Utilizing a Prefabricated Antibiotic-Impregnated Articular Spacer Combined With an Intramedullary Device for Significant Femoral Bone Loss in Periprosthetic Hip Infection

Abstract

Periprosthetic joint infection can be a devastating complication following total hip arthroplasty, which often requires a lengthy treatment course that is fraught with complications. There are various types of antibiotic-impregnated spacers that can be used to treat periprosthetic hip infections, with articulating spacers being utilized frequently with the goal of preserving patient range of motion and functionality. Many of these articulating spacers have pre-set sizes and stem options, which accommodate the majority of patients. However, when significant femoral bone loss is evident at the time of revision surgery, many articulating spacer options are not sufficient to provide stability, and custom modifications of available spacer constructs may be needed to fill the bony void. The goal of this article is to report a surgical technique that can be used in the salvage of failed antibiotic-impregnated spacers where severe femoral bone loss is present.

Keywords: Infection; PJI; Revision; THA.

Figure 1

Pre operative imaging from patient’s twisting trauma prior to custom spacer placement. (a) Preoperative anterior-posterior view of the right hip with the prefabricated hip spacer in place with sequestrum of proximal femur and a midshaft periprosthetic fracture. (b) Preoperative anterior-posterior view of the right femur with the prefabricated hip spacer in place, sequestrum of the right proximal femur, cerclage wire placement, and a periprosthetic midshaft femur fracture.

Figure 2

Intraoperative images of prefabricated spacer-nail device. (a) Intraoperative intramedullary rod fixation to prefabricated spacer head component. (b) Intraoperative provisional implantation of antibiotic spacer to assess length and fixation of the head component into the acetabulum. (c) Intraoperative final implantation of the spacer with distal insertion into the femur and proximal insertion into the acetabulum with surgeon-constructed antibiotic-loaded cement exoskeleton.

Figure 3

Postoperative radiographs after antibiotic spacer insertion. (a) Postoperative anterior-posterior view of the pelvis demonstrates the prefabricated spacer head with screw fixation to the intramedullary nail in anatomic position in the acetabulum. (b) Postoperative anterior-posterior view of the femur demonstrates intramedullary nail fixation into the midshaft and distal femur, cerclage wire fixation, and antibiotic-impregnated cement surrounding the nail.

Figure 4

Final postoperative radiographs after proximal femur replacement. (a) Eight-week postoperative anterior-posterior definitive fixation of right hip radiograph demonstrating proximal femur replacement with multihole acetabular-constrained component. (b) Eight-week postoperative anterior-posterior definitive fixation of right femur radiograph demonstrating the distal aspect of proximal femur replacement with cerclage wiring and cement mantle within the distal femur.