Küntscher nails with static cement spacer: A simple technique in periprosthetic knee infections with massive bone loss and instability

Acute prophylactic antibiotic nailing of open femoral shaft fractures for prevention of fracture-related infection

Background

Open, grossly contaminated femoral shaft fractures pose a significant threat for fracture-related infection. Traditional treatment for these injuries consists of irrigation and debridement with temporizing external fixation placement and staged conversion to definitive fixation.

Methods

We describe a protocol for acute antibiotic cement nailing of open femoral shaft fractures as an infection prophylaxis modality in fractures with a high risk of infection and present three cases.

Results

Three patients presented with open femoral shaft fractures with large soft tissue defects and gross contamination and were successfully treated with acute retrograde antibiotic nailing and external fixation with later conversion to definitive metallic nailing. They did not develop infection and had acceptable postoperative function and fracture alignment.

Conclusion

This technique of early infection prophylaxis after open femoral shaft fracture is reproducible, pragmatic, and cost-effective.

Indications and techniques for non-articulating spacers in massive bone loss following prosthetic knee joint infection: a scoping review

INTRODUCTION

Prosthetic joint infection (PJI) is a destructive complication of knee replacement surgery (KR). In two-stage revision a spacer is required to maintain limb length and alignment and provide a stable limb on which to mobilise. Spacers may be articulating or static with the gold standard spacer yet to be defined. The aims of this scoping review were to summarise the types of static spacer used to treat PJI after KR, their indications for use and early complication rates.

METHODS

We conducted a scoping review based on the Joanna Briggs Institute's "JBI Manual for Evidence Synthesis" Scoping review reported following Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. MEDLINE, EMBASE and CINAHL were searched from 2005 to 2022 for studies on the use of static spacers for PJI after KR.

RESULTS

41 studies (1230 patients/knees) were identified describing 42 static spacer constructs. Twenty-three (23/42 [54.2%]) incorporated cement augmented with metalwork, while nineteen (19/42, [45.9%]) were made of cement alone. Spacers were most frequently anchored in the diaphysis (22/42, [53.3%]), particularly in the setting of extensive bone loss (mean AORI Type = F3/T3; 11/15 studies 78.3% diaphyseal anchoring). 7.1% (79 of 1117 knees) of static spacers had a complication requiring further surgery prior to planned second stage with the most common complication being infection (86.1%).

CONCLUSIONS

This study has summarised the large variety in static spacer constructs used for staged revision KR for PJI. Static spacers were associated with a high risk of complications and further work in this area is required to improve the quality of care in this vulnerable group.

Is the rod necessary? Biomechanical comparison of static knee spacers during axial loading

BACKGROUND

Knee Spacers are required in two-stage revision surgery of periprosthetic joint infection of the knee. Extended bone and ligamentous defects are often temporarily arthrodised via a static spacer. Regarding their weight-bearing potential and construction, there is no current consent. Our aim was to evaluate three individual static spacer variants with regard to their axial loading capacity.

METHODS

The static spacer variants were tested in a cadaver model. One after the other, a spacer with metal-reinforced rods, a spacer without metal reinforcement and a rod-less spacer were implanted and tested up to an axial loading of 1000 Newton. Target parameters were plastic deformation, stiffness and spacer movement at both the femoral and tibial surface. Loading was applied up to 1000 Newton. Radiological controls of the bone substance were performed.

FINDINGS

The spacer variants did not differ regarding deformation, stiffness or spacer movement. However, deformation increased significantly with the axial load in all spacer variants. Radiographs showed no fracture or spacer-dislocation resulting from testing.

INTERPRETATION

While the spacer reinforcement or the sheer presence of a rod did not influence the axial loading capacity in this in vitro study, weightbearing should be discouraged to limit further bone erosion.

Are Static Spacers Superior to Articulated Spacers in the Staged Treatment of Infected Primary Knee Arthroplasty? A Systematic Review and Meta-Analysis

In the treatment of knee periprosthetic joint infection with a two-stage protocol, static spacers allow for the local delivery of high doses of antibiotics and help to preserve soft tissue tension. Articulated spacers were introduced to better preserve flexion after the reimplantation. The aim of this systematic review is to provide a comprehensive data collection of the results of these different spacers. An in-depth search on the main clinical databases was performed concerning the studies reporting data on the topic. A total of 87 studies and 4250 spacers were included. No significant differences were found both in pooling data analysis and meta-analysis of comparative studies about infection recurrences, complications, and clinical scores. Mean active knee flexion at last follow-up after total knee reimplantation was found to be significantly higher using articulated spacers (91.6° ± 7° for static spacers vs. 100.3° ± 9.9° for articulated spacers; p < 0.001). Meta-analysis also recognized this strong significant difference (p < 0.001). This review has confirmed that articulated spacers do not appear to be inferior to static spacers regarding all clinical outcomes, while they are superior in terms of active flexion. However, the low quality of the studies and the risk for selection bias with complex patients preferentially treated with static spacers need to be accounted for.

Comparison of dynamic and static spacers for the treatment of infections following total knee replacement: a systematic review and meta-analysis

Background

Revision surgery is the most common treatment for patients who develop infection after total knee arthroplasty (TKA). Two types of spacers are often used in revision surgery: dynamic spacers and static spacers. The comparative efficacy of these two types of spacers on knee prosthesis infections is not well established. Therefore, we carried out a systematic evaluation and meta-analysis with the aim of comparing the difference in efficacy between dynamic and static spacers.

Methods

We conducted the literature search in PubMed, Web of Science, Cochrane Library, and Embase databases. The articles searched were clinical study comparing the difference in efficacy between dynamic spacers and static spacers for the treatment of prosthetic infections occurring after total knee arthroplasty.

Results

We conducted a literature search and screening based on the principles of PICOS. Ultimately, 14 relevant clinical studies were included in our current study. We use infection control rate as the primary evaluation indicator. The KSS knee scores (KSSs), KSS functional scores, bone loss and range of motion (ROM) are secondary indicators of evaluation. Thirteen of these included studies reported the infection control rates, with no significant difference between dynamic and static shims (RR: 1.03; 95% Cl 0.98, 1.09; P = 0.179 > 0.05). The KSSs were reported in 10 articles (RR: 5.98; 95% CI 0.52, 11.43; P = 0.032 < 0.05). Six articles reported the KSS functional scores (RR: 13.90; 95% CI 4.95, 22.85; P = 0.02 < 0.05). Twelve articles reported the ROM (RR: 17.23. 95% CI 10.18, 24.27; P < 0.0001). Six articles reported the bone loss (RR: 2.04; 95% CI 1.11, 3.77; P = 0.022 < 0.05).

Conclusion

Current evidence demonstrates that dynamic spacers are comparable to static spacers in controlling prosthetic joint infection. In terms of improving the functional prognosis of the knee joint, dynamic spacers are more effective than static spacers.

Does spiked tibial cement spacer reduce spacer-related problems in two-stage revision total knee arthroplasty for infection?

Purpose

Articulating cement spacers are frequently used in staged approaches for infected total knee arthroplasty (TKA). This study investigated whether a tibial cement spacer (TCS) with spikes could reduce spacer-related problems in two-stage revision TKA (R-TKA).

Methods

A total of 27 patients (27 knees; 10 men and 17 women) who underwent two-stage R-TKA for infected TKA were retrospectively analyzed. Group A comprised 12 patients who used TCS with spikes added to the bottom surface, whereas group B consisted of 15 patients who used conventional TCS with a flat bottom. For each group, plain radiographs were obtained after cement spacer implantation and before R-TKA to measure mediolateral (ML) translation and TCS’s tilting angle. Patients’ demographic data, ML translation of the TCS, and changes in the TCS’s tilting angle between the groups were analyzed.

Results

The mean ML translation was significantly lower in group A than that in group B (1.7 mm vs. 5.4 mm, p = 0.04). The mean change in the tilting angle was significantly lower in group A than that in group B (4.5° vs. 19.4°, p = 0.047).

Conclusion

The spiked TCS in two-stage R-TKA provides superior stability compared to the TCS with a conventional design.