Two-stage approach to total knee arthroplasty using colistin-loaded articulating cement spacer for vancomycin-resistant Pseudomonas aeruginosa infection in an arthritic knee

  • Moon Jong Chang
  • Min Kyu Song
  • Jae Hoon Shin
  • Chan Yoon
  • Chong Bum Chang
  • Seung-Baik KangEmail author
Up-to date Review and Case Report • KNEE - ARTHROPLASTY



A two-stage approach to total knee arthroplasty (TKA) using an antibiotic-impregnated articulating cement spacer is an option for an infected arthritic knee. Vancomycin combined with broad-spectrum antibiotics can be used to make an antibiotic-impregnated articulating cement spacer. Causative organisms are sometimes not confirmed before surgery. Joint infections of multidrug-resistant organisms are increasing. Therefore, routine combinations of antibiotics may not be effective.

Methods and results

We present a case of a patient who developed vancomycin-resistant Pseudomonas aeruginosa infection in an arthritic knee. A 71-year-old man was initially diagnosed with pyogenic arthritis caused by Staphylococcus aureus. He underwent arthroscopic debridement elsewhere. However, the infection persisted. He was referred to our hospital, and we performed a two-stage TKA using a vancomycin-based antibiotic-impregnated articulating cement spacer. Vancomycin-resistant P. aeruginosa was identified after surgery. Intravenous colistin was added. However, this failed, either because vancomycin was not effective against P. aeruginosa, or because insufficient systemic colistin due to colistin-induced acute kidney injury. Therefore, debridement was repeated, and colistin-loaded cement spacer was inserted. The spacer delivered high concentrations of colistin to the infected joint with decreased systemic effects. Thus, less systemic colistin was used. The infection was controlled without recurrent acute kidney injury. One year after surgery, conversion to TKA was successfully performed.


A two-stage approach to TKA using a colistin-loaded articulating cement spacer can be used for an arthritic knee infected by vancomycin-resistant P. aeruginosa. Furthermore, local administration of colistin using a cement spacer can reduce the systemic side effects of colistin.


Colistin Infected arthritic knee Vancomycin-resistant Pseudomonas aeruginosa Antibiotic-impregnated cement spacer Two-stage approach 



This research was supported by the Bio & Medical Technology Development Program through the National Research Foundation of Korea (NRF) funded by Grant 2017M3A9D8063538 from the Ministry of Science & ICT. The authors have no conflicting financial interests in the work reported here.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Human and animal rights disclosure

Every institution involved in this work has approved the human protocol for this investigation.

Informed consent

Informed consent was obtained from the participants, and all investigations were conducted in conformity with ethical principles.


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Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  • Moon Jong Chang
    • 1
  • Min Kyu Song
    • 1
  • Jae Hoon Shin
    • 1
  • Chan Yoon
    • 1
  • Chong Bum Chang
    • 1
  • Seung-Baik Kang
    • 1
    Email author
  1. 1.Department of Orthopaedic Surgery, SMG-SNU Boramae Medical CenterSeoul National University College of MedicineSeoulSouth Korea

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