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24 Antibiotic Spacers Used forProsthetic Joint Infections
355
5. Once the length has been restored and remeasured with nails in place, antibiotic
cement can be molded around the nails. A
high-viscosity cement may allow for a more
moldable construct around the nails. The
surgical team should ensure that copious
irrigation is available to prevent thermal
injury to adjacent soft tissues during the curing process.
For femorotibial fusion nails, our technique
includes inserting the rod through a large chest
Massive Bone Loss at Knee Spacers:
Femoral-Tibial Fusion Nail Spacer
a
tube that is situated over the templated region
where there is a bone defect between the femur
and tibia. The chest tube is then lled with
cement, which is allowed to cure. Once the
cement is cured, the chest tube can be incised
sharply and cut off from around the cement. This
allows for a contained spacer with a uniform slim
shape to promote soft tissue reapproximation at
the conclusion of the procedure. In very large
defects, Steinmann pins can be situated throughout the chest tube, with cement lled around the
pins, to create a stronger rebar effect.
c
Femoral-Tibial Fusion Nail Spacer
A. Patient with PJI after tumor endoprosthesis.
B. To facilitate sufcient antibiotic cement
along the length of the long defect, several
spacers can be pre-made to slide over the
nail. In this instance, a Toomey syringe was
cut in half, lled with Steinmann pins for
rebar effect, and cement inserted, over a trephine reamer that was well lubricated and
larger than the nail diameter. Once the cement
begins to harden, the trephine reamer is carefully removed.
C. This technique can be repeated to create sev-
eral smaller rings of cement using a spacer
mold and the trephine reamer (arrow).
D. Final construct demonstrating several spacer
molds and fusion nails in place. While multiple
molds may contribute to a weaker construct,
this technique facilitates easier removal for
later revision. An alternative to this would be to
form a single long column of cement (demonstrated in another gure in this chapter). This
decision is best left to the surgeon based on
their individual discussion with the patient.
356
cd
C. Park et al.
For arthrodesis spacers, off-the-shelf arthrodesis implants can be utilized. This allows for
greater preservation of the native bone above and
below the prior implant. Similar to the femorotibial fusion nail, these robust constructs enable
the possible retention of an arthrodesis spacer for
Massive Bone Loss at Knee Spacers: Knee
Arthrodesis Nail
ab
the remainder of the patient’s life if they are
unable to undergo a repeat surgical procedure.
Technical pearls to these arthrodesis implants
include hollowing out sufcient amounts of bone
circumferentially to accommodate a large amount
of antibiotic cement to help eradicate infection.
Femoral-Tibial Fusion Nail Spacer
A. Patient with PJI and proximal tibia fracture.
B. Following the explant of components, there
was severe bone loss and concern with the
patient’s ability to tolerate limited weightbearing status. Intramedullary nail constructs
have been seen to bend and fail if patients are
non-compliant with these restrictions.
C. An arthrodesis nail allows for immediate
weight-bearing. These stems can be placed in
a cemented or press-t manner. Our preference is to tightly t a stem from this system
without canal cementation to facilitate future
removal with ease if needed.
D. Once the nail is set in place, antibiotic cement
can be placed by hand around the arthrodesis
nail. It benets the surgeon to ensure the
femur and tibia are appropriately recessed to
accommodate antibiotic cement around the
nail. Having a burr available for these canals
is very helpful for this purpose.
24.2.7 Articulating DFR/PTR Spacers
In settings of low virulence organisms or in
patients with severely compromised soft tissues
or medical status that will likely not be amenable
to a later reimplantation procedure, surgeons can
consider reimplantation of a large segmental
prosthesis after explant of all infected components. If this is planned, it is paramount to have
two distinct sterile back table setups to prevent
cross-contamination, as well as to have all surgical staff completely change their gown and
gloves between the explant and reimplantation
de
24 Antibiotic Spacers Used forProsthetic Joint Infections
357
components of the procedure. If this method is
chosen, consideration of the implant design can
be helpful in selecting a reconstruction that balances infection clearance and structural stability.
At the distal femur, selecting a shorter segmental body and a longer stem that sits proudly at
the femur may be helpful. This allows for hand
molding of cement around the residual stem not
inserted inside of the femur. Our preference is to
make our limb length and rotation analyses as
described above, coat the distal portion of the
femoral stem not being inserted inside of the
femur, and let this cure before performing a pressurized cementation procedure at the distal femur.
At the proximal tibia, the method described
above is typically more challenging to perform
[34–37]. However, the selection of a shorter seg-
mental body on the proximal tibial component and
using a long stem that sits proudly proximal to the
tibia may similarly be considered. If planning on
using this technique, using a stem long and large
enough to maintain some stability at the distal tibia
prior to building up the absent tibial metaphyseal
region with cement should be favored.
Articulating Massive Bone Loss Antibiotic
Spacers
ac
b
Articulating Massive Bone Loss Antibiotic
Spacers
A. 50 cm bone defect after explant of prior
implants and radical debridement of bone
and soft tissues.
B. Segmental hinged distal femoral replace-
ment. In this setting, it is our preference to
utilize a grit-blasted stem in a line-to-line
manner, reaming either to the size of the
anticipated stem. In some cases, it is required
to ream 0.5mm over the size of the stem to
facilitate stem implantation. At the conclusion of the implantation, the stems should
have a tight t with provisional axial and
rotational stability. It is our preference to utilize the smallest distal femoral component
available and minimal segmental bodies, to
facilitate for antibiotic eluting cement to be
fashioned around the stems. Performing this
method of cementation reserves the possibility of later stem removal and bone stock preservation in the setting of the revision
procedure.
C. Proximally, a sterile coiled plastic sleeve is
cur longitudinally and wrapped around the
femoral stem. Distally, a Toomey syringe is
cut longitudinally, with loban wrapped
around it to link the two half shells together.
358
C. Park et al.
Prior to cement placement, these tubes are
lled with lube to facilitate easy separation of
plastic from cured cement. Next, cement is
laid into the plastic shells. The shells are
squeezed together by hand initially and can
be held together by bone-holding clamps.
D. Cemented coated distal femur and proximal
tibia replacement stems with sutures tied to
the proximal tibia component and embedded
in cement for extensor mechanism reconstruction in addition to gastrocnemius ap.
E. X-ray of construct.
24.3 Hip
Infected primary hip replacements are typically
managed with two-stage revisions, which have a
high rate of survivorship after reimplantation
[38]. After the explantation of the infected prosthetic components and the removal of devitalized
tissue, it has been demonstrated that the use of
antibiotic- impregnated cement spacers can signicantly enhance patient outcomes by effectively delivering high local concentrations of
antibiotics, thus reducing infection rates, and
improving the chances for successful limb salvage [4, 39]. During these staged revisions, there
are many considerations that need to be taken
including choice of antibiotics, type of spacer,
and chemical and mechanical properties of
cement, among many other features. Evidence
does not indicate an unequivocally superior
spacer or method for periprosthetic hip infection
management. Rather, the debate continues
whether there are differences in rates of infection
eradication between articulating and static spacers as well as between spacers made only with
cement or real components [40].
in such a way that does not promote tissue
ingrowth to allow for uncomplicated removals.
While hip static spacers cannot prevent all hip
motion, they restrict patients from any weight
bearing [41]. They are usually constructed with
an antibiotic-impregnated cement ball placed
into the acetabulum with antibiotic cement
beads or cement-covered rod for the femoral
canal. While these spacers are adept at eliminating infection with possibly increased surface
area for antibiotic exposure, they unfortunately
will usually lead to large limb length discrepancy and soft tissue contracture. Furthermore,
prior to nal reimplantation, patients must be
non-weight bearing, leading to decreased patient
satisfaction.
Static Hip Spacer
24.3.1 Static Spacers
In situations where there is extensive bone loss,
large acetabular defects, decient ligamentous
structures, or inadequate ap coverage, static
spacers can be considered. It is essential that the
spacer is molded with antibiotic-loaded cement
24.3.2 Articulating Spacers
Articulating spacers are benecial in preserving
hip mobility and has been shown to be as efcient
24 Antibiotic Spacers Used forProsthetic Joint Infections
359
at eradicating infection. They may allow for an
easier surgery when transitioning to the nal
implant. They are only contraindicated in situations with acetabular insufciency, pelvic discontinuity, or loss of the abductor mechanism. The
different methods of construction range from
handmade to 3D-printed custom articulating
spacers. The methods of construction generally
utilize similar underlying principles-utilizing a
metal endoskeleton to allow for greater load
endurance, preventing spacer fracture with
weight-bearing. The major tradeoffs between
these different methods remain preoperative and
intraoperative time and cost versus mechanical
complication risk [42].
Articulating spacers can be categorized by
their mode of reconstruction or their design of
cement-on-bone hemiarthroplasty versus a metal
or ceramic head articulating with a cemented
polyethylene liner. Handmade spacers are constructed in the shape of a hemiarthroplasty- when
the size of the femoral head matches, it is useful
to utilize the bulb syringe as a mold. This method
is low cost but requires knowledge and familiarity with the method by the surgical team. While
these are associated with an increased risk of
mechanical failure or dislocation, preventative
measures can be taken to reduce this risk. To
reduce the risk of dislocation with these spacers,
the head should be only 2–3mm smaller than the
acetabular socket to ensure optimal seating and
geometric congruence to optimize joint mechanics. To ensure sufcient xation of the femoral
spacer stem, a cement collar can be formed,
allowing for better control of the spacer height
and anteversion, without increasing difculty
during removal. Many different methods of creating spacers have been documented including
intraoperative sterilization of the prosthetic com-
ponents to construct a mold. These molded spacers have been associated with higher procedural
cost and mechanical complication rates.
Preformed articulating spacers are another
option. They decrease cost and intraoperative
time, but are less universal, limited by sizes and
shapes. Cases with signicant proximal femoral
bone loss should utilize custom- made spacers,
including cemented femoral stems.
A hemiarthroplasty design can be utilized
with a cement femoral component articulating
with the native acetabulum [41]. This has been
associated with greater limitations in hip function
and pain with possible bony erosion. The more
commonly utilized design consists of a metal or
ceramic head on a cemented polyethylene liner.
While the additional implants increase surgical
costs, patients may experience improved functional movement and less pain. Notably, the polyethylene liner may increase the risk of harboring
bacteria due to its propensity for biolm.
To avoid common complications associated
with articulating spacers such as dislocation,
careful attention must be brought to maintaining
an appropriate neck-head ratio to avoid acetabular impingement as well as preservation of femoral offset to keep appropriate muscle tension.
When determining whether the articulating
spacer should be made of cement versus a real
component, no signicant differences were found
in outcomes regarding reinfection and reoperation rates, and time to reimplantation. The only
consideration pertains to patient comfort and
healthcare cost with signicant differences in leg
length in the all-cement groups after the second
stage and with patients in the real-component
group having a higher probability of being discharged after the rst and second-stage
surgeries.
360
cf
Articulating Antibiotic Spacers Following
Primary THA
C. Park et al.
ab
Articulating primary total hip arthroplasty
spacer: A. Metal-backed cement spacer with
open clam shell being lled with high viscosity
cement B.Metallic prosthesis is laid into mold
C.Clamp applied to compress cement around the
metallic implant. Take care to clear off cement
from the superior aspect and prevent cement
from extending to trunnion D. Completed premolded metal-backed antibiotic cement device
E.Hemiarthroplasty mold F.Intra-operative view
of hemiarthroplasty mold G.AP X-Ray of total
hip spacer comprised of metal-backed cement
femoral stem and anged acetabular component
for patient with severe acetabular bone loss at
time of explant
1. Prior to explant, we recommend a preoperative CT to evaluate for extent of bone
loss and the likelihood of requiring certain
instrumentation or osteotomy techniques for
implant removal.
2. Several antibiotic cement total hip spacer
molds exist on the market. Once all prior
ed g
components are removed and debridement
is completed, most systems allow for a
broaching system to be used and estimate
the appropriate stem size for nal
implantation.
3. In instances of severe bone loss or considerable soft tissue loss from infection and
debridement, the option of cementing a constrained liner might be of value to the surgeon.
We recommend familiarizing yourself with
the taper of the antibiotic cement total hip
arthroplasty stems.
4. The total hip stem is created on the back table,
with a mold and metallic compression system
to facilitate proper shaping. Usually, we prefer a high-viscosity cement.
5. Depending on the surgical situation, a
cemented all poly acetabular liner, with or
without constraint, can be implanted for an
infected total hip. Alternatively, for infected
hemiarthroplasties, a large cement head can
be facilitated from a mold similar to the femoral stem.
24 Antibiotic Spacers Used forProsthetic Joint Infections
Massive Bone Loss at Hip Spacers:
Intramedullary Nail Constructs
a bc d e
361
Massive Bone Loss at Hip Spacers:
Intramedullary Nail Constructs
A. Patient with PJI after revision of total hip for
periprosthetic fracture.
B. Intramedullary nail with cement ball fash-
ioned from bulb syringe. A modern alternative to this is to utilize pre-made
hemiarthroplasty molds as shown in another
gure in this chapter and cement this to the
cephallomedullary screw of the nail
construct.
C. Arthroplasty stem impacted into the top of a
femoral-tibial fusion nail and secured with
two stainless steel plates, with screws and
nuts placed through proximal interlocking
holes of the nail.
D. Proximal construct coated in antibiotic
cement on the back table. With a bipolar
hemiarthroplasty head impacted on top of
device.
E. Mechanical axis series of total femur articu-
lating hip and static knee spacer. The patient
was able to ambulate post-operatively on this
device.
24.3.3 Static Versus Articulating
Spacers
Several studies have retrospectively analyzed
outcomes between static and articulating spacers
and consistently found relatively comparable
results in their ability to eradicate infection and
complication rates. A large retrospective study
demonstrated articulating spacers had signicantly lower operative time with nal implantation as well as slightly higher rates of treatment
success. The nancial burden must be taken into
consideration with longer hospital stays
associated with patients receiving static spacers
rather than articulating spacers.
Importantly, evidence may be inuenced by
the selection of statics spacers in more challenging cases including those with more extensive
bone loss and poor soft tissue coverage. A randomized control trial determined that static and
articulating spacers have comparable operative
times during second-stage reimplantation, functional outcome scores, and postoperative complications. The main signicant difference identied
362
C. Park et al.
between them was a longer hospital admission,
implying a potential economic burden. Given
these tradeoffs, articulating spacers should be the
default spacer utilized in hip prosthetic infections
unless otherwise contraindicated.
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Native Hip Joint Infection
AgustinAlbani-Forneris, MartinA.Buttaro,
andPabloA.Slullitel
25
25.1 Introduction
Infection of the native hip joint, either in isolation
or associated with previous hardware, is both a
limb- and life-threatening problem, being considered as a medical emergency when presented in
an acute fashion [1]. Most research about perioperative hip joint infection has been developed in
the setting of a previous hip replacement [2].
However, literature about native hip joint infection and peri-implant hip joint infection in adult
patients is not so abundant. Within this chapter,
the authors will review the epidemiology, etiology, diagnosis and treatment of the most common non-prosthetic hip joint infection scenarios:
(i) septic arthritis of the native hip joint, (ii)
infection following hip preservation surgery, and
(iii) following plating or nailing of a previous hip
fracture.
A. Albani-Forneris · M. A. Buttaro · P. A. Slullitel (*)
Hip Surgery Unit, Institute of Orthopaedics ‘Carlos
E.Ottolenghi’, Hospital Italiano Buenos Aires,
Buenos Aires, Argentina
e-mail: agustin.albani@hiba.org.ar;
martin.buttaro@hiba.org.ar;
pablo.slullitel@hiba.org.ar
25.2 Native Hip Arthritis
intheAdult Patient
25.2.1 Epidemiology
Septic arthritis (SA) is a rare disease that affects
2 persons per 100,000 inhabitants each year [3],
being the hip the second most affected joint in
20–25% of all joints after the knee. The main risk
factors for SA of the hip joint are age over
80 years (due to age-related changes in the
immune system), diabetes, inammatory joint
diseases such as rheumatoid arthritis, recent joint
surgery, skin infection [4], intravenous drug use,
and patients undergoing hemodialysis (e.g., renal
failure) [5]. The most frequent means of infection
is hematogenous dissemination, being unusual
direct inoculation by either trauma, surgical procedure, or an animal bite. Nonetheless, joint
injections with corticosteroids are a rare cause of
infection, affecting about 4 patients per 10,000
injections [6].
The highly vascularized synovium that lacks a
protective membrane is fertile soil for bacterial
inltration [7]. Once microorganisms proliferate
inside the joint, an inammatory reaction is triggered, which in combination with bacterial toxins
and enzymes is responsible for joint damage [8].
The cartilage’s nutrition is mainly dependent on
oxygen diffusion. However, with the increase in
joint pressure due to purulent exudate and
© 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_25
365