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23 Periprosthetic Joint Infection inMegaprostheses
345
infections, such as DAIR, one-stage and twostage revision surgery. Unfortunately, in some
cases, amputation becomes the nal option when
other treatment strategies fail. Two-stage revision
surgery has exhibited superior functional outcomes and elevated success rates, making it the
current gold standard for addressing chronic
infections in tumor prostheses. Nonetheless, for
patients harboring isolated pathogens highly susceptible to antibiotics, one-stage revision surgery
could serve as a feasible alternative. This
approach involves removing the infected implant
and replacing it with a new prosthesis in a single
surgical procedure. In some cases, implant
exchange may not be necessary, depending on
the severity of the infection and the effectiveness
of the antibiotic treatment.
Author Contributions Conceptualization, project administration: AA, PR; data curation and
formal analysis: AA, AF; supervision: AA, PR;
writing-original draft: AA, MCC, GT, EP, AF;
writing-review and editing: AA, EP, PR; drawings: AA; All authors have read and agreed to the
published version of the manuscript.
Institutional Review Board Statement Not
applicable.
Informed Consent Statement
Written
informed consent was obtained from patients at
the time of admission to our Institute. However,
all pictures have been reported anonymized.
Consent for Publication (Include Appropriate
Statements) We conrm that this paper, includ-
ing related data, gures, and tables, has not been
published previously, it is not under consideration for publication elsewhere, and, if accepted,
it will not be published elsewhere in the same
form, in English or in any other language, without the written consent of the publisher.
Conicts of Interest/Competing Interests
(Include Appropriate Disclosures) Ruggieri
P is a consultant for Stryker and Exactech (not
relevant to the present manuscript). The other
authors declare that there are no relationships/
conditions/circumstances that present a potential conict of interest with the present
manuscript.
Availability of Data and Material (Data
Transparency) Manuscript data are embedded
in the text and fully available on specic request.
Funding There was no external funding source
in support of this study.
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Antibiotic Spacers Used
forProsthetic Joint Infections
ClairePark, YazanKadkoy, LuisVallejo,
AshleyCastan, JosephA.Ippolito,
andJosephBenevenia
24
24.1 Introduction
Following treatment of prosthetic joint infection
(PJI), antibiotic-eluting spacers are frequently
utilized to ll bone defects left behind after
debridement and removal of prior reconstructive
components. This chapter will span a variety of
anatomic locations and spacer types. This may
include static spacers, articulating spacers, and
hybrid spacers which may be considered for
long-term use. Given the diversity of patients
who suffer from PJI and in consideration of an
oncologic and revision arthroplasty populations
with large bone defects, possible immunocompromised status, and wide varieties of microorganisms, decisions on spacer type are best left to
a careful discussion between the surgeon and
patient. While other chapters will discuss the
very important considerations for adequate
debridement, laboratory studies, and antibiotic
C. Park
Department of Surgery, Rutgers NJMS,
Newark, NJ, USA
e-mail: cp906@njms.rutgers.edu
Y. Kadkoy · A. Castan · J. A. Ippolito · J. Benevenia (*)
Department of Orthopaedics, Rutgers NJMS,
Newark, NJ, USA
e-mail: yk399@njms.rutgers.edu;
aqc3@njms.rutgers.edu; ippolija@njms.rutgers.edu;
benevejo@njms.rutgers.edu
L. Vallejo
University Hospital, Newark, NJ, USA
e-mail: vallejl2@uhnj.org
stewardship, the objective of this chapter is to
provide surgeons with a review of the literature
and a framework of ideas that empower surgeons
to utilize their technical skills, creativity, and
understanding of patient goals to achieve optimal
results in the aim of limb salvage.
24.2 Knee
24.2.1 Overview
Infection at the knee is the most common site of
PJI following arthroplasty. In addition to being
among the most common anatomic locations for
total joint replacement, the distal femur and proximal tibia remain among the most operated sites
for tumor resection and reconstruction.
Furthermore, given the demands upon the knee,
antibiotic spacers in this region must be of durability and elute of antibiotics.
24.2.2 Spacers After Primary Adult
Reconstruction
Following the explant of components and debridement, if the collateral ligamentous structures can
be preserved at the knee, either static or articulating spacer components can be considered to help
clear infection [1–5]. Static spacers have been
used historically and can be fashioned from a sim-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
P. Ruggieri et al. (eds.), Bone and Joint Infections, https://doi.org/10.1007/978-3-031-96383-4_24
351
352
ce
C. Park et al.
ple block of antibiotic cement with or without
intramedullary stabilization [2]. Potential advantages of articulating spacers include more effective maintenance of the joint space, reduction in
bone loss, and maintenance of range of motion [3,
4]. Traditionally, these spacers have been com-
prised of an articulating femoral and tibial component which can be either cement-on-cement,
cement-on-polyethylene, or metal-on-polyethylene [5].
For cement-only molds, several options exist
for surgeons, including pre-fabricated antibiotic molds with multiple sizes and molds that
can be modied intraoperatively [3]. While
numerous options in industry exist, the main
difference between prefabricated molds and
intraoperative molds is the ability to add addi-
Articulating Antibiotic Spacers Following
Primary TKA
ab
tional or different antibiotic/antifungal powder
to the mold.
Utilization of a with an all-polyethylene tibial
component has grown increasingly popular over
the past several years, particularly in patients
with acute or low virulence organisms [4]. In
these patients, the new components are implanted
in a fashion that allows ease of ease component
removal for a second- stage surgery [6]. However,
several studies have highlighted the ability of
patients to retain their metallic femur and allpoly tibia antibiotic spacer for longer durations
with satisfactory functional outcomes [5–12].
This may be particularly useful in patients with
medical comorbidities or wound issues that
undermine their ability to tolerate a second-stage
procedure [13–16].
fd
Articulating primary total knee arthroplasty
spacer: A. post-explant bone loss B. intraopera-
tive view of all cement mold spacer C.Metallic
femur with all poly tibia with augment
D. Intraoperative view of metal-backed cement
mold E, F.AP & lateral xrays
1. Prior to explant, we recommend placement of
two drill bits above and below the anticipated
hardware explant (one in the femur, one in the
tibia) and measuring the gap between these
for later restoration of limb lengths and soft
tissue tension.
2. Following radical debridement of infected tissue and explant of prior implants, assess the
proper sizing of articulating spacer construct.
3. Once sizing is complete, prepare the appropriate amount of required additional antibioticimpregnated cement, ideally tailored to
pre-operative cultures and microbiology sensitivities. We recommend utilizing a highviscosity cement to enable a more workable
material that stays intact.
4. We recommend preparing the side with less
bone loss rst, then working from there to
restore length on the higher bone loss side by
“oating” the cemented articulating spacer
device with the leg at restored pre-surgical
length.
5. Usually, this framework leads to the tibia
being prepared rst. Ideally, this cement is
allowed to cure into a “sticky” form before
24 Antibiotic Spacers Used forProsthetic Joint Infections
353
implantation to avoid cement dropping down
the canal and molding around the tibia polyethylene. Once the tibial component is
implanted in a satisfactory alignment and
rotation and all loose cement is removed from
the knee, the femoral component can be
addressed.
6. For the preparation of the second construct
(usually the femur), an assistant pulls traction
on the leg and the extension gap distance is
re-checked to anticipate the ideal position of
the cemented component. Similarly, cement is
placed on the femur and the femoral component individually, with an emphasis on preventing cement from being pushed far up into
the femur to facilitate removal for future
revisions.
24.2.3 Static Spacers
Depending on the extent of debridement required,
patients with severe bone loss, collateral ligament insufciency, periarticular fracture, and an
insufcient functional extensor mechanism may
be good candidates for static spacers [17–19]. In
these settings, we prefer the utilization of either
an antibiotic cement dowel or a metallic rod
coated in cement to provide temporary arthrodesis and improved stability around an antibioticeluting cement block. After removal of infected
components, polymethylmethacrylate (PMMA)
cement can be mixed with numerous heat-stable
antibiotic or antifungal medications, including
tobramycin, vancomycin, and amphotericin B on
the back table. A small amount of cement can be
retrieved to create a cement dowel by rolling
cement out on the mayo stand and frequently irrigating it. This can then be inserted into the intramedullary canals of the tibia and femur. Next, the
remaining amount of cement is placed in the
manually held gap between the distal femur and
proximal tibia and gently pressed together to
form an arthrodesis. The coated metallic rod
technique will be discussed in the later section on
larger segmental defect spacers.
24.2.4 Static Versus Articulating Spacers
Several studies have examined the outcomes of
static and articulating spacers. To preface a brief
discussion of these ndings, there are numerous
confounding variables, including the type of
infective organism and the retention or not of
various anatomical structures that can inuence
the choice of static or articulating antibiotic
spacer. In a systematic review of 47 articles,
articulating spacers had lower rates of infection,
greater range of motion, less bone loss, and favorable conditions for reimplantation [19]. In a
review of 34 articles examining types of articulating spacers among pre-fabricated, handmade,
custom molds, and new knee components
implanted with antibiotic cement, there were no
differences in rates of reinfection or difculty in
reimplantation [20]. However, there were fewer
spacer-specic complications with the new metal
femoral and all-poly tibial components compared
to other spacer types.
24.2.5 Distal Femoral or Proximal Tibial Replacement Infection
Following infection of a distal femoral replacement (DFR) or proximal tibial replacement
(PTR), considerations in addition to the infecting
organism(s) must be held, including the status of
the extensor mechanism, surrounding soft tissues, and history of a gastrocnemius ap and possible future need for one [21]. In addition to
explant of components, these patients must
undergo a radical debridement which includes
intramedullary reaming to remove all residual
infectious tissue [21].
The author’s preference is to perform a multistage procedure that includes a debridement may
be repeated with an interim antibiotic eluting
spacer construct prior to reimplantation of segmental arthroplasty components. Compared to
patients with PJI following primary or revision
knee arthroplasty, patients with PJI following
354
fg
C. Park et al.
DFR/PTR require more robust stabilization for
the interim with articulating or arthrodesis type
implants between stages 1 and 2 [21–26].
Additionally, these patients may be more likely
to present with polymicrobial infection and
require more than one debridement procedure
prior to consideration for reimplantation [27, 28].
24.2.6 Stage 1 Arthrodesis Spacers
Segmental arthrodesis antibiotic spacers can be
constructed in various ways, including the use of
a femorotibial fusion nail, the use of a knee fusion
metallic spacer surrounded by cement, or the use
of two standard intramedullary nails linked
Massive Bone Loss at Knee Spacers:
Intramedullary Nail Construct
abcd
e
together and surrounded by cement [29, 30]. For
all these scenarios, pre-operative measurement of
the patient’s segmental defect and rotational
alignment of the limb should be performed to
minimize limb length discrepancy and maximize
the success of reimplantation [31, 33].
If utilizing two intramedullary nails, securing
a conguration that allows for a straight leg can
be slightly challenging if utilizing a tibial nail
and femoral nail. An alternative to this is using a
short femoral nail with a large radius of curvature
on the tibial side and articulating this with a femoral nail proximally. The nail can be secured with
either cerclage or interlocking screws to fasten
the nails together, followed by hand molding
antibiotic cement around the structure.
Static intramedullary nail spacer for massive
bone loss at knee: A.Two intramedullary nails
assembled and locked together B. Interlocking
screws with nut to link nails C.Tensioned cable
to lock nails D.Wiring of nails together in addition to interlocking screws E.Large bone defect
stabilized with intramedullary nails and demonstration of two drill bits placed prior to explant to
conrm restoration of limb length after nail
implantation F.PMMA molded around intramedullary nail G.Two intramedullary nails spanning
a 32cm defect after tumor endoprosthesis explant
1. Prior to explant, we recommend placement of
two drill bits above and below the anticipated
hardware explant (one in femur, one in tibia,
g. E) and measuring the gap between these
for later restoration of limb lengths and soft
tissue tension.
2. Once prior implants are removed and debridement is performed, continue debridement of
the intramedullary canal, either with standard
reamers or with a reamer irrigator aspirator
system to ensure the removal of infected
components.
3. Nail size selection is typically 1–1.5 cm
smaller than the largest reamer used. We recommend templating the ideal length of nails
to retain limb length pre-operatively and conrming during surgery.
4. If there is more than minimal bone loss at the
tibia, two femoral nails may be optimal for
use (one at femur, one at tibia) and allow for
easier linking of the two nails by various
methods shown above. A femoral and tibial
nail can be linked but may require cabling due
to the interlocking holes not matching up as
well.