Antibiotic-coated spacers for total hip arthroplasty infection

Functional Outcome after Reimplantation in Patients Treated with and without an Antibiotic-Loaded Cement Spacers for Hip Prosthetic Joint Infections

Purpose

A staged revision with placement of a temporary antibiotic-loaded cement spacer after removal of the implant is the "gold standard" for treatment of chronic prosthetic joint infection (PJI). It enables local delivery of antibiotics, maintenance of limb-length and mobility, easier reimplantation. However, bacterial colonization of spacers and mechanical complications can also occur. The aim of this study is to evaluate functional results and infection control in two-stage treatment of total hip arthroplasty (THA) PJI with and without a spacer.

Materials and Methods

A retrospective review of 64 consecutive patients was conducted: 34 underwent two-stage revision using a cement spacer (group A), 30 underwent two-stage revision without a spacer (group B). At the final follow-up, functional evaluation of patients with a THA in site, without PJI recurrence, was performed using the Harris hip score (HHS). Measurement of limb-length and off-set discrepancies was performed using anteroposterior pelvic X-rays.

Results

Most patients in group B were older with more comorbidities preoperatively. Thirty-three patients (97.1%) in group A underwent THA reimplantation versus 22 patients (73.3%) in group B (P<0.001). No significant differences in limb-length and off-set were observed. The results of functional evaluation performed during the final follow-up (mean, 41 months) showed better function in patients in group A (mean HHS, 76.3 vs. 55.9; P<0.001).

Conclusion

The use of antibiotic-loaded cement spacer seems superior in terms of functional outcomes and reimplantation rate. Resection arthroplasty might be reserved as a first-stage procedure in patients who are unfit, who might benefit from a definitive procedure.

Clinical evaluation of a new technique for custom-made spacers in septic two-stage revision of total hip arthroplasties

INTRODUCTION

In septic two-stage revision surgery, success depends on numerous factors. Key steps are the procedure of ex- and reimplantation and the choice of spacer in the interim phase. The latter is still a matter of debate. Recently, we showed the microbial non-inferiority of a spacer technique using prosthetic cemented implants with an individualized antibiotic mixture in the cement applying a mechanically inferior cementation method. The aim of the present study was to evaluate the clinical results of these spacers in view of either an endofemoral or a transfemoral procedure.

MATERIALS AND METHODS

Our collective consisted of 86 patients (45 endofemoral and 41 transfemoral procedures). The collective was analyzed with respect to complications, reinfection rate and clinical status at the end of the interim phase. Results of an endofemoral and transfemoral approach were compared.

RESULTS

With a median Staffelstein-Score of 60 (range 31-81) at the end of the interim phase, the first clinical results are promising. The reinfection-free rate after a median follow-up of 50 months was 90%. Spacer-related complications occurred in 8% of the total collective. Comparing the endo- and transfemoral procedure, there were no statistical differences in complications or regarding the clinical and infectiological outcome.

CONCLUSIONS

In this study, we were able to show good clinical results for the presented spacer technique. With no relevant difference in outcome, the decision for an endofemoral or transfemoral technique can be based on technical deliberations. Further prospective comparative studies are necessary to show the clinical benefit of this procedure.

Preliminary outcomes of proximal femur megaspacers

There are very few therapeutic alternatives for patients with proximal femoral epiphyseal bone deficit combined with a fracture at another level and signs of infection. This combination can be successfully managed with a proximal femur megaspacer. This article is intended to review our variation of this technique and to show the initial results obtained from 11 cases. Of these 11 cases, there were 6 women and 5 men. The mean age was 66 years. The average number of previous surgeries was 3. Definitive prosthetic reconstructive treatment was achieved in 7 of these 11 subjects. The average time to reimplantation was 11.7 months. Fractures or nonunion healed uneventfully. Bone union and infection control were achieved in 10 of the 11 patients.

Complications with cement spacers in 2-stage treatment of periprosthetic joint infection on total hip replacement

INTRODUCTION

The aim of the present study was to assess our management of infected total hip replacement in indications for 2-stage surgical treatment according to current guidelines when a cement spacer has been used. The study hypothesis was that the complications rate related to cement spacers is low.

MATERIAL AND METHOD

A single-center retrospective study included 26 patients receiving a spacer between the two stages of total hip replacement, over a 5 year period. We analyzed the spacers used, mechanical complications, infectious complications and the second stage of surgery.

RESULTS

During the interval between surgeries, in the 26 patients, there were 19 spacer-related mechanical complications (73% of patients): 11 dislocations (42.3%), 5 spacer fractures (19.2%), 5 femoral bone lyses or fractures (19.2%) and 3 acetabular lyses or fractures (11.5%). In 4 cases, complications were associated. The greater the femoral offset of the spacer, the more frequent were femoral bone lyses or fractures (p=0.05), and the smaller the offset the more frequent were acetabular lyses or fractures (p=0.05). The rates of mechanical complications (p=0.003) and spacer fracture (p=0.02) were significantly greater in older patients. There were 4 cases of reinfection (19%): i.e., an 81% treatment success rate. One reinfection implicated a new bacterium: methicillin-susceptible Staphylococcus aureus. The second surgical stage was significantly longer in complex bipolar revision (p=0.009).

CONCLUSION

The present results showed a high risk of spacer-related complications, and thus the importance of selection of patients liable to derive real benefit and those for whom a Gilderstone procedure would be preferable.

LEVEL OF EVIDENCE

IV, retrospective study.

Antibiotic-laden Arthroplasty with a Novel Design of Cement Mould and Metallic Endoskeleton for Treatment of Hip Infection, an Inexpensive Alternative: A Preliminary Report of Two Cases

Infection of the hip after implant fixation is an uncommon yet devastating complication that results in poor long-term outcome. The gold standard treatment for chronic infection after hip arthroplasty is a two-stage protocol: eradication of infection, follow by re-implantation arthroplasty. The use of interim antibiotic-laden cement spacer has become a popular procedure to maintain hip joint function and provide antibiotic elution simultaneously before re-implantation. However, antibiotic cement spacer is mechanically weak and breaks if overloaded. Therefore, we designed a cement mould with metallic endoskeleton with the aim of creating a stronger, inexpensive, antibiotic-impregnated spacer resembling a unipolar arthroplasty. We report two cases of severe hip joint infection after implant fixation (bipolar hemiarthroplasty, screw fixation neck of femur). Both patients had undergone first stage surgery of debridement and articulating antibiotic cement insertion using our design. Although the second stage surgery was planned for these patients, both patients delayed the operation in view of good functional status after a year walking with the antibiotic cement spacer. These cases showed that the mechanical property of the new antibiotic cement spacer was promising but further mechanical studies upon this new endoskeleton design are required.

Antibacterial Effect of a 4x Cu-TiO₂ Coating Simulating Acute Periprosthetic Infection-An Animal Model

The purpose of our study was to investigate the antibacterial effect of a spacer (Ti6Al4V) coated with 4x Cu-TiO₂ in an animal model simulating an acute periprosthetic infection by Staphylococcus aureus. Ti6Al4 bolts contaminated with Staphylococcus aureus were implanted into the femoral condyle of rabbits (n = 36) divided into 3 groups. After one week in group 1 (control) the bolts were removed without any replacement. In group2 Ti6Al4V bolts with a 4x Cu-TiO₂ coating and in group 3 beads of a gentamicin-PMMA chain were imbedded into the borehole. Microbiological investigation was performed at the primary surgery, at the revision surgery and after scarification of the rabbits 3 weeks after the first surgery. Blood tests were conducted weekly. The initial overall infection rate was 88.9%. In group 2 and 3 a significant decrease of the infection rate was shown in contrast to the control group. The C-reactive protein (CRP) levels declined one week after the first surgery except in the control group where the CRP level even increased. This is the first in vivo study that demonstrated the antibacterial effects of a fourfold Cu-TiO₂ coating. For the future, the coating investigated could be a promising option in the treatment of implant-associated infections.

Management of periprosthetic infections

Periprosthetic joint infection (PJI) is considered one of the most challenging complications compromising patient health and is considered an economic burden. Despite all strategies PJI prevalence is between 1%-2%. Considerable efforts have been investigated in the past decade to diminish or erradicate PJI prevalence. This article manages the definition of PJI and the new major and minor criteria from Parvizi et al Then a scientific analysis of every minor and major criteria. Multidisciplinary management is reccommended according to guidelines. A numerous of surgical options exist each and everyone with its indications, contraindications and specific antibiotic therapy regimen. Surgical options are: (1) irrigation and cleaning with retention of the prosthesis with a success rate 0%-89%; (2) single-stage revision surgery with a succes rate of > 80%; and (3) two-stage revision surgery (authors preferred method) with a succes rate of 87%. Radical treatment options like arthrodesis and amputation are reserved for specific group of patients, with a succes rate varying from 60%-100%. The future of PJI is focused on improving the diagnostic tools and to combat biofilm. The cornerstone of management consists in a rapid diagnosis and specific therapy. This article presents the most current diagnostic and treatment criteria as well as the different surgical treatment options depending on the type of infection, bacterial virulence and patient comorbidities.

The two-stage standard in revision total hip replacement

Two-stage exchange remains the gold standard for treatment of peri-prosthetic joint infection after total hip replacement (THR). In the first stage, all components and associated cement if present are removed, an aggressive debridement is undertaken including a complete synovectomy, and an antibiotic-loaded cement spacer is put in place. Patients are then treated with six weeks of parenteral antibiotics, followed by an ‘antibiotic free period’ to help ensure the infection has been eradicated. If the clinical evaluation and serum inflammatory markers suggest the infection has resolved, then the second stage can be completed, which involves removal of the cement spacer, repeat debridement, and placement of a new THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:84–7.

Management of total femoral bone loss using a hybrid cement spacer surgical technique

Standard treatment for an infected total hip arthroplasty is 2-stage revision. Bone loss in infected total hip arthroplasty presents specific challenges during the first stage. This is especially the case when there is massive or complete loss of the femoral bone stock. We describe a technique successfully used in the setting of total femoral bone loss using a hybrid cement spacer. We describe 2 cases illustrating the technique and perioperative course. This technique is a potential solution for total femoral bone loss that allows the individual to maintain mobility before definitive surgery.

Biodegradable vs non-biodegradable antibiotic delivery devices in the treatment of osteomyelitis

INTRODUCTION

Chronic osteomyelitis, or bone infection, is a major worldwide cause of morbidity and mortality, as it is exceptionally hard to treat due to patient and pathogen-associated factors. Successful treatment requires surgical debridement together with long-term, high antibiotic concentrations that are best achieved by local delivery devices, either made of degradable or non-degradable materials.

AREAS COVERED

Non-degradable delivery devices are frequently constituted by polymethylmethacrylate-based carriers. Drawbacks are the need to remove the carrier (as the carrier itself may provide a substratum for bacterial colonization), inefficient release kinetics and incompatibility with certain antibiotics. These drawbacks have led to the quest for degradable alternatives, but also devices made of biodegradable calcium sulphate, collagen sponges, calcium phosphate or polylactic acids have their specific disadvantages.

EXPERT OPINION

Antibiotic treatment of osteomyelitis with the current degradable and non-degradable delivery devices is effective in the majority of cases. Degradable carriers have an advantage over non-degradable carriers that they do not require surgical removal. Synthetic poly(trimethylene carbonate) may be preferred in the future over currently approved lactic/glycolic acids, because it does not yield acidic degradation products. Moreover, degradable poly(trimethylene carbonate) yields a zero-order release kinetics that may not stimulate development of antibiotic-resistant bacterial strains due to the absence of long-term, low-concentration tail-release.

Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America

These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation.