Is There a Role for Spacer Exchange in Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection?

Abstract

Periprosthetic joint infection (PJI) continues to be one of the most serious complications after hip and knee arthroplasty. The choice of surgical treatment depends on a multitude of factors like chronicity of infection, host factors, and institutional or surgeon experience. Two-stage exchange remains one of the most commonly used technique for chronic PJI in the United States of America. The intended two-stage revision may involve an additional interim procedure where the initial antibiotic cement spacer is removed and a new spacer is inserted. Mostly, the rationale behind spacer exchange is an additional load of local antibiotics before proceeding to reimplantation. There is no conclusive evidence whether a spacer exchange confers additional benefits, yet it delays reimplantation and exposes already fragile patients to the risks and morbidity of an additional surgery.

Keywords: prosthetic joint infection; reimplantation; spacer; spacer exchange; total hip arthroplasty; total knee arthroplasty; two stage exchange.

Figure 1

The role of spacer exchange in two-stage exchange and its common indications.

Figure 2

Hip radiographs: periprosthetic joint infection (PJI) with history of three prior debridement surgeries and systemic antibiotics. (A) First Hip spacer (Girdlestone); (B) Status post second spacer exchange (third spacer) for persistent infection; (C) Status post third spacer exchange: failure of intended reimplantation. Clinical history: First exchange occurred after recurrence of fever, elevated CRP, local signs of hip infection and positive urinalysis s/p two-weeks off antibiotics. Of note, purulence was observed during the first exchange surgery. Second Exchange occurred after a purulent drainage, with an aspiration culture growing methicillin-resistant Staphylococcus aureus (MRSA). After a third spacer exchange, the intra-operative cultures grew Klebsiella Pneumoniae.