal tibia, the fact that a wide resection with application of local antibiotics contributes to successful management of osteomyelitis, and the usefulness of combining bone transport with flaps as a limb reconstruction procedure.

Prosthetic Knee Infection With Coagulase-Negative Staphylococcus: A Harbinger of Poor Outcomes.

Coagulase-negative staphylococci (CoNS) are biofilm-producing pathogens whose role in periprosthetic joint infection (PJI) is increasing. There is little data on the prognosis and treatment considerations in the setting of PJI. We sought to evaluate the clinical characteristics, outcomes, and complications in these patients. This is a retrospective cohort study of adult patients at a single tertiary medical center from 2009 to 2020 with culture-proven CoNS PJI after total knee arthroplasty, as diagnosed by Musculoskeletal Infection Society criteria. The primary outcome was treatment success, with failure defined as recurrent CoNS PJI, recurrent PJI with a new pathogen, and/or chronic oral antibiotic suppression at one year postoperatively. We identified 55 patients with a CoNS total knee arthroplasty PJI with a mean follow-up of 29.8 months (SD: 16.3 months). The most commonly isolated organism was Staphylococcus epidermidis (n= 36, 65.5%). The overall prevalence of methicillin resistance was 63%. Surgical treatment included surgical debridement, antibiotics, and implant retention in 25 (45.5%) cases and two-stage revision (22 articulating and eight static antibiotic-impregnated spacers). At one-year follow-up, only 47% of patients had successful management of their infection. The surgical debridement, antibiotics, and implant retention cohort had the higher rate of treatment failure (60.0%) compared to two-stage revision (46.7%). These results indicate a poor rate of success in treating CoNS PJI. This likely represents the interplay of inherent virulence through biofilm formation and decreased antibiotic efficacy.

Utilizing a Prefabricated Antibiotic-Impregnated Articular Spacer Combined With an Intramedullary Device for Significant Femoral Bone Loss in Periprosthetic Hip Infection.

Periprosthetic joint infection can be a devastating complication following total hip arthroplasty, which often requires a lengthy treatment course that is fraught with complications. There are various types of antibiotic-impregnated spacers that can be used to treat periprosthetic hip infections, with articulating spacers being utilized frequently with the goal of preserving patient range of motion and functionality. Many of these articulating spacers have pre-set sizes and stem options, which accommodate the majority of patients. However, when significant femoral bone loss is evident at the time of revision surgery, many articulating spacer options are not sufficient to provide stability, and custom modifications of available spacer constructs may be needed to fill the bony void. The goal of this article is to report a surgical technique that can be used in the salvage of failed antibiotic-impregnated spacers where severe femoral bone loss is present.

Результаты двухэтапного эндопротезирования у пациентов с перипротезной инфекцией тазобедренного сустава (ретроспективное когортное исследование)

Introduction Periprosthetic infection (PPI) is a serious challenge for orthopedic surgeons. Two-stage revision with an antibiotic-impregnated spacer is one of the most common methods for treating periprosthetic infection. Purpose To evaluate the functional results of the second stage of revision arthroplasty in patients with PPI and to determine the survival of the endoprosthesis components. Materials and methods We retrospectively studied the results of the second stage of treatment (removal of the spacer and installation of the endoprosthesis) in 23 patients admitted to the department for the period 2016–2019. All patients received a spacer during the first stage of treatment. The mean age of the patients was 53.7 ± 2.2 years. Males prevailed (91.3 %). Results Three patients developed infection recurrence in the follow-up period of 44.4 ± 1.9 months. The effectiveness of revision arthroplasty performed as the second stage of treatment was 87 %. The Harris Hip Score before the second examination was 42.3 ± 2.5 points, at the time of the last follow-up examination it was significantly higher, 78.32 ± 3.8 points (p = 0.000052; Z – 4.04). Discussion The success of two-stage revision arthroplasty is influenced by the factors associated with patients’ co-morbidities, pathogenicity of the pathogen identified at the first stage, as well as the features of the implants used and surgical tactics. Conclusion The second stage of revision arthroplasty in patients who received a spacer with an antibiotic for the treatment of periprosthetic infection at the first stage significantly improved their functional state. The Kaplan-Meier implant survival rate was 77.5 %.

Surgical Solution for Total Carpectomy due to Destructive Wrist Pan-Osteomyelitis Using a Free Femoral Condyle Osteocutaneous Flap for Wrist Arthrodesis

Osteomyelitis of the hand is rare, even more so in the carpal bones. Patients with rheumatoid arthritis (RA) have a higher infection rate overall, and up to a 14-fold increase in the incidence of septic arthritis of the hand. The destruction of immunologic barriers, such as cartilage and joint capsules, as well as the use of immunosuppressive medications will have an impact on the higher incidence of articular infections and osteomyelitis in these patients. Infection in these cases is often overlooked because of the similarity of presentation to an acute event of RA. When osteomyelitis is present, rapid and aggressive treatment should be given. Surgical debridement, lavage, and excision of necrotic bone is the best choice, followed by cemented antibiotic impregnated spacer to resolve the acute scenario. Vascularized bone grafts (VBG) can then be used for a definitive solution, as these have great biologic properties that increase the possibility of a good outcome. We hereby present a report of a wrist arthrodesis, using a free medial femoral condyle VBG for the treatment of destructive osteomyelitis of the carpal bones in a female patient with RA.

Improvement of Perioperative Management of Patients Undergoing Surgical Treatment for Hip Periprosthetic Joint Infection

Two-stage revision arthroplasty in chronic hip periprosthetic joint infection cases is the “gold standard” treatment. First stage debridement leads to large intraoperative and drainage blood loss using standard protocols for thromboprophylaxis and drainage of the surgical wound, which is a significant disadvantage of perioperative management of such patients.The aim of the study was to determine the effect of modified management protocol with delayed start of thromboprophylaxis and a short period of drainage on the blood loss and the effectiveness of debridement with antibiotic-impregnated spacer placement in patients with hip periprosthetic joint infection.Materials and Methods. A single-center prospective study was conducted. 90 patients underwent endoprosthesis components removal and antibiotic-impregnated spacer placement. Patients were divided into 3 groups: start of thromboprophylaxis before surgery and 3–4 days of drainage; start of thromboprophylaxis no earlier than 12 hours after surgery and 3–4 days of drainage; start of thromboprophylaxis no earlier than 12 hours after surgery and 1 day of drainage.Results. There was a statistically significant (p0.05) decrease of drainage and total blood loss, and transfused blood volume in cases with the delayed start of thromboprophylaxis and a short period of drainage. The proposed protocol was safe for prevention of venous thromboembolic complications and did not affect the frequency of periprosthetic hip joint infection recurrence. The effectiveness of the first stage of treatment — 89%, the second stage — 99% in 1 year after rehabilitation according to the second international consensus on musculoskeletal infection criteria.Conclusion. The modified protocol of perioperative management is an effective and safe as a blood-saving strategy and can be proposed for widespread use.

Addressing Antibiotic Hip Spacer Instability via Hybrid Screw-cement Fixation of a Constrained Liner and Cement-rebar Interface Techniques: A Technical Narrative.

Prosthetic joint infection is a challenging and devastating complication after total hip arthroplasty. The benchmark for treatment remains two-stage revision arthroplasty, in which an antibiotic-impregnated spacer is used to eradicate the infection. Although several types of spacer constructs have been described, they have historically been associated with high rates of mechanical complications, namely, dislocation, spacer fracture, and periprosthetic femur fracture. Spacer dislocation is the most common, with reported rates as high as 41%. Here, the authors present a surgical technique to improve the mechanical stability of an articulating hip spacer via a hybrid screw-cement fixation technique that allows for joint motion and weight bearing during the treatment period while minimizing the risk of mechanical failure. An additional technique is described to address acetabular bone loss, which has been associated with a higher spacer dislocation rate, through a cement-rebar interface construct.

A murine femoral ostectomy model with hardware exchange to assess antibiotic-impregnated spacers for implant-associated osteomyelitis

Implant-associated osteomyelitis is a chronic infection that complicates orthopaedic surgeries. Once infected, 50 % of patients suffer treatment failure, resulting in high healthcare costs. While various small animal models have been developed to investigate the efficacy of prophylactic and therapeutic treatments, the minute scale of murine-model bone and hardware has been prohibitive for evaluating interventions with a complete implant exchange in the setting of an infected critical defect. To address this, the aim of the present study was to develop a murine femur model in which an initial mid-diaphyseal infection was established by surgical implantation of a titanium screw contaminated with bioluminescent Staphylococcus aureus (Xen36). 7 d after the infection was established, an ostectomy was performed to remove the middle segment (3 mm flanking the infected screw hole) and a bone-cement spacer, with or without impregnated gentamicin, was secured with a plate and screws to fix the septic segmental defect. Longitudinal bioluminescent imaging revealed a significant decrease in Xen36 growth following one-stage revision, with the antibiotic-impregnated spacer treated systemically with vancomycin (p < 0.05). This result was corroborated by a significant decrease in colony forming units (CFU) recovered from spacer, bone, soft tissue and hardware 12 d post-operative (p < 0.05). However, ~ 105 CFU/g Xen36 still persisted within the bone despite a clinical therapeutic regimen. Therefore, the model enables the investigation of new therapeutic strategies to improve upon the current standard of care in a mouse model of implant-associated osteomyelitis that employs reconstruction of a critical defect.

Proposed Guidelines for the Management of ESBL in Prosthetic Joint Infections.

The aim of this paper is to establish guidelines for the management of extendedspectrum beta-lactamases (ESBL) associated prosthetic joint infections (PJI). This study reviewed 21 patients in the literature documented with ESBL associated PJI. Literature suggests that patients with ESBL PJI are stratified into either early infections (<3 weeks) or late infections (>3 weeks), for which, appropriate laboratory and imaging studies need to be completed. Favorable outcomes require a two-stage revision with an antibiotic-impregnated spacer and a prolonged course of intravenous carbapenem antibiotic.

Drug reaction with eosinophilia and systemic symptoms syndrome after total knee arthroplasty infection and placement of antibiotic spacer

Though 2-stage revision is considered the gold standard in North America for treatment of periprosthetic joint infection, complications can be associated with use of antibiotic-impregnated spacers. We present a unique case of drug reaction with eosinophilia and systemic symptoms syndrome in a patient with retained antibiotic-impregnated spacer placed for the treatment of a periprosthetic joint infection. Although drug reactions in general are common, severe drug reactions like the one described in this article are exceedingly rare. After discontinuation of intravenous antibiotics and the initiation of corticosteroids, the patient’s symptoms resolved, despite retention of the spacer. Steroid administration and supportive care may result in resolution of symptoms without the need for surgical intervention for spacer removal.

Treatment of Endoprosthetic Knee Joint Infection in the Setting of Massive Bone Loss With Fusion of Femoral and Tibial Antibiotic Rods

Chronic periprosthetic joint infection of the knee often requires staged surgical treatment combined with several weeks of intravenous antibiotic treatment. The first stage involves resection arthroplasty and placement of an antibiotic-cement spacer. A massive bone defect results from removal of a tumor-style prosthesis, introducing challenges to spacer creation and placement. This article describes a 27-year-old man who was treated 12 years prior for stage IIB osteosarcoma of the right proximal tibia with wide resection and alloprosthetic composite reconstruction. He developed chronic periprosthetic infection of the construct. Three surgical washouts and intravenous antibiotics failed to eradicate the infection, therefore 2-stage exchange arthroplasty was initiated. The first stage involved resection of all implants and allograft, and placement of a novel antibiotic-impregnated spacer. The spacer was created by locking a retrograde femoral nail and an antegrade tibial nail together at the knee joint level. This construct was then encased in antibiotic-impregnated cement to achieve fill of the massive tibial defect. After 6 weeks of intravenous antibiotic infusion, the infection was successfully eradicated and he was indicated for reimplantation arthroplasty with custom hinged knee components. Utilization of interlocked femoral and tibial nails in this manner has not been described for creating an antibiotic-laden temporary knee arthrodesis spacer as the first stage in treatment of periprosthetic joint infection. This strategy achieves stable knee fusion although avoiding violation of the hip and the complications of external fixation. Application of this technique may be particularly beneficial in the setting of massive bone loss.

Preliminary results of the tribological performance of new modular temporary knee spacer antibiotic-impregnated

PurposeAlthough total knee arthroplasty is one of the most successful and consolidated surgical procedure, the infection rate is still elevate. To treat infected knee arthroplasties, in the past years was approached a procedure that involved the implantation of an antibiotic-loaded temporary spacer. This spacer helps maintain an appropriate soft tissue envelope and the patients are able to walk during the interim period. This study investigated the tribological behavior of antibiotic-impregnated knee spacers under dynamic loading. MethodsThree temporary spacer specimens were subjected to a cyclic test on a knee wear simulator for 500,000 walking cycles under a modified international guidelines (ISO 14243). During this test we address about the evaluation of the mechanical resistance and to quantify the wear rate of the devices. All the kinematics and the axial load were set to simulate more than six months of patient use. ResultsAll the femoral and tibial specimens completed the 500,000 cycles without breakage. The wear patterns observed on the contact surfaces were similar over the specimens. ConclusionsOn the basis of the present data, the authors believe that the use of temporary antibiotic-impregnated knee spacers could be an effective wear-resistance temporary substitute of a total knee two-stage revision arthroplasty.

Calorimetric examination of hip pseudo-capsule after secondary hip surgeries

During revision hip surgeries, a soft pseudo-capsule is formed around the artificial joint. The roles of the pseudo-capsule are to protect and to stabilize the joint. Based on intraoperative observation, we have found that different types of pseudo-capsules have different thickness and elasticity, compared to the primary joint capsule. The purpose of the study was to evaluate and identify the different types of pseudo-capsules, based on thermal characteristics and histological examinations. The pseudo-capsule samples were collected during aseptic hip revision (n = 3), septic hip revision (n = 2) and during revision surgery after antibiotic-impregnated spacer implantation (n = 3). The thermal characteristics (maximal denaturation temperature, Tm, and calorimetric enthalpy change, ΔHcal) were determined from the measurements made by SETARAM Micro DSC-II calorimeter between 37° and 90°C with 0.3 K min−1 heating rate. The denaturation scans of different pseudo-capsule samples have clearly demonstrated specific, representative changes, comparing samples with aseptic and septic origins. These changes were confirmed by histological evaluations; therefore, DSC could be a useful tool in the evaluation of hip pseudo-capsules with different origins, providing further help in the differential diagnostics of septic conditions.

Two-Stage Revision Arthroplasty for the Treatment of Prosthetic Joint Infection.

To review the diagnosis and treatment of prosthetic joint infection (PJI) with a focus on two-stage revision arthroplasty. The text will discuss different spacer constructs in total knee and total hip arthroplasty and will present clinical outcome data for these various options. There is no appreciable difference in infection eradication between mobile and static antibiotic spacers. Mobile spacers have shown improved knee range of motion after second-stage re-implantation. Two-stage revision arthroplasty is the gold standard treatment for PJI. The first stage involves removal of all components, cement, and compromised soft tissues with placement of an antibiotic-impregnated spacer. Spacer options include both mobile and static spacers. Mobile spacers offer maintenance of ambulation and joint range of motion between staged procedures and have shown to be as effective in eradicating infection as static spacers.

Two-Stage Reimplantation in Infected Total Knee Arthroplasty.

Two-stage reimplantation is considered the gold standard for the management of periprosthetic joint infection. The first stage involves the removal of the prosthesis, followed by extensive debridement of all nonviable tissues, synovectomy, irrigation, and reaming of the medullary canals. Once the joint has been prepared, antibiotic-impregnated cement beads and/or spacer are inserted. Antibiotic-impregnated spacers are now more commonly used, and an increasing number of orthopaedic surgeons are using articulating spacers if indicated. Antibiotics are then prescribed to the patient based on the sensitivities of the infecting organism. The duration of systemic antibiotic use is decreasing, and short courses of antibiotic therapy have been shown to be as efficacious as prolonged therapy between the first and second stages. The second stage of the procedure involves removal of the antibiotic-impregnated cement beads and/or spacer, repeat irrigation and debridement, and final reconstruction with revision components. While two-stage reimplantation was considered the gold standard in many parts of the world, recent studies have demonstrated that it is associated with a considerable failure rate. This may be due to the lack of accurate diagnostic tools for infection eradication, and future investigation of risk factors for failure of the two-stage reimplantation should be conducted.

Diagnosis of Persistent Infection in Prosthetic Two-Stage Exchange: Evaluation of the Effect of Sonication on Antibiotic Release from Bone Cement Spacers.

Introduction: When treating periprosthetic joint infection with a two-stage procedure, antibiotic-impregnated spacers can be used in the interval between prosthetic removal and reimplantation. In our experience, cultures of sonicated spacers are most often negative. The objective of the study was to assess whether that sonication causes an elution of antibiotics, leading to elevated antibiotic concentrations in the sonication fluid inhibiting bacterial growth and thus causing false-negative cultures.Methods: A prospective monocentric study was performed from September 2014 to March 2016. Inclusion criteria were a two-stage procedure for prosthetic infection and agreement of the patient to participate in the study. Spacers were made of gentamicin-containing cement to which tobramycin and vancomycin were added. Antibiotic concentrations in the sonication fluid were determined by mass-spectometry (LC-MS).Results: 30 patients were identified (15 hip and 14 knee and 1 ankle arthroplasties). No cases of culture positive sonicated spacer fluid were observed in our serie. In the sonication fluid median concentrations of 13.2µg/ml, 392 µg/ml and 16.6 µg/ml were detected for vancomycin, tobramycin and gentamicin, respectively. According to the European Committee on antimicrobial susceptibility testing (EUCAST), these concentrations released from cement spacer during sonication are higher than the minimal inhibitory concentrations (MICs) for most bacteria relevant in prosthetic joint infections.Conclusion:Spacer sonication cultures remained sterile in all of our cases. Elevated concentrations of antibiotics released during sonication could explain partly negative-cultured sonicated spacers. Indeed, the absence of antibiotic free interval during the two-stages can also contribute to false-negative spacers sonicated cultures.

Diagnosis Of Persistent Infection In Prosthetic Two-Stage Exchange: PCR analysis of Sonication fluid From Bone Cement Spacers.

Introduction: When treating periprosthetic joint infections with a two-stage procedure, antibiotic-impregnated spacers are used in the interval between removal of prosthesis and reimplantation. According to our experience, cultures of sonicated spacers are most often negative. The objective of our study was to investigate whether PCR analysis would improve the detection of bacteria in the spacer sonication fluid.Methods: A prospective monocentric study was performed from September 2014 to January 2016. Inclusion criteria were two-stage procedure for prosthetic infection and agreement of the patient to participate in the study. Beside tissues samples and sonication, broad range bacterial PCRs, specific S. aureus PCRs and Unyvero-multiplex PCRs were performed on the sonicated spacer fluid.Results: 30 patients were identified (15 hip, 14 knee and 1 ankle replacements). At reimplantation, cultures of tissue samples and spacer sonication fluid were all negative. Broad range PCRs were all negative. Specific S. aureus PCRs were positive in 5 cases. We had two persistent infections and four cases of infection recurrence were observed, with bacteria different than for the initial infection in three cases.Conclusion: The three different types of PCRs did not detect any bacteria in spacer sonication fluid that was culture-negative. In our study, PCR did not improve the bacterial detection and did not help to predict whether the patient will present a persistent or recurrent infection. Prosthetic 2-stage exchange with short interval and antibiotic-impregnated spacer is an efficient treatment to eradicate infection as both culture- and molecular-based methods were unable to detect bacteria in spacer sonication fluid after reimplantation.

Articulating antibiotic impregnated spacers in prosthetic joint infections: Where do we stand?

Peri-prosthetic joint infection remains one of the most difficult and challenging complications following hip and knee arthroplasty for both patients and surgeons. Two-stage revision arthroplasty for infection remains the most popular option for the majority of patients and arguably the only option for some. The use antibiotic spacers and in particular articulating spacers has improved the quality of life for patients between stages. The spacers provides local delivery of high concentration antibiotics and provides many benefits to the soft tissues including maintaining soft tissue tension and range of movement. This benefit to the soft tissues also translates into reducing the difficulty and time spent doing the exposure during the second stage procedure. It is generally accepted that peri-prosthetic joint infection should be dealt with my specialist centers who deal with high volumes of patients with this diagnosis in a multidisciplinary approach.

Antibiotic-laden Arthroplasty with a Novel Design of Cement Mould and Metallic Endoskeleton for Treatment of Hip Infection, an Inexpensive Alternative: A Preliminary Report of Two Cases.

Infection of the hip after implant fixation is an uncommon yet devastating complication that results in poor long-term outcome. The gold standard treatment for chronic infection after hip arthroplasty is a two-stage protocol: eradication of infection, follow by re-implantation arthroplasty. The use of interim antibiotic-laden cement spacer has become a popular procedure to maintain hip joint function and provide antibiotic elution simultaneously before re-implantation. However, antibiotic cement spacer is mechanically weak and breaks if overloaded. Therefore, we designed a cement mould with metallic endoskeleton with the aim of creating a stronger, inexpensive, antibiotic-impregnated spacer resembling a unipolar arthroplasty. We report two cases of severe hip joint infection after implant fixation (bipolar hemiarthroplasty, screw fixation neck of femur). Both patients had undergone first stage surgery of debridement and articulating antibiotic cement insertion using our design. Although the second stage surgery was planned for these patients, both patients delayed the operation in view of good functional status after a year walking with the antibiotic cement spacer. These cases showed that the mechanical property of the new antibiotic cement spacer was promising but further mechanical studies upon this new endoskeleton design are required.