Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthroplasty.

![Graphic][1] Infection at the site of a total joint arthroplasty can be classified into four basic categories: Type I (early postoperative), Type II (late chronic), Type III (acute hematogenous), and Type IV (positive intraoperative cultures with clinically unapparent infection). ![Graphic][2] The current standard of care for late chronic infection is considered to be two-stage revision arthroplasty including removal of the prosthesis and cement, thorough debridement, placement of an antibiotic-impregnated cement spacer, a course of intravenous antibiotics, and a delayed second-stage revision arthroplasty. ![Graphic][3] The choice of the spacer, either articulating or nonarticulating, is based on many factors, including the amount of bone loss, the condition of the soft tissues, the need for joint motion, the availability of prefabricated spacers or molding methods, and antibiotic selection. ![Graphic][4] Current data have demonstrated that the use of antibiotic-impregnated cement spacers has improved the outcomes of the treatment of infection associated with total joint arthroplasty. Total joint replacement is one of the most frequent and successful types of operations in orthopaedics. Infection is a rare yet devastating complication of the procedure, with a reported prevalence of 0.5% to 3% and with a higher reported prevalence after total knee arthroplasty than after total hip arthroplasty1-4. There is also a higher rate of infection after revision hip and knee arthroplasties than after primary hip and knee arthroplasties1-8. Two-stage revision surgery was first described in 1983 by Insall et al., who demonstrated the necessity of removing the implants as well as the cement and of introducing antibiotic therapy for definitive treatment9. This procedure has emerged as the standard of care for a late chronic infection at the site of a total joint replacement4,5,10-17. Garvin and Hanssen reviewed twenty-nine studies and found that two-stage … [1]: /embed/inline-graphic-1.gif [2]: /embed/inline-graphic-2.gif [3]: /embed/inline-graphic-3.gif [4]: /embed/inline-graphic-4.gif

[1]  D. Musher,et al.  Elution of vancomycin, daptomycin, and amikacin from acrylic bone cement. , 1991, Clinical orthopaedics and related research.

[2]  J. V. van Horn,et al.  Bacterial survival in the interfacial gap in gentamicin-loaded acrylic bone cements. , 2005, The Journal of bone and joint surgery. British volume.

[3]  R. McGraw,et al.  The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Prosthesis of antibiotic-loaded acrylic cement. , 2000, The Journal of bone and joint surgery. British volume.

[4]  C. Duncan,et al.  A temporary antibiotic-loaded joint replacement system for management of complex infections involving the hip. , 1993, The Orthopedic clinics of North America.

[5]  M. Ritter,et al.  Mucoraceae infections of antibiotic-loaded cement spacers in the treatment of bacterial infections caused by knee arthroplasty. , 2002, The Journal of arthroplasty.

[6]  W. Goldstein,et al.  Temporary Articulating Methylmethacrylate Antibiotic Spacer (TAMMAS): A New Method of Intraoperative Manufacturing of a Custom Articulating Spacer , 2001, The Journal of bone and joint surgery. American volume.

[7]  P. Sarangi,et al.  Cementless acetabular replacement in patients with rheumatoid arthritis: a 6- to 14-year prospective study. , 2003, The Journal of arthroplasty.

[8]  M. Ries,et al.  The ball and socket articulating spacer for infected total knee arthroplasty. , 2005, The Journal of arthroplasty.

[9]  B. Doll.  Die spastische Hand , 2003, Der Orthopäde.

[10]  B. McGrory,et al.  A simple method of intra-articular antibiotic delivery in infected hip arthroplasty. , 2002, American journal of orthopedics.

[11]  Hae-Ryong Song,et al.  Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty. , 2001, The Journal of arthroplasty.

[12]  S. K. Muirhead-Allwood,et al.  Two-stage uncemented revision hip arthroplasty for infection , 2000 .

[13]  K. Kuehn,et al.  Acrylic bone cements: mechanical and physical properties. , 2005, The Orthopedic clinics of North America.

[14]  Mel S. Lee,et al.  Two-stage revision hip arthroplasty for infection with a custom-made, antibiotic-loaded, cement prosthesis as an interim spacer. , 2004, The Journal of trauma.

[15]  H W Buchholz,et al.  Management of deep infection of total hip replacement. , 1981, The Journal of bone and joint surgery. British volume.

[16]  G. Bergmann,et al.  Hip contact forces and gait patterns from routine activities. , 2001, Journal of biomechanics.

[17]  J. Deeks,et al.  Prospective Evaluation of Criteria for Microbiological Diagnosis of Prosthetic-Joint Infection at Revision Arthroplasty , 1998, Journal of Clinical Microbiology.

[18]  J. Ruth,et al.  Two-stage reimplantation in infected total knee arthroplasty. , 1988, Clinical orthopaedics and related research.

[19]  R. Barrack.  Rush pin technique for temporary antibiotic-impregnated cement prosthesis for infected total hip arthroplasty. , 2002, The Journal of arthroplasty.

[20]  J. Kelm,et al.  In vitro evaluation of antibiotic release from and bacteria growth inhibition by antibiotic-loaded acrylic bone cement spacers. , 2005, Journal of biomedical materials research. Part B, Applied biomaterials.

[21]  C. Nelson.  The Current Status of Material Used for Depot Delivery of Drugs , 2004, Clinical orthopaedics and related research.

[22]  R. E. Cooper,et al.  In vitro elution characteristics of commercially and noncommercially prepared antibiotic PMMA beads. , 1992, Clinical orthopaedics and related research.

[23]  M. Itoman,et al.  Treatment outcome of two-stage revision total hip arthroplasty for infected hip arthroplasty using antibiotic-impregnated cement spacer , 2003, Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association.

[24]  Michael A. Mont,et al.  Use of a Functional Temporary Prosthesis in a Two-Stage Approach to Infection at the Site of a Total Hip Arthroplasty , 2003, The Journal of bone and joint surgery. American volume.

[25]  B. Masri,et al.  Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system. , 1998, The Journal of arthroplasty.

[26]  A. Hanssen,et al.  Infection after total hip arthroplasty. Past, present, and future. , 1995, The Journal of bone and joint surgery. American volume.

[27]  A. Hofmann,et al.  Treatment of Infected Total Knee Arthroplasty Using an Articulating Spacer: 2- to 12-Year Experience , 2005, Clinical orthopaedics and related research.

[28]  B. Masri,et al.  Hip Prosthesis of Antibiotic-Loaded Acrylic Cement for the Treatment of Infections Following Total Hip Arthroplasty , 2002, The Journal of bone and joint surgery. American volume.

[29]  A. Hanssen,et al.  Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. , 2004, Clinical orthopaedics and related research.

[30]  Kengo Yamamoto,et al.  Clinical effectiveness of antibiotic-impregnated cement spacers for the treatment of infected implants of the hip joint , 2003, Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association.

[31]  J. Verhaar,et al.  Acute renal failure after local gentamicin treatment in an infected total knee arthroplasty. , 2002, The Journal of arthroplasty.

[32]  V. Alt,et al.  The effects of combined gentamicin-hydroxyapatite coating for cementless joint prostheses on the reduction of infection rates in a rabbit infection prophylaxis model. , 2006, Biomaterials.

[33]  R. Barrack,et al.  Patient satisfaction and outcome after septic versus aseptic revision total knee arthroplasty. , 2000, The Journal of arthroplasty.

[34]  D. Jacofsky,et al.  Systemic Safety of High-Dose Antibiotic-Loaded Cement Spacers after Resection of an Infected Total Knee Arthroplasty , 2004, Clinical orthopaedics and related research.

[35]  S. Odum,et al.  Articulating Versus Static Spacers in Revision Total Knee Arthroplasty for Sepsis , 2000, Clinical orthopaedics and related research.

[36]  C. Ranawat,et al.  A prospective study of the progression of rheumatoid arthritis of the cervical spine. , 1981, The Journal of bone and joint surgery. American volume.

[37]  R. Uhl,et al.  Spacer endoprosthesis for the treatment of infected total hip arthroplasty. , 2004, The Journal of arthroplasty.

[38]  A. Hanssen,et al.  Delayed reimplantation arthroplasty for candidal prosthetic joint infection: a report of 4 cases and review of the literature. , 2002, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[39]  D. Regis,et al.  Preformed acrylic bone cement spacer loaded with antibiotics: Use of two-stage procedure in 10 patients because of infected hips after total replacement , 2001, Acta orthopaedica Scandinavica.

[40]  R. McGraw,et al.  The PROSTALAC functional spacer in two-stage revision for infected knee replacements , 2000 .

[41]  K. Markolf,et al.  Effects of Radial Head Excision and Distal Radial Shortening on Load-Sharing in Cadaver Forearms , 2001, The Journal of bone and joint surgery. American volume.

[42]  T. Sculco,et al.  Liquid gentamicin in bone cement: a laboratory study of a potentially more cost-effective cement spacer. , 2005, The Journal of bone and joint surgery. American volume.

[43]  R. Booth,et al.  A two-stage approach to primary knee arthroplasty in the infected arthritic knee. , 2003, The Journal of arthroplasty.

[44]  B. Masri,et al.  Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. , 1996, The Journal of arthroplasty.

[45]  F. Haddad,et al.  The treatment of the infected hip replacement. The complex case. , 1999, Clinical orthopaedics and related research.

[46]  G. Lewis,et al.  The in vitro elution of gentamicin sulfate from a commercially available gentamicin-loaded acrylic bone cement, VersaBond AB. , 2004, Journal of biomedical materials research. Part B, Applied biomaterials.

[47]  R. Gustilo,et al.  Infection after Total Hip Arthroplasty. A Study of the Treatment of One Hundred and Six Infections* , 1996, The Journal of bone and joint surgery. American volume.

[48]  R. Laskin,et al.  Infection in Total Knee Replacement: A Retrospective Review of 6489 Total Knee Replacements , 2001, Clinical orthopaedics and related research.

[49]  R. Uhl,et al.  Antibiotic-loaded articulating cement spacer in the 2-stage exchange of infected total knee arthroplasty. , 2004, The Journal of arthroplasty.

[50]  J. V. van Horn,et al.  The effect of mixing on gentamicin release from polymethylmethacrylate bone cements , 2003, Acta orthopaedica Scandinavica.

[51]  J. Dawson,et al.  The use of vancomycin and tobramycin in acrylic bone cement: biomechanical effects and elution kinetics for use in joint arthroplasty. , 1999, The Journal of arthroplasty.

[52]  T. Cook,et al.  Ten-year experience using an articulating antibiotic cement hip spacer for the treatment of chronically infected total hip. , 2005, The Journal of arthroplasty.

[53]  C. A. Warren,et al.  In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos. , 1998, American journal of orthopedics.

[54]  I. Learmonth,et al.  Mechanical characteristics of antibiotic-laden bone cement , 2002, Acta orthopaedica Scandinavica.

[55]  V. Goldberg,et al.  Diagnosis and management of infection after total knee arthroplasty. , 2003, The Journal of bone and joint surgery. American volume.

[56]  G. Bannister,et al.  Infection after total hip arthroplasty. The Avon experience. , 2003, The Journal of bone and joint surgery. British volume.

[57]  J. Insall,et al.  Two-stage reimplantation for the salvage of infected total knee arthroplasty. , 1983, The Journal of bone and joint surgery. American volume.

[58]  R. Deshmukh,et al.  An intramedullary cement spacer in total hip arthroplasty . , 1998, The Journal of arthroplasty.

[59]  D. H. Brooks,et al.  Successful salvage of a primary total knee arthroplasty infected with Candida parapsilosis. , 1998, The Journal of arthroplasty.

[60]  R. Emerson,et al.  Comparison of a Static with a Mobile Spacer in Total Knee Infection , 2002, Clinical orthopaedics and related research.

[61]  P. Meere,et al.  A simple method for construction of an articulating antibiotic-loaded cement spacer. , 2002, The Journal of arthroplasty.

[62]  M. Askew,et al.  Effect of vacuum mixing on the mechanical properties of antibiotic-impregnated polymethylmethacrylate bone cement. , 1990, Journal of biomedical materials research.

[63]  P. Baumann,et al.  Aspergillus fumigatus infection in a mega prosthetic total knee arthroplasty: salvage by staged reimplantation with 5-year follow-up. , 2001, The Journal of arthroplasty.

[64]  J. Calhoun,et al.  An articulated antibiotic spacer used for infected total knee arthroplasty: A comparative in vitro elution study of Simplex® and Palacos® bone cements , 2005, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[65]  T. Fehring,et al.  Bone loss associated with the use of spacer blocks in infected total knee arthroplasty. , 1997, Clinical orthopaedics and related research.

[66]  Mel S. Lee,et al.  Two-stage revision hip arthroplasty for infection: comparison between the interim use of antibiotic-loaded cement beads and a spacer prosthesis. , 2004, The Journal of bone and joint surgery. American volume.

[67]  P. D. Di Cesare,et al.  Use of Antibiotic‐Impregnated Cement in Total Joint Arthroplasty , 2003, The Journal of the American Academy of Orthopaedic Surgeons.

[68]  G. Bannister,et al.  Infection after total knee arthroplasty. , 2004, The Journal of bone and joint surgery. British volume.

[69]  K. Kuehn,et al.  Acrylic bone cements: composition and properties. , 2005, The Orthopedic clinics of North America.

[70]  J. Rand,et al.  Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. , 1999, Instructional course lectures.

[71]  A. Eckardt,et al.  Individual bone cement spacers (IBCS) for septic hip revision—preliminary report , 2003, Archives of Orthopaedic and Trauma Surgery.

[72]  D. Berry,et al.  Mid-Term to Long-Term Followup of Two-stage Reimplantation for Infected Total Knee Arthroplasty , 2004, Clinical orthopaedics and related research.

[73]  R. Evans.  Successful Treatment of Total Hip and Knee Infection with Articulating Antibiotic Components: A Modified Treatment Method , 2004, Clinical orthopaedics and related research.

[74]  R. McGraw,et al.  Patient satisfaction and functional status after treatment of infection at the site of a total knee arthroplasty with use of the PROSTALAC articulating spacer. , 2003, The Journal of bone and joint surgery. American volume.

[75]  A. Hanssen,et al.  Treatment of the infected hip replacement. , 2004, Clinical orthopaedics and related research.

[76]  R. McGraw,et al.  The outcome of two-stage arthroplasty using a custom-made interval spacer to treat the infected hip. , 1997, The Journal of arthroplasty.

[77]  C. Scott,et al.  Addition of hand-blended generic tobramycin in bone cement: effect on mechanical strength. , 2004, Orthopedics.

[78]  R. Ganz,et al.  A cement spacer for two-stage revision of infected implants of the hip joint , 1998, International Orthopaedics.

[79]  B. Masri,et al.  Diagnosis of infection following total hip arthroplasty. , 1998, Instructional course lectures.

[80]  V. Goldberg,et al.  Use of an antibiotic impregnated polymethyl methacrylate intramedullary spacer for complicated revision total hip arthroplasty. , 1992, The Journal of arthroplasty.

[81]  P. D. Wilson,et al.  Reimplantation in infection: a 12-year experience. , 1982, Clinical orthopaedics and related research.

[82]  R F Kyle,et al.  Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. , 1999, The Journal of bone and joint surgery. American volume.

[83]  K. Saleh,et al.  Aspergillus infection after total knee arthroplasty. , 2003, American journal of orthopedics.

[84]  G. Waertel.  The role of antibiotic-loaded cement in the treatment of an infection after a hip replacement. , 1996, The Journal of bone and joint surgery. American volume.

[85]  K. Bozic,et al.  The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. , 2005, The Journal of bone and joint surgery. American volume.

[86]  G. Scuderi**,et al.  Blood management in two-stage revision knee arthroplasty for deep prosthetic infection. , 1999, Clinical orthopaedics and related research.

[87]  R. Pitto,et al.  Antibiotic-loaded bone cement spacers in two-stage management of infected total knee arthroplasty , 2004, International Orthopaedics.

[88]  P. Kodali,et al.  In Vitro Analysis of Antifungal Impregnated Polymethylmethacrylate Bone Cement , 2002, Clinical orthopaedics and related research.

[89]  M. Ries,et al.  An inexpensive molding method for antibiotic-impregnated cement spacers in infected total hip arthroplasty. , 1999, The Journal of arthroplasty.

[90]  W. Hozack,et al.  Two-stage reimplantation of septic total knee arthroplasty. Report of three cases using an antibiotic-PMMA spacer block. , 1988, The Journal of arthroplasty.

[91]  R. Barrack,et al.  Cost of Treating an Infected Total Knee Replacement , 1996, Clinical orthopaedics and related research.

[92]  H. Amstutz,et al.  Direct-Exchange Arthroplasty for the Treatment of Infection after Total Hip Replacement. An Average Ten-Year Follow-up* , 1998, The Journal of bone and joint surgery. American volume.

[93]  T. Sculco,et al.  Technique for fabrication of an antibiotic-loaded cement hemiarthroplasty (ANTILOCH) prosthesis for infected total hip arthroplasty. , 2002, American journal of orthopedics.