Articular spacers in two-stage revision arthroplasty for prosthetic joint infection of the hip and the knee

Abstract

Use of articular antibiotic-eluting cement spacers during two-stage revision arthroplasty for prosthetic joint infection (PJI) is a long-established and proven adjunctive technique during first-stage surgery. Articular spacers come in many forms, either static or dynamic. The authors present an instructional review of current evidence regarding their use. A total of 45 studies (for spacer use in PJI involving either hip or knee) were analysed for data regarding eradication rate, functional outcomes, mechanical complications and the impact on second-stage surgery. A large number of case series and retrospective cohort studies were retrieved, with only a small number of prospective studies (2). High levels of infection eradication were commonly reported (>80%). Outcome scores were commonly reported as indicating good-to-excellent function and pain levels. Second-stage procedures were often not required when dynamic spacers were used. Static spacers were associated with more mechanical complications in both the hip and the knee. In the hip, dynamic spacers were more commonly associated with instability compared to static spacers. Consideration should be given to the use of dual-mobility or constrained definitive acetabular components in these cases at second-stage surgery. The use of antibiotic-eluting polymethylmethacrylate articular spacers in two-stage revision for PJI of hip and knee arthroplasty achieves a high rate of infection eradication. Dynamic spacers may confer a variety of benefits compared to static spacers, with a similar rate of infection eradication.

Keywords: intra-articular spacer; prosthetic joint infection; revision arthroplasty.

Figure 1

Types of articular spacers used in revision hip arthroplasty for PJI.

Figure 2

Types of articular spacers used in revision knee arthroplasty for PJI.

Figure 3

Images of the LINK® Endo-model® arthrodesis nail – (from left-to-right) (A) LINK arthrodesis nail; (B and C) Plain film images of LINK® fusion nail with associated (static) cement spacer. Image (A) is reproduced with permission from LINK Orthopaedics UK Ltd. Images (B and C) courtesy of Mr J Palan (co-author).

Figure 4

StageOne® and StageOne Select® injection mould hip spacers – (from left-to-right) (A) Plain film image of StageOne® dynamic hip spacer (no endoskeleton); (B) StageOne Select® hip spacer injection moulds; (C) StageOne Select® dynamic hip spacer; (D) Plain film image of StageOne Select® dynamic hip spacer in situ. Images (A, B and C) is published with permission from Zimmer Biomet. Image (D) courtesy of Mr S Jain.

Figure 5

Heraeus COPAL® injection-moulded dynamic knee spacer system. Images published with permission from Heraeus Medical GmbH.

Figure 6

(From left-to-right) (A) Tecres Spacer G®; (B) Tecres Spacer K®. Imagespublished with permission from Summit Medical Ltd.

Figure 7

(From left-to-right) plain film images of implants in situ – (A) Tecres® Spacer G; (B) Tecres® Spacer K. Images published with permission from Summit Medical Ltd.

Figure 8

PROSTALAC® articulating hip spacer system. Images published with permission from DePuy Synthes.

Figure 9

Plain film image of right hip ‘custom-made articulating spacer’ (CUMARS). Image courtesy of Mr J Palan (co-author).

Figure 10

Plain film images of left knee ‘custom-made articulating spacer’ (CUMARS). Images courtesy of Mr S Jain (co-author).