Cement Spacer Research Articles

BCGitis of the wrist after intravesical BCG therapy: A case report

Septic arthritis of the wrist can result in joint destruction, making timely diagnosis crucial for initiating empiric antibiotics and surgical intervention. Mycobacterium is a rare cause of this disorder. A 47-year-old man with bladder cancer was treated surgically and received BCG intravesical therapy. Eleven months later, this patient developed severe carpal BCGitis requiring total carpal resection. The first step was addition of a cement spacer and radiometacarpal stabilisation (Masquelet technique). Secondary infections occurred aggravating the prognosis. This case emphasises the importance of taking into account the patient's medical history. Tuberculosis of the wrist is a rare etiology for septic arthritis; delayed treatment leads to severe complications and functional sequelae.

A CASE REPORT OF SUCCESSFUL TREATMENT OF STAGE IV EWING’S SARCOMA IN AN ADOLESCENT PATIENT

Background. Ewing’s sarcoma is one of the most common musculoskeletal cancers in children and adolescents. Extremely aggressive clinical course of Ewing’s sarcoma makes a successful treatment of this tumor difficult. Despite a comprehensive multidisciplinary approach to the treatment of this cancer, including chemotherapy, surgery and radiation therapy, rapid tumor progression, recurrence and resistance to chemotherapy are still common.Our purpose was to present the results of a personalized approach to multidisciplinary combination treatment for musculoskeletal cancer involving polychemotherapy, 3D conformal radiation therapy and modern surgical technologies.Description of the clinical case. A female patient presented to Rostov Research Institute of Oncology complaining of a tumor and moderate pain in soft tissues of the left iliac region, left lower extremity, and lameness when walking. After complete examination, the patient was diagnosed with Ewing’s sarcoma of the left ilium with lung metastases (Т3N0M1). The patient received 6 cycles of neoadjuvant chemotherapy according to EURO EWING 2008 protocol; tumor progression and lung metastasis were registered. Two cycles of second-line chemotherapy were performed; by the decision of the doctors’ council, the first stage of surgical treatment was performed: resection of the left ilium and the defect replacement with a temporary cement spacer. In the postoperative period, the patient underwent 8 cycles of adjuvant chemotherapy, external beam radiation therapy to the lungs (12 Gy total dose) and the primary tumor (46 iGy total dose), and 12 cycles of supporting therapy. A delayed second reconstructive stage of surgical treatment involved removal of a temporary cement spacer and implantation of an individual pelvic stability system. The patient was followed-up for 25 months after the combination treatment, had no complaints, and was able to ambulate without assistance; the motor function of the left hip joint was fully preserved. Conclusion. The use of non-standard high-technology approaches to surgical treatment of unfavorably localized Ewing’s Sarcoma in combination with chemo-radiation therapy allows patients with advanced tumors to achieve satisfactory results and good quality of life.

Two-stage Total Knee Arthroplasty for Treatment of Surgical Failure of Septic Arthritis in Degenerative Knee Joints.

The ultimate goal of the treatment of infectious knee arthritis is to protect the articular cartilage from adverse effects of infection. Treatment, however, is not always hundred percent successful and has a 12% failure rate. Persistent infection is more likely to happen in elderly patients and those with underlying joint diseases, particularly osteoarthritis. Eradication of infection and restoration of function in the involved joint usually are not possible by conventional treatment strategies. There are few case series reporting two-stage primary knee arthroplasty as the salvage treatment of the septic degenerative knee joint; however, the treatment protocol remains to be elucidated. Based on a proposed approach, patients with failure of common interventions for treatment of septic knee arthritis and underlying joint degeneration were treated by two-stage TKA and intervening antibiotic loaded static cement spacer. Suppressive antibiotic therapy was not prescribed after the second stage. Complete infection eradication was achieved with mean follow up of 26 months. All cases were balanced with primary total knee prosthesis. The knee scores and final range of motions were comparable to other studies. The two-stage total knee replacement technique is a good option for management of failure of previous surgical treatment in patients with septic arthritis and concomitant joint degeneration. Our proposed approach enabled us to use primary prosthesis in all of our patients with no need for suppressive antibiotic therapy.

A two-stage approach to primary TKA using articulating antibiotic-loaded spacers improve function and eradicate infection in septic arthritic knees.

The treatment of an infected arthritic knee might be challenging. The failure rate has been reported to be high for open or arthroscopic debridement. A subsequently high rate of infection has been noted in these patients undergoing primary total knee arthroplasty (TKA). In the present study, a two-stage approach using an articulating spacer was used. The hypothesis was that the procedure would eradicate the infection and improve pain and function in these patients. A total of 16 consecutive patients were enrolled in this retrospective study. The mean follow-up time was 6.1years (range 2.0-9.9years). Patients with advanced osteoarthritis and infection of the knee were included. All patients had previously undergone one or more failed arthroscopic or open procedures for the eradication of infection. All patients received the same homemade metal-on-plastic articulating antibiotic spacer. Double antibiotic therapy was given for 2weeks intravenously and orally for 4weeks. TKA implantation was performed 6weeks after the first stage. The infection was eradicated without recurrence in all patients. The functional results were significantly improved, and pain was significantly reduced after spacer and TKA implantation. The mean amount of knee flexion was 95 ± 30° preoperatively, and it increased to 109 ± 14° (p = 0.012) after spacer implantation and to 119 ± 10° (p = 0.002) after TKA implantation. The mean KSS objective was 58 ± 12 preoperatively, and it increased to 75 ± 14 (p < 0.0001) after spacer implantation and to 96 ± 3 (p < 0.0001) after TKA implantation. The mean KSS function was 17 ± 11 preoperatively, and it increased to 46 ± 10 (p < 0.0001) after spacer implantation and to 86 ± 6 (p < 0.0001) after TKA implantation. The mean VAS score was 65 ± 11 preoperatively, and it decreased to 2 ± 4 (p < 0.0001) after spacer implantation and to 1 ± 2 (p < 0.0001) after TKA implantation. The two-stage procedure for the treatment of infected arthritic knees after failed eradication surgery was effective in all patients. Using an antibiotic articulating metal-on-plastic cement spacer showed improved functional results between the stages and at the final follow-up. No intra- or postoperative complications occurred.

Reverse shoulder–allograft prosthesis composite, with or without tendon transfer, for the treatment of severe proximal humeral bone loss

The treatment of severe proximal humeral bone loss (PHBL) secondary to tumor resection or failed arthroplasty is challenging. We evaluated the outcomes and complications of reconstruction with reverse shoulder-allograft prosthesis composite (RS-APC), performed with or without tendon transfer. An RS-APC procedure was performed in 25 consecutive patients with severe PHBL (>4 cm): 12 after failed reverse shoulder arthroplasty, 5 after failed hemiarthroplasty for fracture, 6 after failed mega-tumor prosthesis placement, and 2 after tumor resection. The median length of humeral bone loss or resection was 8 cm (range, 5-23 cm). Humeral bone graft fixation was obtained with a long monobloc reversestem and a "mirror step-cut osteotomy," without plate fixation. Nine infected shoulders underwent a 2-stage operation with a temporary cement spacer. In addition, 9 patients (36%) underwent an associated L'Episcopo procedure. The median follow-up duration was 4 years (range, 2-11 years). Overall, 76% of patients (19 of 25) were satisfied. In 8 patients (32%), a reoperation was needed. At last follow-up, we observed incorporation at the allograft-host junction in 96% of the cases (24/25); partial graft resorption occurred in 3 cases and severe in 1. The median adjusted Constant score was 53% (range 18-105); Subjective Shoulder Value, 50% (range 10%-95%). Additional tendon transfers significantly improved active external rotation (20° vs. 0°, P < .001) and forward elevation (140° vs. 90°, P = .045). (1) Shoulder reconstruction with RS-APC provides acceptable shoulder function and high rates of graft survival and healing. (2) Additional L'Episcopo tendon transfer (when technically possible) improves active shoulder motion. (3) The use of a long monobloc (cemented or uncemented) humeral reversestem with mirror step-cut osteotomyprovides a high rate of graft-host healing, as well as a limited rate of graft resorption, and precludes the need for additional plate fixation. (4) Although rewarding, this reconstructive surgery is complex with a high risk of complications and reoperations. The main advantages of using an allograft with a reverse shoulder arthroplasty (compared with other reconstruction options) are that this type of reconstruction (1) allows restoration of the bone stock, thus improving prosthesis fixation and stability, and (2) gives the possibility to perform a tendon transfer by fixing the tendons on the bone graft to improve shoulder motion.

Гистоморфометрические характеристики передней большеберцовой мышцы и малоберцового нерва при экспериментальном замещении пострезекционного дефекта голени аппаратом Илизарова в комбинации с методом Masquelet

Objective Explore structural changes in the tibialis anterior muscle (TAM) and the peroneal nerve (PN) in repair of postresection tibial defect using the Ilizarov external fixation and a cement spacer. Material and methods A defect-nonunion was simulated in the proximal tibia of 10 mongrels using the Ilizarov external fixation followed by use of a cement spacer to fill the 2.5 cm defect-diastasis. The spacer was removed after 30 days and tibia distraction commenced with the rate of 1 mm performed 4 times/day following transverse osteotomy in the distal tibia to achieve docking of bone fragments. Animals were sacrificed after 60-day fixation (F60) and 30 days after frame removal (FR30). Histomorphometric parameters of the TAM and PN samples were examined. Results TAM appeared to be denervated with death or decreased size of myons and angular contours noted at F60 and FR30. Degenerated and intact muscle fibers (MF) were shown to increase by 32.5 % and by 1 %, respectively, at FR30. The peak of histogram distributing MF by diameters at F60 indicated to ischemic muscles, and a 2-fold decrease in muscle diameter and the histogram skewed to the left by 4 classes showed increase in muscle atrophy at FR30. Reactive destructive changes were noted in at least 5.4 % of myelinated nerve fibres of the PN at F60 and FR30. A 1.6-to-1.7 times decrease in larger and a 1.6-to-1.8 times increase in smaller fibers, the presence of regenerative clusters indicated to previous destruction of a large number of motor and sensory nerves. Changes in the population structure, destruction of myelinated fibers and loss of non-myelinated fibers were associated with obliteration of epineurial vessels and loss of endoneurial capillaries at F60. Conclusion Reactive destructive changes in the TAM and PN revealed in bone defects repaired with the Ilizarov external fixation and the Masquelet technique should be considered in planning of postoperative pharmacologic thearapy and rehabilitation.

The Induced Membrane Technique for the Management of Segmental Tibial Defect or Nonunion: A Systematic Review and Meta-Analysis.

Purpose To identify the predicting factors for union and infection after applying the induced membrane technique (IMT) for segmental tibial defects. Methods A systematic review was carried out following the PRISMA guidelines. All databases were searched for articles published between January 2000 and February 2018 using the keywords “Masquelet technique” and “induced membrane technique.” Studies in English reporting more than 5 cases with accessible individual patient data were included. A meta-analysis was performed. Odds ratios (OR) with 95% confidence intervals were calculated. Results After reviewing, 11/243 studies (115 patients) were finally selected. The mean age of the patients was 43.6 years (range: 18-84 years), and the mean length of the tibial defect was 5.5 cm (range: 0-20 cm). The multivariate logistic regression analysis revealed that the risk factors of postoperative infection after IMT were infected nonunion (p = 0.0160) and defect length ≥ 7 cm (p = 0.0291). Patients with postoperative infection after IMT had a lower union rate (p = 0.0003). Additionally, the use of an antibiotic polymethyl methacrylate cement spacer reduced the need for surgical revision (p = 0.0127). Multiple logistic regression indicated no direct association between the union rate and length of the bone defect. Conclusions IMT is a reliable and reproducible treatment for segmental tibial defects. However, initial infected nonunion and defect length greater than 7 cm are risk factors for post-IMT infection, and post-IMT infection was statistically related to nonunion.

The ‘apple core’ cement spacer for the management of massive bone loss in two-stage revision knee arthroplasty for infection

Antibiotic-loaded cement spacers are used in two-stage revision knee arthroplasty for infection, but commercially available spacers may not always be suitable for significant bone loss or soft tissue failure in multiply revised cases. We describe a technique for producing an on-table, static, reinforced cement spacer – the ‘apple core’ spacer – with the intended outcome of providing joint stability in such patients, prior to undertaking a second-stage procedure. Following a radical debridement, the spacer is made of three components: (1) a ‘central bar’ of external fixator connecting rods, combined using cerclage wires as needed; (2) a standard polymethylmethacrylate cement ‘apple core’; and (3) a covering ‘skin’ of high dose antibiotic-loaded cement, which is stippled as it sets, to increase the surface area and facilitate antibiotic elution. This technique was performed in nine patients who underwent two-stage salvage revision for complex, recurrent infected total knee arthroplasty at a single institution. All patients successfully went on to definitive second-stage reimplantation and have retained their limbs. The ‘apple core’ cement spacer allows massive bone defects to be effectively managed between staged revision procedures.

Fungal Periprosthetic Joint Infection of Hip – Report of 2 Cases

A 72-year old woman had revision unipolar hemiarthroplasty for AMA loosening with vertical split fracture of greater trochanter. This was complicated by PJI, treated with staged arthroplasty with articulated antibiotic loaded cement spacer. Revision of antibiotic loaded cement spacer for dislocation and cable plate fixation of greater trochanter was done. Then the tissue specimen grew Candida ablicans. Fluconazole was given. Repeated debridement and exchange of antibiotic loaded cement spacer was done twice again with amphoteric B and vancomycin added to the cement. Unfortunately, the frozen section was still positive despite the CRP was returned to normal for 1 month. Oral fluconazole was continued. Finally, revision total hip replacement was done 14 months after the initial insertion of antibiotic loaded cement spacer. The patient could manage to walk with frame indoor with no hip pain at 3 year follow-up. Another 80-year old woman had removal of AMA, debridement and antibiotics loaded cement spacer was done for PJI. This was complicated by breakage of the articulated cemented spacer during reduction and later hip dislocation despite of cemented acetabular liner. A total of 3 debridement and antibiotics loaded cement spacer were done. Besides Candida albicans, tissue also grew Enterobacter cloacae and Pseudomonas aeruginosa. Exchange of cement space loaded with gentamicin and voriconazole was done as the 4th reoperation 22 weeks after the debridement and antibiotics loaded cement spacer insertion. Intraoperatively, the patient developed haemorrhagic shock and complicated with myocardial infraction and pneumonia postoperatively and eventually succumbed 12 days after the last operation.The control rate of fungal PJI of only 36% was reported in the literature. The use of systemic and local antifungal agents, surgical treatment strategy and outcomes will be reviewed.

TKA感染後，セメントスペーサーで歩行可能となっている症例；2年の経過

TKA感染後，セメントスペーサーで歩行可能となっている症例；2年の経過

A scaffold-free graft for large critical size bone defect: preclinical evidence to clinical proof of concept

Background & Aim Large critical-sized bone defect (CBD) remains a challenging pathology in orthopaedics. The direct application of adipose stem cells (ASCs) remains limited by a low homing efficiency and a low survival rate. This study aims to show the osteogenic role of ASCs in a scaffold-free approach. Methods, Results & Conclusion 3D scaffold-free grafts were characterized by q-RT-PCR (for osteogenesis/angiogenesis). The bioactivity of the graft was studied in 2 nude rat models: (i) the comparison of fresh and decellularized grafts in term of angiogenesis promotion up to 1 month in a fibrotic tissue (cauterized muscular pocket,n=20); (ii) the osteogenicity of the graft (compared to HA/bTCP bone substitute) at 1/2/3 months post-implantation, in an irreversible femoral CBD (n=28). Angiogenesis was assessed by histomorphometry, cellular engraftment by HLA-I staining, mineralization by micro-CTscan and osteogenic genes expression by q-RT-PCR. A 5-year-old boy with congenital pseudarthrosis of the tibia (previously treated by nailing and grafting without success) was proposed for the autologous scaffold-free graft approach in combination with the induced membrane technique. The pseudarthrosis area (fibula and tibia) was firstly resected and filled by a cement spacer. Then, ASCs were isolated from adipose tissue (AT) to produce the graft. After 3 months, the cement was removed, and the graft was placed into the defect to be followed clinically and radiologically. After intra-muscular transplantation in nude rats, cellular survival (with major osteogenic genes expression) and the promotion of angiogenesis (in a fibrotic/hypoxic site) was found. A complete integration and bone fusion were found for the graft in comparison to the bone substitute which revealed a lack of tissue remodelling and osteogenesis. Specific osteogenic genes were overexpressed in the CBD treated with the grafts (at 4 weeks). A large volume (>15cm3) of the 3D-graft was manufactured in GMP conditions and then implanted without any modification of the surgical procedure. The graft was easily handled and implanted. The graft demonstrated a continuous remodelling (with bone formation) during the first 2 years post-implantation to obtain a bone fusion (allowing walk without pain) and no recurrence of the disease. In conclusion, the scaffold-free 3D-graft (made of ASCs) plays a major role to promote ASCs engraftment and consequence to induce osteogenesis in a fibrotic environment and to recover a bone fusion in a critical-sized bone defect.

GUNSHOT INDUCED HUMERUS FRACTURE TREATED USING THE MASQUELET TECHNIQUE

Humerus fractures secondary to gunshot injury are slow to unite and may require multiple surgeries to obtain union. 1We report a gunshot induced humerus fracture treated via the Masquelet technique.Report:A 27-year old gentleman had a shotgun injury to his left arm exposing the humerus bone. He underwent debridement and external fixator and a 4cm segmental bone loss was noted. The following debridement, a humeral nail and 3cm acute shortening was done, as well as the 1st stage Masquelet (Figure 1). After 6 weeks, the 2nd stage Masquelet was performed (Figure 2). At 1 year follow up, radiographical union was noted (Figure 3).Figure 1Figure 2Figure 3Discussion:Masquelet technique consists of cement spacer insertion which is then exchanged with autologous cancellous bone graft packed into an induced membrane. 2To our knowledge, there have not been reported cases of Masquelet technique used to treat shotgun induced open humerus fractures. The use of an external fixator is proposed by many authors1. The key to success is a thorough debridement of the fracture3.Conclusion:The Masquelet technique is a reliable tool in the surgeon’s armamentarium in the management of humeral segmental bone defects2.Reference: Management of shotgun induced open fractures of the humerus with Ilizarov fixator;2015The Masquelet Technique for Thumb Metacarpal Reconstruction Following Trauma ; JBJS; 2018Muscle reconstruction in reconstructive surgery: soft tissue repair and long bone reconstruction; 2003

Salmonella Sp. as the Cause of Periprosthetic Joint Infection of the Hip: Report of a Rare Case and Literature Review

Periprosthetic joint infection of the hip due to Salmonella sp. is rare. It is sometimes difficult to treat and needed a prolonged antibiotic treatment. We reported a case of periprosthetic joint infection of the hip in a 67 years old female who received prior left total hip arthroplasty. Two-stage revision surgery with antibiotic-loaded cement spacer has been performed to the patient and successfully control the infection. Review of the literatures also has been done. Salmonella Sp. has to be considered as one of differential etiology in the case of infected arthroplasty especially in an immunosuppressed patient. It showed still there has been no consensus in the treatment of choice for this particular case.

Arthrodesis with Retrograde Intramedullary Nail for Recurrent Infected Total Knee Arthroplasty with Patellar Tendon Rupture: A Case Report and Literature Review

Patellar tendon rupture after total knee arthroplasty is a rare, but often catastrophic complication. In addition, infection is also a dreaded complication after total knee arthroplasty. We report an 84-year-old female that has late infected total knee arthroplasty with patellar tendon rupture treated with resection arthroplasty and then subsequent arthrodesis with retrograde intramedullary nail.Case Presentation:The 84-year-old female underwent left total knee arthroplasty 2 years ago and revision arthroplasty last year after trauma. She presented to the emergency department with painful disability of left knee. The septic arthritis of left knee was confirmed by bacterial culture through arthrocentesis which yielded methicillinsensitive staphylococcus aureus. Patellar tendon rupture was also noted by loss of extension mechanism and patella alta in plain films. Despite attempts on open debridement and parenteral antibiotics, the infection did not settle. Resection arthroplasty with vancomycin- impregnated cement spacer implantation was performed following by 4-week parenteral antibiotics therapy. The ESR and CRP level of serum improved gradually. Arthrodesis of left knee with retrograde locking intramedullary femoral nail through single incision of the knee was performed. Protected weight bearing was allowed in one week after arthrodesis. The patient discharged 2 weeks later without recurrent infection, but leg length discrepancy about 2cm was noted.Discussion:Patellar tendon rupture after total knee arthroplasty is a rare but disabling complication whose management is often difficult. It was reported that incidence of patellar tendon rupture in literature varies between 0.3- 12.4% for primary total knee arthroplasty and between 1-15% for revision total knee arthroplasty. Contributing factors are excessive dissection and knee manipulation, and trauma. In the literature, various different operative techniques and rehabilitation programs have been described indicating the lack of a golden standard treatment protocol. However, in patients with a total knee arthroplasty, the results have been discouraging. Reconstruction of the patellar tendon can be utilized semitendinosus-gracilis graft with an interference screw and a staple fixation in treating acute ruptures, whereas allografts and synthetic mesh are indicated for chronic cases. Nevertheless, treatment outcomes for ruptured patellar tendon are not good. Gold standard treatment of infected total knee arthroplasty was resection arthroplasty with antibiotic-impregnated bone cement spacer and parenteral antibiotics therapy and then second stage revision total knee arthroplasty until the infection is eradicated. The patella tendon repair and second revision arthroplasty were not suggested by Jake et al. Patellar tendon rupture is best treated with primary repair, but infected prosthetic knee with patellar tendon rupture seemed to be more difficult to manage. Arthrodesis but not revision arthroplasty may be the best choice after infection control to improve the patient’s level of function.

Evaluation of global gene expression in regenerate tissues during Masquelet treatment.

The Masquelet induced-membrane (IM) technique is indicated for large segmental bone defects. Attributes of the IM and local milieu that contribute to graft-to-bone union are unknown. Using a rat model, we compared global gene expression profiles in critically sized femoral osteotomies managed using a cement spacer as per Masquelet to those left empty. At the end of the experiment, IM and bone adjacent to the spacer were collected from the Masquelet side. Nonunion tissue in the defect and bone next to the empty defect were collected from the contralateral side. Tissues were subjected to RNA isolation, sequencing, and differential expression analysis. Cell type enrichment analysis suggested the IM and the bone next to the polymethylmethacrylate (PMMA) spacer were comparatively enriched for osteoblastic genes. The nonunion environment was comparatively enriched for innate and adaptive immune cell markers, but only macrophages were evident in the Masquelet context. iPathwayGuide was utilized to identify cell signaling pathways and protein interaction networks enriched in the Masquelet environment. For IM vs nonunion false-discovery rate correction of P values rendered overall pathway differences nonsignificant, and so only protein interaction networks are presented. For the bone comparison, substantial enrichment of pathways and networks known to contribute to osteogenic mechanisms was revealed. Our results suggest that the PMMA spacer affects the cut bone ends that are in contact with it and at the same time induces the foreign body reaction and formation of the IM. B cells in the empty defect suggest a chronic inflammatory response to a large segmental osteotomy.

Masquelet technique for treatment of post-traumatic bone defects

Background: Segmental bone defects from traumatic injuries are complicated problems with significant long term morbidity. Historically, amputation was the preferred treatment although, limb salvage by Ilizarov technique, vascularized fibular graft, and acute limb shortening were also used. The treatment regimes were long, burdensome and patient unfriendly involving multiple procedures and complications. Masquelet described the technique of antibiotic cement spacer following debridement for an induced bio-membrane, with subsequent bone- grafting within this space. However, similar results were not reported at multiple centers due to damage to the biomembrane while removal of the cement. Hence, the present study describes the technique of cementation and cement retrieval in order to prevent the damage of the bio-membrane. Objective: To study the outcome of the role of Masquelet technique in the management of post-traumatic (long) bone defects following trauma presenting at our center.Method: 15 patients with mean bone defect of 7.2 cm after debridement were operated with the modified Masquelet technique.Results: Union was obtained in all of the cases; the average time for bony union was 8 months since first presentation with mean follow up of 2.5 years. Conclusion: The technique of delayed bone grafting with definitive fixation after initial debridement and placement of a cement spacer provides excellent results for patients with large posttraumatic bone segment loss.

Antibiotic cement spacer retention for chronic shoulder infection after minimum 2-year follow-up

The treatment of periprosthetic shoulder infections and proximal humerus osteomyelitis is challenging. The outcomes of antibiotic cement spacer retention are poorly defined in the literature. The purpose of this study was to review long-term functional and patient-reported outcomes data of patients with retained antibiotic cement spacers. We predict reasonable functional outcomes and minimal pain. We identified 22 patients of the senior author who have been treated with definitive antibiotic spacer placement. All patients were originally offered a 2-stage revision and declined. Twelve patients had a minimum follow-up of 2 years and were included in our cohort. Mean age was 70.7 (range 59-81), 8/12 patients were female, and the average body mass index was 27.8 (range = 17-45). Functional outcome assessments included the Standardized Shoulder Assessment Form, the Quick Disabilities of the Arm, Shoulder, and Hand Score (QuickDASH), and visual analog scale (VAS) along with clinical range of motion examination. Thepatients were followed up for a mean of 5.6 years. Eight patients had spacer placement for chronic shoulder arthroplasty infections, whereas 4 patients had spacer placement for chronic osteomyelitis of the proximal humerus. No patients were currently being treated with suppressive antibiotics. One patient had negative cultures at the time of antibiotic spacer placement. The most common organisms were Cutibacterium acnes (6), Staphylococcus epidermidis (6), and methicillin-resistant Staphylococcus aureus (4), with 4 patients growing more than 1 species. The average ASES score was 54 (range = 27-73), QuickDASH was 45 (range = 14-89), and VAS score 2.8 (range = 0-8). Average active range of motion was 68° of forward elevation and 35° of external rotation. Retention of antibiotic cement spacer is a viable option in the treatment algorithm for chronic shoulder infections. Long-term antibiotic cement spacer may be considered for those patients who are unwilling or unable to undergo a 2-stage revision. Patients can expect a reasonable amount of function and little to no pain with an antibiotic cement spacer.

Fighting Megaprosthetic Infections: What are the Chances of Winning?

Megaprosthetic infections continue to be a leading mode of failure after limb salvage surgery. Though challenging, amputations can be avoided with proper management in majority of the cases. This study aims to describe the spectrum of mega-endoprosthetic infections at our institute and assess the treatment efficacy in these patients. All patients treated for endoprosthetic infection at our institute between 2010 and 2018 were retrospectively analyzed for overall survival of reconstruction method, site and type of megaprosthesis, adjuvant therapy, microbial isolates, surgical and medical management and outcomes. Thirty-five patients (22 males: 13 females) were analyzed following treatment for endoprosthetic infection. Majority were around the knee joint [most commonly with proximal tibia (n = 14) followed by distal femur (n = 12) megaprosthesis]. Ten patients had undergone primary surgical procedure at our institute, while 25 patients presented with infection after megaprosthesis implantation. In the 28 culture-positive infections, the most common micro-organism was Staphylococcus spp. (18 patients: methicillin-sensitive Staphylococcus aureus = 9, coagulase-negative Staphylococcus = 5, methicillin-resistant Staphylococcus aureus = 1, Staphylococcus epidermidis = 3) and poly-microbial infection was present in three patients. Nine patients underwent successful debridement and wound wash with insertion of antibiotic impregnated cement beads in 5/9 cases. Twenty-one patients required a two-stage revision. Of these 30 patients, all but one has completely resolved infections. One patient with resurfaced late infection after re-implantation is on chronic suppressive antimicrobial therapy and close follow-up. Amputation because of uncontrolled infection was performed in three patients (one death post-operatively due to systemic complications of septicemia), while two patients opted for amputation as opposed to stage revisions. Median antimicrobial therapy duration was 6weeks (1-12weeks). Reconstructive surgery for soft tissue cover was required in seven patients. In patients with early or acute presentation without frank granulation or pus around the implant, debridement and insertion of antibiotic cement beads was adequate. Two-stage revisions with complete removal of the megaprosthesis showed best results in infections that could be controlled with antimicrobial therapy. More than one exchange of cement spacer was required for uncontrolled infections. Multidisciplinary approach in consultation with the infectious disease team is essential to determine choice of antibiotic cement for beads/spacer as well as appropriate adjuvant antimicrobial therapy to solve the challenging problem of endoprosthetic infections following bone tumor surgery. Adequate and healthy soft tissue cover of the implant should be achieved wherever indicated.

Antibiotic Cement Spacers for Infected Total Knee Arthroplasties.

Periprosthetic infection remains a frequent complication after total knee arthroplasty. The most common treatment is a two-stage procedure involving removal of all implants and cement, thorough débridement, insertion of some type of antibiotic spacer, and a course of antibiotic therapy of varying lengths. After some interval, and presumed eradication of the infection, new arthroplasty components are implanted in the second procedure. These knee spacers may be static or mobile spacers, with the latter presumably providing improved function for the patient and greater ease of surgical reimplantation. Numerous types of antibiotic cement spacers are available, including premolded cement components, surgical molds for intraoperative spacer fabrication, and the use of new metal and polyethylene knee components; all these are implanted with surgeon-prepared high-dose antibiotic cement. As there are advantages and disadvantages of both static and the various mobile spacers, surgeons should be familiar with several techniques. There is inconclusive data on the superiority of any antibiotic spacer. Both mechanical complications and postoperative renal failure may be associated with high-dose antibiotic cement spacers.

Staged Revision of Infected-hip Arthroplasty Using an Antibiotics-loaded Intra-articular Cement Spacer: Impact on Cemented and Cementless Stem Retention.

PurposeCurrently, standard management of a peri-prosthetic infection is a two-stage revision precedure. However, removal of well-fixed cement is technically demanding and associated with numerous potential complications. For theses reasons, two-stage revision with preservation of the original femoral stem can be considered and several previous studies have achieved successful results. While most prior studies used cemented stems, the use of cementless stems during arthroplasty has been gradually increasing; this study aims to assess the comparative effectiveness of a two-stage revision of infected hip arthroplasties at preserving cemented and cementless stems.Materials and MethodsBetween December 2001 and February 2017, Inje University Sanggye Paik Hospital treated 45 cases of deep infections following hip arthroplasty with a two stage revisional arthroplasty using antibiotics-loaded cement spacers. This approach was applied in an effort to preserve the previously implanted femoral stem. Of these 45 cases, 20 were followed-up for at least two years and included in this analysis. Perioperative clinical symptoms, radiological findings, function and complications during insertion of an antibiotics-loaded cement spacer were analyzed in this study.ResultsPeri-prothetic infections were controlled in 19 of the 20 included cases. Clinical outcomes, as assessed using the Harris hip score, Western Ontario and McMaster University score, also improved. Importantly, similarly improved outcomes were achieved for both cemented and cementless femoral stems.ConclusionIn cases of deep infection following hip arthroplasty, two-stage revision arthroplasty to preserve the previously implanted femoral stem (cemented or cementless) effectively controls infections and preserves joint function.