Permanent Spacer Research Articles

Novel, static, permanent spacers to treat chronic knee periprosthetic joint infections

PurposeTo discuss a static and permanent spacer in the treatment of chronic periprosthetic knee infection. MethodsIn this study, patients who were diagonised with chronic periprosthetic knee infection and not appropriate to undergo revision operations were included and were treated with static and permanent spacers. Infection recurrence rate was recorded, Visual Analogue Scale (VAS) score and Knee Society Score (KSS) were used to record patients’ pain and knee function before the operation and at the final follow-up (minimum 24 months).ResultsFifteen patients were identified for this study. Pain and function were significantly improved at the latest follow-up evaluation. One patient had a recurrent infection and underwent amputation. No patients had signs of residual instability at the final follow-up evaluation, and no breakage or subsidence of the antibiotic spacer were identified at the final radiographic follow-up evaluation.ConclusionOur study provided evidence that the static and permanent spacer was a reliable salvage procedure to treat periprosthetic knee infection in compromised patients.

Tuberoplasty: Indications, Technique, and Preliminary Results

The optimal approach to treatment of massive irreparable rotator cuff tears (MIRCTs) continues to be debated among shoulder surgeons. While nonsurgical treatment is a reasonable option for some, many of these patients continue to experience pain, weakness, and overall limited function of the shoulder [1], [2]. Superior capsular reconstruction has become a widely accepted approach to treatment of MIRCT, however there exists several technical and biologic challenges of this technique. Overcoming many of these difficulties, a recently described technique involves the placement of a biological interpositional graft over the greater tuberosity which acts as a permanent spacer between the humerus and acromion[3]. With the primary goal of providing pain relief, this technique may function to improve the benefit of rehab following MIRCT. In this article, we describe the indications, technique, and early outcomes of this so-called “tuberoplasty” approach to MIRCT.

Infection periprothetique de l’épaule : révision en deux temps versus spacer antibiotique articulé permanent

IntroductionPeriprosthetic shoulder infections (PSIs) represent a serious complication following shoulder arthroplasty. No consensus exists regarding the optimal option. We conducted a retrospective case-control study to compare the outcomes of 2-stage revision shoulder arthroplasty and those of definitive articulating antibiotic spacer implantation with regards to eradication of the infection, improvement of pain and shoulder function. Materials and methods30 patients treated for an infected shoulder arthroplasty were retrospectively reviewed after a mean follow-up of 8 years (range, 2–10 years). Nineteen underwent definitive articulating antibiotic spacer implantation and 11 underwent 2-stage revision arthroplasty. Mean age at surgery was 68.8 years. Assessment included Constant-Murley score, visual analog scale pain score, objective examination, patient subjective satisfaction score as well as standard radiographs. ResultsAt the most recent follow-up, none of the patients had clinical or radiographic signs suggesting recurrent infection. Most patients reported satisfying subjective and objective outcomes. Follow-up examination showed significant improvement of all variables compared to preoperative values (p<0.001). Radiographs did not show progressive radiolucent lines or change in the position of the functional spacer. No statistically significant differences were reported between the two groups concerning Constant-Murley and VAS scores, while average forward flexion and abduction were significantly higher in patients undergoing 2-stage revision surgery. ConclusionsBoth surgical procedures provided infection eradication and satisfying subjective functional outcomes. Functional results were superior in patients treated with revision shoulder prosthesis, although a higher rate of complication was reported in this cohort of patients, thus suggesting the use of permanent spacer in high-risk or low-demanding elderly patients. Level of evidenceIII, Retrospective case-control study.

Two-stage revision shoulder prosthesis vs. permanent articulating antibiotic spacer in the treatment of periprosthetic shoulder infections

IntroductionPeriprosthetic shoulder infections (PSIs) represent a serious complication following shoulder arthroplasty. No consensus exists regarding the optimal option. We conducted a retrospective case-control study to compare the outcomes of 2-stage revision shoulder arthroplasty and those of definitive articulating antibiotic spacer implantation with regards to eradication of the infection, improvement of pain and shoulder function. Materials and methodsThirty patients treated for an infected shoulder arthroplasty were retrospectively reviewed after a mean follow-up of 8 years (range, 2–10 years). Nineteen underwent definitive articulating antibiotic spacer implantation and 11 underwent 2-stage revision arthroplasty. Mean age at surgery was 68.8 years. Assessment included Constant-Murley score, visual analog scale pain score, objective examination, patient subjective satisfaction score as well as standard radiographs. ResultsAt the most recent follow-up, none of the patients had clinical or radiographic signs suggesting recurrent infection. Most patients reported satisfying subjective and objective outcomes. Follow-up examination showed significant improvement of all variables compared to preoperative values (p<0.001). Radiographs did not show progressive radiolucent lines or change in the position of the functional spacer. No statistically significant differences were reported between the two groups concerning Constant-Murley and VAS scores, while average forward flexion and abduction were significantly higher in patients undergoing 2-stage revision surgery. ConclusionsBoth surgical procedures provided infection eradication and satisfying subjective functional outcomes. Functional results were superior in patients treated with revision shoulder prosthesis, although a higher rate of complication was reported in this cohort of patients, thus suggesting the use of permanent spacer in high-risk or low-demanding elderly patients. Level of evidenceIII, Retrospective case-control study.

Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty.

The aim of this scoping review is to assess the current evidence regarding periprosthetic shoulder infection to inform development of evidence and consensus-based guidelines. A search of Medline, Embase and PubMed was performed; two authors screened the results independently for inclusion. Totally 88 studies were included. Incidence of periprosthetic shoulder infection ranged from 0.7% to 7%. The most common organisms to cause periprosthetic shoulder infection were Propionibacterium acnes, Staphylococcus aureus, Staphylococcus epidermidis and coagulase-negative Staphylococcus. Male gender and younger age are the most reported risk factors. Erythrocyte sedimentation rate, C-reactive protein and serum/synovial biomarkers had limited diagnostic accuracy. Thirty-nine studies reported the outcome of surgical management of periprosthetic shoulder infection. Eradication rates vary from 54% to 100% for debridement procedures; 66-100% for permanent spacers; 50-100% following single-stage revision; 60-100% following two-stage revision; and 66-100% following resection arthroplasty. There is wide heterogeneity in study designs and outcomes of studies are often contradictory and due to issues with methodology and small sample sizes the optimal pathways for diagnosis and management cannot be determined from this review. Future research should be based on larger cohorts and randomised trials where feasible to provide more valid research for guiding future treatment of periprosthetic shoulder infection.

Therapy of Periprosthetic Shoulder Infection

There are several therapeutic options for the treatment of periprosthetic joint infections of shoulder arthroplasties. In acute infections, the implant can remain in place with open debridement, septic lavage with antibacterial solutions such as octinedine or polyhexanide solution and exchange of all mobile components. In late infections, the therapeutic options after removal of the infected implant are: permanent spacer, resection arthroplasty, one stage revision and two stage revision with or without a temporary spacer. The functional results are best for one stage revisions, with similar prosthetic survival to two stage revisions. For one stage revisions, the microorganism has to be identified prior to revision surgery, in order to use targeted antibiotics locally in the cement, and systemically.

Revision of reversed shoulder arthroplasty: Is a reoperation possible?

IntroductionAs the number of reversed shoulder arthroplasty (RSA) procedures increases, the revision rate will also increase. In case of severe bone insufficiency, instability or infection of the primary RSA, revision to another RSA is preferable but not always possible. Hemiarthroplasty (HA), spacers and resection arthroplasty (RA) have been described in this indication.Materials and methodsBetween 2004 and 2016, 20 shoulders in 19 patients were treated at Ghent University Hospital for failed revision of RSA. Nine received a megahead prosthesis, a spacer was implanted in 6, and 5 underwent RA.ResultsIndications for implantation of a megahead prosthesis were loosening RSA (n = 5), infection (n = 4), dislocation (n = 1) and nerve irritation (n = 1). Improvement of range of motion was observed. Anterosuperior migration of the prosthesis was noted in 2 patients. Another 2 patients were ultimately revised to RSA. Seven permanent spacers were implanted for infection, of which 2 remain in place till today. The other 5 were revised to RSA. Of the 5 patients treated with RA, 3 were revised further on to RSA, resulting in pain relief and regain of function.DiscussionOur study shows that a megahead prosthesis has better functional results than RA, but is inferior to RSA. Due to increasing surgical experience and improving technique, 9 patients could ultimately be reconverted to another RSA. A review of current literature is presented. In HA and RA, the functional results are poor, and pain relief is uncertain. Results of spacers are variable and can be satisfactory. Arthrodesis is a last resort.ConclusionIn our case series study, a hemiarthroplasty can be performed in case of failure of RSA. However, the results are inferior to another RSA.

Surgical treatment of infected shoulder arthroplasty. A systematic review.

To investigate the best surgical management of infected shoulder arthroplasty. A literature review from 1996 to 2016 identified 15 level IV studies that met inclusion criteria. Persistent infection (PI) was considered as treatment failure. Success was regarded as the absence of symptomatic PI without necessity for further treatment. Surgical outcomes were reported according to the mean weighted Constant and Murley score (CMS) for each treatment group. Overall, 287 patients (146 males/141 females) were identified at a mean follow-up of 50.4 (range 32-99.6) months. The PI in the whole population was 11.5%. The pooled mean CMS, available for 218 patients, was 39 ± 13. Twenty-seven patients (9.4%) were treated with debridement (PI 29.6%, CMS 41 ± 12), 52 patients (18.1%) with resection arthroplasty (PI 11.5%, CMS 29 ± 16), 33 patients (11.5%) with permanent spacers (PI 6.1%, CMS 31 ± 14), 98 patients (34.2%) with two-stage revisions (PI 14.3%, CMS 42 ± 12) and 77 patients (26.8%) with one-stage revisions (PI 3.9%, CMS 49 ± 11). Debridement showed the highest PI rate (29.6%) and one-stage revisions reported the lowest PI rate (3.9%). Resection arthroplasty and spacers showed the poorest CMS when compared to the other procedures (p ≤ 0.0001). The debridement PI rate was significantly higher than almost any other procedure. CMS was significantly higher in patients undergoing revision compared to non-revision procedures (45 ± 12 vs. 35 ± 14) (p < 0.0001). One-stage revisions achieved significantly better results in terms of the PI rate compared to two-stage revisions (p = 0.0223), but not in terms of CMS. Debridement showed the highest PI rate (29.6%) and should not be recommended for the management of infected shoulder arthroplasty. Revisions reported better functional outcomes compared to non-revision procedures. The presence of a significantly lower PI rate with comparablely high mean CMS values suggests that one-stage (where technically applicable) could be superior to two-stage revisions. Unfortunately, well-designed randomized controlled trials using validated patient-based outcomes are lacking in this field. Systematic Review of level IV studies, Level IV.

Periprosthetic Joint Infection of Shoulder Arthroplasties: Diagnostic and Treatment Options

Periprosthetic joint infection (PJI) is one of the most frequent reasons for painful shoulder arthroplasties and revision surgery of shoulder arthroplasties. Cutibacterium acnes (Propionibacterium acnes) is one of the microorganisms that most often causes the infection. However, this slow growing microorganism is difficult to detect. This paper presents an overview of different diagnostic test to detect a periprosthetic shoulder infection. This includes nonspecific diagnostic tests and specific tests (with identifying the responsible microorganism). The aspiration can combine different specific and nonspecific tests. In dry aspiration and suspected joint infection, we recommend a biopsy. Several therapeutic options exist for the treatment of PJI of shoulder arthroplasties. In acute infections, the options include leaving the implant in place with open debridement, septic irrigation with antibacterial fluids like octenidine or polyhexanide solution, and exchange of all removable components. In late infections (more than four weeks after implantation) the therapeutic options are a permanent spacer, single-stage revision, and two-stage revision with a temporary spacer. The functional results are best after single-stage revisions with a success rate similar to two-stage revisions. For single-stage revisions, the microorganism should be known preoperatively so that specific antibiotics can be mixed into the cement for implantation of the new prosthesis and specific systemic antibiotic therapy can be applied to support the surgery.

Alternative to H3PO4 for Si3N4 Removal by Using Chemical Downstream Etching

Silicon Nitride is with SiO2, one of the most used material in the VLSI. Most of the time it is deposited as a sacrificial layer: etch stop and CMP buffer layers, temporary or permanent spacers, hard masks for epitaxies, etc… In the present work we have been able to remove Si3N4 without the use of conventional H3PO4 chemistry. We managed to integrate a chemical downstream etching (CDE) process to 28nm and 14nm FDSOI wafers. Aspects of uniformity, selectivity and defectivity will be discussed in this paper.

What treatment for periprosthetic shoulder infection? Results from a multicentre retrospective series

Controversy still exists as to the best surgical treatment for periprosthetic shoulder infections. The aim of this multi-institutional study was to review a continuous retrospectiveseries of patients treated in four European centres and to assess the respective eradication rate of various treatment approaches. Forty-four patients were available for this retrospective follow-up evaluation. Functional and clinical evaluation of treatment for infection was performed using the Constant-Murley score, visual analogue scale and patient satisfaction Neer score. Erythrocyte sedimentation rate, serum leucocyte count and C-reactive protein were measured and shoulder X-ray examination performed prior to surgery and at the latest follow-up. At a mean follow-up of 41 months (range 24–98),42 of 44 patients (95.5%) showed no signs of infection recurrence/persistence. Comparable eradication rates were observed after resection arthroplasty (100%; 6/6), two-stage revision (17/17) or permanent antibiotic-loaded spacer implant (93.3%; 14/15). No patient was treated by one-stage revision. On average, both functional and pain scores improved significantly; the worst joint function was observed after resection arthroplasty. This retrospective analysis conducted on the largest published series of patients to date shows comparable infection eradication rates after two-stage revision, resection arthroplasty or permanent spacer implant for the treatment of septic shoulder prosthesis.

Clinical outcome and microbiological findings using antibiotic-loaded spacers in two-stage revision of prosthetic joint infections

Antibiotic-loaded spacers may improve antimicrobial efficacy in two-stage revision of prosthetic joint infections, but they may also interfere in the course of infection. This prospective study of prosthetic joint infections managed with two-stage revision and antibiotic-loaded spacers (2004-09) analyzes case outcomes and proposes a second-stage culture interpretation scheme. Second-stage infection was diagnosed upon second-stage cultures (synovial membranes, joint fluid, spacers), as either superinfection (≥2 samples, new organism) or persistence (≥1 samples, previously isolated organism). Isolated positive antibiotic-loaded spacers cultures were considered as colonizations. Of 42 patients, two had two prosthetic infections (n=44): 25 knees, 19 hips. Spacers contained gentamicin (33), vancomycin (10) and aztreonam (1). Three patients (7%) with wound healing impairment required debridement and spacer exchange. The remainder underwent second-stage surgery as planned: 34 (77%) new arthroplasties, five arthrodeses, one resection arthroplasty and one permanent spacer. Of 18 cases (44%) with ≥1 positive sample, only four (10%) were second-stage infections. Fourteen antibiotic-loaded spacers cultures (34%) were positive. Four new prostheses (9%) supervened further infections: one by the organism isolated in the spacer, three by new bacteria. The findings of second-stage cultures show that the surgical site is frequently non-sterile at reimplantation. Isolated positive antibiotic-loaded spacer cultures usually have no clinical consequences, but together with tissue cultures they help to diagnose second-stage infections when clinical signs are absent.