Two-stage Reimplantation in Infected Total Knee Arthroplasty by Using Resterilized Femoral and Tibial Components with a New Polyethylene Insert: Report of 4 Cases with at Least 15 Years’ Follow-up

Background. This study evaluates 15 years’ results of the implantation of autoclaved femoral and tibial prosthesis components together with a new same brand polyethylene insert which were used as a temporary articulating spacer in patients with periprosthetic infection of total knee arthroplasty (TKA) in a two-stage reimplantation procedure in 6 patients. Material and methods. The femoral and tibial prostheses of 6 patients with deep chronic periprosthetic infection of TKA who underwent elective two-stage exchange arthroplasty were autoclaved and reinserted with a new polyethylene insert of the same brand and bone cement mixed with tecoplanin in 2004. Results. Four patients were followed for 15 years. They were all female and between 47-70 years old. The infectious agent was meticillin-resistant Staphylococcus aureus (MRSA) in 3 and coagulase negative Staphy­lococcus in one patient. Patients were invited for second stage reimplantation, but they refused to undergo the second stage. Three of them had their second stage reimplantation after 15, 13 and 10 years while one patient was reinfected after 5 years, in 2009, and arthrodesis was performed. They were all happy with the result and infection free at last follow-up. Conclusions. 1. Regarding the results of our patients, reinsertion of autoclaved femoral and tibial prostheses together with a new same brand polyethylene insert with teicoplanin loaded bone cement can be used cautiously in the management of periprosthetic deep infection of TKA. 2. That is because patients might not want the second stage reimplantation. 3. We believe that the refusal of patients to undergo the surgery shows that the single-stage treatment is effective.

The autoclaving and re-implantation of an infected prosthesis as a spacer during resection knee arthroplasty: a systematic review

Background Hofmann et al., in 1995, first described an articulating spacer made by cleaning and autoclaving the original femoral component, which is then re-implanted with a new tibial polyethylene. This systematic review aims to assess the state of existing evidence on the intraoperative autoclaving and re-use of an infected prosthesis, as a spacer, during a two-stage revision following Periprosthetic Joint Infections (PJI). Methods A systematic review was conducted with methods described in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. OVID-MEDLINE®, EMBASE, Cochrane Library, SCOPUS, Web of Science, Google Scholar and PubMed were searched from 1995 to April 2020 to identify relevant studies. Results Fourteen studies were included in this systematic review: two prospective case series; six retrospective comparative studies and six retrospective case series. The reviewed studies included 567 patients (571 knees): 394 patients treated with autoclaved components and 173 with a spacer made of new components. The cumulative re-infection rate in patients treated with re-used autoclaved components was 13.7% (54 re-infections in 394 patients), whereas in control patients the re-infection rate was 13.3% (23 re-infections in 173 patients). The final Range of Movement in patients treated using the autoclaved components as a spacer, compared with patients receiving static spacers, was significantly higher in three out of four comparative studies. Conclusion There is a moderate level of evidence that the intraoperative autoclaving and re-use of an infected prosthesis as a spacer, during a knee resection arthroplasty, is an effective procedure in the management of knee PJI.

Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS)

Background There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems. Methods Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence. Results Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7–7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6–5.1). Conclusions Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

External validation study of hip peri-prosthetic joint infection with cemented custom-made articulating spacer (CUMARS)

Introduction: Peri-prosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty (THA). The use of custom-made articulating spacers (CUMARS) has been described for use in the first of 2-stage treatment. We report our outcomes of managing PJI using CUMARS. Methods: Patients undergoing 1st-stage revision using the Exeter standard stem, all-polyethylene acetabulum and antibiotic-loaded cement were identified. Medical records were assessed for demographics, microbiological and operative treatment, complications, eradication of infection and reoperations. No postoperative restrictions were enforced. 2nd-stage revision was undertaken in the presence of pain or subsidence. Results: 53 patients underwent 1st-stage revision using this technique. The average follow-up was 3.9 (range 0.5–7.2) years. Infection was eradicated in 47 (88.7%) patients. 2 patients had chronic infection managed with suppressive antibiotics, 2 patients died before eradication confirmed, 1 patient had raised inflammatory markers but no positive aspiration cultures, 1 patient was lost to follow-up. Complications occurred in 5 (9.4%) patients – 4 dislocations and 1 infected haematoma. 4 patients required a repeated 1st stage. 2nd-stage revision was performed in 19 patients (35%). Conclusions: The CUMARS technique is an effective way of eradicating PJI after THA. It maintains function by providing a stable construct that permits weight-bearing. It delays or negates the need for 2nd-stage revision. Furthermore, it allows surgeons to choose between managing patients prospectively as a single-stage revision with the option of reverting to a 2nd stage.

An articulated spacer made of new primary implants in two-stage exchange for infected total knee arthroplasty may provide durable results

Aims Our objective is to describe our early and mid-term results with the use of a new simple primary knee prosthesis as an articulating spacer in planned two-stage management for infected knee arthroplasty. As a second objective, we compared outcomes between the group with a retained first stage and those with a complete two-stage revision. Methods We included 47 patients (48 knees) with positive criteria for infection, with a minimum two-year follow-up, in which a two-stage approach with an articulating spacer with new implants was used. Patients with infection control, and a stable and functional knee were allowed to retain the initial first-stage components. Outcomes recorded included: infection control rate, reoperations, final range of motion (ROM), and quality of life assessment (QoL) including Western Ontario and McMaster Universities osteoarthritis index, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, 12-Item Short-Form Health Survey questionnaire, and University of California Los Angeles (UCLA) activity score and satisfaction score. These outcomes were evaluated and compared to additional cohorts of patients with retained first-stage interventions and those with a complete two-stage revision. Mean follow-up was 3.7 years (2.0 to 6.5). Results Eight knees failed directly related to lack of infection control (16%), and two patients (two knees) died within the first year for causes not directly related, giving an initial success rate of 79% (38/48). Secondary success rate after a subsequent procedure was 91% (44/48 knees). From the initially retained spacers, four knees (22%) required a second-stage revision for continuous symptoms and one (5%) for an acute infection. There were no significant differences regarding the failure rate due to infection, ROM, and QoL assessment between patients with a retained first-stage procedure and those who underwent a second-stage operation. Conclusion Our protocol of two-stage exchange for infected knee arthroplasties with an articulating spacer and using new primary knee implants achieves adequate infection control. Retained first-stage operations achieve comparable results in selected cases, with no difference in infection control, ROM, and QoL assessment in comparison to patients with completed two-stage revision surgery. Cite this article: Bone Joint J 2020;102-B(7):852–860.