Is There a Role for Spacer Exchange in Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection?

Abstract

Periprosthetic joint infection (PJI) continues to be one of the most serious complications after hip and knee arthroplasty. The choice of surgical treatment depends on a multitude of factors like chronicity of infection, host factors, and institutional or surgeon experience. Two-stage exchange remains one of the most commonly used technique for chronic PJI in the United States of America. The intended two-stage revision may involve an additional interim procedure where the initial antibiotic cement spacer is removed and a new spacer is inserted. Mostly, the rationale behind spacer exchange is an additional load of local antibiotics before proceeding to reimplantation. There is no conclusive evidence whether a spacer exchange confers additional benefits, yet it delays reimplantation and exposes already fragile patients to the risks and morbidity of an additional surgery.

Risk of reinfection after two‐ or multiple‐stage knee revision surgery using superficial vancomycin coating and conventional spacers

“…In contrast to this findings, previous studies have shown that positive cultures during the second stage are associated with a higher failure rate 25,26 . Therefore, if there are evidently signs of persistent spacer infection preoperatively or intraoperatively, reimplantation of an implant seems precarious and spacer exchange should be performed 27 …”

“… 25 , 26 Therefore, if there are evidently signs of persistent spacer infection preoperatively or intraoperatively, reimplantation of an implant seems precarious and spacer exchange should be performed. 27 …”

Current Concepts on the Application, Pharmacokinetics and Complications of Antibiotic-Loaded Cement Spacers in the Treatment of Prosthetic Joint Infections

“…One or multiple ALCS exchanges between the first-stage surgery and the final prosthesis insertion are reported in 12-17% of patients with PJI [ 62 , 76 , 78 ].…”

“…Spacer exchange is dictated by mechanical causes or because of persisting infection [ 62 ]. Mechanical causes of spacer replacement are the risk of wound or skin compromise secondary to pressure, compression of nerves or vessels and, finally, pain and discomfort from a dislocated spacer.…”

Prosthetic Joint Infection: Updates on Prevention, Diagnosis and Therapy

“…Secondly, Kozaily et al tried to examine a place for an additional spacer intervention (i.e., the initial antibiotic cement spacer is removed and a new spacer is inserted) during two-stage PJI treatment [18]. There may be mechanical and biological reasons for a spacer to be exchanged.…”