• Cemex Spacer K
• Copal Exchange G
• Copal G + C
• Copal G + V
• PMMA spacer
• periprosthetic joint infection
• two-stage revision
• vancomycin

• arthroplasty infections
• cement
• hip
• joint reconstruction
• knee
• periprosthetic joint infections

• Copal G+V
• PMMA
• VancogenX
• efficacy
• elution
• manually added vancomycin
• mechanical properties

• admixed antibiotic
• antibiotic-impregnated cement
• difficult to treat
• easy to treat
• septic revision arthroplasty
• two-stage revision

• extended trochanteric osteotomy
• periprosthetic joint infection
• postoperative complications
• revision total hip arthroplasty
• two-stage revision

• Humans
• Arthroplasty, Replacement, Hip/adverse effects
• Prosthesis-Related Infections/epidemiology
• Prosthesis-Related Infections/etiology
• Prosthesis-Related Infections/surgery
• Reoperation/adverse effects
• Femur/surgery
• Femoral Fractures/surgery
• Arthritis, Infectious/surgery
• Retrospective Studies

• ELISA
• gentabeads
• pharmacokinetic release profile
• poly methyl methacrylate (PMMA)
• spacers

• Humans
• Anti-Bacterial Agents/therapeutic use
• Polymethyl Methacrylate
• Bone Cements
• Gentamicins/pharmacokinetics
• Drainage
• Enzyme-Linked Immunosorbent Assay
• Prosthesis-Related Infections/drug therapy

• THA
• TKA
• periprosthetic joint infection
• revision arthroplasty
• spacer interval
• time to reimplantation
• two-stage exchange

• Antibiotic-loaded spacer
• Low dose
• Periprosthetic joint infection
• Systemic toxicity
• Two-stage revision
• Vancomycin

• Antibiotics
• Cement
• Infection
• PMMA
• Release

• Anti-bacterial agents
• Arthroplasty
• Biofilms
• Debridement
• Hip prosthesis
• Knee prosthesis
• Orthopedic surgeons
• Prosthesis-related infections/prevention & control
• Prosthesis-related infections/surgery

The diagnostic value of C-reactive protein (CRP) and the serum white blood cell (WBC) count is still barely defined for decision making during septic two-stage revision surgery of hip arthroplasty. We, therefore, compared these values between stages as well as between the groups without and with reinfection in 117 patients. A total of 106 patients were reinfection-free (91%). The median follow-up was 51 months. With a ΔCRP of −10 mg/L and a ΔWBC count of −1000/µL, a significant decrease between stages (p = 0.001) could be observed. When comparing the CRP and WBC count values between groups, however, no significant difference was found at stage one, stage two and even the difference between these two time points (reinfection-free ΔCRP of −11 mg/L and ΔWBC count of −1000/µL vs. reinfection ΔCRP of −5 mg/L (p = 0.131) and ΔWBC count of −1100/µL) (p = 0.424). The diagnostic value was poor for the calculated parameters (area under the curve (AUC) 0.5–0.6). The courses of the mean CRP values of both groups were similar. We conclude that the CRP and WBC count are not helpful to guide the decision making in individual cases.

• Continuous local antibiotic perfusion
• fracture-related infection
• gentamicin
• intramedullary antibiotic perfusion
• intrasoft tissue antibiotic perfusion

• Antibiotic carrier
• periprosthetic joint infection
• revision
• total hip arthroplasty

• multiple revisions
• periprosthetic joint infection
• revision knee arthroplasty
• revision surgery
• survivorship
• total knee arthroplasty

• Antibiotic-loaded cement
• Antimicrobial resistance
• Arthroplasty
• Clindamycin
• Gentamicin
• Periprosthetic joint infection

• Antibiotics
• Biomechanics
• Clindamycin
• Efficacy
• PMMA bone cement

• Anti-Bacterial Agents/administration & dosage
• Biomechanical Phenomena
• Bone Cements/chemistry
• Clindamycin/administration & dosage
• Humans
• Materials Testing
• Polymethyl Methacrylate/chemistry
• Powders
• Propionibacteriaceae/drug effects
• Staphylococcus/drug effects

• arthroplasty
• knee prosthesis
• prevention
• prosthetic-joint infection
• septic revision
• superinfection
• total knee arthroplasty

• antibiotic delivery
• bone graft substitute
• calcium polyphosphate
• hydrogel

• Anti-bacterial agents
• Infection
• Polymethyl methacrylate
• Powder
• Vancomycin

• Bone cement
• antibacterial resistivity
• borate minerals
• cost-efficiency
• proper mechanical strength

• PMMA
• antibiotics
• bacterial infection
• bone implant
• cement
• delivery
• release

• AQRF04816-17RD2 Advance Queensland

Two-stage revision arthroplasty with an antibiotic-loaded spacer is the treatment of choice in chronically infected total hip arthroplasties. Interval spacers can be functional articulating or prefabricated. Functional results of these spacers have scarcely been reported.

To compare retrospectively the patient reported outcome and infection eradication rate after two-stage revision arthroplasty of the hip with the use of a functional articulating or prefabricated spacer. 

All patients with two-stage revision of a hip prosthesis at our hospital between 2003 and 2016 were included in this retrospective cohort study. Patients were divided into two groups; patients treated with a functional articulating spacer or with a prefabricated spacer. Patients completed the Hip Osteoarthritis Outcome Score and the EQ-5D-3L (EQ-5D) and the EQ-5D quality of life thermometer (EQ-VAS) scores. Primary outcomes were patient reported outcome and infection eradication after two-stage revision. The results of both groups were compared to the patient acceptable symptom state for primary arthroplasty of the hip. Secondary outcomes were complications during spacer treatment and at final follow-up. Descriptive statistics, mean and range are used to represent the demographics of the patients. For numerical variables, students’ t-tests were used to assess the level of significance for differences between the groups, with 95% confidence intervals; for binary outcome, we used Fisher’s exact test.

We consecutively treated 55 patients with a prefabricated spacer and 15 patients with a functional articulating spacer of the hip. The infection eradication rates for functional articulating and prefabricated spacers were 93% and 78%, respectively (P > 0.05). With respect to the functional outcome, the Hip Osteoarthritis Outcome Score (HOOS) and its subscores (all P < 0.01), the EQ-5D (P < 0.01) and the EQ-VAS scores (P < 0.05) were all significantly better for patients successfully treated with a functional articulating spacer. More patients in the functional articulating spacer group reached the patient acceptable symptom state for the HOOS pain, HOOS quality of life and EQ-VAS. The number of patients with a spacer dislocation was not significantly different for the functional articulating or prefabricated spacer group (P > 0.05). However, the number of dislocations per patient experiencing a dislocation was significantly higher for patients with a prefabricated spacer (P < 0.01).

Functional articulating spacers lead to improved patient reported functional outcome and less perioperative complications after two-stage revision arthroplasty of an infected total hip prosthesis, while maintaining a similar infection eradication rate compared to prefabricated spacers.

• Two-stage revision
• Periprosthetic joint infection
• Hip arthroplasty
• Functional articulating spacer
• Prefabricated spacer
• Patient reported outcome

Objective: Periprosthetic infections (PPI) after total hip and total knee arthroplasty (THA, TKA) are subdivided into early and late infections. Early PPIs are defined as the occurrence of infection within 6 weeks following the primary surgery. Aim of therapy in early PPI is the retention of the prosthesis using dilution, jet dilution or local antibiotics. However, as of yet, no evidence is available supporting these procedures. The aim of this study was to evaluate their success rates.

Methods: We conducted a systematic literature review of studies reporting on early PPI. Clinical trials published after 1990 that reported success or failure rates as the primary outcome were included. A meta-analysis using the Scheffé-Test showed if there are any advantages of single treatment concepts.

Results: We identified 575 patients over 10 studies. Success rates were diverse: Undergoing dilution without jet lavage revealed treatment success in 49.48%, using jet dilution increased the success rate to 78.26%. Local antibiotics were successfully used in 55% of the cases. The meta-analysis compared the three interventions and showed no significant difference in using dilution, jet dilution or local antibiotics. Even combining local antibiotics and dilution/jet dilution does not provide significantly higher success rates.

Conclusion: Previous studies showed differences in methods and results, however pooling the data of these studies for our meta-analysis didn’t show significant advantages. We therefore conclude that studies conducted until thus far cannot provide any recommendation as to whether using dilution, jet dilution, local antibiotics or any combination of three is better for treating early PPI cases.

• anti-bacterial agents
• prosthesis-related infections
• therapeutic irrigation

Two-stage revision is considered the gold standard treatment for chronic periprosthetic joint infection (PJI). During the interim period, between explantation of the infected hip endoprosthesis and revision arthroplasty, individually formed articulating hip spacers made of polymethylmethacrylate (PMMA) bone cement can be used to provide better soft tissue preservation, local antibiotic release, and improved postoperative mobilization. If effective prevention from luxation is achieved, hip function and hence overall patient satisfaction is improved. Zirconium oxide particles inside conventional PMMA bone cement, however, are known to enhance third-body wear, which may cause alterations of the metal head in the articulating spacer and hence become a serious risk for the patient. Therefore, the aim of our study was to analyze whether the articular surface of cobalt-chrome (CoCr) femoral heads is significantly altered in the setting of a metal-on-cement articulation during the interim period of two-stage revision for PJI. We analyzed a consecutive series of 23 spacer cases and compared them with femoral heads from two series of conventional hip arthroplasty revisions with metal-on-polyethylene articulations and different time intervals in situ. To investigate metallic wear, the femoral heads were thoroughly examined, and their surface roughness was measured and analyzed. We found no significant differences between the two conventional hip arthroplasty groups, despite their very different times in situ. Furthermore, the individually different times in situ within the spacer group had no significant impact on surface roughness, either. Compared with the spacer group, the surface roughness of the metal femoral heads from both conventional hip arthroplasty groups were even higher. Within the spacer group, roughness parameters did not show significant differences regarding the five predefined locations on the metal head. We conclude that metal-on-cement articulations do not cause enhanced surface alterations of the metal femoral head and hence do not limit the application in articulating hip spacers in the setting of two-stage revision for PJI.

• articulating spacer
• cement spacer
• hip spacer
• metal-on-cement articulation
• periprosthetic joint infection
• surface alteration
• surface roughness
• third-body wear
• two-stage revision
• zirconium oxide particles

• acetabular bone loss
• femoral bone loss
• hip revision
• periprosthetic joint infection
• two-stage hip revision

To explore the effect of different types of articulating antibiotic-loaded cement spacers in two-stage revision for chronic hip prosthetic joint infection (PJI).

A retrospective cohort study was performed involving 36 chronic PJI patients treated with different types of articulating antibiotic-loaded cement spacers between January 2014 and December 2017. The incidence of complications and the therapeutic effects of different types of antibiotic-loaded articulating cement spacers were compared.

A total of 36 patients with chronic hip PJI were included. Of these, 13 patients were treated with spacers with Kirschner wires as an endoskeleton (group I), ten patients were treated with spacers with a cemented femoral prosthesis as an endoskeleton (group II), and 13 patients were treated with cemented femoral prostheses combined with polyethylene sockets as a spacer (group III). All patients were followed for 12 to 60 months, with a mean follow-up period of 26.44 months (SEM 14.09). Infection was controlled in 34 patients (94.44%), and there were no significant differences in the eradication rate among the three groups (p = 0.705), but the risk of complications related to the spacer in group III was significantly lower than that in groups I and II (p = 0.006).

Articulating antibiotic-loaded cement spacers is effective in the treatment of chronic hip PJI, but we must pay attention to the occurrence of spacer fracture and dislocation, which can lead to poor joint function. The risk of spacer-related mechanical complications is low, and better joint function can be achieved when using cemented femoral prostheses combined with polyethylene sockets as spacers.

Cite this article: Bone Joint Res 2020;9(8):484–492.

• Articulating antibiotic-loaded cement spacer
• Chronic prosthetic joint infection
• Two-stage revision surgery

Bacterial bone infections after revision surgeries and diseases, like osteomyelitis, are still a challenge with regard to surgical treatments. Local bone infections were treated with antibiotics directly or by controlled drug-releasing scaffolds, like polymethylmethacrylate (PMMA) spheres, which have to be removed at a later stage, but there is a risk of a bacterial contamination during the removement. Therefore, biomaterials loaded with antibiotics for controlled release could be the method of choice: The biomaterials degrade during the drug release, therefore, there is no need for a second surgery to remove the drug eluting agent. Even non-resorbable bone materials are available (e.g., hydroxyapatite (HA)) or resorbable bone graft materials (e.g., beta-tricalcium phosphate (β-TCP)) that will be replaced by newly formed bone. Composite materials with organic additives (e.g., collagen) supports the handling during surgery and enhances the drug loading capacity, as well as the drug releasing time. The purpose of this study was to investigate the loading capacity and the release rate of Vancomycin and Gentamicin on TCP and HA granules in the shape of a degradable scaffold compared to composite materials from TCP mixed with porcine collagen. Its antibacterial efficacy to a more elementary drug with eluting in aqueous solution was examined. The loading capacity of the biomaterials was measured and compared according to the Minimum Inhibition Concentration (MIC) and the Minimum Biofilm Eradication Concentration (MBEC) of a bacterial biofilm after 24 h aging. Antibiotic elution and concentration of gentamycin and vancomycin, as well as inhibition zones, were measured by using the Quantitative Microparticle Systems (QMS) immunoassays. The antibiotic concentration was determined by the automated Beckman Coulter (BC) chemistry device. For examination of the antibacterial activity, inhibition zone diameters were measured. Generally, the antibiotic release is more pronounced during the first couple of days than later. Both TCP granules and HA granules experienced a significantly decline of antibiotics release during the first three days. After the fourth day and beyond, the antibiotic release was below the detection threshold. The antibiotic release of the composite material TCP and porcine collagen declined less drastically and was still in the frame of the specification during the first nine days. There was no significant evidence of interaction effect between antibiotic and material, i.e., the fitted lines for Gentamycin and Vancomycin are almost parallel. During this first in vitro study, β-TCP-Collagen composites shows a significantly higher loading capacity and a steadily release of the antibiotics Gentamycin and Vancomycin, compared to the also used TCP and HA Granules.

• Minimum Biofilm Eradication Concentration (MBEC)
• Minimum Inhibitory Concentration (MIC)
• antibiotics
• bone substitute
• controlled drug release
• elution rate
• foam

There is a concern regarding the use of a closed-suction drain (CSD) in two-stage exchange arthroplasty for periprosthetic joint infection as it may decrease the antibiotic concentrations in the joint fluids. The purpose of this study was to identify whether the use of a CSD could reduce local antibiotic concentrations following spacer implantation.

A prospective, randomized, controlled trial was conducted at our institution between January 2018 and November 2018. We enrolled 32 patients undergoing two-stage exchange arthroplasty for periprosthetic hip infection with an interim cement spacer containing 4-g vancomycin and 2-g meropenem per 40-g methyl-methacrylate cement polymer. Patients were randomized and evenly divided into the study group (non-CSD) and control group (CSD group) by sealed envelopes. Drainage samples of joint fluids (n = 160) were collected every 24 h for the first five days following spacer implantation. The antibiotic concentrations of drainage samples were measured by high-performance liquid chromatography, and the bioactivities of the drainage samples against methicillin-sensitive and methicillin-resistant Staphylococcus aureus (MSSA and MRSA) and E. coli were assessed.

There was no significant difference in the decrease of vancomycin (study group vs. control group: 163.20 ± 77.05 vs. 162.39 ± 36.31; p = 0.917) and meropenem concentration (123.78 ± 21.04 vs. 117.27 ± 19.38; P = 0.548) between the two groups during the first five days following spacer implantation. All joint drainage samples in each group exhibited antibacterial activity against MSSA, MRSA and E. coli.

The use of CSD following the implantation of an antibiotic-loaded cement spacer does not reduce the effectiveness of such a spacer in two-stage exchange arthroplasty.

(Chinese Clinical Trial Registry, ChiCTR-INR-17014162. Registered 26 December 2017.)

• Antibiotic concentration
• Antibiotic-loaded cement spacer
• Closed-suction drain
• Periprosthetic joint infection
• Two-staged exchange arthroplasty

• Periprosthetic infection
• antibiotic
• biomaterial
• hip
• knee
• periprosthetic joint
• prosthetics.

We describe the use of local antibiotics to salvage an infected below-knee amputation in a diabetic patient and prevent the need to convert to the above-knee level. After débridement, an antibiotic tibial “dowel” was fashioned and inserted into the intramedullary canal before closure. The wound was fully healed after four months, and the patient remained satisfied at 15 months.

This case report offers an adjunct to the conventional management of diabetic stump infections. The addition of an antibiotic spacer could offer an alternative to a higher level of amputation and improve the survival rates of below-knee amputation in this difficult population.

• antibiotic loaded acrylic cement spacer
• antibiotic loaded bone cement
• gentamicin beads
• osteomyelitis
• polymethylmethacrylate
• prosthetic join infection

• Clindamycin
• PMMA cement
• antibiotic loaded bone cement (ALBC)
• gentamicin
• prosthetic joint infection (PJI)
• revision arthroplasty

• antibiotic beads
• antibiotic duration
• antibiotic route of administration
• antibiotic therapy
• antibiotic-loaded cement spacer
• bioavailability
• extended oral antibiotic prophylaxis
• intravenous antibiotics
• reimplantation
• resection arthroplasty
• short-term antibiotic treatment

• complications
• periprosthetic joint infection
• revision
• total hip arthroplasty
• two-stage

• Antibiotic spacer
• Dislocation rate
• Dual mobility cup
• ENDO spacer
• Prosthetic joint infection
• Two-stage septic exchange (revision)

Two‐stage revision arthroplasty is the treatment of choice for periprosthetic infection, a serious complication after knee or hip arthroplasty. Our prospective clinical trial aimed to investigate the concentrations of gentamicin and vancomycin in wound exudate and tissue in two‐stage revision arthroplasty. Wound exudate and periprosthetic membrane samples were collected from 18 patients (10 hip and eight knee patients), who were due for two‐stage treatment after a periprosthetic joint infection. Samples were taken during insertion of antibiotic‐impregnated spacers and after their removal. The concentrations of gentamicin and vancomycin in wound exudates and adjacent tissue were analyzed using high‐performance liquid chromatography mass spectrometry. Average time period of spacer implantation was 13.6 weeks (9.3–22.6 weeks). The concentration of vancomycin in wound exudate decreased from a median of 43.28 μg/mL (0.28–261.22) after implantation to 0.46 μg/mL (0.13–37.47) after the removal of the spacer. In the adjacent tissue, vancomycin concentration was mainly undetectable prior to spacer implantation (0.003 μg/g [0.003–0.261]) and increased to 0.318 μg/g [0.024–484.16] at the time of spacer removal. This was also observed for gentamicin in the tissue of patients who previously had cement‐free implants (0.008 μg/g [0.008–0.087] vs. 0.164 μg/g [0.048–71.75]) while in the tissue of patients with previously cemented prosthesis, baseline concentration was already high (8.451 μg/g [0.152–42.926]). Despite the rapid decrease in antibiotics release from spacer cement observed in vitro, in vivo antibiotics are much longer detectable, especially in the adjacent soft tissue. © 2018 The Authors. Journal of Biomedical Materials Research Part B: Applied Biomaterials Published By Wiley Periodicals, Inc. J Biomed Mater Res B Part B, 2019. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1587–1597, 2019.

• antibiotics release
• cement spacer
• gentamicin
• periprosthetic joint infection
• revision arthroplasty
• two-stage treatment
• vancomycin

• Biofilm
• Colonization barrier
• Manual application
• PMMA cement
• Recommendations

• 2-stage revision
• antimicrobial resistance
• minimum inhibitory concentration
• periprosthetic joint infection
• persistent infection

Two-stage reimplantation is considered the gold standard for the management of periprosthetic joint infection. The first stage involves the removal of the prosthesis, followed by extensive debridement of all nonviable tissues, synovectomy, irrigation, and reaming of the medullary canals. Once the joint has been prepared, antibiotic-impregnated cement beads and/or spacer are inserted. Antibiotic-impregnated spacers are now more commonly used, and an increasing number of orthopaedic surgeons are using articulating spacers if indicated. Antibiotics are then prescribed to the patient based on the sensitivities of the infecting organism. The duration of systemic antibiotic use is decreasing, and short courses of antibiotic therapy have been shown to be as efficacious as prolonged therapy between the first and second stages. The second stage of the procedure involves removal of the antibiotic-impregnated cement beads and/or spacer, repeat irrigation and debridement, and final reconstruction with revision components. While two-stage reimplantation was considered the gold standard in many parts of the world, recent studies have demonstrated that it is associated with a considerable failure rate. This may be due to the lack of accurate diagnostic tools for infection eradication, and future investigation of risk factors for failure of the two-stage reimplantation should be conducted.

• Antibiotics
• Arthroplasty
• Infection
• Knee
• Reimplantation
• Spacer

Introduction: When treating periprosthetic joint infection with a two-stage procedure, antibiotic-impregnated spacers can be used in the interval between prosthetic removal and reimplantation. In our experience, cultures of sonicated spacers are most often negative. The objective of the study was to assess whether that sonication causes an elution of antibiotics, leading to elevated antibiotic concentrations in the sonication fluid inhibiting bacterial growth and thus causing false-negative cultures.

Methods: A prospective monocentric study was performed from September 2014 to March 2016. Inclusion criteria were a two-stage procedure for prosthetic infection and agreement of the patient to participate in the study. Spacers were made of gentamicin-containing cement to which tobramycin and vancomycin were added. Antibiotic concentrations in the sonication fluid were determined by mass-spectometry (LC-MS).

Results: 30 patients were identified (15 hip and 14 knee and 1 ankle arthroplasties). No cases of culture positive sonicated spacer fluid were observed in our serie. In the sonication fluid median concentrations of 13.2µg/ml, 392 µg/ml and 16.6 µg/ml were detected for vancomycin, tobramycin and gentamicin, respectively. According to the European Committee on antimicrobial susceptibility testing (EUCAST), these concentrations released from cement spacer during sonication are higher than the minimal inhibitory concentrations (MICs) for most bacteria relevant in prosthetic joint infections.

Conclusion:Spacer sonication cultures remained sterile in all of our cases. Elevated concentrations of antibiotics released during sonication could explain partly negative-cultured sonicated spacers. Indeed, the absence of antibiotic free interval during the two-stages can also contribute to false-negative spacers sonicated cultures.

• Infection
• Sonication
• Spacer
• Two-Stage Exchange

The aim of this study was the evaluation of possible outcome differences of patients undergoing two-stage hip exchange with antibiotic-loaded spacers, compared to patients without an interim spacer implantation.

We evaluated 46 patients undergoing two-stage hip revision surgery. Twenty-five patients received an interim ALS. Additional to a Kaplan–Meier survival analysis, a competing risk analysis was performed to estimate the cumulative incidence function for re-revisions due to infection accounting for death as a competing event.

Nine patients (seven non-ALS vs. two ALS) had to undergo re-revision surgery due to reinfection of the hip joint. The non-ALS group showed a risk of re-revision of 19% (95% CI 5–38%) at 12 and 24 months and 30% (95% CI 12–51%) at 36 months. The group with ALS implantation displayed a 0% risk of re-revision surgery in the first 36 months. The Gray test revealed a significant difference in the cumulative incidence between both observed groups (p = 0.026).

Our findings suggest that ALS implantation significantly reduces the risk of reinfection after two-stage hip revision surgery.

• Hip
• Periprosthetic joint infection
• Spacer