Evaluation of the importance of a ready-made, gentamicin-impregnated spacer in relation to bacteriological findings in patients with periprosthetic joint infections

Česká verzia

Authors: T. Proček ¹; Lenka Ryšková ² ; T. Kučera ¹; J. Šrot ¹; P. Šponer ¹; J. Gallo ³; L. Plíšková ⁴
Authors place of work: Ortopedická klinika FN a LF UK Hradec Králové ¹; Ústav klinické mikrobiologie FN a LF UK Hradec Králové ²; Ortopedická klinika LF UP a FN Olomouc ³; Ústav klinické biochemie a diagnostiky FN a LF UK Hradec Králové ⁴
Published in the journal: Epidemiol. Mikrobiol. Imunol. 63, 2014, č. 3, s. 254-260
Category: Review articles, original papers, case report

Summary

Background:
Periprosthetic infection is a serious complication in total hip and knee arthroplasty. The complex therapeutic approach within two-stage reimplantation includes the use of antibiotic-impregnated spacers (temporary joint replacements). The aim of this paper was to evaluate bacteriological findings in selected patients with periprosthetic infection in whom a ready-made gentamicin-impregnated spacer was used to treat the infection.

Materials and methods:
Between 2008 and 2012, a ready-made, gentamicin-impregnated cement spacer was used in 24 patients to treat periprosthetic hip or knee infection within two-stage reimplantation. All components of the prosthesis and periprosthetic tissue samples were sent for microbiological examination at the first revision surgery, while at the second revision surgery, the spacer and surrounding tissue samples were sent in. In six patients with an inserted knee spacer, the level of gentamicin in the joint fluid was measured. Subsequently, the patients were regularly monitored.

Results:
Twenty-two (92%) of 24 patients were bacteriologically positive by culture. The most commonly detected causative agents were coagulase-negative staphylococci. Other isolates were Staphylococcus aureus, Corynebacterium, anaerobic bacteria, and Salmonella serotype Enteritidis. Nineteen (76%) of 25 primary pathogens were gentamicin sensitive. Spacers from two patients were culture positive for coagulase-negative staphylococci that tested resistant to gentamicin. During the follow-up of at least two years, none of the patients developed another periprosthetic infection.

Conclusion:
The success rate of two-stage-reimplantation total hip and knee arthroplasty using ready-made, gentamicin-impregnated spacers was 100 % in our cohort of patients; no other periprosthetic infection was reported during the follow-up of at least two years. From the bacteriological results, it appears that the ready-made, gentamicin-impregnated spacer only covers 76 % of the range of the causative agents. The solution would be to use a spacer impregnated with a combination of vancomycin and gentamicin that would be effective against all cultured species.

Keywords:
total hip arthroplasty – total knee arthroplasty – periprosthetic joint infection – two-stage reimplantation – gentamicin-impregnated spacer

Zdroje

1. Jahoda D, Landor I, Pokorný D, Judl T, et al. Současné trendy v léčbě infikované aloplastiky. Ortopedie, 2011;5:179–185.

2. Pignatti G, Nitta S, Rani N, Dallari D, et al. Two stage hip revision in periprosthetic infection: Results of 41 cases. The Open Orthopaedics Journal, 2010;4:193–200.

3. Tsukuyama DT, Estrada R, Gustilo R. Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Sur., 1996;78-4:512–523.

4. Winkler H, Stoiber A, Kaudela K, Winter F. One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics. J Bone Jt Surg, 2008;90(12):1580–1584.

5. Garvin K, Hanssen A. Infection after total hip arthroplasty: Past, present and future. J Bone Joint Surg, 1995;77(10):1576–1588.

6. Anagnostakos K, Furst O, Kelm J. Antibiotic-impregnated PMMA hip spacers: Current status. Acta Orthop, 2006;77(4):628–637.

7. Buchholz HW, Engelbrecht H. Depot effects of various antibiotics mixed with Palacos resins. Chirurg, 1970;41:511–515.

8. Mutimer J, Gillespie G, Lovering AM, Porteous AJ. Measurements of in vivo intra-articular gentamicin levels from antibiotic loaded articulating spacers in revision total knee replacement. The Knee, 2009;16:39–41.

9. Baleani M, Traina F, Toni A. The Mechanical behaviour of pre-formed hip spacer. Hip International, 2003;13(3):159–162.

10. D’Angelo F, Negri L, Binda T, Zatti G et al. The use of a preformed spacer in two-stage revision of infected hip arthroplasties. Musculoskelet Surg, 2011;10(5):12306-011.

11. D’Angelo F, Negri L, Zatti G, Grassi F. Two-stage revision surgery to treat an infected hip implant. A comparison between a custom-made spacer and a pre-formed one. Chir Organi Mov, 2005;90(3):271–279.

12. Leunig M, Chosa E, Speck M, Ganz R. A cement spacer for two-stage revision of infected implants of the hip joint. Int Orthop, 1998;22(4):209–214.

13. Gallo J, Smižanský M, Radová L, Potomková J. Porovnání léčebných postupů používaných v terapii infekce kloubních náhrad kyčle a kolena. Acta Chir Orthop Traum Čech, 2009;76:302–309.

14. Gallo J, Bogdanová K, Šiller M, Švábová M et al. Mikrobiologické a farmakologické vlastnosti kostního cementu VancogenX. Acta Chir Orthop Traum Čech, 2013;80:69–79.

15. Ouředník J, Pilnáček J, Eliášová G. Bakteriální nálezy ze sonikovaných spacerů impregnovaných gentamycinem. Ortopedie, 2010;4:232–235.

16. Coventry M. Treatment of infections occuring in total hip surgery. Orthop Clin North Am, 1975;6(4):991–1003.

17. Pilnáček J, Bébrová E. Problémy v přístupu k infikované TEP a mikrobiologická diagnostika infikované TEP – sonikace. Ortopedie, 2011;4:162-168.

18. Bejon P, Berendt A, Atkins L, Green N et al. Two-stage revision for prosthetic joint infection: Predictors of outcome and the role of reimplantation microbiology. J Antimicrob Chemother, 2010;65:569–575.

19. Corvec S, Portillo ME, Pasticci BM, Borenz O, et al. Epidemiology and new developments in the diagnosis of prosthetic joint infection. Int J Artif Organs, 2012;35:932–934.

20. Gallo J, Raska M, Dendis M. Molecular diagnosis of prosthetic joint infection. A review of evidence. Biomed Papers, 2004;148(2):123–129.

21. Schäfer P, Fink B, Sandow D, Marqull A, et al. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis, 2008;47:1403–1409.

22. Gallo J, Kolár M, Koukalová D, Sauer P, et al. Bakteriální původci periprotetických infekcí a možnosti jejich diagnostiky. Klin Mikrobiol Infekc Lek, 2006;12:117–123.

23. Finch RG, Geenwood D, Norrby SR, Whitley RJ. Antibiotic and Chemotherapy. Ninth edition, Elsevier, 2010, 900 s, ISBN 978-0-7020-4064-1.

24. Kusuma SK, Ward J, Jacofsky M, Sporer SM, et al. What is the role of serological testing between stages of two-stage reconstruction of the infected prosthetic knee? Clin Orthop Relat Res, 2011;469(4):1002–1008.