Destination Joint Spacers: A Similar Infection-Relief Rate But Higher Complication Rate Compared with Two-Stage Revision

Abstract

Objective: To evaluated the clinical outcomes of periprosthetic joint infection (PJI) patients with destination joint spacer compared with that of two-stage revision.

Methods: From January 2006 to December 2017, data of PJI patients who underwent implantation with antibiotic-impregnated cement spacers in our center due to chronic PJI were collected retrospectively. The diagnosis of PJI was based on the American Society for Musculoskeletal Infection (MSIS) criteria for PJI. One of the following must be met for diagnosis of PJI: a sinus tract communicating with the prosthesis; a pathogenis isolated by culture from two separate tissue or fluid samples obtained from the affected prosthetic joint; four of the following six criteria exist: (i) elevated ESR and CRP; (ii) elevate dsynovial fluid white blood cell (WBC) count; (iii) elevated synovial fluid neutrophil percentage (PMN%); (iv) presence of purulence in the affected joint; (v) isolation of a microorganism in one periprosthetic tissue or fluid culture; (vi) more than five neutrophilsper high-power fields in five high-power fields observed from histological analysis of periprosthetic tissue at ×400 magnification. Age, sex, body mass index (BMI), and laboratory test results were recorded. All patients were followed up regularly after surgery, the infection-relief rates were recorded, Harris hip score (HHS) and knee society score (KSS) were used for functional evaluation, a Doppler ultrasonography of the lower limb veins was performed for complication evaluation. The infection-relief rates and complications were compared between destination joint spacer group and two-stage revision group.

Results: A total of 62 patients who were diagnosed with chronic PJI were enrolled, with an age of 65.13 ± 9.94 (39-88) years. There were 21 cases in the destination joint spacer group and 41 cases in the temporary spacer group, namely, two-stage revision group (reimplantation of prosthesis after infection relief). The Charlson comorbidity index (CCI) in the destination joint spacer group was higher than that in the temporary spacer group, and this might be the primary reason for joint spacer retainment. As for infection-relief rate, there were three cases of recurrent infection (14.29%) in the destination joint spacer group and four cases of recurrent infection (9.76%) in the two-stage revision group, there were no significant differences with regard to infection-relief rate. Moreover, there two patients who suffered from spacer fractures, three cases of dislocation, one case of a periarticular fracture, and three cases of deep venous thrombosis in destination joint spacer group, while there was only one case of periprosthetic hip joint fracture, one case of dislocation, and one patient suffered from deep venous thrombosis of the lower extremity in two-stage revision. The incidence of complications in the destination joint spacer group was higher than that of two-stage revision.

Conclusions: In summary, the present work showed that a destination joint spacer might be provided as a last resort for certain PJI patients due to similar infection-relief rate compared with two-stage revision.

Keywords: Complication; Destination joint spacer; Infection-relief; Periprosthetic joint infection; Two-stage revision.

Fig. 1

Diagram of destination joint spacer ¹⁴ .

Fig. 2

Two types of joint spacers used in this study for hips: type I (A, B): one to two Kirschner wires were bent to approximately 130° in advance and used as stents, which were placed in a silicone mold, embedded with antibiotic‐impregnated cement, and molded under pressure; type II (C, D), 105 mm femoral stem, 28 mm femoral head, and 32 mm femoral neck were used as scaffolds, embedded with antibiotic‐impregnated cement, and molded under pressure. Two types of joint spacers used in this study for knees: type I (E, F): an aseptic silicone mold imitating the joint shape was used, and a joint‐like spacer was made intraoperatively; type II (G, H): the removed femoral end prosthesis was washed, soaked in povidone iodine solution, and resterilized, and the resterilized tibial prosthesis was used or replaced with a new polyethylene tibial component.

Fig. 3

Representative radiographic images of complications in destination joint spacers group. (A) periarticular fracture; (B) spacer dislocation; (C) spacer fracture.