Management of Infected Total Knee Arthroplasty by a New Innovative Customized Articulating Knee Spacer: An Early Experience

What to Learn from this Article?

Antibiotic knee spacers are an important tool in the armamentarium of an arthroplasty surgeon. Indigenous knee spacers as designed by us are more stable and give better functional results with minimal spacer-related complications as compared to readymade articulating spacers available in the market.


Case Report | Volume 6 | Issue 4 | JOCR September-October 2016 | Page 20-22 | Dhiraj P Marothi, Vipin Sharma, Ashish N Sheth, Vikram I Shah, L Bharath, J A Pachore. DOI: 10.13107/jocr.2250-0685.552


Authors: Dhiraj P Marothi[1], Vipin Sharma[1], Ashish N Sheth[2], Vikram I Shah[2], L Bharath[2], J A Pachore[2]

[1]Department of Orthopaedics, Dr. RPGMCH, Kangra, Himachal Pradesh, India, 2Department of Arthroplasty, Shalby Hospital, Ahmedabad, Gujarat, India.

Address of Correspondence
Dr. Vipin Sharma,
Department of Orthopaedics, Dr. RPGMCH, Kangra, Himachal Pradesh, India.
E-mail: vipinsh_hp@rediffmail.com


Abstract

Introduction:

Management of infected total knee arthroplasty is a challenge to patient and surgeon alike. Two stage exchange is the universally acclaimed method to tackle this problem. Various spacer devices are available for the first stage surgery for local delivery of antibiotics. Here we report our experience with management of infected total knee arthroplasty patients with our indigenously designed and produced knee spacer.

Case Report: Between 2012-13  twenty eight patients of infected TKR have been managed by our indigenous knee spacer.   Minimal spacer related complications and a stable knee joint with range of motion upto 100 degree were noted in these patients.  After a mean period of 6-8 weeks spacer was removed and definitive TKR fixation done. At a mean follow up of 4 months post second stage definitive surgery patients were infection free with no evidence of recurrence of infection.

Conclusion: Our new innovative customized articulating knee spacer  which has intramedullary stem extension has potential to significantly reduce spacer related complications along with providing improved  knee function .

Keywords: Infected total knee replacement, Knee spacer, Bone cement.



Introduction

With the increasing incidence of total knee arthroplasty (TKA), the incidence of infected TKA is also on the rise. The infection rate after primary total knee arthroplasty (TKA) ranges from 0.5 to 2%  and is a serious problem despite modern technology and rigorous prophylaxis. However  considering the increasing number of patients with TKA, infection is still a complication of major concern [1]. A variety of techniques and devices have been developed to improve the management of the infected TKA. Antibiotic-loaded bone cement spacers in the two stage re-implantation technique are the gold standard as they allow early joint and patient mobilisation, a shorter hospital stay and potentially a reduced rate of re-infection.   Many off the shelf  readymade spacers are available but these  are not very cost effective and are associated with a variety of spacer related complications. We describe our experience of managing infected TKR patients with our indigenous customised knee spacer in initial stage of a two stage reimplantation  complications.

Case Report

In  year 2012 -13 , 28 patients of infected TKR were managed by our new innovated   customized articulating cement spacer in first stage of two stage exchange arthroplasty. Thirteen of the twenty eight  patients were females. The average age of the patients was 70 years (range:56–79 years). 20 were knees with advanced osteoarthritis while the other 8 were post rheumatoid knees, all of these had been managed by primary total knee replacement.  After first stage implant removal and debridement and our indigenous spacer implantation no evidence of spacer dislocation, mediolateral tilting or spacer subluxation was noted while only 2 patients had spacer fracture.fig-1

Procedure After due consent and enrolment clinical profile of all the patients is taken. Features like pain, warmth, redness, severe restriction of movement with or without frank discharging sinuses are noted. Neutrophilia, persistently elevated ESR and CRP and radiographic loosening of implants are considered criteria of diagnosis of infected total knee replacement. After epidural anaesthesia in first stage surgery total knee components are removed, cement and loose bodies being curetted out along with thorough cleaning of femoral and tibial canals   with pulse lavage.fig-2

During surgery itself indigenous  knee spacer is prepared on a clean trolley  with  20g (two pacs) and 40g (four pacs) of high viscosity gentamicin loaded bone cement. Depending on preoperatively determined femoral or tibial canal size , 5 cc or 10 cc disposable syringes are selected. These are filled with high viscosity gentamicin bone cement which is allowed to cure. Syringes are slit to retrieve the  cement stems . After thorough debridement and lavage  these stems are inserted  in the femoral and tibial canals with one centimetre of their ends projecting into the joint. Cement in doughy form is layered on femoral and tibial side to make femoral and tibial spacer components. For spacer construction 40 gm (four packets) of  gentamicin loaded PMMA high viscosity cement  is used, two each for the femur and tibia . Cement prepared for femoral side is layered on the femoral surface and the projected stem to shape it like femoral condyles of desired thickness. A groove on the anterior surface of the spacer is made with the femoral component for better alignment of the patella.   For tibial tray cement is placed on tibial surface in a doughy state and shaped into a spacer of desired thickness as determined preoperatively [Fig 1] .  Flexion extension matching is done to confirm an optimum spacer thickness and provide a smooth knee range of motion .   No thumb test is used for assessment of patellar tracking [Fig 2]   Physiotherapy is started  by knee range of motion and quadriceps strengthening exercises as soon as the pain permits and walker ambulation by  2nd postoperative day .  Patients are discharged by 2 weeks and followed up regularly. By four weeks patients are weaned off the walking aids [Fig 3]. Postoperative antibiotics are started as per culture and sensitivity report of the fluid and tissue sent for culture preoperatively and  continued for six weeks followed by a two week antibiotic free period. Normal skin condition over operative site without any redness or sinuses and normal range of serial ESR and CRP markers make the patient eligible for second stage of surgery which involves spacer removal and definitive TKR implant fixation. In our series no evidence of dislocation, mediolateral tilting or knee subluxation was noted  except for 2 patients who had spacer fracture and were operated by spacer reimplantation.  The mean  range of knee motion with spacer in our series has been 100 deg flexion with complete eradication of infection and definitive surgery  6-8 weeks after spacer implantation. The cost of manufacturing these on table spacers is nominal when compared to off the shelf available articulating spacers , thus providing economic advantage to the patient [Table 1  ].fig-3

Discussion

Two-stage exchange arthroplasty with an antibiotic-impregnated cement spacer remains the standard treatment for patients with an infected total knee arthroplasty [3] .Spacers not only  help in maintaining knee joint space but also act as a source of local antibiotic delivery. Various types of spacers are available to handle the problem of knee infection. Nonarticulating block spacers can be easily made peroperatively by antibiotic impregnated PMMA and are fashioned to fit the existing bone defect. Although useful  in infected knees with substantial bone loss , they present several disadvantages like knee immobility and subsequent  stiffness,  spacer dislodgement and bone erosion. Scar formation, tissue adherence and quadriceps shortening make subsequent surgery a difficult one [4] .Temporary prosthesis , prefabricated articulating spacers and on table articulating spacers are some of the various options used to overcome problems faced with static block spacers.

Use of temporary prosthesis technique involves autoclaving removed femoral component and using a new tibial poly and fixing both these components with antibiotic cement to the parent bone, medullary canals being packed with antibiotic laden beads. But there is possibility of bacterial adhesion to surface of these components[5] and increased cost of management of patients with infected TKA [ 6] .

Commercially available prefabricated  cemented articulating spacers  have various disadvantages in the form of size mismatch , lack of modularity, unsatisfactory antibiotic impregnation ,  fixed antibiotic type and dose, often allowing delivery of a single antibiotic .

All these spacers have had their set of  spacer related complications which are largely due to their nonconformity to articulating surfaces, inadequate size and thickness and no or poor fixation to underlying bone. Spacer fixation to bone and its stability in the joint is largely compromised because of lack of intramedullary purchase in femur and tibia. This problem has been successfully addressed by our innovation where we have used intramedullary antibiotic bone cement stems along with on table custom made spacers. Stems not only provide sound anchorage to the overlying spacers but also act as a channel to deliver antibiotics  deep inside the intramedullary canals.

Other factors like range of motion, patient satisfaction, and infection healing have been comparable to readymade contemporary devices available but cost effectiveness of our spacers is an advantage to the patient . Commercially available articulating knee spacers are very costly and most of the times out of reach of the patient already burdened by challenges of infection, multiple surgeries and loss of livelihood. We have been able to achieve eradication of infection in all our patients of infected TKR with our indigenous cost effective device.

Spacer removal before second stage surgery was easy and no difficulties were encountered . Ours is a dynamic spacer , hence with knee flexion femoral component  is removed first  followed by tibial spacer removal. Moreover cement spacer is made in later setting stage of cement  while stems are inserted in medullary canal only after cement has cured completely  , hence there is no incorporation of cement in bone , making spacer removal in toto quite easy.

Our innovation  provides specific advantage in the form of spacer stability inside the knee and  capability of intramedullary local antibiotic delivery .  However a multicenter study and a long term follow up is required to confirm potential usefulness of  this spacer device.

Conclusion

The articulating antibiotic knee spacer as designed by us for management  of infected TKR is cost effective, customised , easy to manufacture on operation table and is associated with negligible spacer related complications. Its intramedullary stem component provides stability and deep delivery of antibiotics

Clinical Message
Our innovative knee spacer  as a management option in first stage of a  two stage exchange for infected TKR  is   easy to make on table in a customised fashion. Moreover  it  is biomechanically more stable and associated with negligible spacer related complications. This spacer device can give better outcome in patients with infected knee arthroplasty as compared to conventionally available spacers.

References

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2.Fitzgerald RH Jr, Nolan  DR, Ilstrup  DM, Van  Scoy RE,    Washington JA    2nd Coventry   MB.   Deep    wound   sepsis  following   total   hip   arthroplasty. JBJS

.[Am]1977; 59(7):847-55.

3.Kuechle  DK ,  Landon  GC ,  Musher  DM , Noble PC.  Elution   of  vancomycin, daptomycin, andamikacin from acrylic bone cement. CORR  1991 ; 264 : 302–8.

4.Pitto  RP, Spika  I. A.    Antibiotic – loaded   bone  cement  spacers  in   two – stage management   of  infected   total  knee  arthroplasty.  International    Orthopaedics

2004;28:129–33.

5.Goldman RT,  Scuderi  GR, Insall  JN .     2 – stage   re implantation  for   infected total kneereplacement.ClinOrthop1996 ;331: 118–24.

6.Hebert CK, Williams  RE, Levy  RS, Barrack  RL.  Cost   of   treating   an   infected total  knee replacement. Clin Orthop 1996 ;331:140–45.


How to Cite This Article: Marothi DP, Sharma V, Sheth AN, Shah VI, Bharath L, Pachore JA. Management of Infected Total Knee Arthroplasty by a New Innovative Customized Articulating Knee Spacer: An Early Experience. Journal of Orthopaedic Case Reports 2016 Sep-Oct;6(4): 20-22. Available from: http://www.jocr.co.in/wp/2016/10/10/2250-0685-552-fulltext/

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