Periprosthetic infection is becoming more and more common and devastating.Better treatment modality of two staged antibiotic cement spacer is becoming more and more common with excellent results.Antibiotic Cement Spacer for Infected Hip Joint Replacement (THR) Surgery, Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maharashtra,India

1. Management of Infected Hip (THR)
joint Replacement Surgery by Hand
Made Antibiotic Cement Spacer
Dr.Sandeep Agrawal
MS . DNB
Agrasen Hospital
Gondia
Maharashtra India
ANTIBIOTIC
CEMENT
SPACER

2. Hip Arthroplasty: Increasingly
Common
so more cases of Infected hip

3. THA Infection: A Treatment Challenge

4. Clinical Challenges

5. THA Infection: Classification

6. Common Pathogens
Zimmerli et al, 2005

7. Biofilm

8. Clinical Diagnosis
► 1.Clinical S/S: Pain (rest, non-weight bearing),
erythema, fever, discharging sinus, turbid joint fluid
► 2.Laboratory: ESR/CRP, leukocytosis
► 3.Culture and cytology from joint tapping
► 4.Exploration
► 5.Radiographic: normal or bone destraction
► 6.Histopathological: > 5-10 PMN/HPF
► 7.Nuclear medicine
► No Single Test

9. Treatment choices

10. Treatment Algorithm for Management of the infected THA
Depth of
infection
Wound
debridement/
antibiotics
Debilitated
patient
“Prosthesis retention
with debridement”(2)
Intravenous
antibiotics
Reinsertion of
another
prosthesis
Remove implant
Symptom
onset
Well-fixed
implant
Chronic oral
antibiotic
suppression
chronic
Poor soft-tissue envelope
Recalcitrant infection
Poor medical condition
superficial yes
yes
failure
Resection
arthroplasty(3)
deep no acute
failure
no yes
no
failure
AAOS ADVANCED RECONSTRUCTION HIP P.234 2005

11. ► Medically infirm patients
► Low virulent pathogen
► Oral antibiotics available
► Tolerable long-term antibiotics
► Prosthesis removal is not feasible and
no loose
1…Antibiotic suppression

12. ► Very strict criteria :
▪ Symptoms< 3 weeks
▪ Stable prosthesis
▪ No discharging sinus
▪ Susceptible pathogen
► Success rate: 50-70%
► Acceptable early successful rate but also
high recurrence Trampuz A et al, 2005
2…Debrideemnt with prosthesis retention

13. ► Remove prosthesis:
Girdlestone procedure over
hip joint
► High success rate
► Poor functional status
► For the very debilitated
3..Resection Arthroplasty

14. Antibiotic-cement: The Key to Success
Buchholz et al, 1984
Adams et al, 1992

15. Girdlestone Problems
► Leg length inequality
► Inability to bear weight
► Disuse osteoporosis
► Extensive scarring
► Distorted tissue plane
► Difficult reimplantation

16. Dose of antibiotics
► Elution of antibiotics from the PROSTALAC is
effective when at least
!
3.6 g tobramycin
and 1g vancomycin were added
!
!
Masri et al 1998, J Arthroplasty

17. Do these spacers work better than the beads?

18. Materials and Methods
Group A
(Beads)
► 1994-1996
► 70 hips
► M:F= 53:17
► Age: 60 (34-85) y/o
► Follow= 5.4 (2-8) yrs
Group B (Spacer)
► 1996-2000
► 58 hips
► M:F=43:15
► Age: 63 (28-81) y/o
► Follow= 4.2 (2-6) yrs

19. Infection control
60%
64%
68%
72%
75%
79%
83%
87%
91%
95%
98%
Group A Group B
Infection c
96.5%94.3%
66/70
56/58
(P=0.69)

20. Ambulatory status
0
15
30
45
60
Ambulatory Non-ambulator
7
49 51
12
Beads
Spacer
87.5%
19.0%
(P=0.001)

21. ► Selected patients
▪ Low- virulent organisms
▪ Identify organism before operation
▪ No sinus tract
▪ No major bone loss
▪ Antibiotic-loaded cement fixation
► More popular in Europe
► Success rate: 73%-92% (OKU 8)
!
► Hope et al, 1989
► Ure et al, 1998
Raut et al, 1994
4..One-stage revision arthroplasty

22. 5.“Two stage revision
arthroplasty”
A simple molding method
of antibiotic-loaded
cement prosthesis as an
interim spacer

23. J-Trauma
Hsieh et al, 2004

24. Antibiotic-cement spacer is not new
► Zilkens et al, 1990
► Ivarsson et al, 1994
► Leunig et al, 1998
► Deshmukh et al, 1998
► Younger et al, 1998
► Magnan et al, 2001
•Small series
•Hand-made prosthesis
•Hemiarthroplasty-like

25. osthesis of Antibiotic-loaded Acrylic Cement:
Duncan et al, 1993
PROSTALAC

26. ► 1st Stage :
▪ Removal of all components, debridement
▪ Antibiotic-cement spacer
► Between Stages :
▪ IV antibiotics (2 weeks)
▪ +/- Oral antibiotics (4 weeks)
► 2nd Stage :
▪ Normal CRP
▪ Antibiotics in cement
Treatment Protocol

27. ACETABULUM PREPARATION

29. Silicon Mould

30. A refined metal rod
ENDOSKELETON

31. ENDOSKELETON IN MOLD

33. Pressure Till Cement Sets

35. FINAL FEMORAL CEMENT SPACER

36. INSERTION IN MEDULLARY CANAL

37. Cement-on-cement
Proximal
cementation
Metal Rod as
endoskeleton
•Temporary prosthesis
•Local antibiotic delivery

38. AMBULATION WITH SUPPORT

39. Choice of antibiotics
Heat-stable
► Powdered form
► Broad spectrum
▪ G(+): vancomycin, teicoplanin
▪ G(-): tobramycin, piperacillin, aztreonam
Antibiotics: bone cement = 1: 5

40. Complication of the cement spacer
FractureDislocation

41. Fracture
Dislocation

42. ► Antibiotic elution from cement:
biphasic; high initially followed by sustained
release for months
Duncan et al, 1994 JBJS-A
► Antibiotic elution from cement spacer:
similar pattern
Minelli et al, 2004 JAC

46. ► Most reliable method
► High success rate: 88-100% (OKU 8)
► Better functional result after revision hip
reconstruction procedure
Two-stage revision arthroplasty

47. Conclusions
► Remove prosthesis is mandatory when
face a infective hip arthroplasty
► 1.Debride alone: a very limited indication
► 2.One-stage revision: selected cases
► 3.Two-stage revision: most reliable and
effective
► With a cement spacer prosthesis: simple,
safe, effective, and versatile

48. Thanks To DR.HSIEH
Dr.Pang Hsieh
Taiwan