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Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection

Javad Parvizi MD, FRCS
Thorsten Gehrke MD


Title:
Spacers

Liaisons:
Mustafa Citak, MD

Leaders:
Jean-Noel Argenson MD (International), Bas Masri MD, FRCSC (International), Daniel Kendoff MD (International), Bryan Springer MD (US)

Delegates:
Volker Alt MD, Andrea Baldini MD, Quanjun Cui MD, Gregory K Deirmengian MD, Hernan del Sel MD, Michael F Harrer MD, Craig Israelite MD, David Jahoda MD, Paul C Jutte MD, Eric Levicoff MD, Enzo Meani MD, Fernando Motta MD, Orestes Ronaldo Pena MD, Amar S Ranawat MD, Oleg Safir MD, Matthew W Squire MD, Michael J Taunton MD, Charles Vogely MD, Samuel S Wellman MD

Vol 1, Num S1, September 2014

 

   

Question 1: Is there a functional difference in the use of non-articulating or articulating spacers for the treatment of periprosthetic joint infection (PJI) in the knee, between two-stage exchange arthroplasty?

Consensus: Articulating spacers provide better function than non-articulating spacers for the patient in between the stages of total knee arthroplasty (TKA). An articulating spacer is especially preferred for patients who are likely to have a spacer in place for longer than 3 months.

Delegate Vote: Agree: 89%, Disagree: 6%, Abstain: 5% (Strong Consensus)


Question 2: Is there a functional difference in the use of non-articulating or articulating spacers for treatment of PJI in the knee at minimum two years after reimplantation?

Consensus: There is a non-significant trend in range of motion improvement with articulating compared to non-articulating spacers, but the panel believes that this is still of value to the patient.

Delegate Vote: Agree: 82%, Disagree: 12%, Abstain: 6% (Strong Consensus)


Question 3: Is there a functional difference in the use of non-articulating or articulating spacers for the treatment of PJI in the hip between the stages of two-stage exchange arthroplasty?

Consensus: A well performing articulating spacer provides better function for the patient in between the stages of total hip arthroplasty (THA). These are especially preferred for patients who are likely to have a spacer in place for longer than 3 months.

Delegate Vote: Agree: 89%, Disagree: 7%, Abstain: 4% (Strong Consensus)


Question 4: Is there a functional difference in the use of non-articulating or articulating spacers for the treatment of PJI in the hip, at a minimum of two years after reimplantation?

Consensus: There is a non-significant trend in functional improvement with articulating compared to non-articulating spacers, but the panel believes that this is still of value to the patient.

Delegate Vote: Agree: 81%, Disagree: 12%, Abstain: 7% (Strong Consensus)


Question 5: Is there a difference in reimplantation (surgical ease) with the use of non-articulating or articulating spacers for the treatment of PJI in the knee and hip?

Consensus: Yes. Reimplantation surgery is easier overall in patients receiving articulating spacers compared to non-articulating spacers.

Delegate Vote: Agree: 81%, Disagree: 8%, Abstain: 11% (Strong Consensus)


Question 6: Is there a difference with regards to control of infection with the use of articulating or non-articulating spacers in the knee?

Consensus: No. The type of spacer does not influence the rate of infection eradication in two-stage exchange arthroplasty of the knee.

Delegate Vote: Agree: 89%, Disagree: 6%, Abstain: 5% (Strong Consensus)


Question 7: Is there a difference with regards to control of infection with the use of articulating or non-articulating spacers in the hip?

Consensus: No. The type of spacer does not influence the rate of infection eradication in two-stage exchange arthroplasty of the hip.

Delegate Vote: Agree: 95%, Disagree: 3%, Abstain: 2% (Strong Consensus)


Question 8: Is there a difference with regards to control of infection between different types of articulating spacers used in the knee?

Consensus: Control of the infection is no different between different types of articulating spacers in the treatment of infected TKA.

Delegate Vote: Agree: 90%, Disagree: 5%, Abstain: 5% (Strong Consensus)


Question 9: Are there contraindications for the use of non-articulating and/or articulating spacers?

Consensus: There are no clear contraindications for the use of non-articulating or articulating spacers, other than the technical feasibility of the procedure. In patients with massive bone loss and/or lack of integrity of soft tissues or ligamentous restraint, strong consideration should be given to the use of non-articulating spacers.

Delegate Vote: Agree: 92%, Disagree: 3%, Abstain: 5% (Strong Consensus)


Question 10: Are there any differences in functional outcome between manufactured spacers versus surgeon-made dynamic spacers used in the knee?

Consensus: There is no difference in functional outcome between manufactured spacers versus surgeon-made articulating spacers used in the knee. However, issues of cost, ease of use, and antibiotic delivery should be considered.

Delegate Vote: Agree: 89%, Disagree: 5%, Abstain: 6% (Strong Consensus)


Question 11: Are there any differences in the rate of infection control between manufactured spacers versus surgeon-made articulating spacers used in the knee?

Consensus: There are no differences in the rate of infection control between manufactured spacers and surgeon-made articulating spacers used in the knee. However, issues of cost, ease of use, and antibiotic delivery should be considered.

Delegate Vote: Agree: 93%, Disagree: 2%, Abstain: 5% (Strong Consensus)


Question 12: Are there any differences in functional outcome between manufactured spacers versus surgeon-made dynamic spacers used in the hip?

Consensus: There is no difference in functional outcome between manufactured spacers versus surgeon-made articulating spacers used in the hip. However, issues of cost, ease of use, and antibiotic delivery should be considered.

Delegate Vote: Agree: 89%, Disagree: 7%, Abstain: 4% (Strong Consensus)


Question 13: Are there any differences in the rate of infection control between manufactured spacers versus surgeon-made dynamic spacers used in the hip?

Consensus: There is no difference in the rate of infection control between manufactured spacers versus surgeon-made articulating spacers used in the hip. However, issues of cost, ease of use, and antibiotic delivery should be considered.

Delegate Vote: Agree: 94%, Disagree: 3%, Abstain: 3% (Strong Consensus)


Question 14: Which antibiotic should be used and how much of it should be added to cement spacers?

Consensus: The type of antibiotic and the dose needs to be individualized for each patient based on the organism profile and antibiogram (if available) as well as the patient's renal function and allergy profile. However, most infections can be treated with a spacer with Vancomycin (1 to 4 g per 40 g package of cement) and gentamicin or tobramycin (2.4 to 4.8 g per 40 g package of cement). We provide a list of all available antibiotics and the range of doses to be used against common infecting organisms.

Delegate Vote: Agree: 89%, Disagree: 7%, Abstain: 4% (Strong Consensus)


Question 15: What is the optimal technique for preparing a high-dose antibiotic cement spacer (mixing, when and how to add antibiotics, and porosity)?

Consensus: There is no consensus on the best method of preparation of high-dose antibiotic cement spacers.

Delegate Vote: Agree: 93%, Disagree: 3%, Abstain: 4% (Strong Consensus)


General principles of mixing antibiotics to cement:

Antibiotic needs to be bactericidal, in powder form to allow better integration with cement, sterile, heat/thermo stable, and soluble in water.
The technical aspects of preparing a spacer include:
For preparation of antibiotic-loaded cement for the spacer, some technical aspects apply. As the dosage of antibiotics increases, the difficulty of incorporating the antibiotics into the cement during the mixing process increases. In these situations, mixing the cement powder and monomer for 30 seconds, followed by the addition of the antibiotic powder in multiple small doses, will facilitate incorporation. It is also advisable to crush clumps of antibiotic, although some irregularity in the antibiotics is acceptable, and may be preferable for early elution of active antibiotics. Hand mixing in a bowl without vacuum is recommended as bubbles facilitate elution of the antibtioics. Addition of fillers such as Xyletol or Ancef may improve the elution of active antibiotics. The addition of a high amount of antibiotic to cement will decrease the fatigue strength and increase the fracture risk. The addition of more than 4.5g of powder substantially weakens the cement. For most antibiotic spacers, elution of antibiotics is a primary concern over the mechanical property, but the surgeon must keep this in mind for structural spacers.