Introduction: Chronic infection after total joint arthroplasty is a complication of major concern to orthopaedic surgeons, especially if patients suffer from any type of immunodeficiency. But for extensive surgical and systemic treatment recurrence rates are high.

Silver is a long known local antimicrobial agent. The use of silver coated prostheses is a valuable option in some cases.

Yet there are patients for whom the permanent implantation of large amounts of silver does not seem to be the perfect solution.

Methods: From 02/2004 to 12/2005 nine patients with severe deep infections after multiple revisions following total joint replacement underwent two-stage revision and implantation of silver coated megaendoprostheses (MUTARS®).

From 04/2004 to 01/2006 seventeen patients of slightly less impaired disposition were treated by a comparable two-stage procedure using silver-augmented cemented spacer prostheses or cement fills.

Patients are closely observed regarding toxic side effects.

Concentration of silver in blood and puncture samples are measured using an argon plasma mass spectrometer.

Results: To date eight of nine patients with silver coated megaendoprostheses are free of infection. One patient with known cellular and humoral immunodeficiency recently developed a fistula, puncture showing superinfection by coag. neg. staphylococci.

In the second group one patient of seventeen actually shows a persisting infection, but cannot be matched properly as he primarily suffered from a long-term infected knee arthrodesis.

Silver concentrations ranged from a maximum of 1010 to 243 μg/kg (ppb) to a minimum of 84 to 304 μg/kg (ppb) with silver coating, and a maximum of 380 to 22,9 μg/kg (ppb) to a minimum of 76 to 5,02 μg/kg (ppb) with silver spacers.

There are large individual differences in both groups.

We found no signs of argyrosis or recently developed neurological deficits.

Discussion: The use of silver in the treatment of severely infected joint prostheses is a promising approach, but it is not without risks and throwbacks. Strict indication and surveillance are needed to keep possible side effects under control. It ought not to be used out of specialized centres.

We have investigated in a prospective, randomised placebo-controlled study the effect of high-dose aprotinin on blood loss in patients admitted for major surgery (revision arthroplasty of the hip or knee, or for resection of a soft-tissue sarcoma). The mean intraoperative blood loss was reduced from 1957 ml in the control group to 736 ml in the aprotinin group (p = 0.002). The mean requirement for intraoperative homologous blood transfusion in the aprotinin group was 1.4 units (95% CI 0.2 to 2.7) and 3.1 units (95% CI 1.7 to 4.6) in the control group (p = 0.033). The mean length of hospital stay was reduced from 27.8 days in the control group to 17.6 days in the aprotinin group which was not statistically significant.

The intraoperative use of aprotinin in major orthopaedic operations significantly reduced blood loss and the required amount of packed cells. It may result in a decrease in the length of hospital stay and costs.