Acute Renal Failure due to a Tobramycin and Vancomycin Spacer in Revision Two-Staged Knee Arthroplasty

Abstract

Two-stage revision total knee arthroplasty (TKA) is the standard of care for prosthetic joint infections. The first stage involves removal of the infected prosthesis and placement of an antibiotic impregnated cement spacer; following a period ranging from 4 weeks to 6 months, the spacer is then removed and replaced with a permanent prosthesis. The advantage to this approach is that antibiotic impregnated spacers provide supratherapeutic levels in the joint without toxic accumulation in serum. However, it remains important for physicians and pharmacists to be aware of antibiotic associated complications in knee revisions. We present a case of a two-stage revision total knee arthroplasty in which a cement antibiotic spacer caused acute renal failure and ultimately resulted in persistent chronic kidney disease without hemodialysis at 2 months' follow-up. Our case reports the third highest serum tobramycin (13.7 mcg/ml) and second highest serum creatinine (8.62 mg/dl) for patients experiencing ARF due to an antibiotic spacer in two-stage revision TKA.

Utilizing a Prefabricated Antibiotic-Impregnated Articular Spacer Combined With an Intramedullary Device for Significant Femoral Bone Loss in Periprosthetic Hip Infection

“…Additionally, it is possible to introduce as much as 10-12 g of antibiotics in 1 bag of bone cement, but >4.5 g of antibiotics per bag of bone cement will decrease the mechanical properties of a standard prosthesis [ 23 ]. Although there is no consensus as to the optimal range for antibiotic-loaded bone cement in spacers, several case reports suggesting a dose-dependent risk of acute kidney injury (AKI) from surgeon-made antibiotic spacers utilizing aminoglycosides have been described [ 24 , 25 ]. In a study by Menge et al.…”

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

“…Increased serum creatinine above 50% from normal has been reported in 20% of patients with tobramycin-impregnated spacer during the first postoperative week after the first-stage surgery [66]. Underlying renal dysfunction predisposes to ALCS-related nephrotoxicity [64][65][66]. However, other studies support that the high levels of the antibiotics observed immediately after spacer implantation return to normal within 24 hours, therefore systemic side effects are not a potential risk for the patient [9,41,42].…”

“…Older patients are probably more prone to such complications [ 38 ]. Occasionally, removal of the ALCS is mandatory to restore renal function [ 8 , 59 , 64 , 65 ]. Increased serum creatinine above 50% from normal has been reported in 20% of patients with tobramycin-impregnated spacer during the first postoperative week after the first-stage surgery [ 66 ].…”

Timely explantation of tobramycin-impregnated beads and bone cement to avoid haemodialysis in a patient with worsening renal failure

“…Complications include hepatotoxicity and bone marrow depression following gentamicin plus vancomycin plus cefotaxime hip spacer implantation,6 allergic reactions with tobramycin plus vancomycin impregnated hip spacer7 8 and commonly acute kidney injury (AKI) or acute renal failure (ARF) with the use of aminoglycosides alone or in combination with vancomycin. Several published case reports describe ALBC-related AKI,9–19 with most patients requiring haemodialysis and spacer explantation 9 13 15 17 20–22. This is an additional case of AKI attributed to the systemic absorption of an aminoglycoside following implantation of ALBC and beads with recovery of renal function following explantation of the tobramycin cement spacer and beads, thus preventing haemodialysis.…”