Introduction. The surgical management of late PJI was usually done in two stages with the placement of a temporary cement spacer. The development of one-stage surgical care raises questions about the two-stage strategy. The objectives of this study are to identify the complications related to the presence of the cement spacer within a two-stage strategy. The septic recurrence rate is also evaluated after a minimum follow-up of two years. Material and methods. Medical files of 208 patients (101 knees and 107 hips) who underwent a two-stage revision for late PJI prosthesis infection were retrospectively reviewed. Antibiotic loaded articulated homemade cement spacers were used. Second stage was usually planned on average 4 to 6 weeks after the first stage. Patients were allowed to walk without loading. The success rate was defined as the absence of septic recurrence after a minimum follow-up of two years. Descriptive statistics and uni- and multivariate analysis were conducted. Results. The spacers were left in place for an average of 42 days for the knees and 30 days for the hips. Six patients (3%) died before performing the second stage. Hip spacers were associated with 8 fractures for only one observed in the knee (4%). Spacer dislocation (11%) was observed in 23 cases (13 for the hip and 10 for the knee respectively). Treatment failure with recurrence of the infection within 2 years was observed in 26 patients (12%). Resistance to the antibiotic present in the cement was found in one third of infectious failures. The presence of a prior cemented prosthesis was significantly associated with the presence of a germ resistant to gentamicin and the persistence of the germ at the second stage. However, it was not associated with failure at two years. Discussion. the two-stage management of PJI is associated with a non-negligible mortality rate before the second stage, rarely reported in studies. The presence of an initially cemented prosthesis is associated with the presence of germs resistant to the antibiotic contained in the cement and exposes to the persistence of the resistant germ at the second stage. Spacer fractures are observed more at the hip, but less frequently than in previous reports, while dislocations are observed at both the hip and the knee, particularly due to loss of tibial fixation in this area. These observations are all arguments for further consideration of revision surgery in 1 stage

Aim. The aim of this study is to evaluate if the gentamycin elution from bone cement is influenced by the timing of application of the antibiotic powder. Method. This was an experimental in vitro study that compared the elution properties of different formulation of gentamycin from a commercially available hip, knee and shoulder cement spacers. Four different experimental models were prepared. Five different spacers were prepared for each experimental mode and for each joint. We compared four different formulation of cement spacers: spacer #1, in which the spacer was prepared with a premixed bone-cement antibiotic mixture; spacer #2, in which the spacer was prepared by adding antibiotic powder to the bone cement at the time of spacer preparation; spacer #3, in which the spacer was prepared as spacer #2 but was stored for two months before starting the experiment; spacer #4, in addition to the gentamycin, other two antibiotics (tobramycin and vancomycin) were added to the bone cement. Gentamycin concentration was documented at seven intervals of time: T0 = 0h, T1 = 1h, T2 = 24h, T3 = 1W, T4 = 2W, T5 = 1M, T6 = 3M and T7 = 6M. The gentamycin elution at each interval of time was evaluated by using a T-student test. Results. Spacer #2, in which the gentamycin powder was added to the bone cement at the time of spacer preparation showed the higher gentamycin elution at each interval of time observed. In addition, Spacer #1, in which gentamycin powder was premixed with the bone cement showed a higher gentamycin elution when compared with spacer #3, in which the spacers were stored for two months to simulate the preformed spacers. Lastly, the addition of different antibiotic to the bone cement increases the gentamycin elution from the spacers (as demonstrated by spacer #4 model). Conclusions. a higher gentamycin elution was observed if spacer was prepared at the time of surgery when compared with preformed spacer. Lastly, our study confirmed the synergistic effect of adding one or more antibiotics with the aims to increase gentamycin elution

Introduction. Periprosthetic joint infection (PJI) is a serious problem and requires great effort and cost for its treatment. Treatment options may vary from resection arthroplasty, retention of prosthesis with debridement, one stage revision and two stage revision with handmade antibiotic impregnated cement spacer or with prefabricated antibiotic loaded cement spacer. Two stage revision remains the gold standard for the treatment of periprosthetic joint infection after Total Hip Arthroplasty (THA). This study was aimed to find the efficacy and cost effectiveness of handmade antibiotic impregnated articulating cement spacer over commercially available prefabricated antibiotic loaded cement spacer for the treatment of deep PJI of hip prosthesis and to evaluate its functional outcome. Material and methods. A total of 23 PJI patients were enrolled in this prospective cohort study. In the two stages of revision, the first stage consisted of thorough debridement, implant removal and implantation of handmade articulating antibiotic impregnated cement spacer. The second stage surgery consisted of removal of cement spacer, thorough debridement and implantation of new prosthesis. All patients were followed for a period of 24 months. Results. A total of 23 patients (15 males and 8 females) underwent two stage revision arthroplasty for chronic periprosthetic joint infection. The mean age of the patient was 57 years. The handmade antibiotic impregnated cement spacer was retained for 16– 20 weeks. Common organism observed was coagulase negative staphylococci followed by Staphylococcus aureus. After an average follow up of 2 years, 20 patients with PJI remained clinically free of infection. In 2 patients there was recurrence of infection. Conclusion. We conclude that two stage revision by hand made cement spacer is successful in eradication of infection with satisfactory functional outcome. Furthermore, these handmade cement spacer are cost effective and their efficacy may be comparable to commercially available prefabricated spacer

Aim. Studies have shown that retention of antibiotic cement spacer in selected elderly patients with low functional demand represents a viable option for periprosthetic joint infections (PJI) treatment. 1,2. . The aim of this study is to compare the efficacy in infection treating among modular taylored preformed and hand-made antibiotic spacers. Our hypothesis is that modular tailored preformed spacer provides a better rate of infection resolution, better radiological and functional outcomes compared to hand-made spacers. Materials and methods. We identified 48 patients treated with antibiotic cement spacer for shoulder chronic infection between 2015 and 2021 in our institution; (13 hand-made spacers and 35 modular tailored preformed spacers). We collected data about comorbidities, associated microorganism, infection resolution, clinical and radiographic evaluation. Results. The mean age at surgery was 63.2 years, (45.8% female − 54.2% male), mean BMI 28.3. The mean time of infection diagnosis after first surgery was 30 months; (31.2% infection after ORIF in proximal humeral fractures, 68.8% PJI after shoulder arthroplasty). The main pathogens were Propionibacterium Acnes (37.5%), Staphylococcus Epidermidis (29.2%), Staphylococcus Aureus (16.7%), negative intraoperative coltures (14.6%), Enterococcus (4.17%), Pseudomonas Aeruginosa (4.17%). The mean time of antibiotic spacer retention was 18 months: 23 patients (47.9%) underwent second stage surgery for prosthesis implantation; 2 removed the spacer because of spacer dislocation, 2 died during follow up; while 21 patients still hold the antibiotic spacer (17 patients in treatment with prefabricated spacers and 4 with self-constructed spacer). The mean value for clinical assessment for patients with modular tailored preformed spacer were: Constant Score 34 – QuickDASH 40 – SST 33 – ASES Score 66 – VAS 2. Patients treated with hand-made spacer registered the following scores: Constant Score 20 – QuickDASH 51 – SST 25 – ASES Score 38 – VAS 6. Two patients presented fracture of the spacer (one hand-made spacer and one tailored preformed). Conclusions. According to our data patients treated with modular tailored preformed antibiotic spacer show better functional outcomes. Patients are more likely to retain the spacer as a permanent implant, avoiding the risks of a second stage surgery in those low-demanding patients, achieving a reasonable satisfying quality of shoulder motion without pain

At first-stage revision surgery for infection of total knee arthroplasties, antibiotic-impregnated cement spacers are frequently implanted. Two types of cement spacers are commonly used, “static” and “articulating” cement spacers. Advocates of cement spacers state that they deliver high doses of antibiotics locally, increase patient comfort, allow mobility and provide joint stability. They also minimize contracture of collateral ligaments, thereby facilitating re-implantation of a definitive prosthesis at a later stage. The use of these cement spacers, however, are not without significant complications, including patella tendon injuries. We describe a series of three patients who sustained patella tendon injuries in infected total knee arthroplasties following the use of a static cement spacer at first-stage knee revision. The patella tendon injuries resulted in significant compromise to wound healing and knee stability requiring multiple surgeries. The mid-term function was poor with an Oxford score at 24 months ranging from 12–20. Based on our experience, we advise caution in the use of static cement spacer blocks. If they are to be used, we recommend that they should be keyed in the bone to prevent patella tendon injuries

BACKGROUND. High-dose antibiotic cement spacers are commonly used to treat prosthetic joint infections following knee arthroplasties. Several clinical studies have shown a high success rate with antibiotic cement spacers, however there is little data on the systemic complications of high-dose antibiotic spacers, particularly acute kidney injury (AKI). This study aims to determine the incidence of AKI and identify risk factors predisposing patients undergoing staged revision arthroplasty with antibiotic cement spacers. METHODS. A single-institution, retrospective review was used to collect and analyze clinical and demographic data for patients who underwent staged revision total knee arthroplasty with placement of an antibiotic-impregnated cement spacer from 2006 to 2016. A search was made through specific procedure (DRG) and diagnostic (CD) codes. Baseline descriptive data were collected for all patients including age, sex, medical comorbidities, type and quantity of antibiotics used in the cement spacer, pre- and postoperative hemoglobin (Hg), BMI, smoking status, peak creatinine levels, and random vancomycin levels. Acute kidney injury was defined as a more than 50% rise in serum creatinine from a preoperative baseline within 90 days postoperatively. RESULTS. A total of 54 staged revision TKA surgeries performed by 5 different surgeons between 2006 and 2016. The total incidence of AKI was 31% (n=17). There was a significant positive association between change in creatinine level and use of oral/intravenous antibiotics (p=0.03, Spearman's rho=0.33) and a significant positive association between AKI and the use of tobramycin cement (p=0.01, Spearman's rho=0.38). Factors that were not significantly associated with AKI include presence of preexisting hypertension (p = 0.26), hyperlipidemia (p = 0.83), coronary artery disease (p = 0.86), chronic kidney disease (p=0.56), and smoking status (p=.35). There was a trend towards increased risk of AKI in patients with diabetes mellitus (p= 0.12), however this was not significant. CONCLUSION. In single staged revision knee arthroplasty there is a significant association between acute kidney injury and type of oral/intravenous antibiotic used in the treatment. Both the use of intravenous vancomycin and tobramycin cement are independently associated with higher rates of AKI. Preexisting medical comorbidities are not independent risk factors for development of AKI. Serum creatinine and measurement of serum aminoglycoside and vancomycin levels should be performed after placement of an aminoglycoside-containing antibiotic cement spacer in a staged revision arthroplasty

Background. Vancomycin and fosfomycin are antibiotic commonly used in Methicillin-resistant Staphylococcus aureus (MRSA) infection. This study compares the efficacy of articulating cement spacer implegnated with vancomycin and articulating cement spacer implegnated with fosfomycin to inhibit MRSA. Methods. Vancomycin implegnated articulating cement spacers and Fosfomycin implegnated articulating cement spacers were immersed in sterile phosphate buffered saline(PBS) and then incubated at 37 C. The samples were collected and change daily. Aliquots were tested for MRSA inhibition by disc diffusion method. The inhibition zones diameters were measured. Results. Vancomycin group showed an MRSA inhibition zone up to four weeks. However, Fosfomycin group showed inhibition zone in day 3 in some samples but after that no sample had the potential to inhibit MRSA. Conclusion. In this experiment. Vancomycin impregnated articulating cement spacers showed longer efficacy to inhibit MRSA when compared to Fosfomycin

Aim. infected segmental bone defect (ISBD) is frequent in developing countries. The aim of this study was to assess the efficacy of the Masquelet technique in the treatment of ISBD in a low-resource setting. Patients and Method. We performed a prospective cohort study during the period from 2018 to 2022. Patients with infected bone defect of long bones were included. Management protocol consisted of two stages in all patients. The first stage consisted in debridement, tissues biopsy for microbiological culture, stabilization with external fixator and defect filling with gentamicin cement spacer. The second stage consisted of reconstruction using a cancellous bone autograft alone, or a mixture of autograft with allograft (demineralized bone matrix + tricalcium phosphate) and 1 gram of vancomycin powder. All patients were followed-up for at least one year. The results were assessed based on both objective (clinical and radiographic evaluation) and subjective (limb function and patient satisfaction) criteria. Main outcomes were bone union, reoperation and failure rates, union time, and limb function. Results. We included 31 patients in this study (80.6% men), with a median age of 35 [9 – 80] years. The tibia was affected in 12 cases and the femur in 15 cases. The median size of bone defect was 4 [1.5 – 12] cm. The most prevalent microorganisms were Klebsiella pneumoniae and Staphylococcus aureus. The mean interval between both stages was 14 (8 – 36) weeks and the median follow-up period after the second stage was 20 [12-62] months. External fixation was used in both stages in 25(80%) cases. Bone union was achieved in 26 (83.8%) patients of whom 24 without recurrence of infection, over a median time of 9 [6 – 16] months. All patients with a mixed graft (allograft and autograft) impregnated with local antibiotics achieved bone union. Two patients needed reoperation for relapse of infection between both stages, and subsequently achieved bone union without recurrence of infection. There were three cases of failure related to persistent infection or insufficient fixation stability in the second stage. Conclusions. Masquelet technique is a reliable procedure that can be safely performed in limited resources settings with satisfactory results. The mixture of autograft and allograft when available, all mixed with vancomycin seems to give promising results

Introduction. Periprosthetic infection is a serious complication after total hip arthroplasty (THA). Two stage procedure using antibiotic-impregnated cement spacer is one of the treatments for late chronic infection after THA. We investigated the effects of two stage procedure on the infection control and the recurrence of infection after revision THA. Materials and Methods. We retrospectively reviewed a consecutive series of 10 cases of a periprosthetic infection after hip arthroplasty, including 3 THA and 7 bipolar hemiarthroplasty (BHA). They were treated with two stage procedure using antibiotic-impregnated cement spacer from 2004 to 2009. There were 4 women and 6 men with an average age of 68.4 years. The pathogens were methicilin-resistant Staphylococcus aureus (MRSA) in 3 cases, coagulase-negative Staphylococcus (CNS) in 2 cases, Enterococcus in 2 cases, Streptococcus in 2 cases, and unknown in 1 case. After removal of the prosthesis, extensive debridement was performed to remove infected tissues and residual cement. After irrigation with iodine solution, antibiotic-impregnated cement spacer was inserted with proximal cement fixation to prevent dislocation and fracture of the cement spacer. The antibiotics that were impregnated in the cement spacer were VCM in 8 cases, MEPM in 1 case, and CAZ in 1 case. Intravenous antibiotics were administrated for 3 weeks after this first stage surgery, and then oral antibiotics were administrated until C-reactive protein (CRP) rates became negative. After confirming the culture of joint fluid contained no pathogens, second stage revision surgery was performed. The average follow-up period after revision THA was 2.3 years. We investigated the period from first stage surgery to the day when CRP became negative, and to the day of second stage surgery. The incidence of recurrence of infection after revision THA was investigated. Results. The average period to negative CRP was 25 days, and that to the second stage surgery was 64 days. There has been no recurrent infection until now. Discussion. The antibiotics-impregnated cement spacer for the treatment of periprosthetic infection was introduced around 1990, and success rate of this technique was reported to exceed 90%. In our series, we experienced no recurrence of infection in spite of containing 3 MRSA cases and 2 CNS cases. The advantages of the antibiotics-impregnated cement spacer were to avoid soft tissue shortening and to allow patient to walk without weight bearing. We concluded that two-stage revision technique with antibiotics-impregnated cement spacer is an effective treatment for peripros

Aim. To assess the effectiveness of role of frozen section in revision arthroplasty. Method. 21 patients with infected hip arthroplasties were operated in the form of one or two-staged revision hip arthroplasties. A frozen section was obtained intra-operatively and >5 PMN's/ HPF was considered as a positive indicator of infection. Fig 1 llustrating frozen section image. If the frozen section was reported negative (≤5 PMN's/HPF), the revision prosthesis was implanted after a thorough debridement and a wash. If the frozen section was reported as positive, after the debridement a non-articulating antibiotic loaded cement spacer was implanted for 8 weeks, supplemented with 3 weeks of intravenous antibiotics and 3 weeks of oral antibiotics. This was followed by an antibiotic free interval of 2 weeks. The patient was taken up for a revision surgery once the frozen section study was negative (≤5 PMN's/HPF). The patients were followed up for minimum of 1 year to a maximum of 2 years after the revision for any evidence of infection (assessed clinically and serologically, radiologically). Results. 15 patients had a positive frozen section (>5PMN's/HPF) in the first stage and were treated with prosthesis removal and cement spacer insertion for 8 weeks. In the 2nd stage, out of 15 patients, 14 underwent revision arthroplasty, while 1 patient underwent reapplication of the cement spacer. As per the follow up of ESR & CRP values, clinically and radiologically no patients had any evidence of infection. The average follow up was 17.04 months (range 12–24 months). 1 patient had persistently raised ESR (34mm/hr) which may be attributable to other causes Frozen section analysis of PMN's per high power field had 100% specificity in our patients in detecting periprosthetic joint infection. Conclusions. Intraoperative frozen section study is a reliable indicator in predicting a diagnosis of PJI with good accuracy in ruling out this diagnosis. Frozen section study should thus be considered a relevant part of the challenging diagnostic work-up for patients undergoing revision hip arthroplasty

Background. Infection is one of the most severe comlications of the total arthroplasty. We sometimes encounter cases, which are very hard to finish repeated recurrence. Usage of steroids, immunosuppressants, and biologics would possibly effect to the incidence of the prosthetic infection and to the result of its treatment. Biologics have drastically decreased the number of the total arthoplasic patients, on the other hand, we must be more careful about the infectious conditions. For the infection two stage revision surgery; first removal and antibiotics cement spacer insertion then reimplantation later; is often chosen but sometimes one time antibiotics cement spacer cannot stop the infection and requires multi times spacer insertion. In those cases the dead spaces, poor blood supply and tight skin could be the cause of the recurrence. For these cases we had been performing musclo-cutaneal flap and successfully finish the infection. Objectives. Our objectives are to review infection cases treated with musclo-cutaneal flap and compare with treatment without it. Methods: Since 2004 to 2013, 6 infection cases were treated. Our standard policy is 2-staged revision. In the first surgery, the prosthesis was removed and cement spacer was inserted. If no evidence of the remained infection was found reimplantation would be done in the second surgery. Otherwise debridement and cement spacer were repeated. In 3 cases, the infection could be finished without musclo-cutaneal flap but in 3 cases musclo-cutaneal flap was finally done then the infection was finished. The clinical courses were reviewed. Results. Case 1. After right hip revision, fistula formation was occurred. Later, enterococcus fecalis was detected. Six times cement spacer insertion was performed. But fistula was remained. Musclo-cutaneal flap of sartorius muscle was performed. No fistula was seen after that. Case 2. Fistula was appeared 3 years after hip replacement. The culture was negative. New prosthesis insertion was done after one time spacer treatment then the infection was controlled. Case 3. Six weeks after primary hip replacement, fistula was appeared. MRSA was found. Three times antibiotic spacer insertions were done then re-implantation was successfully done. Case 4. Three weeks after total knee replacement, the wound became lose and MRSA was found. The wound was communicated with the joint and the patient had general weakness, so musclo-cutaneal flap was done in one time. No recurrence was seen. Case 5. Two weeks after total hip replacement, MRSA superficial infection was found. Wound washing and both injection and oral antibiotics were used. Case 6. This patient was sent from a certain hospital after 3 times open debridement. MRSA was still positive. One time antibiotics spacer was done, and then revision with musculo-cutaneal flap of lateral vastus muscle was performed. No recurrence is seen so far. In all flap cases, infection was finished in our case. On the other hand, the surgical invasion was much bigger. So we can take musculo cutaneal flap into consideration to overcome the recurent infection

Purpose. Management and outcomes of fungal periprosthetic joint infection (PJI) remain unclear due to its rarity. Although two-stage exchange arthroplasty is considered a treatment of choice for its chronic features, there is no consensus for local use of antifungal agent at the 1st stage surgery. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer in two-stage exchange arthroplasty against chronic fungal PJIs after total knee arthroplasty (TKA). Methods. Nine patients who were diagnosed and treated for chronic fungal PJIs after TKA in a single center from January 2001 to December 2016 were enrolled. Two-stage exchange arthroplasty was performed. During the 1st stage resection arthroplasty, amphotericin-impregnated cement spacer was inserted for all patients. Systemic antifungal medication was used during the interval between two stage operations. Patients were followed up for more than 2 years after exchange arthroplasty and their medical records were reviewed. Results. The average duration from the initial symptom to fungal PJI diagnosis was 20 months (range, 5 to 72 months). Average erythrocyte sedimentation rate and C-reactive protein level at diagnosis were 56 mm/h (range, 30 to 89 mm/h) and 2.25 mg/dl (range, 0.11 to 3.97 mg/dl), respectively. Fungal PJI was confirmed by preoperative joint aspiration culture in 6 cases. For the other 3 cases, it was confirmed by open debridement tissue culture. All infections were caused by Candida parapsilosis except for one case which was caused by Candida pelliculosa. The average number of operations before exchange arthroplasty to solve the infection was 2.7 times (range, 1 to 5 times). Average duration of antifungal agent use confirmed by sensitivity test was 7 months (range, 4 to 15 months). Mean interval between two stage operation was 6 months (range, 1.5 to 15 months). After two-stage exchange arthroplasty, no patient had recurrent fungal infection during a mean follow-up of 66 months (range, 24 to 144 months). Conclusions. Due to its ill-defined symptoms and inconclusive blood test, fungal PJI after TKA is difficult to diagnose and has a prolonged clinical course. Two-stage exchange arthroplasty with antifungal-impregnated cement spacer is a very effective strategy with excellent outcome

INTRO. Two-stage revision arthroplasty for PJI may make use of an antibiotic-loaded cement spacer (ACS), as successful long- term prevention of reinfection have been reported using this technique.[i] However, there is little data on systemic complications of high-dose antibiotic spacers. Acute kidney injury (AKI) is of clinical significance, as the drugs most commonly utilized, vancomycin and aminoglycosides, can be nephrotoxic. We intended to determine the incidence of AKI in patients that underwent staged revision arthroplasty with an ACS, as well as to identify potential predisposing risk factors for the disease. METHODS. Local databases of six different orthopaedic surgeons were retrospectively reviewed for insertion of either a static or articulating antibiotic cement spacer by from 2007–2017. Dose of antibiotic powder implanted, as well as IV antibiotic used, was collected from operative records. Demographics, comorbidities, and preoperative and postoperative creatinine and hemoglobin values were recorded from the EHR. AKI was defined by a more than 50% rise in serum creatinine from preoperative baseline to at least 1.4 mg/dL, as described by Menge et al.[ii] Variables were analyzed for the primary outcome of AKI within the same hospital stay as insertion of the ACS. Categorical variables were analyzed with Chi-Square test, and continuous variables with univariate logistic regression. RESULTS. 75 patients (39 M, 36 F) receiving an ACS were identified, with a mean age of 70.0 (SD=10.6) and a mean BMI of 31.3 (SD=7.3). Incidence of in-hospital AKI was 13.3%. Patients reached AKI at a mean 6.7 days (SD=4.5), during a median length of stay of 13.5 days (IQR=21.8). No significant correlation was found between AKI and the variables of age (p=.430), BMI (p=.569) or gender (p=.181). AKI was also not associated with increased dose of vancomycin (p=.416), tobramycin (p=.440), or gentamycin (p=.846) within the cement spacer, or the comorbidities of hypertension (p=.094), diabetes (p=.146), coronary artery disease (p=1.00) and renal disease (p=.521). However, decreased baseline hemoglobin showed significantly increased risk for AKI (OR=1.67, p =.049), and increased creatinine showed a trend (OR=2.9, p=.059). Percentage of hemoglobin decrease (preoperative to postoperative) did not increase odds for AKI (p=.700). CONCLUSION. The incidence of acute kidney injury in patients that receive antibiotic cement spacers is relatively high when compared to the data reported in primary TKA. ii,[iii]. Our results suggest that patient related risk factors, such as low preoperative hemoglobin, may be involved in the etiology of AKI in this population. Therefore, it may be clinically appropriate to monitor anemic patients for AKI when implanting an ACS

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

In two-stage revision surgery of infected joint prosthesis, temporary bone cement spacers have been used for several years. By adding antibiotics to the cement, high local antibiotic concentrations that exceed the minimum inhibiting and bactericidal concentration of the respective pathogen during the first days after surgery, are achieved. Currently, aminoglycosides (e.g. gentamicin and tobramycin), as well as glycopetides (e.g vancomycin) are used as antibiotic agents and mixed into the acrylic cement. In order to increase the quantity of active antibiotic substances, we established a novel surgical technique of additional superficial vancomycin coating (SVC) of temporary bone cement spacer. The aim of this study was to analyze the safety of this method by measuring postoperative joint and serum vancomycin concentrations, as well as the creatinine levels. We reviewed prospectively collected data on all patients, which were treated by explanting the prosthetic components, following temporary spacer implantation and SVC between 05/2013 and 04/2015 at the Department of Orthopedic Surgery, Medical University of Graz. In total 13 patients were treated by addition SVC during the study period. Before hardening, vancomycin powder (2 grams) was pressed manually onto the surface of the bone cement. Vancomycin levels were obtained from drains and blood samples on postoperative days 1 to 5. Forty-six blood serum samples and 52 drain fluid samples were available for further. On postoperative day one to five, a median serum vancomycin level of < 2.0 μg/mL was present (range <2.0 – 3.9). The highest median vancomycin level from the drain was documented on postoperative day 1 with a value of 388.0 μg/mL (range 44.4–1650.0), continually decreasing until postoperative day 4. After SVC, neither an anaphylactic reaction nor side effects such as a red man syndrome, fever and chills were observed. Furthermore, no patient complained about subjective hearing loss. No serum creatinine increase of 0.5 mg/dL from creatinine baseline value or a ≥50% increase from baseline was detected. After a median of 64 days (range 18–82), the temporary cement spacer was explanted followed by prosthesis implantation. During this time no reinfection occurred. One patient suffered from a dislocation of the spacer with a distal femur fracture and was therefore re-operated after 18 days. Powdered vancomycin as an additional superficial coating of bone cement spacer results in much higher local antibiotic concentrations than in conventional spacers. The newly introduced method is feasible, safe and promising to enhance local inhibiting concentrations of vancomycin

Report of a case of migrating periprosthetic infection from a hip replacement to a contralateral knee joint undergoing a total knee replacement. We present a 74-year old female patient who underwent a total hip arthroplasty of the left hip after a subcapital fracture of the femur. Four months after the index procedure the patient presented with signs and symptoms of infection of the operated joint. Staph aureus and Enterococcus faecalis were recognized as the infecting bacteria. The implants were removed, cement spacers were placed and a total hip arthroplasty was performed again after three months. Unfortunately, infection ensued again and the patient underwent three more procedures until the joint was considered clean and t he hip remained flail without implants. The patient elected to undergo a total knee arthroplasty due to severe osteoarthritis of right knee. Intraoperatively tissue samples were taken and sent for cultures which identified Enterococcus faecalis present in the knee joint. Enterococcus migrated from the infected hip to nonoperated knee joint. Intravenous antibiotics were administered for three weeks but the knee presented with infection of the arthroplasty ten months after its insertion. The implants were removed the joint was debrided and cement spacers were inserted. The patient decided not to proceed with another procedure and she remains with the cement spacers in her knee. Rare report of migrating periprosthetic infection. Nosocomial enterococci acquired resistance cannot be ruled out. Unique characteristics in enterococci antibiotic resistance and biofilm formation

Aim. The effectiveness of mandatory joint aspiration prior to re-implantation in patients with a cement spacer already in place is unclear. The aim of this study was to evaluate the role of culturing articular fluid obtained by joint aspiration prior to re-implantation in patients who underwent a two stage septic revision. Method. A retrospective observational study was conducted, assessing51 patients that underwent a two stage septic hip or knee revision from 2010 to 2017. According to the results of intraoperative cultures, after the first stage revision each patient was treated with an antibiotic protocol for 6–8 weeks. Following two weeks without antibiotics, a culture of synovial fluid was obtained. Synovial fluid was obtained by direct joint aspiration in cases of knee spacers by and by joint aspiration guided by fluoroscopy in the theatre room in cases of hip spacers. Synovial fluid was transferred into a Vacutainer ACD. ®. flask. Samples were processed and analysed in the microbiology laboratory. Gram stains were performed and the sample was subsequently transferred into a BacALERT bottle (bioMérieux, France) and incubated in a BacALERT instrument for seven days. Results of these cultures were recorded and compared with cultures obtained during re-implantation surgery. Results. Of the 51 patients analysed, 9 were excluded because joint aspiration was not performed or the samples were not correctly processed. The remaining 42 patients (21 hip and 21 knee spacers) were included in the final analysis. In 40 cases, the culture of synovial fluid was negative while in the remaining two cases (hip spacers) no analysis was possible due to dry aspiration. In 5 of the patients, two or more intraoperative synovial fluid cultures taken during the re-implantation surgery were positive. Conclusions. Although in theory, synovial fluid culture may provide useful information regarding the infection status of the joint, in our study, we found no evidence to support mandatory joint aspiration prior to re-implantation in patients with a cement spacer in place

Introduction. Temporary use of antibiotic-impregnated polymethylmethacrylate (PMMA) bone cement spacers in two-stage revisions is considered to be standard of care for patients with a chronic infection of a joint replacement. Spacers should be wear resistant and load-bearing to avoid prolonged immobilisation of the patient and to reduce morbidity. Most cement spacers contain barium sulphate or zirconium dioxide as radio-opaque substrate. Both are quite hard materials that may negatively influence the wear behaviour of the spacer. Calcium carbonate is another radio-opaque substrate with lower hardness potentially increasing the wear resistance of the spacer materials. The purpose of the study was to compare a prototype PMMA knee spacer (calcium carbonate loaded) with a commercially available spacer (containing barium sulphate) regarding the wear performance and particle release in a knee wear simulator. Material and Methods. Spacer K (TECRES, Italy) was used as barium sulphate (10%) containing spacer material. A prototype material (Heraeaus Medical, Germany) with 15% calcium carbonate was compared. Both were gentamicin impregnated, ready-made for clinical application (preformed) and consist of a tibial and a femoral component. Force-controlled simulation was carried out on an AMTI knee simulator. The test parameters were in accordance to ISO 14243–1 with a 50% reduced axial force (partial weight bearing). Tests were carried out at 37 °C in closed chambers filled with calf serum. Tests were run for 500,000 cycles at a frequency of 1 Hz. For wear analysis, gravimetric wear measurements according to ISO 14243–2 and wear particle analysis according to ASTM F1877–05 were performed. Results. Fig. 1 presents the results of the gravimetric wear measurements. For the Spacer K cement a mean articular wear mass of 375.53±161.22 mg was determined after 500.000 cycles (femoral components: 149.55±17.30 mg, tibial components: 225.98±153.01 mg). The prototype cement showed lower mean total wear of 136.32±37.58 mg (femoral components: 74.32±33.83 mg, tibial components: 61.99±15.74 mg). However, a statistically significant lower wear rate was only seen for the femoral components (p=0,027). In Fig. 2 isolated PMMA wear particles are shown and the morphological characteristics are given in Tab. 1. Discussion and conclusion. The prototype material showed better wear performance in terms of gravimetric wear and particle release. Thus calcium carbonate seems to be a promising material as radio-opaque substrate in PMMA spacers. Nevertheless, the wear amount released from both spacer materials is much higher as compared to conventional total knee replacements with polyethylene inserts. In this context biological reactions against PMMA particles and an increased release of cytokines have been reported in vitro [1] and furthermore, the promotion of osteolysis has been shown in vivo in the presence of PMMA particles [2]. As a clinical consequence we suggest excessive debridement during removal of the cement spacer components to reduce the risk of third body wear for the final joint replacement. Beside the wear performance further studies are essential to prove the mechanical stability and the antibiotic release kinetics for the prototype cement

Introduction:. 20 cases of bone defect have been treated by the induced membrane technique avoiding allograft, microsurgery and amputation. Material and Methods:. 9 cases of long bone defect (humerus and forearm) and 11 cases of bone defect at the hand have been included in this multicentre prospective study (3 centers). The aetiology in 11 cases was trauma, 7 cases were septic nonunions and 2 cases followed tumors. In the hand the bone loss was at least one phalanx, and for long bones the mean defect was 5 cm (3–11). All cases were treated by the induced membrane technique which consists in stable fixation, flap if necessary and in filling the void created by the bone defect by a cement spacer (PMMA). This technique needs a second stage procedure at the 2. nd. month where the cement is removed and the void is filled by cancellous bone. The key point of this induced membrane technique is to respect the foreign body membrane which appeared around the cement spacer and which creates a biologic chamber for the second procedure. Bone union was evaluated prospectively in each case by a surgeon not involved in the treatment, by X-ray and CT scan. Failure was defined as a nonunion at 1 year, or an uncontrolled sepsis at 1 month. Results:. 3 cases failed to achieve bone union, 2 in the hand and 1 in a long bone. No septic complications occurred and all septic cases healed. In 14 cases bone union was achieved with a delay of 5 months (1, 5–12). 2 biopsies allowed us to prove that osteoid tissue was created by the technique. At hand level all fingers have included. At shoulder and elbow level, function reached 75% of motion of the contralateral side. Discussion:. Masquelet first reported 35 cases of large bone defect of tibia nonunion treated by the induced membrane technique which allow filling a bone defect with cancellous bone alone. The cement spacer induces a foreign body membrane (neo periosteum) which constitute a biological chamber. Animal models showed the properties of the membrane: secretion of growths factors (VEGF, TGFbéta1, BMP2) and osteoinductive activitie of the cells. Conclusion:. This technique is useful in emergency or in septic condition where a bone defect cannot be solved by shortening. The technique avoids the use of microsurgery and the limit is the quantity of available cancellous bone

Several risk factors can and should be addressed during first stage or spacer implantation surgery in order to minimize complications. Technical aspects as well as practical tips and pearls to overcome common nuisances such as spacer instability or femoral and acetabular bone loss will be discussed and shown with pictures. Total joint arthroplasty (TJA) is one of the most successful procedures in orthopaedics and excellent results are expected in virtually all cases. Periprosthetic joint infection (PJI) though unusual, is one of the most frequent and challenging complications after TJA. It is the third most common cause of revision in total hip replacement, responsible for up to 15% of all cases. In the past few years several improvements have been made in the management of an infected total hip prosthesis. Nevertheless it remains a challenging problem for the orthopaedic surgeon. Although numerous studies report favourable outcomes after one-stage revision surgery, two-stage has traditionally been considered as the gold standard for management of chronic infection. Two-stage exchange consists of debridement, resection of infected implants and usually temporary placement of an antibiotic-impregnated cement spacer before reimplantation of a new prosthesis. Spacers can be classified as static or articulating. The goals of using an articulating antibiotic loaded cement spacer are two-fold: to enhance the clearance of infection by local antibiotic therapy and dead-space management while maintaining joint function during treatment thus improving the functional outcome at reimplantation. Still, hip spacer implantation is not innocuous and there are several possible complications. Going forward, one must consider not just eradicating infection but also the importance of restoring function. In this regard using a mobile spacer adds an element of physiologic motion that both increases patient comfort between stages and facilitates re-implantation surgery. Conversely, mechanical complications are one of the major consequences of this preference. Be that as it may there are ways to minimize these problems. It is the surgeon responsibility to optimize mechanical circumstances as much as possible. I would like to thank Dr. Ricardo Sousa for his help with this work