Two-Stage Exchange Knee Arthroplasty: Static Spacers

Chapter

Abstract

Antibiotic spacers are an important tool in the management of periprosthetic joint infection. The concept of spacers has evolved from a static block in which the knee is immobilized in full extension to more conforming articulating surfaces that allow more knee motion, in an attempt to improve patients’ quality of life before and after reimplantation. Static spacers are still indicated in knees with significant bone and soft tissue compromise to avoid complications related to mobility in the absence of the proper amount of constraint. Increasing the amount of antibiotics added to the cement results in a higher and longer elution but could lead to potential systemic toxicity. It also reduces the mechanical strength of cement which becomes a concern if mobility and weight bearing are to be permitted. The ideal dose of antibiotics to be mixed with cement remains unclear. Large doses have been demonstrated to be clinically safe, but have not shown to be cost-effective in providing better infection control.

Keywords

Porosity Migration Toxicity Creatinine Mold 

References

  1. 1.
    Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty. Clin Orthop Relat Res. 2004;428:35–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Hirakawa K, Stulberg BN, Wilde AH, et al. Results of 2-stage reimplantation for infected total knee arthroplasty. J Arthroplasty. 1998;13:22–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Mittal Y, Fehring TK, Hanssen A, et al. Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am. 2007;89:1227–31.PubMedCrossRefGoogle Scholar
  4. 4.
    Mont MA, Waldman BJ, Hungerford DS. Evaluation of preoperative cultures before second-stage reimplantation of a total knee prosthesis complicated by infection. A comparison-group study. J Bone Joint Surg Am. 2000;82-A:1552–7.PubMedGoogle Scholar
  5. 5.
    Salgado CD, Dash S, Cantey JR, et al. Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 2007;461:48–53.PubMedGoogle Scholar
  6. 6.
    Baker AS, Greenham LW. Release of gentamicin from acrylic bone cement. Elution and diffusion studies. J Bone Joint Surg Am. 1988;70:1551–7.PubMedGoogle Scholar
  7. 7.
    Wahlig H, Dingeldein E, Buchholz HW, et al. Pharmacokinetic study of gentamicin-loaded cement in total hip replacements. Comparative effects of varying dosage. J Bone Joint Surg Br. 1984;66:175–9.PubMedGoogle Scholar
  8. 8.
    Marks KE, Nelson CL, Lautenschlager EP. Antibiotic-impregnated acrylic bone cement. J Bone Joint Surg Am. 1976;58:358–64.PubMedGoogle Scholar
  9. 9.
    Wahlig H, Dingeldein E. Antibiotics and bone cements. Experimental and clinical long-term observations. Acta Orthop Scand. 1980;51:49–56.PubMedCrossRefGoogle Scholar
  10. 10.
    Meyer J, Piller G, Spiegel CA, et al. Vacuum-mixing significantly changes antibiotic elution characteristics of commercially available antibiotic-impregnated bone cements. J Bone Joint Surg Am. 2011;93:2049–56.PubMedCrossRefGoogle Scholar
  11. 11.
    Neut D, van de Belt H, van Horn JR, et al. The effect of mixing on gentamicin release from polymethylmethacrylate bone cements. Acta Orthop Scand. 2003;74:670–6.PubMedCrossRefGoogle Scholar
  12. 12.
    van de Belt H, Neut D, Uges DR, et al. Surface roughness, porosity and wettability of gentamicin-loaded bone cements and their antibiotic release. Biomaterials. 2000;21:1981–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Greene N, Holtom PD, Warren CA, et al. In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos. Am J Orthop (Belle Mead NJ). 1998;27:201–5.Google Scholar
  14. 14.
    Chang Y, Chen WC, Hsieh PH, et al. In vitro activities of daptomycin-, vancomycin-, and teicoplanin-loaded polymethylmethacrylate against methicillin-susceptible, methicillin-resistant, and vancomycin-intermediate strains of Staphylococcus aureus. Antimicrob Agents Chemother. 2011;55:5480–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Fulkerson E, Valle CJ, Wise B, et al. Antibiotic susceptibility of bacteria infecting total joint arthroplasty sites. J Bone Joint Surg Am. 2006;88:1231–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Johnson AJ, Sayeed SA, Naziri Q, et al. Minimizing dynamic knee spacer complications in infected revision arthroplasty. Clin Orthop Relat Res. 2012;470:220–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Springer BD, Lee GC, Osmon D, et al. Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty. Clin Orthop Relat Res. 2004;427:47–51.PubMedCrossRefGoogle Scholar
  18. 18.
    Cui Q, Mihalko WM, Shields JS, et al. Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthroplasty. J Bone Joint Surg Am. 2007;89:871–82.PubMedCrossRefGoogle Scholar
  19. 19.
    Grimsrud C, Raven R, Fothergill AW, et al. The in vitro elution characteristics of antifungal-loaded PMMA bone cement and calcium sulfate bone substitute. Orthopedics. 2011;34:e378–81.PubMedGoogle Scholar
  20. 20.
    Rouse MS, Heijink A, Steckelberg JM, et al. Are anidulafungin or voriconazole released from polymethylmethacrylate in vitro? Clin Orthop Relat Res. 2011;469:1466–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Goss B, Lutton C, Weinrauch P, et al. Elution and mechanical properties of antifungal bone cement. J Arthroplasty. 2007;22:902–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Marra F, Robbins GM, Masri BA, et al. Amphotericin B-loaded bone cement to treat osteomyelitis caused by Candida albicans. Can J Surg. 2001;44:383–6.PubMedGoogle Scholar
  23. 23.
    Kweon C, McLaren AC, Leon C, et al. Amphotericin B delivery from bone cement increases with porosity but strength decreases. Clin Orthop Relat Res. 2011;469:3002–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Bunetel L, Segui A, Cormier M, et al. Release of gentamicin from acrylic bone cement. Clin Pharmacokinet. 1989;17:291–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Brien WW, Salvati EA, Klein R, et al. Antibiotic impregnated bone cement in total hip arthroplasty. An in vivo comparison of the elution properties of tobramycin and vancomycin. Clin Orthop Relat Res. 1993;296:242–8.PubMedGoogle Scholar
  26. 26.
    Masri BA, Duncan CP, Beauchamp CP. Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system. J Arthroplasty. 1998;13:331–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Hsieh PH, Chang YH, Chen SH, et al. High concentration and bioactivity of vancomycin and aztreonam eluted from Simplex cement spacers in two-stage revision of infected hip implants: a study of 46 patients at an average follow-up of 107 days. J Orthop Res. 2006;24:1615–21.PubMedCrossRefGoogle Scholar
  28. 28.
    van Raaij TM, Visser LE, Vulto AG, et al. Acute renal failure after local gentamicin treatment in an infected total knee arthroplasty. J Arthroplasty. 2002;17:948–50.PubMedCrossRefGoogle Scholar
  29. 29.
    Curtis JM, Sternhagen V, Batts D. Acute renal failure after placement of tobramycin-impregnated bone cement in an infected total knee arthroplasty. Pharmacotherapy. 2005;25:876–80.PubMedCrossRefGoogle Scholar
  30. 30.
    Patrick BN, Rivey MP, Allington DR. Acute renal failure associated with vancomycin- and tobramycin-laden cement in total hip arthroplasty. Ann Pharmacother. 2006;40:2037–42.PubMedCrossRefGoogle Scholar
  31. 31.
    Calton TF, Fehring TK, Griffin WL. Bone loss associated with the use of spacer blocks in infected total knee arthroplasty. Clin Orthop Relat Res. 1997;345:148–54.PubMedCrossRefGoogle Scholar
  32. 32.
    Cohen JC, Hozack WJ, Cuckler JM, et al. Two-stage reimplantation of septic total knee arthroplasty. Report of three cases using an antibiotic-PMMA spacer block. J Arthroplasty. 1988;3:369–77.PubMedCrossRefGoogle Scholar
  33. 33.
    Kotwal SY, Farid YR, Patil SS, et al. Intramedullary rod and cement static spacer construct in chronically infected total knee arthroplasty. J Arthroplasty. 2012;27:253–9..e4.PubMedCrossRefGoogle Scholar
  34. 34.
    Freeman MG, Fehring TK, Odum SM, et al. Functional advantage of articulating versus static spacers in 2-stage revision for total knee arthroplasty infection. J Arthroplasty. 2007;22:1116–21.PubMedCrossRefGoogle Scholar
  35. 35.
    Haddad FS, Masri BA, Campbell D, et al. The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Prosthesis of antibiotic-loaded acrylic cement. J Bone Joint Surg Br. 2000;82:807–12.PubMedCrossRefGoogle Scholar
  36. 36.
    Durbhakula SM, Czajka J, Fuchs MD, et al. Antibiotic-loaded articulating cement spacer in the 2-stage exchange of infected total knee arthroplasty. J Arthroplasty. 2004;19:768–74.PubMedCrossRefGoogle Scholar
  37. 37.
    Meek RM, Masri BA, Dunlop D, et al. Patient satisfaction and functional status after treatment of infection at the site of a total knee arthroplasty with use of the PROSTALAC articulating spacer. J Bone Joint Surg Am. 2003;85-A:1888–92.PubMedGoogle Scholar
  38. 38.
    Emerson Jr RH, Muncie M, Tarbox TR, et al. Comparison of a static with a mobile spacer in total knee infection. Clin Orthop Relat Res. 2002;404:132–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Hofmann AA, Goldberg T, Tanner AM, et al. Treatment of infected total knee arthroplasty using an articulating spacer: 2- to 12-year experience. Clin Orthop Relat Res. 2005;430:125–31.PubMedCrossRefGoogle Scholar
  40. 40.
    Van Thiel GS, Berend KR, Klein GR, et al. Intraoperative molds to create an articulating spacer for the infected knee arthroplasty. Clin Orthop Relat Res. 2011;469:994–1001.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery and RehabilitationUniversity of Nebraska Medical CenterOmahaUSA

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