Intraoperative Molds to Create an Articulating Spacer for the Infected Knee Arthroplasty

ArticleinClinical Orthopaedics and Related Research 469(4):994-1001 · November 2010with4 Reads
DOI: 10.1007/s11999-010-1644-6 · Source: PubMed
Chronic infections in TKA have been traditionally treated with a two-stage protocol incorporating a temporary antibiotic-loaded cement spacer. The use of a static as opposed to an articulating spacer is controversial. Some surgeons believe a static spacer results in a higher rate of infection eradication, whereas others believe an articulating spacer provides equivalent rates of infection control with improved function between stages and the potential for better eventual range of motion. We determined the rates of infection control and postoperative function for an articulating all-cement antibiotic spacer fashioned intraoperatively from prefabricated silicone molds. We retrospectively reviewed 60 patients with an infected TKA using the same cement-on-cement articulating spacer. A minimum of 4 g antibiotic per package of cement was used when making the spacer. Complications and pre- and postoperative knee flexion, extension, and Knee Society scores were recorded. Bone loss associated with the spacer was determined radiographically and by intraoperative inspection of the bony surfaces at the second stage. Minimum followup was 24 months (mean, 35 months; range, 24-51 months). Seven patients (12%) became reinfected, four with an organism different from that identified at the index resection arthroplasty. One spacer femoral component broke between stages but did not require any specific treatment. We identified no bone loss between stages and no complications related to the cement-on-cement articulation. The mean pretreatment Knee Society scores of 53 improved to 79. The mean preoperative flexion of 90.6º improved to 101.3º at final followup. An articulating antibiotic spacer was associated with control of a deep periprosthetic infection in 88% of patients while allowing range of motion between stages. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
    • "Infection is a devastating complication after TKA or THA. The two-stage exchange approach using an antibiotic-loaded cement spacer has become the preferred treatment for any chronically infected TKA or THA [10, 16, 19, 25, 27, 28, 36, 41]. The rationale for the choice of antibiotics to be included in such local delivery systems must follow several principles [10, 17], but the antimicrobial activity of the antibiotic at the infection site is of paramount importance, since drug selection depends on the microorganism(s) to be targeted. "
    [Show abstract] [Hide abstract] ABSTRACT: Industrially preformed antibiotic-loaded cement spacers are useful to facilitate the second stage of two-stage exchange arthroplasty for infected THAs and TKAs. However, whether gentamicin alone or a combination of antibiotics (such as vancomycin and gentamicin) is more effective is not known. We therefore sought to compare industrially prefabricated spacers containing either gentamicin or gentamicin and vancomycin with respect to (1) infection control, (2) complications, and (3) quality of life, pain, and patient satisfaction. We performed a review of 51 patients with chronic infections treated at one center using either gentamicin or vancomycin and gentamicin-prefabricated spacers. The former were used exclusively from January 2006 until May 2009, and the latter from June 2009 until July 2011, and there was no overlap. We collected data on demographics, immunologic status (McPherson classification), prosthetic joint infection location, type of prosthesis, microbiologic results, and time between stages. We evaluated the primary outcome of infection control or recurrence after at least 12 months followup. We also recorded complications. Each patient completed a quality-of-life survey, VAS, and a self-administered satisfaction scale. The overall infection control rate was 83% after a mean followup of 35 months (range, 12.4-64.7 months). There were no differences between gentamicin and vancomycin and gentamicin spacers in terms of infection eradication (80 % versus 85 %, respectively; p = 0.73), nor in terms of complications, quality of life, pain, or satisfaction scores. Prefabricated, antibiotic-loaded cement spacers has been proven effective for infection control in TKAs and THAs but with the numbers available, we did not find any differences between a gentamicin or vancomycin and gentamicin-prefabricated spacer, and therefore, we are unable to validate the superiority of the combination of vancomycin and gentamicin over gentamicin alone. Because of the higher costs involved with vancomycin and gentamicin spacers, and the potential risks of unselective use of vancomycin, further comparative studies are necessary to evaluate their role in the treatment of infected THAs or TKAs. Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
    Full-text · Article · Oct 2013
    • "The gold standard for treating chronic periprosthetic infection is based on a two-stage protocol, including initial explantation of the infected components, adequate debridement , and antibiotic cement spacer prostheses implantation with systemic antibiotic therapy followed by secondary TKA once the optimal condition is achieved [13] [14]. The antimicrobial-impregnated spacer utilized in this process allows for maintenance of limb length, partial mobility during the recovery process, and infection control rates of 91% to 100% [15] [16]. Initially, cement spacers were static, therefore not providing sufficient range of motion (ROM); bone loss, soft tissue contracture, and increased scar tissue formation as a result have been mentioned [17] [18] [19]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Periprosthetic infections remain a devastating problem in the field of joint arthroplasty. In the following study, the results of a two-stage treatment protocol for chronic periprosthetic infections using an intraoperatively molded cement prosthesis-like spacer (CPLS) are presented. Methods: Seventy-five patients with chronically infected knee prosthesis received a two-stage revision procedure with the newly developed CPLS between June 2006 and June 2011. Based on the microorganism involved, patients were grouped into either easy to treat (ETT) or difficult to treat (DTT) and treated accordingly. Range of motion (ROM) and the knee society score (KSS) were utilized for functional assessment. Results: Mean duration of the CPLS implant in the DTT group was 3.6 months (range 3-5 months) and in the ETT group 1.3 months (range 0.7-2.5 months). Reinfection rates of the final prosthesis were 9.6% in the ETT and 8.3% in the DTT group with no significant difference between both groups regarding ROM or KSS (P = 0.87, 0.64, resp.). Conclusion: The results show that ETT patients do not necessitate the same treatment protocol as DTT patients to achieve the same goal, emphasizing the need to differentiate between therapeutic regimes. We also highlight the feasibility of CLPS in two-stage protocols.
    Full-text · Article · Sep 2013
    • "80% of the patients were satisfied with the result of their knee. Eight studies of between 50 and 60 patients reported reinfection rates of 4% [52], 7% [32], 8% [33], 12% [59] and [70], 25% [40] and 28% [45]. Similarly to the study by Freeman and colleagues, Fehring [32] made a comparison between static (n = 25) and articulating spacers (n = 30). "
    [Show abstract] [Hide abstract] ABSTRACT: Periprosthetic infection about the knee is a devastating complication that may affect between 1% and 5% of knee replacement. With over 79 000 knee replacements being implanted each year in the UK, periprosthetic infection (PJI) is set to become an important burden of disease and cost to the healthcare economy. One of the important controversies in treatment of PJI is whether a single stage revision operation is superior to a two-stage procedure. This study sought to systematically evaluate the published evidence to determine which technique had lowest reinfection rates. A systematic review of the literature was undertaken using the MEDLINE and EMBASE databases with the aim to identify existing studies that present the outcomes of each surgical technique. Reinfection rate was the primary outcome measure. Studies of specific subsets of patients such as resistant organisms were excluded. 63 studies were identified that met the inclusion criteria. The majority of which (58) were reports of two-stage revision. Reinfection rated varied between 0% and 41% in two-stage studies, and 0% and 11% in single stage studies. No clinical trials were identified and the majority of studies were observational studies. Evidence for both one-stage and two-stage revision is largely of low quality. The evidence basis for two-stage revision is significantly larger, and further work into direct comparison between the two techniques should be undertaken as a priority.
    Full-text · Article · Jul 2013
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