Chapter 109.fm - osteomielite.net

109
Resection Arthroplasty and
Use of Dynamic Spacers
CarloLuca RomanÒ
Two-stage exchange arthroplasty is the most often performed procedure for the treatment of prosthetic knee
infection. In the 1980s, two-stage reimplantation was done
with no interim antibiotic spacer placed. While successful
eradication of infection was demonstrated in a high percentage of cases, functional results were rather poor.1,2 In
the 1990s, use of static cement spacers in the interim
period became widespread. The use of an impregnated
antibiotic cement spacer block was introduced to maintain
the joint space and stability, prevent retraction of the collateral ligaments, and provide local antibiotic release.3-5
Complete rest between stages was also considered helpful
for soft tissue healing.
Despite encouraging results in infection eradication, the
block spacer also showed several disadvantages, including
decreased ability to comfortably perform activities of daily
living such as sitting, riding in a car, using a toilet, and
climbing stairs. In addition, exposure in two-stage revisions remained difficult, due to scar formation, tissue
adherence, and quadriceps shortening. Static spacers
maintain the knee in extension, allowing for quadriceps
shortening and capsular contracture, which may increase
the need for extensile exposure techniques such as quadriceps snip, V-Y quadricepsplasty, or tibial tubercle osteotomy. Significant dissection during exposure may increase
the need for constrained revision implants. Static spacers
were also reported to cause measurable bone loss during
the interim period because the spacer could dislodge,
resulting in bone erosion.4
To overcome the disadvantages of block spacers, articulating or dynamic spacers were introduced. This new option
was developed to facilitate exposure at the time of reimplantation, to preserve knee function, and to prevent interim
bone loss between stages and ultimately to provide a better
functional outcome.
Different types of articulating spacers have been proposed, including resterilized prosthetic components or new
components (spacer prostheses)6-9; cement spacer molded
during operation with a thin metal-on-polyethylene
runner10-14; all cement spacer, molded15-17 or custommade18-20 during the operation; and, more recently, preformed cement spacers.21-24
Many different studies have documented in the last two
decades how the interim use of an articulating antibioticimpregnated spacer maintains excellent infection eradication rates and an acceptable function between stages, minimizing bone loss and ultimately improving patient function
and satisfaction.
PREOPERATIVE EVALUATION
History and Examination
The preoperative workup starts with a detailed clinical
history and physical examination. The diagnosis of infection should be established, together with the assessment of
the local and general conditions of the patient. The general
status of the patient should be compatible with a two-stage
procedure. Local signs of acute or chronic infection (redness, warmth, swelling, stiffness, draining sinuses), type and
109-1
The Knee: Reconstruction, Replacement, and Revision
extent of skin scars, bone or implant exposure, mobility of
the subcutaneous tissues around the knee, residual passive
and active range of motion of the knee and adjacent joints,
joint stability, length of the patellar tendon, and overall
function of the extensor apparatus should be carefully evaluated before surgery.
Local and systemic risk factors for infection (smoking or
alcohol abuse, diabetes, peripheral vasculopathy, renal
insufficiency, etc) must be recorded.25 Physical examination
is repeated at the time of spacer removal and before joint
replacement. Persistence or recurrence of clinical signs of
infection may warrant further laboratory or imaging tests
and delay or prevent joint reimplantation.
Laboratory and Imaging
Laboratory tests for infection diagnosis and before
prosthetic removal include a white blood cell count
(WBC) with differential, erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP) level. These tests
should also be performed at least at the time of spacer
removal and before joint reimplantation. While it is
expected that CRP levels are in the normal range before
spacer removal, ESR levels usually stay above the normal
levels for months and should not be regarded as an indicator of infection persistence.26 In general, more than a single value, it is worth considering the trend of the
laboratory tests over the postoperative period, to rule out
an infection recurrence and persistence. Patients with
inflammatory diseases, such as rheumatoid arthritis, are
expected to return to their baseline values. Procalcitonin
and interleukin-6 serum levels may be added to refine the
diagnosis in the case of suspected infection.27
Before spacer implantation if infection recurrence/Persistence is suspected, knee joint aspiration should be performed to obtain the white blood cell count and differential
of the synovial fluid and to identify the pathogen for culture
and sensitivity to antibiotics.28 Joint aspiration should be
performed after antibiotic discontinuation for 2 weeks. A
negative joint aspiration does not exclude infection, because
false-negative cultures are not unusual, especially in
patients who underwent previous antibiotic therapies.
Plain long radiographs of the affected and contralateral
limb are aimed at assessing joint angles, prosthesis and
cement position, degree of periprosthetic osteolysis, and
quality and extent of residual bone. Nuclear imaging studies, including leukocyte bone scans and positron emission
tomography scans, should be reserved for selected cases.29
Before spacer removal, plain radiographs of the affected
knee are sufficient to disclose spacer position and residual
bone.
109-2
Preparation of Patient for Surgery
Patient information should include a description of the
general risks of surgery and specific risks connected to the
two-stage revision procedure; explanation in simple language of how the temporary implant is aimed at preserving
soft tissue balance, some joint mobility and function, and
delivering antibiotics directly to the site of the infection is
critical. Antibiotic resistance and allergies should be collected and the necessity of a second surgical intervention
after treatment of the infection made clear. Reduced joint
mobility, risk of spacer dislocation or fracture, especially in
the case of abnormal weight bearing, ligament laxity, and
bone loss should be pointed out. Postoperative management,
including the need for partial weight bearing with two
crutches, eventually coupled with a knee brace, will be illustrated. Alternative treatments, including suppressive antibiotic therapy, one-stage revision with antibiotic-loaded
cement, two-stage revision using a block spacer, and knee
arthrodesis or amputation will be discussed as suitable for
any given case.
Antibiotics should be suspended 2 weeks before the surgical planning visit to allow more chance for positive culture
with aspiration. Antibiotic prophylaxis will start at the time
of surgery or immediately after intraoperative cultural examination, with targeted antibiotic(s) administered parenterally,
when the pathogen is known, or with broad-spectrum antibiotics with good bone penetration such as cefazolin, until the
results of the initial sensitivity tests are available.
Local and systemic risk factors for infection persistence
and recurrence should be corrected as possible, including
smoking cessation, pre- and perioperative glycemic control,
nutritional support, renal function, and so forth. Standard
precautionary measures should be taken as necessary (septic
procedure, for patients with multiresistant strains).
SURGERY
Indications
Late chronic periprosthetic knee infections (type III
according to McPherson et al25 or type 2 according to Segawa et al30) are candidates for two-stage revision with an
articulating spacer, provided that the general condition of
the patient allows subsequent surgeries and the surrounding
soft tissues, extensor apparatus, collateral ligaments, and
bone stock are considered sufficient for later joint reconstruction. The longer the expected interval between stages
and the higher the expectations of function, the stronger the
indication will be for implanting an articulating knee spacer.
Resection Arthroplasty and Use of Dynamic Spacers
Contraindications
Absolute contraindication to two-stage revision using an
articulated spacer is represented by the lack of a competent
extensor mechanism. Relative contraindications include
bone or implant exposure with large soft tissue defects,
extensive bone defects that may preclude primary stable fixation of the articulated spacer,31 complete collateral ligament insufficiency, neurologic syndromes that render
coordinated motion impossible, morbid obesity, and noncompliant patients.
Approach and Technique
Both the procedures of spacer implantation and the revision surgery require the preparation of a total knee revision
set, lavage, and driver set. The patient should be positioned
supine and the tourniquet placed at the proximal third of the
thigh; it may be inflated only at the time of cementing the
spacer or the implant.
Spacer implant
The operating room should be prepared for an infection
procedure. Instruments for prosthesis and cement removal
should be immediately available. There is usually scarred
skin and subcutaneous tissue due to the history of multiple
surgical procedures in the setting of infection, a fibrotic
quadriceps mechanism, and a shortened patellar tendon with
varying degrees of knee stiffness.
A standard midline skin incision, if possible, is the best.
Previous surgical incisions should be used and in the case
of multiple incisions the most lateral incision that will provide for appropriate exposure should be chosen. Excision
of the skin around a fistula is not necessary. Care should be
taken to maintain thick soft tissue flaps and preserve the
local vascular supply. In the presence of adherent scar tissue, multiple incisions or poor skin quality on the anterior
aspect of the knee, tissue expansion, local rotational flaps,
gastrocnemius muscle flaps, and free flaps may be
required.
The necessary exposures are usually obtained in the
majority of cases by doing a resection of scar tissue from the
suprapatellar pouch and parapatellar gutters, a medial subperiosteal release, and at times a lateral patellar release.
Everting the patella is not required in most of the cases and
should be avoided whenever possible. Usually, after soft tissue release and modular polyethylene removal, a sufficient
joint exposure can be achieved. If all these maneuvers do
not allow enough knee exposure, than a rectus snip or a V-Y
Chapter 109
quadricepsplasty, tibial tubercle osteotomy, or a femoral
peel technique may be used.
Quadriceps snip technique causes minimal damage to
the extensor mechanism and no postoperative immobilization is required for it, although it might not give extensile exposure in very stiff knees. V-Y quadricepsplasty
has the advantage of an extensile knee exposure and
allows controlled lengthening of the extensor mechanism, improving the range of motion. The disadvantages
are compromised healing of the extensor mechanism at
the apex of the incision, an extensor lag, quadriceps
weakness, and the need to protect the knee from active
extension postoperatively. An extended tibial tubercle
osteotomy is useful for removal of well-fixed stemmed
tibial components and adjusting the position of the
patella in patella baja. The disadvantages are risk of fracture of the tibia below the distal margin of the osteotomy
and an extensor lag. The femoral peel consists of entire
subperiosteal dissection of the distal femur and can
include peeling of the collateral ligaments or an epicondylar osteotomy. This gives the most extensile exposure and is useful in patients with stiff or ankylosed
knees.
Multiple intraoperative culture (usually three to six)
specimens should be taken, preferably before the administration of intravenous antibiotic therapy. Cultures can be
taken from synovial fluid, inflamed synovial tissue, and
the bone–prosthesis or bone–cement membrane. Periprosthetic membrane and bone fragments should be sent to the
laboratory for cultural and histological examination. When
necessary, to confirm intraoperatively the diagnosis of
infection, samples of periprosthetic membrane and synovia may be sent for frozen section histological examination.
Thorough debridement of infected and devitalized tissue
is then performed, with femoral, tibial, and patellar components removal along with all cement. Explanted hardware
and cement fragments should be sent to the laboratory for
sonication whenever possible to increase the chance of isolating living bacteria from the biofilm.
The residual bony surfaces of the femur and tibia are
then cut with an oscillating saw, high-speed burr, or rasp, to
remove all infected bone and granulomatous membranes.
Thorough bony debridement is also performed inside the
metaphyseal and diaphyseal region of the tibia and femur.
All cement should be removed. Thorough debridement is
then followed by generous irrigation with saline, eventually
with pulsatile lavage. At the end of debridment, after
regowning and regloving, surfaces of tibia and femur are
measured to determine the desired size of the spacer’s components.
109-3
The Knee: Reconstruction, Replacement, and Revision
Five types of articulating spacers have been described in
the literature thus far:
1.
Resterilized component (usually resterilized femoral
component with a new polyethylene insert)6-9 (Fig.
109-1).
2.
Cement spacer molded during operation with a thin
metal-on-polyethylene runner; the bulk of the prosthesis is the antibiotic-laden acrylic cement, whereas the
articulating surface is a thin metal and polyethylene
surface (PROSTALAC system: prosthesis of antibioticladen acrylic cement, DePuy, Warsaw, IN).10-14 For the
best antibiotic release, the use of at least 3.6 g of tobramycin and 1 g of vancomycin per package of bonecement has been recommended32; cycling load of this
articulating antibiotic-laden spacer has been recently
shown in vitro to increase both tobramycin and vancomycin elution.33
3.
All cement spacer, molded during operation,15-17 with
possible preparation of intramedullary stems, as
described by Lombardi and coworkers15 (StageOne
Spacer Mold; Biomet Orthopaedics, Inc, Warsaw, IN).
These authors recommended the use of four 40-g units
of cement, with 3.6 to 4.8 g of tobramycin and 3 to 4 g
of vancomycin added into each 40-g unit of cement.
Poor cementing technique is also advocated by the
same authors, with the tourniquet released, so that
cementation occurs in a bloody field and, during the
curing stage, the components are separated from the
bone.
4.
All cement, customized spacer, built and customized
intraoperatively to the type of bone defect, using retractors and a high-speed tip burr to shape spacer aspect, as
described by Villanueva and coworkers.18-20
5.
Preformed cement spacers (Fig. 109-2).21-24 Preformed spacers are manufactured in the factory with
ultracongruent condylar knee prosthesis design made
exclusively of acrylic cement impregnated with gentamicin and/or vancomycin antibiotics (InterSpace
Knee, Exactech Inc., Gainesville, FL; Spacer-K,
TECRES S.P.A., Verona, Italy). No additional reinforcement device is used. Both components, femoral
and tibial, are produced in three sizes, with correspondent trials to allow for intraoperative choice. Mechanical and fatigue resistance of preformed spacers has
been laboratory tested and found to be suitable for
clinical use.34 Elution of antibiotic from retrieved preformed spacer has been demonstrated in vivo to last
several months after spacer implant.35 Like other
articulating spacers, preformed spacers are relatively
loosely fixed to the bone with cement, loaded with
109-4
antibiotics of the surgeon’s choice, allowing partial
weight-bearing and knee motion exercises between
stages.
All the described spacers and techniques present distinct advantages and disadvantages and no study has been
designed to compare the outcome of different articulated
spacers. Theoretically, the presence of metallic hardware
or polyethylene, such as in the resterilized component
procedure or in the PROSTALAC system, may be more
prone to bacterial recolonization.36 Moreover, the cement
spacer molded in the operative room may not have reproducible mechanical and antibiotic elution characteristics
and may have an increased risk of component fracture37;
both the use of a spacer-prosthesis and of a molded
spacer increases operatory times, while, however, molds
and preformed spacers do add some cost to the procedure. Intraoperatively molded spacers allow the surgeon
to choose during surgery the type and concentration of
the antibiotic(s) to be added to the cement, while preformed spacers come with a predetermined concentration
of one or two antibiotics (usually gentamicin and/or vancomycin), even if, upon request of the surgeon, the preformed spacer may be prepared “on demand,” with any
desired antibiotic. Finally, both molded and preformed
spacers offer a limited choice of sizes and this may be a
problem in large bone defects or in fitting extreme anatomic variations.
After a spacer implant has been prepared or selected,
it is fixed with antibiotic-loaded cement, chosen on the
basis of preoperative antibiograms, when available. To
prevent significant interdigitation of the cement with
bone, the tourniquet can be released and poor cementing
technique is preferred, as described above. Cement in
excess may be left in place if it does not interfere with
joint motion or soft tissues (Fig. 109-1). Before soft tissue closure, joint mobility and patellar tracking should be
checked and any cement remnants within the joint space
removed.
Reimplantation
At the time of reimplantation previous surgical incisions
are utilized. Removal of the spacer is usually easily
achieved after standard revision exposure of the joint. Care
should be taken not to cause unnecessary further bone damage during this procedure. Accurate bone and soft tissue
debridement is performed, removing any granulomatous
membrane that may be found under the spacer and the
cement. Multiple specimens for cultural examination are
taken once more, as previously described.
Resection Arthroplasty and Use of Dynamic Spacers
Chapter 109
B
C
A
C
D
E
FIGURE 109-1. Resterilized femoral component and a new
polyethylene layer may be used as a temporary spacer. (A) Preoperative
X-ray of a septic loosened total knee prosthesis. (B) Quadriceps snip
allows for large knee exposure. (C and D) Resterilized femoral
component and new polyethylene layer, prepared with antibiotic-loaded
cement, before implantation. (E) Spacer implant. Note the large amount
of antibiotic-loaded cement that may be left in place, increasing local
delivery surface. (F) Postoperative X-ray.
F
109-5
The Knee: Reconstruction, Replacement, and Revision
A
B
FIGURE 109-2. (A) Preformed, antibiotic-loaded, knee spacer (Spacer-K, TECRES S.P.A., Verona, Italy, or InterSpace Knee,
Exactech Inc., Gainesville, FL). Approximately 26,000 from year 2001 and 12,000 from year 2004 have been implanted in
Europe and in the United States, respectively . (B) Intraoperative view after spacer implant and postoperative X-ray.
At revision, significant bone loss is commonly encountered (Fig. 109-3). Multiple options are available for reconstruction of bone defects, including cement augmentation,
modular or custom implants, allograft and autograft reconstruction. Bone defect is classified according to the size,
location, and depth of the defect and the presence or
absence of an intact peripheral rim for placement of the
prosthesis and containment of the bone defect. In the
absence of a classification specifically designed for bone
loss after infection, the Anderson Orthopaedic Research
Institute (AORI) bone defect classification provides some
guidelines for management of bone defects.38,39
In type I defects, the metaphyseal bone is intact and only
minor bone defects are present, which do not compromise
component stability. In type II defects, there is metaphyseal
bone damage and cancellous bone loss, which lead to
requirements for cement reinforcement, bone grafting, and
metal augments to restore joint line. Type II bone defects
can occur in one femoral or tibial condyle (type IIA) or both
femoral and tibial condyles (type IIB). Bone cement usually
is used for small, preferably contained bone defects up to 5
mm in depth. The advantages are low cost, ease of use, and
availability. Cement does have a modulus of elasticity that is
much lower than bone. It performs poorly when subjected to
shear forces and performs well under compression. So the
wedges need to be converted to flat cut-shaped defects to
make a mechanically strong construct. In vitro biomechanical studies have shown that addition of screws in cement can
lead to increased strength. Autogenous bone graft is usually
used for defects deeper than 5 mm in thickness and involving more than 50% of the tibial hemisphere. The autograft
heals readily, has no chance for disease transmission, and
has osteoinductive properties but is also associated with a
109-6
limited available amount and donor site morbidity. Modular
augmentation blocks can be used to restore the correct position of the joint line, balance flexion and extension gaps,
and improve the rotation of the femoral component.
In type III defects, the metaphyseal region is deficient
and therefore a revision prosthesis with an extended
intramedullary stem and/or a metaphyseal augment is
required (Fig. 109-4); in selected cases a structural allograft
or a custom-made implant may be indicated. Distal bone
loss can lead to elevation of joint line, which can be dealt
with by using distal femoral augmentation blocks. Posterior
bone deficiency can lead to a mismatch between flexion and
extension gap and instability, which can be dealt with by
using posterior femoral augmentation. The rotation of the
femoral component can be improved by selectively increasing the augmentation over the posterior lateral femoral
condyle in comparison to the posterior medial femoral
condyle. Over the tibial side, metallic wedges or block augmentations can be used. The advantages of allografts are
easy availability, low cost (compared to custom implant),
bone stock restoration, and the opportunity for attachment
of collateral ligaments and intraoperative flexibility. The
disadvantages can be disease transmission, malunion, nonunion, collapse and fracture of the graft, graft resorption,
and a high infection rate.
Allografts can be used in morselized form, as particulate
bone graft and as structural allografts. The particulate bone
grafting is more appropriately used in contained bone
defects (AORI I and II) in which the immediate stability of
the prosthesis is not dependent on the support provided by
the graft. It requires tight packing of appropriately sized
particulate graft into a contained vascularized defect and a
rigid implant fixation. Knees with massive segmental bone
Resection Arthroplasty and Use of Dynamic Spacers
Chapter 109
B
A
C
D
FIGURE 109-3. At spacer removal (A), a distal tibial osteotomy may be required (B). (C) AORI grade III bone defect in the
femoral region. (D) Reimplantation, using antibiotic-loaded cement only in the epiphyseal part of the prosthesis and
noncemented stems. Intraoperative picture before osteotomy fragment repair.
109-7
The Knee: Reconstruction, Replacement, and Revision
A
C
B
FIGURE 109-4. (A) AORI grade III bone defect at reimplantation. (B)
Intraoperative picture before septic prosthesis removal (left) and at the
second stage, after reimplantation of the femoral component. Note the
need of femoral augment and bone cement to fill the bone defect
associated with the implant loosening and infection. (C) Postoperative
X-ray. Extended intramedullary stems and metaphyseal augments were
used both at the femoral and tibial level.
loss are usually candidates for either a rotating hinge prosthesis or an allograft-prosthesis composite. Stemmed components are recommended for structural allograft use.
During revision arthroplasties after infection, considerable patellar bone loss may be encountered, which may be
109-8
due to loosening of the component, osteolysis, or removal of
a well-fixed patellar component. This extensive bone loss
may preclude placement of the patellar prosthesis. There are
multiple ways to deal with this problem: patellar component
resection arthroplasty, patellar bone grafting, and patellectomy. Patellar resection arthroplasty has been used as an
Resection Arthroplasty and Use of Dynamic Spacers
option by various authors. This option may be associated
with multiple complications such as patellar fracture, persistent patellofemoral pain, patellar subluxation, recurvatum
deformity, and extensor lag. Patellectomy performed as a
part of a revision knee replacement has been associated with
markedly inferior functional results as well as difficulties
with weakness or delayed disruption of the extensor mechanism. Good clinical results and reconstitution of patellar
bone stock with bone grafting have been recently
reported.40
Massive bone loss of the distal femur or proximal tibia
may cause extensive damage to the knee collateral ligaments leading to instability. Therefore, a constrained
prosthesis might be required to provide stability in valgus-varus and anteroposterior planes. The implant
options range from the least constrained to the most constrained, including posterior-stabilized, nonlinked constrained, rotating hinge, and modular segmental
replacement designs. It is desirable to use the least
degree of component constraint to decrease stresses at
the implant–bone interface and increase participation of
the soft tissues in load sharing. If the flexion-extension
gaps are well balanced and the collateral ligaments are
competent, a posterior-stabilized implant can be used.
However, if there is functional loss of the medial or lateral collateral ligament, inability to balance the flexion
and extension spaces, or a severe valgus deformity, then a
constrained condylar prosthesis is necessary. It has an
increased width and height of the tibial post with corresponding increased depth of the femoral box. This resists
valgus-varus instability and mediolateral displacement
and prevents the dislocation of the tibial component in
knees with a lax flexion gap. Constrained implants without a rotating platform design allow for only limited rotation so components must be placed in accurate rotational
alignment.
Chapter 109
tibial components tend to decrease the stresses over the
graft. The stems can be cemented or uncemented. The
cementless stems provide enhanced fixation by engaging
the diaphyseal bone distal to the area of metaphyseal
bone loss and revision and are basically used as canalfilling stems. In case a re-revision is required, the
cementless stems are easier to remove compared with
their cemented counterparts. The regular cementless
stems, because of their canal-filling properties, might
create displacement of the femoral or tibial component
from the desired location because of any deformity in the
bone such as one created by any previous osteotomy. In
such a case, an offset stem is useful. The incidence of
end-of-stem pain in cases of cementless stems is almost
the same as in cases of cemented stem.41 The proponents
of the cemented stems cite advantages such as easier
achievement of positioning of components with narrower
cemented stems obviating the need of offset stems, especially when the translation or malalignment would result
from canal-filling stems. Another indication for using
cemented stems is in osteopenic bone. The problem with
the cemented stems is the extreme difficulty in removing
these stems once revision becomes necessary, since the
condylar surface of the implant blocks the access to the
canal. The proximal stress shielding of cemented stems is
another reason not to use them. Alternatively, the use of
short cemented stems is associated with less consistent
results.42 Our preference is to cement the condylar surface and use the stem in the cementless press-fit fashion,
as described by Haas and coworkers.43
POSTOPERATIVE MANAGEMENT
Care should be taken to control postoperatively any
risk factor for infection persistence or recurrence.
Smoking44 and alcohol should be prohibited for at least
the first 6 months after surgery; normal glycemia,45 renal
function, and nutritional status should be targeted in any
case.
The indications for use of hinged knee prosthesis include
anteroposterior instability with a very large flexion gap,
complete absence of the collateral ligaments, and complete
absence of a functioning extensor mechanism. The thirdgeneration of the hinged prosthesis incorporates increased
congruency at patellofemoral articulation, modular canal
filling by slotted fluted stems, metaphyseal sleeves, and a
rotating hinge that accommodates axial rotation and broad,
congruent contact areas between femoral and tibial components to best distribute surface and subsurface stresses in the
polyethylene.
In general, one or a combination of two antibiotics,
selected on the basis of available antibiograms and eventually under the guidance of an infectious diseases consultant,
is administered intravenously or orally46,47 for 4 to 6 weeks
after the first-stage and second-stage procedure.48 However,
recent studies have reported a successful short antibiotic
course after the second stage.49,50
There is general agreement that modular stemmed
femoral and tibial components should be used whenever
there is substantial damage to the condylar surface and a
graft or wedge is used. Modular stemmed femoral and
Prophylaxis of thromboembolic complications and adequate pain control are performed in all cases. Monitoring of
laboratory tests, including hemochromocytometric and
white blood cell count with differential ESR and CRP level
109-9
The Knee: Reconstruction, Replacement, and Revision
and renal and hepatic function, is performed periodically
after the first- and the second-stage procedure to detect any
sign of infection recurrence or side effects due to the protracted antibiotic therapy. Plain radiographs of the knee are
usually performed immediately after either surgery, before
spacer removal and then at 2, 6, and 12 months postreimplantation.
Rehabilitation
The postoperative management of individual patients
is dependent on numerous variables, including the general conditions, the status of the soft tissue coverage, the
type of exposure required, residual ligament apparatus,
and the degree of bone defect and implant stability. After
spacer implantation, patients are usually encouraged to
actively mobilize the knee immediately after surgery;
passive joint motion, walking, and stair climbing with
partial weight bearing and two crutches are normally
allowed until the second-stage surgery. In selected cases
with significant bone loss or insufficient soft tissue, a
knee brace may be required and weight bearing
restricted, with joint motion postponed or performed at a
reduced range.
Gait parameters of patients with a preformed knee spacer
have been recently shown to be in the range of a normal reference control population, walking at a reduced speed.51
Rehabilitation after joint reconstruction does not differ from
that of aseptic revision surgery.
Complications
General complications of two-stage revision of septic
knee prosthesis do not differ from those reported after aseptic revision surgery. However, the implant of an articulated
spacer may lead to spacer dislocation (Fig. 109-5) or to
spacer breakage; both of these complications have been
reported occasionally and treated with restricted weight
bearing and joint range of motion until spacer removal, with
no long-term consequences.50,52
The risk of spacer dislocation may be minimized by
shaping the cement needed to fix the spacer as a short
(approximately 5 cm) stem, to partially fill the femoral and
tibial diaphysis (Fig. 109-6). Another useful tip is represented by testing the spacer with repeated gentle flexion and
extension movements before soft tissue closure to verify
implant stability. No clinically relevant side effects due to
the presence of the articulated spacer have been reported
with regard to local antibiotic release, cement debris production, or bone loss.
109-10
OUTCOME
Two-Stage Versus One-Stage Reimplantation
Successful treatment of a periprosthetic infection is
defined as eradication of the infection and maintenance of a
pain-free, functional joint. In the treatment of late chronic
infections the best results, both for the eradication of the
disease and for function recovery, have been obtained with
either one-stage or two-stage exchange arthroplasty. Antibiotic suppression and irrigation and debridement procedures
are treatment alternatives with less satisfactory results,53,54
while the outcomes associated with resection arthroplasty,55
arthrodesis,56 and amputation57 are much less desirable.
With regard to infection eradication rate, current literature supports two-stage delayed reimplantation as the gold
standard treatment regimen for periprosthetic knee infection. Data available show that the two-stage procedure is
routinely performed in the vast majority of orthopaedic centers around the world and the number of reported cases
largely exceeds that of patients treated with a one-stage procedure (Tables 109-1 and 109-2).
Because of the lack of quality comparative studies
between one- and two-stage procedures, we calculated the
average infection eradication rate reported from the available studies in the English literature (cf. Table 109-1 and
109-2). However, caution should be used when interpreting
comparisons between different treatment approaches in different studies, because of possible selection bias. Other misleading conclusions may be driven by comparing
percentages instead of raw numbers as shown in the article
by Jämsen and coworkers, where one-stage and two-stage
revisions of infected knee prostheses are reported as providing similar results when percentages are compared, while an
absolute number comparison shows the two-stage procedure
to be clearly better than the one-stage procedure, or 80.8%
versus 94.8%.58 A similar finding can be observed when
comparing Tables 109-1 and 109-2, where mean percentages of eradication of infection seem not to differ when
comparing one- or two-stage procedures, while the mean
calculated on raw numbers shows a success rate of 81.9% in
204 patients after the one-stage exchange and 89.8% success rate in 1421 patients after two-stage procedures (data
from 38 centers worldwide).
Articulated Versus Static Spacer
Block spacers were created as an instrument to relieve
knee pain from instability, maintain the joint space by preserving the anatomical tension of the collateral ligaments
and surrounding soft tissues, preserve bone stock quality,
and safely elute high concentrations of antibiotics in an
Resection Arthroplasty and Use of Dynamic Spacers
Chapter 109
A
B
C
D
FIGURE 109-5. Anteroposterior (A) and lateral (B) postoperative X-rays after the implant of a preformed knee spacer.
Implant instability due to the bone loss (C) and improper cement fixation (D) may lead to spacer dislocation.
109-11
The Knee: Reconstruction, Replacement, and Revision
A
C
B
D
FIGURE 109-6. (A) Preoperative photograph of the knee demonstrating multiple crossing scars in the anterior aspect of the
joint due to previous surgeries. (B) Preoperative anteroposterior and lateral X-rays of the septic total knee prosthesis. (C)
Postoperative anteroposterior and lateral X-rays, after the spacer implant. The risk of spacer dislocation may be minimized by
adequately fixing the spacer to the cement and shaping the underlying cement as a short stem. (D) Photograph of the
premolded cement spacer at spacer removal.
Continued
109-12
Resection Arthroplasty and Use of Dynamic Spacers
Chapter 109
E
F
G
H
FIGURE 109-6. Con’t. (E-H) In this clinical scenario, the severe bone defect (E) was managed with metal augments and a
modular implant (F and H), fixed with antibiotic-loaded cement only in the meta-epiphyseal region, while precise repair of
the V-shaped quadriceps snip allowed for full active extension with no lag (G).
109-13
The Knee: Reconstruction, Replacement, and Revision
TABLE 109-1. Published Infection Eradication Rates of One-Stage Direct Exchange for Knee Periprosthetic Sepsis
Follow-up
(months)
No. of TKAs
No. of Eradicated
Eradication Rate
(%)
Buechel et al60
22
22
20
90.9
Goksan and Freeman61
60
18
16
88.9
Lu et al62
20
8
8
100
Silva et al63
48
37
33
89.2
Sofer et al64
18
15
14
93.3
von Foerster et al65
76
104
76
73.1
204
167
Author
Total
Mean
40.7
89.2
SD
24.42
8.9
Mean eradication rate
81.9
TKA, total knee arthroplasty.
TABLE 109-2. Published Infection Eradication Rates of Two-Stage Exchange for Knee Periprosthetic Sepsis
Follow-up
(months)
No. of TKAs
No. of Eradicated
Eradication Rate
(%)
Anderson et al66
54
25
24
96.0
Booth and Lotke67
25
25
24
96.0
Borden and Gearen3
46
11
10
90.9
Cuckler68
65
44
44
100
Durbhakula et al52
33
24
22
91.7
Emerson et al8
90
48
44
91.7
Evans69
36
31
29
93.5
Fehring et al12
36
55
51
92.7
Freeman et al59
71
76
69
90.8
Gacon et al70
42
29
24
82.8
Goldman et al71
90
64
58
90.6
Goldstein et al72
12
5
5
100
Gooding et al73
108
115
101
87.8
Haddad et al13
48
45
41
91.1
Author
109-14
Resection Arthroplasty and Use of Dynamic Spacers
Chapter 109
TABLE 109-2. (Continued).
Follow-up
(months)
No. of TKAs
No. of Eradicated
Eradication Rate
(%)
Haleem et al74
86
96
87
90.6
Hanssen et al75
52
89
79
88.8
Henderson and Booth76
27
28
27
96.4
Hirakawa et al77
61
55
41
74.5
Hofmann et al7
74
50
44
88.0
Hsu et al16
101
28
25
89.3
Huang et al78
52
21
20
95.2
Jamsen et al79
32
34
26
76.5
Lonner et al80
56
53
44
83.0
MacAvoy and Ries81
28
13
9
69.2
McPherson et al82
17
21
20
95.2
Meek et al14
41
54
52
96.3
Ocguder et al83
20
17
15
88.2
Pascale and Pascale19
12
14
14
100
Pietsch et al84
15
24
22
91.7
Pitto et al22
24
19
19
100
Rosenberg et al85
29
15
12
80.0
Scott et al9
24
7
7
100
Siebel et al86
18
10
10
100
Van Thiel et al87
36
60
53
88.3
Villanueva-Martínez et al20
36
30
30
100
Whiteside88
24
33
28
84.8
Windsor et al89
48
38
34
89.5
Wilde and Ruth2
30
15
12
80.0
1421
1276
Author
Total
Mean
44.7
90.6
SD
25.5
7.6
Mean eradication rate
89.8
109-15
The Knee: Reconstruction, Replacement, and Revision
brace immobilization between stages, while quadriceps and
collateral ligament shortening and arthrofibrosis occur,
making surgical exposure in the second-stage procedure
rather difficult. Tibial bone loss has been reported to average 6.2 mm in 40% of patients treated with a static spacer,
whereas femoral bone loss averaged 12.8 mm in 44% of
cases, with bone defect directly related to the length of the
interim period.4
effort to eradicate the local septic process. Advocates of
static spacers also suggest that a basic tenet of infection
treatment is placing the wound at rest. As a result, static
spacers have been developed and implemented with excellent published results for many years (cf. Table 109-3) and
still are in use in different centers.
Despite these advantages, static block spacers have several disadvantages. Knee movement is restricted by cast or
TABLE 109-3. Published Infection Eradication Rates of Two-Stage Exchange for Knee Periprosthetic Sepsis Using
Static Spacers
Follow-up
(months)
No. of TKAs
No. of Eradicated
Eradication Rate
(%)
Booth and Lotke67
25
25
24
96.0
Borden and Gearen3
46
11
10
90.9
Emerson et al8
90
48
44
91.7
Fehring et al12
36
55
51
92.7
Freeman et al59
71
28
25
89.2
Gacon et al70
42
29
24
82.8
Henderson and Booth76
27
28
27
96.4
Hirakawa et al77
61
55
41
74.5
Lonner et al80
56
53
44
83.0
Rosenberg et al85
29
15
12
80.0
Scott et al9
24
7
7
100
Whiteside88
24
33
28
84.8
Windsor et al89
48
38
34
89.5
Wilde and Ruth2
30
15
12
80.0
440
383
Author
Total
Mean
43.5
87.6
SD
20.1
7.2
Mean eradication rate
109-16
87
Resection Arthroplasty and Use of Dynamic Spacers
To overcome the disadvantages of block spacers and to
facilitate reimplantation surgery, articulating spacers were
introduced. However, some controversy still exists concerning whether static or articulating spacers are the best treatment method. Like static spacers, mobile spacers preserve
joint space, elute high antibiotic concentrations, and have
comparable eradication rates. However, they have an additional advantage of greater postoperative range of motion
and improved patient comfort during the interim period and
they facilitate an easier reimplantation process, which
emerges from minimal tibial femoral bone loss, reduced
incidence of quadriceps shortening, reduced incidence of
arthrofibrosis, and improved soft tissue health.
To our knowledge, no study has demonstrated a difference in eradication rate of articulating compared to static
spacers that seems similar, when comparing different studies. With the limitations reported above, we reviewed and
compared available data from the English literature concerning the eradication rate of two-stage procedures, using
static (Table 109-3) or articulated spacers of any type (Table
109-4). In contrast with that previously reported by Lombardi and coworkers,15 our review shows a small superiority
of articulated spacer over static, with the average calculated
infection eradication rate being higher in the articulating
spacer group.
However, small sample size, short follow-up, and limited
outcome measures have produced only limited evidence to
confirm that patients have better long-term function if
interim articulating spacers are used. To our knowledge,
only four studies have compared articulating to static spacers directly. In one study,10 in 30 patients treated with tobramycin-laden, cement-on-cement articulating spacers, there
was no significant difference in measurable bone loss on the
tibia or femur between stages, exposure techniques, or need
for constrained implants between articulating and static
spacers. Ultimate range of motion was 98° in the static
group and 108° in the articulating group. This was not statistically significant (p = .14). Emerson et al8 compared 26
static and 22 articulating spacers, followed for more than 3
years. Recurrent infection occurred in two patients in each
group. There was statistically better range of motion in the
articulating group with flexion averaging 108° compared to
the static group where range of motion averaged 94°. However, this study did not report Knee Society scores or clinical function outcomes other than range of motion.
Fehring and coworkers failed, in an early article,12 to
show a better functional outcome using articulated spacers,
compared to static ones, while reporting an “unexpected
bone loss between stages” using the static solution. In a
more recent article,59 the same group was able to show that
articulating spacers provide equivalent eradication rates
Chapter 109
while improving function after reimplantation compared to
static spacers. In this study the infection eradication rates
were comparable at 92% for static spacers and 95% for
articulating spacers. Knee Society pain scores post-reimplantation were similar and not significantly different
between the groups. Knee Society functional scores, which
represent a patient's ability to walk, climb stairs, and use an
assist device, showed a trend toward being significantly better in patients in the articulating group. In addition, the
number of patients with good to excellent functional results
were significantly greater in the articulating group compared with the static group (p = .05). Limitations of this
study included the nonrandomized, retrospective nature of
the study. Another limitation of this study was the significant 6-year age difference between the two cohorts of
patients (p = .002) that may have affected the reported
results. In addition, with the cohort size available, the study
did not have sufficient power. A post hoc power analysis
indicated that the power was approximately 30% based on
pain scores and approximately 50% based on function
scores. A simultaneous randomized, controlled study of
articulating versus static spacers clearly would be beneficial
but may be difficult to justify in light of the data now available.
Two-Stage Versus Aseptic Knee Revision
Functional outcomes after two-stage reimplantation have
been thought to be less optimal than primary arthroplasties
and even aseptic revisions; however, there is little comparative documentation in the literature concerning knee14,90-92
or hip93 revision surgery due to aseptic reasons and twostage exchange for periprosthetic infection.
In a first published study, Barrack et al90 reported their
results regarding patient satisfaction and outcome after
aseptic (N = 99) versus septic (N = 28) revision of total knee
arthroplasty, treated with two-stage revision and a static
block spacer. At a mean follow-up of 36 months, the postoperative Knee Society clinical score was markedly lower in
the septic versus aseptic revisions (115 vs. 135; p = .02).
Patients with infection had a significantly lower function
score (44 vs. 57; p = .03) and a significantly higher percentage of patients stated that they were unable to return to normal activities of daily living after septic versus aseptic
revision total knee arthroplasty (24% vs. 7%; p < .05). In
spite of these results, septic and aseptic revision cases
reported an equal degree of satisfaction. Similar results
were reported by Wang et al.91 However, the most recent literature does not confirm such a clear difference in the functional outcome after septic or aseptic revision surgery. Meek
et al reported on a total of 55 patients in the aseptic
109-17
The Knee: Reconstruction, Replacement, and Revision
TABLE 109-4. Published Infection Eradication Rates of Two-Stage Exchange for Knee Periprosthetic Sepsis Using
Articulated Spacers
Follow-up
(months)
No. of TKAs
No. of Eradicated
Eradication Rate
(%)
Anderson et al66
54
25
24
96.0
Cuckler68
65
44
44
100
Durbhakula et al52
33
24
22
91.7
Evans69
36
31
29
93.5
Fehring et al.12
12
30
29
96.7
Freeman et al59
71
48
44
91.7
Goldstein et al72
12
5
5
100
Gooding et al73
108
115
101
87.8
Haddad et al13
48
45
41
91.1
Haleem et al74
86
96
87
90.6
Hanssen et al75
52
89
79
88.8
Hofmann et al7
74
50
44
88
Hsu et al16
101
28
25
89.3
Huang et al78
52
21
20
95.2
Jamsen et al79
32
34
26
76.5
MacAvoy and Ries81
28
13
9
69.2
McPherson et al82
17
21
20
95.2
Meek et al14
41
54
52
96.3
Ocguder et al83
20
17
15
88.2
Pascale and Pascale19
12
14
14
100
Pietsch et al84
15
24
22
91.7
Pitto et al22
24
19
19
100
Siebel et al86
18
10
10
100
Van Thiel et al87
36
60
53
88.3
Villanueva-Martinez et al20
36
30
30
100
947
864
Author
Total
Mean
43.3
92.2
SD
27.7
7.4
Mean eradication rate
109-18
91.2
Resection Arthroplasty and Use of Dynamic Spacers
group, compared to 47 patients in the septic group, treated
with an articulating spacer and two-stage reimplantation.
Patient satisfaction score, Western Ontario and McMaster
Osteoarthritis Index (WOMAC), Oxford-12, and Medical
Outcomes Study 12-Item Short-Form Health Survey (SF12) instruments were recorded and, surprisingly, in no category were the septic outcomes worse than the aseptic outcomes.14 Similarly, Patil and coworkers92 recently
reported the results using a static spacer in a cohort of 15
patients, treated with two-stage revision, compared to 30
patients who underwent knee revision surgery for aseptic
failure, at a mean follow-up of 40 months. In this study,
comparative analysis by adjusted regression models
showed that patients operated on for infection had significantly better postoperative Knee Society scores (p = 0.01),
function scores (p = 0.009), and SF-36 mental scores (p =
0.01) than patients operated for aseptic failures. The
patients in the septic group also demonstrated significant
improvement in activities of daily living, stair climbing,
and work and social activities.
CASE EXAMPLE
A 55-year-old man was admitted to the hospital 19
months after knee surgery with a history of continuing pain
and restricted mobility in his operated left knee. Total knee
replacement had been performed for severe posttraumatic
osteoarthritis. A review of the past medical history revealed
a history of a cholecystectomy, type 1 diabetes, and smoking more than 10 cigarettes per day.
Chapter 109
Eleven weeks after spacer implant, in the absence of clinical
signs and symptoms of infection recurrence and with a CRP
value returned to the normal range, knee revision was performed.
At surgery (Fig. 109-6, E-H) the severe bone defect was
managed with metal augments and a modular implant, fixed
with antibiotic-loaded cement only in the meta-epiphyseal
region, while precise repair of the V-shaped quadriceps snip
allowed the patient to obtain a satisfactory active range of
motion of 0° to 100° at 3 months after surgery. Intraoperatively multiple cultures were taken and found to be negative,
and after 3 years the patient had recovered completely with
no prosthetic loosening and no sign of infection, even if, 2
years after revision, he came to our observation with a posttraumatic infected wound of his left ankle that required open
debridement.
PEARLS AND PITFALLS
The following are some pearls and pitfalls in two-stage
resection arthroplasty and the use of dynamic spacers:
•
The number of published articles on two-stage
exchange arthroplasty and the reported overall number
of patients treated according to this procedure largely
exceeds the respective values of the one-stage procedure, suggesting that the two-stage approach is actually
the preferred option for the treatment of chronic prosthetic knee infection worldwide.
•
Dynamic (or articulating) spacers offer the following
advantages over static spacers:
Clinical examination showed a painful, swollen, and
warm knee, with a limited range of motion (10°–60°) and
crossing scars in the anterior aspect of the joint, due to previous surgeries (Fig. 109-6A). Twelve milliliters of cloudy
joint fluid was aspirated from the knee (leukocyte count:
12,800/mL, neutrophils differential 80%); culture examination was positive for coagulase-negative Staphylococcus,
which was oxacillin-resistant. ESR (52 mm/h) and CRP (23
mg/L) were elevated, while X-ray showed a cemented, still
well-fixed hinged knee prosthesis (Fig. 109-6B).
The patient underwent removal of the septic prosthesis
and of the cement and implant of a preformed, gentamicin
and vancomycin antibiotic-loaded, cement spacer (Fig. 1096, C and D). Intraoperative samples yielded the same
microorganism isolated preoperatively and, based on the
antibiograms, vancomycin 1 g twice daily and cotrimoxazole (sulphamethoxazole 400 mg and trimethoprim 80 mg)
were administered for 2 weeks, at the end of which vancomycin was stopped and levofloxacin 750 mg per day was
administered orally with cotrimoxazole for 3 more weeks.
• Partial knee function and walking ability
between stages, providing a better comfort for the
patient;
•
Easier exposure at the time of revision;
•
Less quadriceps shortening; and
• No additional bone loss during the interim
period.
•
However, small sample size, short follow-up, and inadequate outcome measures have produced only limited
evidence to confirm that patients have better long-term
function if interim articulating spacers are used, compared to static ones.
•
Different types of articulating spacers have been proposed:
• Resterilized prosthetic components or new
components (spacer prostheses);
109-19
The Knee: Reconstruction, Replacement, and Revision
knee arthroplasty. J Bone Joint Surg. 1983;65(8):
1087-1098.
• Cement spacer molded during operation with a
thin metal-on-polyethylene runner;
• All-cement spacer, molded or custom-made
during the operation; and
•
•
Preformed cement spacers.
No comparative studies have investigated the outcome
of different types of articulating spacers and the choice
still relies on theoretical and practical considerations of
each surgeon.
•
The implant of a dynamic spacer may be associated
with all the general complications related to knee revision surgery. Specific risks include
•
Spacer dislocation and
•
Spacer breakage.
Both of these complications have been only occasionally reported and have been usually managed conservatively, without reported long-term consequences.
2.
Wilde AH, Ruth JT. Two-stage reimplantation in
infected total knee arthroplasty. Clin Orthop Relat
Res. 1988;236:23-35.
3.
Borden LS, Gearen PF. Infected total knee arthroplasty: a protocol for management. J Arthroplasty.
1987;2(1):27-36.
4.
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;345:148-154.
5.
Walker RH, Schurman DJ. Management of infected
total knee arthroplasties. Clin Orthop Relat Res.
1984;186:81-89.
6.
Hofmann AA, Kane KR, Tkach TK, et al. Treatment of infected total knee arthroplasty using an
articulating spacer. Clin Orthop Relat Res. 1995;
321:45-54.
7.
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;430:125-131.
•
The risk of spacer dislocation may be reduced by shaping the cement needed to fix the spacer as a short stem,
to partially fill the femoral and tibial diaphysis.
•
No study has directly compared one-stage versus twostage revision or static versus any dynamic spacer in a
prospective, randomized, controlled fashion.
8.
Emerson RH Jr, Muncie M, Tarbox TR, et al. Comparison of a static with a mobile spacer in total knee
infection. Clin Orthop Relat Res. 2002;404:132-138.
• A review of the available literature shows, at
comparable follow-up, an average infection eradication
rate of 81.9% in 204 patients after the one-stage
exchange and a 89.8% success rate in 1421 patients
after two-stage procedures.
9.
Scott IR, Stockley L, Getty CJM. Exchange arthroplasty for infected knee replacements. J Bone Joint
Surg Br. 1993;74(1):28-31.
10.
Duncan CP, Beauchamp C. A temporary antibioticloaded joint replacement system for management of
complex infections involving the hip. Orthop Clin
North Am. 1993;24(4):751-759.
11.
McPherson EJ, Lewonoswski K, Dorr LD. Use of an
articulated PMMA spacer in the infected total knee
arthroplasty. Clin Arthroplasty. 1995;10(1):87-89.
12.
Fehring TK, Odum S, Calton TF, et al. Articulating
versus static spacers in revision total knee arthroplasty
for sepsis. The Ranawat Award. Clin Orthop Relat
Res. 2000;380:9-16.
13.
Haddad FS, Masri BA, Campbell D, et al. The Prostalac functional spacer in two-stage revision for
infected knee replacements. J Bone Joint Surg Br.
2000;82(6):807-812.
14.
Meek RM, Dunlop D, Garbuz DS, et al. Patient satisfaction and functional status after aseptic versus septic revision total knee arthroplasty using the
PROSTALAC articulating spacer. J Arthroplasty.
2004;19(7):874-879.
• Similarly, a systematic review of the literature
shows a slightly better eradication rate of articulating
compared to static spacers (respectively 91.2% vs.
87%) at similar follow-up.
• However, caution should be taken when combining and comparing data from different investigations.
•
The most recent literature does not confirm a clear difference in the functional outcome after two-stage septic
revision surgery either with a static or and articulating
spacer, compared to aseptic revision surgery.
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Resection Arthroplasty and Use of Dynamic Spacers
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