Aim. Antibiotic loaded spacers are often used during a two-stage exchange for periprosthetic joint infections (PJI) both for its mechanical properties and as a means for local antibiotic delivery. The main goal of this study is to compare the rate of positive cultures during reimplantation with the use of different antibiotic loaded spacers: aminoglycoside only vs. combined glycopeptide/aminoglycoside vs. combined glycopeptide/carbapenem/aminoglycoside. Method. We retrospectively evaluated every two-stage exchange procedures for infected hip/knee arthroplasty between 2012–2018. Microbiological findings in the first and second stage were registered as well as the type of spacer and antibiotic(s) used. Cases in whom no cultures were obtained during reimplantation and cases without sufficient data on antibiotic(s) used in cement spacers were excluded. Results. Fifty-four cases were included (20THA and 34TKA), with an overall rate of positive cultures during reimplantation of 18.5% (10/54). The rate of positive cultures was statistically significant higher among spacers with monotherapy with aminoglycoside compared to spacers with combined antibiotic therapy- 35.7% (5/14) vs. 12.5% (5/40) respectively(p<0.05). Comparing those with combined glycopeptide/aminoglycoside (2/19) with triple glycopeptide/carbapenem/aminoglycoside therapy (3/21) there was no significant difference. Microorganisms present during the second stage were mostly staphylococci (coagulase-negative in four cases, S.aureus in three), Corynebacterium striatum, Enterococcus faecalis, C.albicans in one case each. In most cases (8/10), the isolated microorganism was the same as the first stage and was resistant to the antibiotic(s) used in the spacer in seven cases. Failure rate with the need for subsequent surgery was significantly higher at 60% (6/10) in cases with positive cultures at reimplantation compared to 4.5% (2/44) for those with negative cultures during reimplantation(p=0.0005). Conclusions. It has recently been suggested that adding a glycopeptide to the spacer may be advantageous when compared to spacers with aminoglycoside monotherapy, as it will produce significantly lower rates of positive cultures during reimplantation which have been shown to increase the risk of subsequent failure as is the case in our study. Local unavailability of obtaining powder aminoglycosides has driven us to manually add high doses of vancomycin and meropenem to commercially available low-dose gentamicin cement in many of our spacers and they seem to to perform just as well as commercially available vancomycin/gentamicin combination. Although many other variables not considered in this study may influence the rate of positive cultures during the second stage (quality of initial debridement, systemic antibiotic therapy, etc.), we believe these results portrait a sufficiently accurate picture of clinical results with the use of different spacers

The use of antibiotic-spacer, it is essential to treat infections in orthopedics. They play a dual role, to fight the infection directly on the outbreak and keep the length or the articulation of the limbs thus facilitating the second operation. To date it is not known, the superiority of use of 3 antibiotics compared to two. Authors try to compare industrial preformed spacers with two antibiotics with custom made spacers with three antibiotics to assess (a) the control of infection, (b) complications, (c) quality of life, (d) pain and (e) patient satisfaction. 137 patients treated at the Institute Codivilla-Putti from January 2010 to December 2012 were considered: 68 patients treated with antibiotic preformed spacer (clindamycin + gentamicin) or (Erythromycin + Colistin), 69 patients treated with antibiotic spacer added with 3 antibiotics (clindamycin + gentamicin + vancomycin) or (Erythromycin Vancomycin + Colistin). Demographic data were collected:. type and site of infection (classified by Cerny-Mader). microbiological results. previous surgeries. years of illness. Primary outcome of infection control or relapse after at least 12 months of follow-up were assessed. Complications were recorded. Each patient completed a test on the quality of life and a satisfaction scale self-referenced. After a mean follow-up of 33.82 months (SD 14:50), at the end of the treatment, at last follow up 15/133 were infected. 4 died from other causes not correlated with infection, whit a 11.3% rate of reinfection. Up to our knowledge, there is only one study using the procedure in two steps comparing the use of spacers loaded with 2 or 3 antibiotics. Our results show that a revision protocol in two steps with 3 antibiotic loaded spacers have a high success rate in the treatment of chronic osteomyelitis. We can observe that patients treated with custom-made cements are 4 percentage points lower than those treated with preformed cements, but there are no statistically significant differences in the rate of recurrence of infection. Our results suggest that a two stages procedure with three antibiotic loaded spacers should be considered in selected patients to avoid rescue procedures, such as amputation and arthrodesis. We think is important to do more randomized trials, controlled, prospective study with a larger group to detect statistically significant differences

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

The practice at most centers in North America for the investigation and management of non-acute infection after hip replacement has been relatively standard for some time. Diagnosis has depended on a thorough history, physical examination, plain radiographs, straightforward laboratory inflammatory markers, joint aspiration for bacteriologic study, intraoperative frozen section in selected cases, and intraoperative synovial biopsies for confirmatory bacteriologic evaluation. The cornerstone of treatment on this continent has revolved around two-stage revision hip replacement, with increasing popularity for the use of interval articulating antibiotic loaded spacers, and increasing use of cementless fixation at the second stage. But this standard approach has been under increasing scrutiny in recent years, for good reason. The use of more precise “best evidence” paradigms on which to base the diagnosis have been developed. There is encouraging work on the application of more specific synovial and serum markers. The need to remove all implant material in all cases has been challenged. And there is evidence that the two stage approach is associated with greater morbidity, mortality and cost. The latter has led to a re-examination of the role and results of single-stage exchange revision, at least in selected cases, where the patient is immune competent, the soft tissue and bone anatomy is not badly deficient, the organism is known, and the antibiotic sensitivity is favorable. The most encouraging of the recent developments is the increasing consensus that multicenter collaborative study is required if we are to make genuine progress in the one-stage/two-stage debate. At least one multicenter prospective randomised study is scheduled to commence in 2015

A “two-stage exchange” remains the gold standard for treatment of the infected TKA in North America. Although there is interest in “one-stage exchange” this technique is not as familiar to many US surgeons and it is unclear if the reported results of Europe can be translated to North American practice. Specific concerns include the “radicalness” of the debridement required (which oftentimes includes the collateral ligaments, hence the popularity of hinged implants where this approach is common) and the use of fully cemented stems, which are extremely difficulty to remove if infection recurs. Thus while the idea of a one stage exchange is attractive to many North American surgeons, careful study will be required to determine if success can be achieved with a more “conservative” debridement and the use of cementless stems which are preferred by some surgeons. The basic principles of a two-stage exchange include: Thorough debridement of all infected appearing foreign material and all cement; Placement of an interval antibiotic loaded spacer (note that the addition of antibiotics to bone cement is NOT FDA approved) – 4–6g of antibiotics per pkg of cement; typically vancomycin + tobramycin; Higher viscosity cement may be associated with higher elution; The combination of antibiotics also leads to higher elution. Antibiotic spacers can be “articulating” or “static”. Potential advantages of an articulating spacer include greater patient comfort and an easier approach at the second stage exchange as soft tissue tension and range of motion is maintained. However, these spacers are oftentimes more costly and can break or dislocate. The first stage is followed by approximately 6 weeks of organism specific IV antibiotics. An interdisciplinary approach with an infectious disease specialist, internal medicine and a nutritionist optimises outcomes. Our protocol then includes weekly ESR and CRP to monitor their trend. These labs are re-checked two weeks after cessation of antibiotics to ensure the trend has not changed. The knee is routinely aspirated at this time point and the fluid obtained sent for a synovial fluid WBC count with differential and cultures (although the value of such cultures is controversial). We have found that while the ESR and CRP are significantly lower than prior to removal of the infected implant, they often times DO NOT normalise and there is no specific cut-off value that predicts persistent infection

A “two-stage exchange” remains the gold standard for treatment of the infected THA in North America. Although there is interest in “one-stage exchange” this technique is predicated on the use of fixation of the revision implants with antibiotic loaded cement, which is not as popular in North America. Diagnosis is critical and in general consists of a screening serum ESR and CRP followed by selective aspiration if the above are abnormal and/or if the clinical history is suspicious. The aspirated fluid is sent for a synovial fluid WBC (cut-off approximately 3,000 WBC/μL), differential (cut-off 80% PMN) and culture. The basic tenets of treatment include: . Thorough debridement of all infected appearing cement and all foreign material. Placement of an interval antibiotic loaded spacer (note that the addition of antibiotics to bone cement is NOT FDA approved). –. 4–6 g of antibiotics per pkg of cement; typically vancomycin + tobramycin. –. Higher viscosity cement may be associated with higher elution. –. Higher elution with combination of antibiotics. Antibiotic spacers can be “articulating” or “static”. Potential advantages of an articulating spacer include greater patient comfort and an easier approach at the second stage exchange as leg length and soft tissue tension is maintained. However, these spacers are oftentimes more costly and can dislocate. May not be appropriate in cases where there is severe bone loss that cannot support partial weight bearing or if the abductors are compromised (higher risk of dislocation). The first stage is followed by approximately 6 weeks of organism specific IV antibiotics. An interdisciplinary approach with an infectious disease specialist, internal medicine and a nutritionist optimises outcomes. Our protocol then includes weekly ESR and CRP to monitor their trend. These labs are re-checked two weeks after cessation of antibiotics to ensure the trend has not changed. We have found that while the ESR and CRP are significantly lower than prior to the 1st stage, they often times DO NOT normalise and there is no specific cut-off value that predicts persistent infection. An intra-operative aspiration for synovial fluid WBC count and differential is obtained intra-operatively (cut-off values of approximately 3,000 WBC/μl and 80% PMN) and are the best tests to identify persistent infection

Aim: To review the early complications associated with staged revision hip Arthroplasty utilising the Biomet antibiotic loaded cement spacer. Method: We report on 80 consecutive staged revision hip replacements using the Biomet antibiotic loaded cement system in our institution over 3 years (1999–2002), performed by three consultant surgeons, with a minimum 1 year follow up. Results: Our patients had an average age of 68 (range 48–90) years, with an equal sex distribution. The median time between the first and second stage was 147 (range 50–619) days. Fractures of the Biomet antibiotic loaded acrylic spacer occurred in 11% revisions when associated with an increase in time between stages and there was a 7% dislocation rate. Patients did not receive a revision prosthesis in 19% cases and had early recurrent sepsis following their two stage procedure in 6%. Three patients had a single episode of dislocation of their revision hip prosthesis within a month postoperatively. Two patients had a proximal DVT and one patient had a pulmonary embolus. The mortality within eight weeks was 7%, rising to 10% within a year. This may be related to patient sepsis and comorbidities or the energy expenditure required to mobilise following a first stage procedure that we have analysed. Conclusions: The risks of staged revision hip surgery for infection are substantial when considering the time involved, the energy expenditure required to mobilise following a first stage, the possibility of not achieving a revision hip prosthesis and the mortality rate. The Biomet antibiotic loaded cement system articulates and maintains soft tissue length in the majority of patients for the duration required between stages

Aims: Purpose of this study was to evaluate the results of a staged revision technique in the treatment of deep infection after limb salvage surgery for bone tumors and to identify factors possibly affecting the outcome. Methods: A retrospective study of 19 consecutive patients with an infected bone tumor reconstruction treated at our Institution in the period 1986–1997 was undertaken. All the patients underwent staged revision (two stages in 13 cases, three stages in 5, four stages in 1) using one or more antibiotic loaded cement spacers after debridement and partial (10 cases) or complete (9 cases) removal of the original implant. Postoperatively, all the patients received oral or parenteral antibiotics for a minimum of 4 weeks. Delayed reimplantation was performed in 15 cases, average time to reimplantation being 7 months (4–14). A minimum follow up of 3 years was available in all patients. Cultures identiþed S. Epider-midis in 12 cases (63%), S. Aureus in 4 (21%), mixed organisms in 2 (11%), and were negative in 1 case (5%) despite clinical evidence of infection. Results: At a minimum follow-up of 3 years, 13 patients were continuously infection-free (68%) while 6 relapsed (32%). Two of the 6 relapses were cleared by amputation while 4 remained infected. Average functional result of infection-free patients according to the International Society Of Limb Salvage (ISOLS) was 71% (21.2 points), ranging from 60% to 80% (18 to 24 points). Conclusions: Staged revision with antibiotic loaded cement spacer for infected bone tumor reconstruction is a demanding and expensive technique requiring prolonged inability. Overall success rate in this series approaches 70%. Complete removal of the infected implant, microbiology, appropriate antibiotic selection, and negative cultures before reimplantation are crucial

Objectives: Total ankle replacement (TAR) is increasingly used for treatment of primary or posttraumatic arthritis of the ankle joint, if joint movement is intended to be preserved. Data on characteristics and treatment of ankle prosthetic joint infection (PJI) is limited and no validated therapeutic algorithm exist. Therefore, we analyzed all infections, which occurred in a cohort of implanted ankle prostheses during a 5-year-period. Methods: Between 06/2004 and 12/2008, all patients with an implanted ankle prosthesis at our institution were retrospectively reviewed. All patients were operated by the same surgical team. Ankle PJI was defined as visible purulence, acute inflammation on histopathology, sinus tract, or microbial growth in periprosthetic tissue or sonication fluid of the removed prosthesis. The surgery on the infected ankle prosthesis and the follow-up were performed by the surgical team, who implanted the prosthesis. A specialized septic team consisting of an orthopaedic surgeon and infectious diseases consultant were included in the treatment. Results: During the study period, 92 total ankle prostheses were implanted in 90 patients (mean age 61 years, range 28–80 years). 78 patients had posttraumatic arthritis, 11 rheumatoid arthritis and 3 other degenerative disorder. Ankle PJI occurred in 3 of 92 TAR (3.3%), occurring 1, 2 and 24 months after implantation; the causative organisms were Enterobacter cloacae, Streptococcus pyogenes and Staphylococcus epidermidis, respectively. The ankle prosthesis was removed in all infected patients, including debridement of the surrounding tissue was debrided and insertion of an antibiotic loaded spacer. Provisional arthrodesis was performed by external fixation in two patients and by plaster cast in one. A definitive ankle arthrodesis with a retrograde nail was performed 6 to 8 weeks after prosthesis removal. One patient needed a flap coverage. All 3 patients received intravenous antibiotic treatment for 2 weeks, followed by oral antibiotics for 4–6 weeks. At follow-up visit up to 18 months after start of treatment, all patients were without clinical or laboratory signs of infection. Conclusions: The infection incidence after TAR was 3.3%, which is slightly higher than reported after hip (< 1%) or knee arthroplasty (< 2%). A two-step approach consisting of removal of the infected prosthesis, combined with local and systemic antibiotic treatment, followed by definitive ankle arthrodesis shows good results. Larger patient cohort and longer follow-up evaluation is needed to define the optimal treatment approach for ankle PJI

With the dramatic improvement of conservative surgery in patients with bone sarcoma, infection becomes 1 of the most devastating complication, leading frequently to amputation. The aim of this monocentric study is to precise the influence of spacer loaded with high doses of vancomycin on late Results: PATIENTS From 1984 to 2007, we operated more than 600 patients (p)with bone sarcoma. Age of p. was 4,5 to 82 years (mean 25 y). Histology was osteosarcoma (304), Ewing (142), chondrosarcomas (148), fibrosarcomas or MFH (23), giant cell tumours in others. In 484 cases, p received chemotherapy, and radiotherapy in 50 cases. The mean follow-up from tumour removal is 15 years. 57 p suffered of deep infection of the material used to reconstruct the skeletal defect. We have seen also 3 p for recurrence of deep infection initially treated elsewhere. Altogether, we treated 60 patients for deep infections. Methods: 26 p had debridment and cleaning of the pros-thesis and long adapted antibiotherapy as first treatment. When ineffective (23/26), a removal of the prosthesis was performed with immediate replacing the new prosthesis in 19 cases. When infection recurred (16/19) and in all other patients the treatment included a two stages protocol with interposition of a spacer with antibiotic loaded cement during 4 to12 weeks. Until 2004, the spacer was made with gentamycin containing palacos mixed with conventional doses of antibiotics adapted to the germ. From 2004/6 we used high doses of vancomycin (4 g per batch of 40 g) with an average total dose of 11g of vancomycin per spacer. The new prosthesis was placed in a later time, when infection, cutaneous and muscular problems were solved. Results: At the last control, 15 were amputated, following a mean of 6 ineffective procedures. 45 p. benefited from conservation surgery but a new prosthesis could be inserted only in 43, following a mean of 3.2 surgical procedures, Analysis shows the bad prognostic value of initial radiotherapy, of distal locations, and of insufficient muscular coverage and the better efficacy of high dose antibiotics in spacer. Up to date, none of the high dose antibiotic loaded spacers was followed by amputation. Conclusion: Infection of massive prostheses is the most serious orthopaedic complication of limb salvage. Treatment must be preventive, avoiding any radiotherapy. Good prognostic factors are early removal of the prosthesis, effective antibiotherapy, improvement of the muscular coverage, and use of spacers with high dose vancomycin

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

Aim. Which patients is bone-defect-reconstruction with the Masquelet-technique suitable and which problems did we see?. Method. From 11/2011 to 4/2016 we treated 49 Patients (12f/37m) with bone-defects up to 150mm after septic complications with the Masquelet-technique. We had infected-non-unions of upper and lower extremity, chronic osteomyelitis, infected knee-arthrodesis and upper-ancle-empyema. On average the patients were 48 (8–74) years old. The mean bone-defect-size was 60 mm (25–150). From other hospitals came 47 of the 49 patient, where they had up to 20 (mean 4,9) operations caused by the infection. The time before transfer to our hospital was on average 177days (6–720). 40 patients receaved flaps because of soft tissue-defects (12 free flaps, 28 local flaps). 21 patients suffered a polytrauma. In 8 cases the femur, in 4 cases a knee-arthrodesis, in 34 cases tibia, in 2 cases humerus and in 1 case the ulna were infected resulting in bone defects. Indication for the Masquelet-technique was low-/incompliance in 35 cases due to higher grade of traumatic brain injury and polytrauma and difficult soft-tissue conditions, in 9 times problems with segment-transport and in 5 cases as dead space management. Positive microbial detection succeeded in 32 patients at the first operation. Mainly we found difficult to treat bacteria. After treating the infection with radical sequestrectomy, removal of foreign bodies and filling the defect with antibiotic loaded cement spacer and external fixation we removed the spacer6–8 weeks later and filled the defect with bone graft. In 23 cases we stabilized the defect then with an internal angle stable plate. All patients were examined clinically and radiologically every 4–6 weeks in our outpatient-department until full weight bearing, later every 3 months. Results. In 41 of 49 cases the infection was clinically treated successfully. 21 patients are allowed for full weight bearing (all with secondary internal plates). There were 8 recurrences of infection, 22 instabilities needing internal stabilization and further bone graft. We saw “Plate-breaks” in 4 cases. 2 patients underwent amputation. Conclusions. For patients with low-/incompliance for various reasons and for those with difficult soft tissue conditions following flaps the Masquelet technique is a valuable alternative to the normal bone graft and to the segment transport. The stiffness of the new Masquelet bone like a rod is a problem. Internal fixation is often necessary

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

Aims

Prior studies have identified that malseating of a modular dual mobility liner can occur, with previous reported incidences between 5.8% and 16.4%. The aim of this study was to determine the incidence of malseating in dual mobility implants at our institution, assess for risk factors for liner malseating, and investigate whether liner malseating has any impact on clinical outcomes after surgery.

35 patients with an infected total knee arthroplasty were operated with a two-stage revision protocol including the use of custom hand-made antibiotic loaded articulating spacers. Spacers were built intraoperatively, without specific tools, regarless the defect being considered cavitary or segmentary. Patients were allowed to walk with an orthosis. Range of motion (ROM) with the articulating spacer averaged 80° and after reimplantation 106.5°. All but two patients in our series were treated with a combination of antibiotics including rifampicin and the antibiotics used in the spacers constituted from 7.5% of its final weight. Reimplantation was successfully performed in 33 out of 35 cases at an average time of 10.2 weeks, excluding a patient were we had to wait 2.5 years. An extended exposure at reimplantation was necessary in 21% of the patients (five “Q-snip” and two anterior tibial tuberosity osteotomies). According to the Knee Society Score (KSS) the results were considered excellent or good in 27 patients (84.8%), and fair or poor in 6 patients (14.2%) out of the 33 reimplantated. No significant differences related to the micro-organism or the time elapsed until reimplantation, as compared for ROM and functional and clinical KSS were found but early infections had significant worst ROM than late or sub-acute infections. Intercondylar constrained designs had better functional, clinic KSS and ROM that posterostabilised designs or hinge designs without significant differences. Our modified technique for custom made spacers can be applied in any surgical theatre with a minimum cost. Our results are comparable to those reported in the literature, demonstrating the consistency of the two-stage reimplantation protocol despite multiple modifications and different dosages of antibiotic used in the cement spacers

INTRODUCTION. Conventional surgical exposures are usually inadequate for 2-stage revision knee replacement ofinfected implants. Reduced range of motion, extensor mechanism stiffness, peripatellar contracture and soft tissue scarring make patellar eversion difficult and forced eversion places the integrity of the extensor mechanism at risk. On the contrary, a wide exposure is fundamental to allow complete cement spacer removal, soft tissue balancing, management of bone loss and reimplantation without damaging periarticular soft tissues. OBJECTIVES. To compare the long-term clinical, functional and radiographic results and the reinfection rate of the quadriceps snip approach and the tibial tubercle osteotomy in 2-stage revision knee replacement performed for septic loosening of the primary implant. METHODS. In our department, 87 patients had a 2 stage revision knee replacement for septic loosening of the primary implant between 1996 and 2008. In all patients, first stage consisted of primary implant removal, extensive soft tissue debridement and positioning of a static antibiotic loaded cement spacer. The timing for reimplantation was decided basing on negative clinical and laboratory (ESR, CRP) signs and negative Leukoscan results. For reimplantation, a quadriceps snip was used in patients with an intraoperative flexion >90° (Group A) while a tibial tubercle osteotomy (Group B) was used in patients with an intraoperative flexion <90°. RESULTS. At observation point, 4 patients died for reasons unrelated to surgery, leaving 42 patients in Group A and 41 in Group B. We had a total amount of 10 recurrent infections (11%) after reimplantation, 7 patients in Group A and 3 patients in Group B (p<0.005). Patients with a reinfection in Group A were treated with a knee fusion in 4 cases, a rerevision in 2 cases and an amputation above the knee in 1 case, while all those with a reinfection in Group B had a knee fusion. According to HSS score, 11 patients were rated as Excelent/Good in Group A and 9 patients in Group B (p=n.s.). Three patients had a major complication in Group A and 0 patients in Group B (p=0.005). No differences were found between the two groups regarding range of motion and subjective satisfaction. CONCLUSION. Tibial tubercle osteotomy is a safe procedure to obtain a wide exposure in 2-stage revision knee replacement performed for septic loosening of the primary implant and it is effective in reducing reinfection rate without compromising clinical results and range of motion

Revision arthroplasty for infected hip arthroplasty creates a challenging scenario to surgeons. Either a single stage or more traditionally a two-stage revision is performed. Most surgeons utilise an antibiotic loaded cement spacer, but the implant is often rotationally unstable predisposing to dislocation, acetabular bone loss and fracture of the spacer. Pain and discomfort on mobilisation also often occur. We would like to introduce an alternative approach to this challenging scenario with the use of a two-stage revision with an extended trochanteric osteotomy and loosely cemented hip arthroplasty as the first stage spacer. Surgical Technique: The first stage involves removal of metal ware with all infected tissue and cement performed through an extended trochanteric osteotomy. Circlage wires reduce the osteotomy and a long stem femoral component is inserted with antibiotic infused cement limited to the calcar region. The acetabulum is similarly removed and replaced with a loosely cemented polyethylene liner. The second stage is delayed until the infection is settled and the osteotomy is healed. Removal of the metalware is performed with relative ease, without need for an osteotomy. Reinsertion of an uncemented femoral and acetabular component is then performed. However a second stage is not always required in some patients. We report a single surgeon series comprising 10 patients from December 2003 to June 2007. The most common organism isolated was Staphylococci species. All operations were performed via a posterior approach. 9 patients were clinically assessed and the Harris hip score calculated. All patients were radiologically assessed. Osteotomies healed in all patients. Only 6 patients underwent a second stage and radiographs show good osseous integration of both components. Two patients are awaiting a second stage revision, while the other two are asymptomatic and not interested in undertaking the second stage. No dislocations, bony erosions or reinfection was noted in our series. We recommend this alternative approach to the conventional one or two staged revision arthroplasty. The extended trochanteric ostoetomy ensures rapid and complete removal of all foreign and infected material. The loosely cemented spacer effectively delivers local antibiotic and provides a stable, asymptomatic hip whilst awaiting the second stage, which may not be required

Revision of infected TKA is one of the most challenging operation as the surgeon should achieve two goals, ie eradication of infection and restoration of function. For the eradication of infection, a minimum of two operations are needed in most of cases. First stage of revision is meticulous debridement and insertion of antibiotic loaded cement. During arthrotomy, thick fibrous and granulation tissues which is located in the suprapatella pouch, lateral site to the patella tendon and posterior joint space should be removed so as to get better exposure, to get rid of infection source and to get better functional result. During debridement, I use highly concentrated antibiotic saline (1 gm vancomycin in 10cc saline), for irrigation of the operation field. I also pack the opening of the medullary canal so as to prevent the debris from entering into the medullary canal. I use antibiotics with the ratio of 1:3. To reduce the dead space in the medullary canal I insert a dowel shaped antibiotic loaded cement spacer made from one pack of cement and fill the medullary canal. Thereafter two packs of cement are used to make a block to fill the gap between femur and tibia. The cement block should be large enough to cover the distal femur and proximal tibia so as not to cause bone defect and knee dislocation during walking. After first stage of operation, antibiotics are administered for 4∼8 wks until the CRP levels become normalized and clinical findings show no sign of infection. The 2. nd. stage of operation is planned when clinical and laboratory signs of infection subside. The decision whether to reimplant the prosthesis or not is based on the operation findings and polymorphonuclear cell count on frozen section. However operation findings are considered more important than the frozen section results for reimplantation. If operative findings are clean, I do reimplanation even though the polymorphonuclear cell count is more than 5 on high power field(hpf) on frozen section. I have adopted numbering system to take specimen. Number 1 is specimen from suprapatella pouch, No 2 is that from gap between the femur and tibia, No 3 is that from femoral intramedullary canal, No 4 is that from tibial intramedullary canal, and No 5 is that from most unhealthy site. In a retrospective analysis of 16 cases which received reimplantation despite of the prescence of more than five polymorphonuclear cells on intra-operative frozen sections, none of the cases had recurrence of infection at a final follow up of 2 years. The femoral medullary canal was the most prevalent site for higher polymorphonuclear cell count. In conclusion, indication is the first step for successful reimplantion. Two stage revision is recommended and meticulous debridement is utmost important in first stage operation. Block type antibiotic loaded cement is sufficient for a good result. Clinical, laboratory and operative findings are more important than polymorphonuclear cell count on frozen section to decide reimplantation. I propose numbering system of the specimen site for frozen section, just as in tumor surgery

Introduction: Chronic hip arthroplasty infection is a difficult situation to solve. The use of uncemented stem is questionable, as no antibiotic loaded cement is used to fix the implant. Bone deficiencies are often enlarged by the chronic infection process and the multiple previous surgeries. We report our experience in two stage revisions with massive allograft and uncemented distal locked stem. Material and method: We have retrospectively reviewed 15 patients operated on from chronic hip arthroplasty infection and secondary large femoral defects. Two stages revision with a temporarily antibiotic loaded cement spacer and 6-weeks second look reconstruction were performed with massive proximal femoral allograft and a long distally locked stem. The uncemented stem was cemented into the allograft and remained uncemented in the recipient distal femur. Outcome was assessed regarding infection control, allograft complication and function according to the Merle d’Aubigné score. Results: Patients mean age was 62 years (SD 11). Patients were already operated from the same hip 5.9 +/− 2.3 times before the actual procedure. Isolated microorganisms were MRSE (7), staph Aureus (4), MRSA (1), VRE (1), enterococcus (2). Muscle flaps were performed in 2 cases and discuss for 2 more. Allograft length was 22 +/− 9 cm. Antibiotic treatment was maintained for 4.6 +/− 2.5 months (median 3 months). Mean follow-up was 29 months (SD 26; median 23). Clinical outcome based on Merle d’Aubigné score is 5.3 +/− 3 before treatment and 13.8 +/− 2.5 at the last visit. Complications were registered in 4 cases. Infection recurrence was observed in 3 cases (2,7,20 months) but the function was preserved in all cases. One of them needed a two stage procedure with a new allograft after 19 months due to acute staph Aureus infection. One allograft was broken after 80 months and need one stage revision. Discussion: While the treatment of these cases was particularly demanding as bone deficiencies and microorganisms antibiotic resistance were high, functional result obtained was good. When infection recurrence was observed, function remains preserved. The use of uncemented distal locked stem with a cemented massive allograft did not lead to mechanical or hardware problem and allow us to restore the bone stock and the gluteus tendons insertion. The use of a modular stem was very helpful in solving these complex situations. Massive allografts can be used in case of infection as antibiotic delivery system

Aims

With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases.