Primary arthroplasty of infected hips and knees in special cases using antibiotic-loaded bone-cement for fixation

The Use of a Supra-Acetabular Antibiotic-Loaded Cement Shelf to Improve Hip Stability in First-Stage Infected Total Hip Arthroplasty

BACKGROUND

Antibiotic-loaded cement spacers in first-stage revision total hip arthroplasty (THA) for managing infection are associated with high dislocation and fracture rates. The aim of this study was to report the use of an antibiotic-loaded cemented supra-acetabular roof augmentation to reinforce hip stability after cement spacer insertion for first-stage total hip revision in the treatment of infected THA.

METHODS

We retrospectively reviewed a consecutive series of 50 THAs involving 47 patients with an infected hip requiring staged revisions of THA. We documented dislocation, reinfection, and time for revision and outcome.

RESULTS

There were no cases of hip dislocation, cement fractures, or any other technical complications associated with the use of the roof augmentation lip. Thirteen cases (26%) had a cemented spacer for longer than 120 days. Seven (14%) cases had recurrent infection after staged revision THA.

CONCLUSION

The antibiotic-loaded cemented supra-acetabular roof augment improved femoral head spacer coverage for patients requiring a staged revision THA for infection.

Drug-eluting cements for hard tissue repair: a comparative study using vancomycin and RNPA1000 to inhibit growth of Staphylococcus aureus

Bone cement used in orthopaedic applications can become colonized with bacterial biofilms, resulting in severe medical complications. Consequently, bone cements are often loaded with antibiotics in an effort to prevent bacterial colonization. However, current formulations may not release antibiotics into the environment at sufficient and sustained concentrations required to impede bacterial growth or may be incompatible with antibiotics that are effective against the colonizing organism. Thus, new cement formulation options are needed. This report describes the performance of a novel SiO2-TiO2-ZnO-CaO-SrO-based glass polyalkenoate cement as a carrier of antimicrobials active against Staphylococcus aureus, the predominant cause of orthopaedic biofilm-associated infections. The antibiotic vancomycin and a novel Staphylococcus aureus RnpA inhibitor under pre-clinical development, RNPA1000, were included in these studies. Rheological testing characterized the workability of the glass polyalkenoate cement over a range of powder-to-liquid ratios and polyacrylic acid concentrations and revealed that the most suitable powder-to-liquid ratio was 2/1.25 with 40 wt% polyacrylic acid. Loading glass polyalkenoate cement with either 20-30% RNPA1000 or vancomycin prevented bacterial growth. However, longer incubations allowed for Staphylococcus aureus colonies to form near the vancomycin-infused cement, indicating that vancomycin may not be suitable for long-term biofilm inhibition in comparison to RNPA1000. Scanning electron microscopy and energy-dispersive X-ray analyses confirmed successful incorporation RNPA1000 into the cement matrix and were indicative of its slow release. These studies establish a drug-eluting formulation of glass polyalkenoate cement with great potential in orthopaedic implants that incorporates known antibiotics as well as RNPA1000 to prevent growth of the dangerous pathogen Staphylococcus aureus.

One stage conversion of an infected fused knee to total knee replacement - a surgical challenge

Background and Purpose:

Two-stage revision arthroplasty is a common technique for the treatment of infected total knee replacement. Few reports have addressed the conversion of a fused knee into a total knee replacement. However, there is no case reported of converting an infected fused knee into a hinge knee using a one-stage procedure.

Methods:

We report on a 51-year old male patient with an infected fused knee after multiple surgeries.

Results and Interpretation:

A one-stage conversion of septic fused knee into total knee arthroplasty by a rotational hinge prosthesis was performed. The case highlights that with profound preoperative assessment, meticulous surgical technique, combined antibiotic treatment and the right implant, one-stage revision in a surgical challenge may have a role as a treatment option with good functional outcome.

Peri-prosthetic hip infections: in favour of one-stage

Although it does offer certain obvious advantages, the one-staged revision approach in infected THA remains rare in the field of orthopaedics. Besides the reduced number of surgical interventions for patients, it is associated with a decreased inpatient hospital stay and quicker mobilisation. Furthermore, it might be the more cost-effective approach and enables a reduced duration of post-operative systemic antibiotics, usually less than 14 days in our setting. Technically speaking, the presence of a positive culture of a pre-operative aspiration and respective antibiogram are mandatory requirements. A general cemented implant fixation using topical antibiotics is the treatment of choice for single-staged procedures. The key to surgical success is based on the well-defined and detailed intra-hospital infrastructure, including a meticulous pre-operative hip aspiration regime, pre-operative planning and an aggressive intra-operative surgical approach.

Efficacy of a single dose of cefazolin as a prophylactic antibiotic in primary arthroplasty

We analyzed the wound infection rate of 1,367 primary total hip and knee arthroplasties performed between 1991 and 1999. Two hundred and fifteen arthroplasties were performed with 3 doses (3 x 750 mg) of cefuroxime, and 1,152 arthroplasties were performed with a single preoperative dose (1 x 1 g) of cefazolin as antimicrobial prophylaxis. All wound infections that occurred within 2 years of the index surgery were analyzed. The deep wound infection rate of total hip arthroplasty was 1.1% (95% confidence interval [CI], 0%-3.3%) in the cefuroxime group and 1.1% (95% CI, 0%-2.2%) in the cefazolin group (Fisher's exact test, P = 1.0). The deep wound infection rate of total knee arthroplasty in the cefuroxime group (1.6%; 95% CI, 0%-3.8%) was not significantly different from the cefazolin group (1.0%; 95% CI, 0.3%-1.7%) (Fisher's exact test, P =.63). We concluded that a single dose (1 g) of cefazolin given at anesthetic induction offered similar protection to 3 doses (3 x 750 mg) of cefuroxime in preventing infection in primary total joint arthroplasty.