Antibiotic Spacer Research Articles

Three-Stage Masquelet Technique and One-Stage Reconstruction to Treat Foot and Ankle Tuberculosis.

Background:The purpose of this article was to report the feasibility and effectiveness of 3-stage Masquelet technique and 1-stage operation for different stages of foot and ankle tuberculosis (TB).Methods:Ten consecutive patients with foot and ankle TB were retrospectively analyzed between January 2014 and December 2018. Five patients were treated with the 3-stage Masquelet technique, including thorough debridement with vacuum sealing drainage, implantation of antibiotic cement spacer, and subsequent reconstruction. Five patients were treated with a 1-stage reconstruction. The American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) pain scores were recorded at the last follow-up. The follow-up was 30.3 ± 17.8 months.Results:No reactivation of TB was observed in any patients. For the 3-stage operation group, 1 patient developed a distal tibia fracture. The duration of anti-TB therapy was 12.0 ± 0.8 months. The AOFAS score increased from 39.5 ± 9.9 preoperatively to 75.3 ± 7.0 postoperatively (P < .05). The VAS pain score decreased from 6.3 ± 1.9 to 1.5 ± 1.3 (P < .05). For the 1-stage operation, 1 patient had wound necrosis. The duration of anti-TB therapy was 13.8 ± 1.1 months. The AOFAS score increased from 51.8 ± 15.0 to 81.8 ± 6.3 (P < .05). The VAS pain score decreased from 5.4 ± 1.1 to 1.0 ± 0.7 (P < .05).Conclusion:Three-stage operation was effective for foot and ankle TB with stage IV, sinus tracts or other infections, and 1-stage reconstruction was effective for early-stage TBs.Level of Evidence:Level IV, case series.

Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients

BackgroundStudies addressing the management of intramedullary infection are mainly retrospective and with a limited number of cases. Reaming can be performed using either conventional reaming or using the reamer/irrigator/aspirator (RIA) system. Until now there have been no comparative prospective studies between these two methods. We aimed to compare the efficacy of RIA with conventional reaming followed by insertion of antibiotic-loaded cement, for the treatment of intramedullary nail infection of long bones. We assessed the rate of remission between groups after two-year follow-up and identified microorganisms using tissue cultures and sonication of explanted intramedullary nail (IMN).MethodsA noninferiority, randomized clinical trial was carried out between August 2013 and August 2015 involving 44 patients of whom a locked IMN implant of the femur and/or tibia was retrieved and who all met the clinical and radiological criteria for IMN-associated osteomyelitis. Patients were randomized into two groups: RIA alone versus conventional reaming followed by antibiotic-loaded cement insertion. Both groups also underwent six-weeks of antibiotic treatment according to the results of the antibiogram. Patients were evaluated after 1, 3, 6, 12 and 24 months for radiological and clinical follow-up.ResultsAfter 24 months, the rate of infection remission was similar between the two groups, 87% in the RIA group and 95.5% in the conventional reaming group (p = 0.60). Among four patients who had recurrence of infection, the time to reappearance of symptoms varied from 20 days to twenty-two months. Staphylococcus aureus and coagulase-negative Staphylococci were isolated in 23 (40.4%) and 13 (22.9%) patients, respectively. Interestingly, we identified 20% (9/45) of polymicrobial infection.ConclusionThis study concludes that the RIA system alone, is noninferior to conventional reaming followed by antibiotic cement spacer in the treatment of IMN infection. However, RIA shows greater efficacy in the collection of infected medullary bone tissue, mainly in cases of infected retrograde nail of the femur.Trial registrationISRCTN82233198. Retroactively registered on July 29, 2019.

Résection de la première chaîne de carpe et remplacement prothétique avec RCPI. Plus de dix ans d’expérience personnelle

Proximal row carpectomy is an accepted treatment for degenerative wrist diseases like scaphoid nonunion advanced collapse (SNAC), scapholunate advanced collapse (SLAC), scaphoid chondrocalcinosis (SCAC) and advanced stages of Kienbock disease (KDAC). From March 2004 to November 2018, we treated 91 patients by proximal row carpectomy and replacement of capitate's head with RCPI implant. Forty patients were affected by SNAC, 20 by SLAC, 15 by SCAC, 7 by KDAC, 3 by failure of previous PRC, 3 by chronic transcapho perilunate fracture-dislocations, 2 Apsis prosthesis luxation and 1 patient by gout wrist. Mean age at surgery was 54 years (range 22–81). Patients were evaluated by active and passive range of motion (ROM), Jamar grip strength, Disability of the arm, Shoulder and Hand (DASH) score, visual analogue scale (VAS). They were requested to express their satisfaction or unsatisfaction after surgery. Radiographs were undertaken to check implant stability, sinking or failure, subchondral osteolysis and ulnar instability. We controlled 74 patients, average follow-up was 63 (range 14–134) months. Mean VAS was 1.4 (8.4 preoperatively), complete pain relief (VAS 0) was achieved in 31 patients, average grasp strength was 22.1 kg (12.3 kg preoperatively); average ROM was 78° for flexion-extension and 24° for radial-ulnar deviation. Mean DASH score was 8.4 (56.9 before). In 50 cases, implant was correctly anchoraged. In 19 patients, a slight medial translation was observed, without pain. Two patients affected by stage 3rd SLAC and 4th SLAC, presented ulnar instability with impingement between implant and caput ulnae at 6 months from surgery. The patient affected by gout, 2 years after had a recurrence of stiffness with calcification incorporating the implant. One patient had an infection 7 years after intervention: she underwent implant removal and application of a cemented antibiotic spacer. Seventy-one patients were satisfied, 3 unsatisfied. When arthritis affects capitate's head, PRC is not indicated: replacement with resurfacing capitate pyrocarbon implant (RCPI) combined with PRC represents a good alternative to four corner arthrodesis or capitate-lunate arthrodesis associated to scaphoidectomy. RCPI prosthesis associated to PRC demonstrated good clinical and radiographic results on 74 patients controlled: it can be indicated in cases of SNAC, SLAC, SCAC 4th stage with alterated articular surface of lunate fossa of distal radius, KDAC and chronic peri-lunar fracture-dislocations with severe arthrosis.

A Novel Technique for Creating an Articulating Cement Spacer for Ankle Prosthetic Joint Infections

Total ankle arthroplasty has been increasing as a treatment for end-stage ankle arthritis. With this increase, the incidence of total ankle prosthetic infections will also increase. Treatment of these infections depends on the duration of symptoms and whether the infection is acute or chronic in presentation. The treatment of choice for chronic infections is a 2-stage procedure, the removal of implants and placement of a static cement spacer. We describe a technique for creating an articulating antibiotic cement spacer through an anterior approach in a patient with an infected total ankle arthroplasty. The articulating antibiotic cement spacer allows high doses of local antibiotics, decreases soft tissue contractures, and allows continued motion of the joint.

1551. Systemic Tobramycin Absorption Resulting from Antibiotic-Impregnated Cement Spacers for the Treatment of Prosthetic Joint Infection

BackgroundAntibiotic-impregnated cement spacer (ACS) placement has been a cornerstone of two-stage surgical management of prosthetic hip and knee infection for decades. Utilized antibiotics have included aminoglycosides and vancomycin. Pharmacokinetic modeling studies have described peak systemic levels within the first 24–48 hours post-operatively, followed by rapid clearance. While this systemic exposure was previously felt insufficient to cause organ toxicity, a few studies have described antibiotic-induced nephrotoxicity.MethodsWe prospectively enrolled patients with prosthetic hip or knee infection, and subsequent ACS placement, containing vancomycin and tobramycin, from October 2017 to February 2019, at Allegheny General Hospital. Risk factors for post-operative nephrotoxicity, including patient comorbidities, receipt of potentially nephrotoxic medications, estimated creatinine clearance (CrCl), perioperative hypotension, total spacer tobramycin dosage, and post-operative day 1 (POD1) and 3 (POD3) serum tobramycin levels were recorded. Patients who had antibiotic cement spacer exchange, or had received systemic aminoglycoside therapy, were excluded.ResultsThirteen patients were enrolled, comprising 4 hip and 9 knee ACS, with respective median (interquartile range (IQR)) tobramycin cement dosages of 3.8 (2.86–4.58) and 4.8 (4.8–9.6) grams. Tobramycin levels were measured at a median 16.5 and 60.7 hours on POD1 and POD3, respectively. Three hip and six knee ACS had respective, detectable POD1 median serum tobramycin levels of 0.6 (0.38–1.20) and 0.8 (0–0.8) μg/mL; three knees, but no hip ACS had detectable POD3 serum tobramycin levels. Six of the nine patients with detectable POD1 serum tobramycin levels had a CrCl of less than or equal to 65 mL/minute (figure), while each patient with detectable POD3 levels had a CrCl of less than 45 mL/minute. No significant changes in baseline CrCl were identified. A relationship between tobramycin cement dosage and detectable serum tobramycin levels was not observed.ConclusionLow baseline CrCl, but not the total tobramycin dosage or other nephrotoxicity risk factors, may be the single most reliable predictor of detectable postoperative systemic tobramycin levels in patients who have received hip or knee ACS. Disclosures All authors: No reported disclosures.

Point/Counterpoint: Static vs Articulating Spacers—Static Spacers for Resection Arthroplasty of the Knee

Antibiotic spacers play a significant role in the treatment of periprosthetic joint infections. They help maintain soft-tissue tension and provide delivery of high dose of antibiotics to the local tissue. The use of static or dynamic spacers is based on multiple factors including the extent of soft-tissue, ligamentous and bone compromise, overall patient function, comorbid conditions, and virulence of the organism. There is no difference in reinfection incidence between static vs dynamic spacers following two-stage reimplantation. Static spacers can be customized to treat all cases of periprosthetic total knee infections and offer intraoperative flexibility to vary the cement quantity and amount of antibiotics in the spacer to provide high-dose local delivery of antibiotics to address the dead space, bone loss, and soft-tissue compromise. Static spacers are especially advantageous in cases of extensor mechanism and ligamentous compromise where articulating spacers may not be able to provide adequate stability.

Advanced septic arthritis of the shoulder treated by a two-stage arthroplasty.

BACKGROUNDThe usual treatment of septic shoulder arthritis consists of arthroscopic or open lavage and debridement. However, in patients with advanced osteoarthritic changes and/or massive rotator cuff tendon tears, infection eradication can be challenging to achieve and the functional outcome is often not satisfying even after successful infection eradication. In such cases a two-stage approach with initial resection of the native infected articular surfaces, implantation of a cement spacer before final treatment with a total shoulder arthroplasty in a second stage is gaining popularity in recent years with the data in literature however being still limited.AIMTo evaluate the results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint.METHODSWe retrospectively included five consecutive patients over a five-year period and evaluated the therapeutic management and the clinical outcome assessed by disability of the arm, shoulder and hand (DASH) score and subjective shoulder value (SSV). All procedures were performed through a deltopectoral approach and consisted in a debridement and synovectomy, articular surface resection and insertion of a custom made antibiotic enriched cement spacer. Shoulder arthroplasty was performed in a second stage.RESULTSMean age was 61 years (range, 47-70 years). Four patients had previous surgeries ahead of the septic arthritis. All patients had a surgical debridement ahead of the index procedure. Mean follow-up was 13 mo (range, 6-24 mo). Persistent microbiological infection was confirmed in all five cases at the time of the first stage of the procedure. The shoulder arthroplasties were performed 6 to 12 wk after insertion of the antibiotic-loaded spacer. There were two hemi and three reverse shoulder arthroplasties. Infection was successfully eradicated in all patients. The clinical outcome was satisfactory with a mean DASH score and SSV of 18.4 points and 70% respectively.CONCLUSIONShort interval two-stage approach for septic shoulder arthritis is an effective treatment option. It should nonetheless be reserved for selected patients with advanced disease in which lavage and debridement have failed.

The Use of Structurally Augmented 3D Printed Cages in Segmental Defects of the Tibial Shaft

Category:Trauma, Emerging TechnologyIntroduction/Purpose:Modern day management of segmental defects of the tibia shaft (SDTS) involve autologous nonvascularized grafts, autologous vascularized contralateral fibula grafts, as well as bone transport distraction osteogenesis, however single stage titanium cages with adjuvant biologics continue to demonstrate advantages. With the development of advanced additive manufacturing further modalities such as complex variable lattice structure and submicron texture may be incorporated into custom fit implants. We aim to further investigate the potential of this technology on osteoinduction, and hypothesize early bone in-growth.Methods:A retrospective analysis was performed on 3 patients undergoing custom cage implantation for SDTS. All three patients were male with an average age of 60, 2 patients were diabetic, and one was a smoker. All three cases were performed in the setting of post-infection salvage. Pertinent demographic and clinical history was retrieved through the medical record.Results:All three cases were uncomplicated in the post-surgical period, and early bone in-growth was demonstrated in successive follow-ups. One case was single-staged and built into a prior total ankle arthroplasty, the next was a deformity correcting intramedullary rod that became infected requiring two-stage salvage with an antibiotic spacer and subsequent custom cage with Intramedullary rod supplementation, and the third case was a two-stage trauma salvage initially using an antibiotic spacer with subsequent custom cage implantation.Conclusion:3D printed custom cages were found to be a safe and efficacious option for management of SDTS, with demonstrated early bone in-growth. Considering the incorporation of advanced additive manufacturing techniques, strong implementations may be present for salvage cases.

Masquelet Technique for Hindfoot Fusion of Gustilo IIIA Open Ankle Dislocation with Complete Talar Extrusion and Loss

Category:Hindfoot, Trauma, AnkleIntroduction/Purpose:Complete talar extrusion is a rare injury resulting from high-energy trauma, with dissociation of the talus from surrounding bony and soft-tissue structures. Complications after complete talar extrusion include infection, osteonecrosis, posttraumatic osteoarthritis, and leg-length discrepancy. There is a lack of consensus on the optimal treatment algorithm for complete talar extrusion, due in part to high complication rates associated with injury and treatment. Thus, we report a staged treatment method utilizing the Masquelet Technique with temporary cement spacer, followed by bone grafting with use of femoral shaft autograft and bulk cancellous allograft.Methods:44-year-old male status post high-speed motorcycle collision presented with left ankle Gustilo IIIC open fracture dislocation with complete talar extrusion and loss, concomitant ipsilateral tibial plateau fracture and metatarsal shaft fractures. Twelve weeks post-injury, after multiple staged debridements, external fixation and extensive wound vac treatments, removal of the left leg multi-planar external fixator was performed with left distal tibial, fibular, navicular and calcaneal articular and subchondral bone debridement in preparation for Masquelet procedure and pantalar fusion. Open reduction and realignment of left ankle and foot with intramedullary fixation with hindfoot fusion nail was performed, with placement of antibiotic cement spacer for development of secondary reactive periosteal membrane. After nine weeks, intramedullary bone reaming aspiration tool was utilized for removal of left femur intramedullary bone marrow for autograft. Hindfoot pantalar fusion was performed using ipsilateral femoral shaft autograft and bulk cancellous allograft in place of antibiotic spacer.Results:Patient went on successfully to fusion and had one transfixation screw removed during the course of his recovery. Patient was also treated using a long leg ankle foot orthosis brace as a stress shielding device during heavy labor. Patient returned back to work and heavy labor as a landscaper and has had no residual pain. At 24 months postoperative, patient achieved an AOFAS ankle-hindfoot score of 83/100 (good).Conclusion:To our knowledge, this is the first case of complete talar extrusion treated with a Masquelet procedure with ipsilateral femoral shaft autograft and bulk cancellous allograft. While chronic pain is reported in as many as 75% of patients post- complete talar extrusion, and infection rates as high as 88%, our patient reports no residual pain and did not experience a postoperative infection. This technique represents a reasonable approach and warrants consideration for the treatment of this rare, complex injury.

Applications of the Vascularized Medial Femoral Condyle for Nonunion with Associated Bone Loss of the Foot: A Case Series

Category:Hindfoot, Midfoot/ForefootIntroduction/Purpose:Persistent nonunions with large bone defects continue to represent a challenging problem for foot and ankle surgeons. Vascularized corticocancellous grafts have been well described for various applications and represent a comprehensive solution to these difficult nonunion cases. We describe four cases of nonunions with concomitant large bony defects treated with a vascularized medial femoral condyle (VMFC).Methods:We retrospectively identified four cases of VMFC flaps used for foot nonunions with large bone defects. Surgical indications included talonavicular nonunion with associated avascular necrosis of the navicular, talonavicular-cuneiform nonunion, navicular-cuneiform nonunion, and first metatarsophalangeal nonunion. All cases had large associated segmental bone defects. The average age at the time of surgery was 62-years-old. The average follow up was 2.6 years (1.5-5.0). One patient had a remote history of tobacco use. Another patient quit smoking pre-operatively and had normal nicotine metabolite levels at the time of surgery. There was one Type II diabetic.Results:Two patients underwent staged reconstruction with placement of an antibiotic cement spacer, but intra-operative cultures were negative. No patient had a previous infection. The average graft dimensions were 3 x 2.25 x 1.5 cm. After obtaining adequate compression, all grafts were secured with bridge locking plates. The average time to weight bearing was 14.5 weeks. All patients had knee pain post-operatively that resolved with time. Two patients required reoperation. In one patient, the VMFC graft did not adequately fill the defect requiring supplement allograft. The VMFC-allograft interface went on to nonunion requiring tricortical iliac crest bone grafting. Another patient developed a split-thickness skin graft (STSG) infection requiring debridement and repeat STSG. There were no VMFC graft failures, and all patients went on to successful union.Conclusion:Vascularized medial femoral condyle autografts are a technically demanding solution to difficult nonunion cases with significant associated bone loss of the foot.

Review of Use of Amniotic Membrane Allograft in Total Ankle Replacements

Category:Ankle ArthritisIntroduction/Purpose:Wound complications after total ankle replacement (TAR) lead to increased postoperative morbidity with lasting consequences. Previous studies demonstrate delayed wound healing in 6.6% to 28% of all TARs. Soft tissue breakdown along the anterior incision can cause exposure of anterior tendons and the implants. In addition, adhesions of the extensor tendons can develop causing significant morbidity. Recent publications advocate for the use of dehydrated human amnion/chorion membrane allograft (dHACM) during closure of anterior ankle incisions during TAR. dHACM is shown to promote increased epithelial cell proliferation, recruitment, and differentiation and reduce the likelihood of tendon adhesions. The goal of this study was to review the use of dHACMs in TARs and to investigate the number and type of postoperative wound complications including extensor tendon adhesions.Methods:We retrospectively reviewed 92 TARs performed between April, 2016 through August, 2018 by two board certified, fellowship trained foot and ankle orthopaedic surgeons. A standard anterior approach was done in all cases. All TARs had dHACM graft placed deep to the tibialis anterior and extensor longus tendon and along the extensor retinaculum prior to final closure of the wound. Upon data review, we identified the subset of patients who had anterior wound dehiscence postoperatively requiring an additional procedure(s) for wound coverage. We compared the demographics, medical comorbidities, and operative characteristics of those with and without perioperative wound complications.Results:12 patients who underwent TARs sustained wound dehiscence below the subcutaneous tissue and required operative intervention (13%). Of these 12 cases, 5 required bipedical or rotational fasciocutaneous flap coverage (5.4%), 6 required less extensive soft tissue surgery (6.5%) and one case involved a deep periprosthetic infection that resulted in explant and antibiotic spacer placement (1.1%). 6 of the 12 cases required a split thickness skin graft application (6.5%) and 2 cases required tenolysis of extensor tendon adhesions (2.2%). Normal excursion of extensor tendons was seen in 90 patients (97.8%). Except for the one infected ankle, there were no cases with wound dehiscence that communicated with the joint. There were no statistically significant differences in medical comorbidities/operative characteristics between patients with wound complications and those without.Conclusion:Wound complications after total ankle replacements often lead to poor long-term outcomes for patients. Our data suggests that the application of the amniotic membrane allograft and its inherent healing potential decreases postoperative tendon adhesions and significant wound dehiscence. This may lead to less deep wound infections that communicate with the joint and may be protective against total ankle replacement failures due to these complications.

One-Stage Exchange Revision Arthroplasty for the Treatment of Prosthetic Joint Infection: Rational and Technique

Prosthetic joint infection is devastating complication of total joint arthroplasty and represents a significant burden both financially and to the patient's overall health. Challenges are in part due to difficulty in eradicating the disease and that there is no census in the most economical and effective techniques for treatment. In the United States the treatment standard is a 2-stage exchange in which the components are removed and an antibiotic spacer is placed, several weeks of intravenous antibiotics, and then a second procedure to remove the antibiotic spacer and place the final components. A 1-stage exchange removes the infected components and places new components in the same surgical setting. The success rate are similar between the 2 options but to date no large scale randomized study has been performed, however a 1-stage exchange limits the total number operations, decreases the morbidity associated in between stages, and is associated with a decrease in overall cost. Surgeons treating prosthetic joint infections should consider this technique.

A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?

Trunnionosis is a type of corrosion and wear at the head-neck taper junction of the femoral implant, and it can be a slow and silent catastrophe. Simultaneous prosthetic joint infection (PJI) is occasionally possible based on the fulfillment of a few of the minor criteria from the Musculoskeletal Infection Society (MSIS), but the existing literature lacks adequate evidence to support that the infection actually exists. We are presenting a case of an 82-year-old man with right total hip arthroplasty performed over a decade prior to presenting to the emergency room with a sudden-onset pop followed by groin pain and difficulty in walking. Radiographs showed a dissociated femoral implant at the level of trunnion with malalignment and heterotopic ossification. Metal Artifact Reduction Sequence MRI of the right hip showed mixed type-two and type-three pseudotumors, and atrophy of surrounding abductor muscles. The erythrocyte sedimentation rate was within normal limits, C-reactive protein was borderline raised, and serum cobalt-chromium levels were elevated without any signs of systemic metal toxicity. Hip joint aspirate revealed blood-stained fluid flooded with red blood cells, leukocytes and neutrophils, and a positive alpha-defensin assay. These findings were interpreted as positive for prosthetic joint infection. Intraoperatively, there was severe wear of the inferomedial aspect of the femoral head-neck junction and extensive metallosis throughout the right hip. Tissue and fluid specimens were sent for cultures, sensitivities, and histopathology for pseudotumor and infection evaluation. An articulating antibiotic spacer was then placed with the intent to perform a staged reconstruction of the femur and right acetabulum. Final synovial, bone, and soft tissue cultures, as well as histopathological photomicrograph of the tissue slides, were negative for infection. This case demonstrates the striking features of metallosis associated with trunnion failure of a metal-on-polyethylene total hip joint prosthesis that was simultaneously showing signs of prosthetic infection by satisfying the minor criteria according to the latest guidelines by the MSIS with a strikingly high cell count of red blood cells in the synovial fluid exam, indicating inflamed hyper-vascular pseudotumors vs. hemarthrosis vs. bloody tap. Diagnostic dilemma led by positive synovial fluid alpha defensin, high synovial neutrophil and white cell count results with negative final cultures or infection on histological slides raises concern that infection was not present and two-stage revision arthroplasty with six weeks of antibiotics was not necessary along with increased risk of morbidity, mortality as well as cost of care.

Mechanical failure of articulating polymethylmethacrylate (PMMA) spacers in two-stage revision hip arthroplasty: the risk factors and the impact on interim function

BackgroundThis study aimed to investigate the risk factors for mechanical failure of cement spacers and the impact on hip function after two-stage exchange arthroplasty for periprosthetic joint infection (PJI).MethodsThirty-one patients (19 males and 12 females) with hip PJIs underwent resection arthroplasty and implantation of cement spacers from January 2014 to December 2015. Patients who encountered spacer-associated mechanical complications in the interim period (14 of 31) were compared with those without complications (17 of 31). Complications were defined as spacer dislocation, spacer fracture, spacer fracture with dislocation, and femoral fracture during or following spacer implantation. Hip functional outcome was assessed using the Harris hip score (HHS). Treatment success was defined according to the following criteria: (1) no symptoms or signs indicative of infection; (2) no PJI-related mortality; and (3) no subsequent surgical intervention for infection after reimplantation surgery. Multivariate logistic regression and Kaplan-Meier survival curves were used for analysis.ResultsFourteen patients (14/31 = 45%) suffered at least one spacer-related complication within the interim period. The development of spacer complications was associated with a younger age (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.83–1.00, p = 0.045) and chronic PJI (OR 14.7, 95% CI 1.19–182, p = 0.036). Patients with spacer complications also had a lower median HHS (37 vs. 60, p < 0.001) before reimplantation in comparison to those without spacer complications. After reimplantation, the two groups had a similar median HHS (90 vs. 89, p = 0.945). Two patients did not undergo reimplantation due to extensive comorbidities, and subsequently retained the antibiotic spacer for definitive treatment. The 2-year treatment success rate was 84.6% in the spacer-complication group and 87.5% in the non-spacer-complication group (p = 0.81).ConclusionThere was a high complication rate for articulating PMMA spacers during the interim period of two-stage revision total hip arthroplasty. A young age and chronic infection were the primary risk factors associated with mechanical complications. Patients at high risk of spacer-related mechanical complications should be advised accordingly by surgeons. Knowing the possible risk factors, surgeons should educate patients thoroughly to avoid spacer complications, thereby increasing patient satisfaction in the interim stage.Level of evidencePrognostic Level III.

Creating a dual articulating antibiotic spacer for management of an infected total femur prosthesis hemiarthroplasty.

The gold standard for management of chronic periprosthetic joint infections is a 2-stage revision arthroplasty with the first stage being explantation, debridement, and placement of a spacer. While there are implants designed to manage periprosthetic infections in hip and knee arthroplasty, there are not any commercially available implants designed to specifically manage an infected total femur megaprosthesis. This creates a unique surgical challenge and requires custom construction of a spacer to be performed by the surgeon intraoperatively. Here, we present our surgical technique for manufacturing a dual articulating total femur spacer. This technique facilitates range of motion at both the hip and knee joints, provides stability for axial loading in the extremity, and preserves the acetabulum while the patient undergoes antibiotic therapy to eradicate the infection.

Total Knee Arthroplasty: The Efficacy of Calcium Sulfate Beads in One-Stage Aseptic Revision

Background: The risk of periprosthetic joint infection following revision total knee arthroplasty is high, as is the cost of care. Decreasing periprosthetic joint infection risk may include utilization of calcium sulfate beads. Calcium sulfate beads have been gaining momentum in treating infected joints because of their potential advantages, including antibiotic elution and dissolvability. However, literature documenting their utilization in aseptic revision is sparse. This study compares: 1) infection rates; 2) length of stay; 3) subsequent infection procedures; and 4) final surgical outcome between one-stage aseptic revision total knee arthroplasty patients who received calcium sulfate beads and those who did not. Methods: We performed a retrospective chart review to identify patients who underwent aseptic one-stage revision total knee arthroplasty between January 2013 and December 2017. Outcomes collected included postoperative infection rate, length of stay, subsequent irrigation and debridement, and final surgical outcome, classified as a successful total knee arthroplasty reimplantation, a retained antibiotic spacer, or an above knee amputation. Chi-square analysis was used to analyze all categorical variables, while Student’s t-testing was used for continuous variables. A p-value of 0.5 was set as the threshold for statistical significance. Results: Calcium sulfate bead patients did not differ from non-calcium sulfate bead patients with regard to the number of postoperative infections (p=0.103), lengths of stay (p=0.210), irrigation and debridement procedures (p=0.063) and surgical outcome (p=0.085). Conclusion: Patients who received calcium sulfate beads had analogous surgical outcomes and infection rates to non-calcium sulfate bead patients. The use of calcium sulfate beads in aseptic one-stage revision total knee arthroplasty may not be beneficial in preventing infection and reducing costs.

Should Aspiration of the Ankle With an Antibiotic Spacer Be Performed Prior to Reimplantation?

We recommend that aspiration of the ankle with an antibiotic spacer prior to a second-stage reimplantation be strongly considered. Available studies indicate that a positive culture of the aspirate in this setting is predictive of residual infection, while a negative aspirate culture does not rule out infection and should be interpreted in light of other clinical indicators and laboratory values. Consensus. Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus).

An Anatomic Intraoperatively Prepared Antibiotic Spacer in Two-Stage Shoulder Reimplantation for Deep Infection: The Potential for Early Rehabilitation.

Molded antibiotic shoulder spacers allow for intraoperative customization of antibiotics and multiple size options. The purpose of this study was to evaluate the efficacy of an anatomic intraoperatively molded spacer in the two-stage treatment of infection and to assess the safety of early rehabilitation when the capsule and rotator cuff are present. During 2014 and 2015, 27 shoulders were treated with a molded antibiotic cement spacer as part of a two-stage treatment. Indications included periprosthetic joint infection (n=18), native shoulder infection (n=8), and infection after internal fixation (n=1). All patients were followed for a minimum of 2 years. Mean follow-up time was 29.6 months. Patients were allowed to perform motion exercises (group I; n=16) or were instructed to avoid motion (group II; n=11) after spacer implantation, depending on the condition of their rotator cuff. Infection was eradicated in 23 of the 27 shoulders (85%). At most recent follow-up, pain scores were lower in group I. Mean final elevation was 115° in group I compared with 93° in group II. Mean final active external rotation was 36°, with no difference between the groups. In 3 (4%) shoulders with significant proximal humeral bone loss, the spacer became rotationally unstable. An anatomic intraoperatively molded spacer can be implanted safely in two-stage treatment for deep infection and has a reasonable rate of eradication. When adequate capsule and rotator cuff tissue is present, early motion in between stages can be safely recommended with a trend toward improved forward elevation at final follow-up and may facilitate the second stage reimplantation. [Orthopedics. 2019; 42(4):211-218.].

Management of infected shoulder arthroplasty: a comparison of treatment strategies

The study purpose was to determine whether 2-stage revision procedures result in superior outcomes and whether reverse shoulder arthroplasty produced superior outcomes to hemiarthroplasty or anatomic total shoulder arthroplasty at the time of reimplantation. Our prospectively collected database was retrospectively reviewed for all surgically treated infected shoulder arthroplasties between 2006 and 2014. We included 47 patients in this study: 27 underwent a 2-stage revision, and 20 were treated with an antibiotic spacer as definitive treatment. Preoperative laboratory results, intraoperative cultures and pathology findings, recurrence of infection, complications, and outcome measures were compared between treatment groups. A recurrent infection developed in 3 patients in the antibiotic spacer group and 2 patients in the 2-stage revision group (P = .25). A total of 20 procedure-related complications and 11 medical complications occurred between the 2 groups; however, there was no statistically significant difference between groups. The 2-stage group had statistically significantly better Constant scores (58.1 vs. 33.3, P = .04) and elevation (94.4° vs. 48.6°, P = .02) than the antibiotic spacer group. Subanalysis of the 2-stage revision group showed that reverse total shoulder arthroplasties had statistically superior Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons, University of California at Los Angeles, and Constant scores; elevation; and abduction compared with hemiarthroplasties or anatomic total shoulder arthroplasties. Two-stage revision procedures and use of an antibiotic spacer for definitive management of periprosthetic shoulder infections appear to be similar and effective in eradicating infections. Two-stage revisions using a reverse total shoulder arthroplasty at the time of reimplantation generatesuperior range of motion and functional outcome scores.

PROSTHETIC INFECTION TREATMENT BY USING ANTIBIOTIC CEMENT SPACER WITH CUSTOM MOLD: 05 CASES REPORT

Background: According to statistical data of many countries in the wold, the more proportion of patients in hip replacement have, the more prosthetic infection have been treated. In Vietnam, treatment of prosthetic infection is often difficult beacause of antibiotic resistance, high cost treatment and difficult rehabilitation in post-surgery. Nowadays, there are many methods of treatment for prosthetic infected patients, using antibiotic cement spacer for prosthetic infection have applied in common of a lot of countries all over the wold. We report five cases hip prosthetic infection treatment by using antibiotic impregnated cement spacer with custom mold. Aim of study: Inform 05 cases hip prosthetic infection treatment by using antibiotic impregnated cement spacer with custom mold. Methods: Serial cases report. Key words: Prosthetic infection, Antibiotic cement spacer