Articulating spacers: what are available and how to utilize them?

Abstract

Periprosthetic joint infection (PJI) is the most devastating complication following total joint arthroplasty (TJA) and is posing a global healthcare challenge as the demand for TJA mounts. Two-stage exchange arthroplasty with the placement of antibiotic-loaded spacers has been shown to be efficacious against chronic PJI. This study aimed to review the key concepts, types, and outcome evaluations of articulating spacers in the two-stage exchange for PJI. Previous studies indicated that articulating spacers have been widely used due to better functional improvement and a comparable infection control rate relative to static spacers. Several types of articulating spacers are reportedly available, including hand-made spacers, spacers fashioned from molds, commercially preformed spacers, spacers with additional metal or polyethylene elements, new or autoclaved prosthesis, custom-made articulating spacers, and 3D printing-assisted spacers. However, limited evidence suggested no significant difference in clinical outcomes among the different subtypes of articulating spacers. Surgeons should be familiar with different treatment strategies when using various spacers to know which is the most appropriate.

Augmented Articulating Spacers in Infected Total Knee Arthroplasty: Surgical Technique

“…All cement spacers are still widely used worldwide to address PJIs in TKA in a twostage approach [22]. Our concerns about this type of spacer are linked to the limitations well described in the current literature, such as the preformed sizes not allowing personalization to the patient, and the incapability to provide enough stability to the joint, strongly limiting the quality of life and knee function [9,23].…”

Incidence, associated factors, and outcomes of acute kidney injury following placement of antibiotic bone cement spacers in two-stage exchange for periprosthetic joint infection: a comprehensive study

“…The rationale for this phenomenon was still not clear. Possible reasons were as follows: firstly, there was a high degree of heterogeneity between studies, as the type and dose of antibiotics were often adjustable, resulting in differentiated results; secondly, these data indicated that the pathogenesis of AKI following first-stage exchange was multifactorial, with host-related factors likely to play an even more critical role, whereas the available evidence suggested that the administration of nephrotoxic antibiotics within reasonable doses (less than 8 g/40 g cement ( Li et al., 2023 )) may not significantly increase the risk of AKI.…”

Mechanically stable rifampin antibiotic cement inhibits Pseudomonas aeruginosa biofilm surface growth

“…The elution of rifampin from the PMMA and the bactericidal potential were investigated using the KB assay. Interestingly, there was no inhibition of bacterial growth from any of the elution sample time points (2,6,12,24, and 48 h) at 24-or 48-h incubation. Orally administered rifampin has been shown previously to be effective in treating prosthetic joint infection (PJI) from P. aeruginosa.…”

“…Early removal of implants and extensive debridement followed by prolonged antibiotic systemic delivery and local antibiotic spacer is effective, but outcomes vary across the literature and are often disabling to the patient. [10][11][12] The selection of the spacer lacks standardization in both methodology and antibiotics used, but allows for preservation of the joint space, early ambulation, and potentially reduced rate of reinfection. [10][11][12] Numerous studies have shown the efficacy of polymethyl methacrylate (PMMA) with commonly added antibiotics, vancomycin, gentamicin, or tobramycin, in the treatment and clearance of pathogens associated with PJI.…”

“…[10][11][12] The selection of the spacer lacks standardization in both methodology and antibiotics used, but allows for preservation of the joint space, early ambulation, and potentially reduced rate of reinfection. [10][11][12] Numerous studies have shown the efficacy of polymethyl methacrylate (PMMA) with commonly added antibiotics, vancomycin, gentamicin, or tobramycin, in the treatment and clearance of pathogens associated with PJI. While effective in PJI, these same antibiotics have been shown to be ineffective in cases of PJI with associated biofilm formation due to their limited ability to penetrate the extracellular polymeric substance (EPS) which encases the bacterial biofilm.…”