• anterior cruciate ligament (ACL) reconstruction
• antibiotic therapy
• arthroscopic debridement
• diagnosis
• joint infection
• microbiology
• open surgical debridement
• rheumatoid arthritis
• septic arthritis

• Articulating antibiotic knee spacer
• Chronic septic knee arthritis
• Metal-on-polyethylene knee spacer
• Native knee septic arthritis

• Arthroplasty
• Articulating spacer
• Outcomes
• Periprosthetic joint infection

• 2020YFC2004900 National Key Research and Development Program of China
• 82002323 Natural Science Foundation of China
• 82102585 Natural Science Foundation of China
• 21QNPY110 Military Medical Science and Technology Youth Training Project

• nontuberculous mycobacteria
• periprosthetic joint infection
• two stage exchange arthroplasty

• articulated spacer
• knee arthroplasty
• knee revision surgery
• periprosthetic joint infection
• static spacer
• two-stage protocol

Prosthetic joint infection (PJI) is a devastating complication of total joint replacement surgery. It affects about 2% of primary total joint replacements. Treatment aims at infection eradication and restoration of patient's mobility. Two-stage revision arthroplasty with an interim application of an antibiotic-loaded cement spacer (ALCS) is the widely accepted treatment for PJI. Spacers are powerful local carriers of antibiotics at the site of infection, effective against biofilm-protected microbes. On the other hand, spacers permit some mobility of the patient and facilitate final prosthesis implantation. ALCS's are either commercially available or prepared intraoperatively on prefabricated or improvised molds. Antibiotic elution from the spacer depends on the amount of the antibiotic used for cement impregnation, at the expense of mechanical stiffness of the spacer. The antibiotic should not exceed 4g per 40g of bone cement to preserve the mechanical properties of the cement. Spacers are frequently accompanied by local or systemic complications. The spacer may break, dislocate and compress vessels or nerves of the limb. Systemic complications are the result of excess elution of antibiotic and include nephrotoxicity, hepatotoxicity, ototoxicity, allergic reactions or neutropenia. Elderly patients with comorbidities are at risk to present such complications. Microbial resistance is a potential risk of long-lasting spacer retention. Persisting infection may require multiple spacer replacements.

• Arthroplasty
• Hip
• Knee
• Septic arthritis
• Two-stage

• Arthritic knee
• Infection
• Spacer
• Total knee arthroplasty
• Two-stage procedure

• Aged
• Arthroplasty, Replacement, Knee/adverse effects
• Bone Cements/therapeutic use
• Debridement
• Humans
• Male
• Mycoses/drug therapy
• Stem Cells

• Cement spacer
• Infection-free survival
• Joint infection
• Outcome measures
• Septic arthritis
• Two-stage primary knee arthroplasty

Patients with advanced knee arthritis who develop a septic joint are not adequately treated with irrigation and debridement and intravenous antibiotics because of antecedent cartilage damage. The gold standard treatment has been a 2-stage approach. The periprosthetic joint infection literature has demonstrated the superiority of articulating spacers, and metal-on-poly (MOP) spacers are being used with increasing frequency. The purpose of this study was to compare the postoperative outcomes of patients with infected, arthritic knees treated by a 2-stage approach to those of patients who received single-stage treatment with a MOP spacer.

Sixteen patients with native knee septic arthritis treated with an antibiotic spacer between 1998 and 2019 were reviewed. Demographic data, clinical data, knee motion, Knee Society score, Timed-Up-and-Go, and pain scores were collected. Survivorship of final implants was compared.

Six of 16 knees (38%) received single-stage treatment, and 10 received 2-stage treatment (62%). Five of 6 MOP spacers (83%) were retained at a mean follow-up of 3 ± 1.2 years. Nine of 10 (90%) receiving static spacers had subsequent reconstruction, with 9 (100%) surviving at mean follow-up of 7 ± 3.2 years. The patients who received MOP spacers trended toward greater terminal flexion, higher Knee Society score, and faster Timed-Up-and-Go at final follow-up.

Infection in a native, arthritic knee may be effectively treated using single-stage MOP spacer. Postoperative outcomes of single-stage MOP spacers compare favorably to staged static spacers and with those undergoing revision surgery for other indications. Longer follow-up is needed to evaluate durability of MOP spacers.

• Antibiotic spacer
• Cement
• Infected arthritic knee
• Infection
• Septic arthritis

Knee joint arthrodesis is an established treatment for periprosthetic infections (PPI) providing stability and pain relief. In this study the outcome after arthrodesis of the knee joint for persistent infections was compared and evaluated depending on the surgical procedure (intramedullary vs. extramedullary).

In a retrospective case analysis, all patients who underwent knee joint arthrodesis between 1 January 2010 and 31 December 2016 were identified and divided into two groups: IMA and EMA. All patients were examined clinically and radiologically and the patient files were evaluated. In addition, the FIM score, the LEFS, the WHOQOL-BREF and NRS were evaluated.

The median LEFS score for the IMA group was 26 points and in the EMA group 2 points (p = 0.03). The IMA patients showed a median pain scale at rest of 0 and during exercise of 2. The EMA group recorded a pain scale of 3 at rest and 5 during exercise (p = 0.28 at rest; p = 0.43 during exercise). In the IMA group the median postsurgical leg length difference was −2.0 cm and −2.5 cm in the EMA group (p = 0.31). At the end of the follow-up examinations, the FIM score of patients in the IMA group was 74.5 points and 22 points in the EMA group (p = 0.07).

The study showed that no arthrodesis procedure is obviously superior with respect to the postoperative outcome. The IMA combines advantages especially in the early phase after surgery in terms of function as well as patient comfort and is therefore currently the procedure of choice. The attending physician should be familiar with the advantages and disadvantages of the various procedures in order to be able to make an individual decision and thus maximize the chance of treatment success.

• Debridement
• Gonarthrosis
• Periprosthetic infection
• Retrospective study
• Total knee arthroplasty

• Articulating
• Bone loss
• Infection
• Spacer
• Static
• Two-stage revision

• Anti-Bacterial Agents/therapeutic use
• Arthroplasty, Replacement, Knee
• Bone Cements/therapeutic use
• Humans
• Knee Prosthesis
• Prosthesis-Related Infections/surgery
• Quality of Life
• Reoperation
• Treatment Outcome

• Knee
• Septic arthritis
• Spacer
• Two-staged joint replacement

• Aged
• Anti-Bacterial Agents/administration & dosage
• Arthritis, Infectious/physiopathology
• Arthritis, Infectious/surgery
• Arthroplasty, Replacement, Knee/methods
• Bone Cements
• Debridement
• Female
• Humans
• Knee Joint/physiopathology
• Knee Joint/surgery
• Male
• Middle Aged
• Range of Motion, Articular
• Tibia
• Treatment Outcome

• MRI
• Osteoarthritis
• Primary
• Septic knee
• Stage
• TKR

• antibiotic-loaded bone cement
• periprosthetic joint infection
• postinfectious osteoarthritis
• septic arthritis
• total knee arthroplasty

• Arthroscopy
• Arthrotomy
• Artritis séptica
• Artroscopia
• Artrotomía
• Debridement
• Desbridamiento
• Prótesis total de rodilla
• Septic arthritis
• Total knee replacement

• End-stage degenerative joint disease
• Joint arthroplasty
• Septic arthritis
• Two-stage exchange arthroplasty

• Arthritis
• Arthroscopy
• Infection
• Outcomes
• Total knee arthroplasty

• Aged
• Aged, 80 and over
• Arthritis, Infectious/surgery
• Arthroplasty, Replacement, Knee/methods
• Arthroscopy
• Bone Cements
• Female
• Humans
• Male
• Middle Aged
• Patient Reported Outcome Measures
• Prostheses and Implants
• Range of Motion, Articular
• Recurrence
• Retrospective Studies
• Visual Analog Scale

The usual treatment of septic shoulder arthritis consists of arthroscopic or open lavage and debridement. However, in patients with advanced osteoarthritic changes and/or massive rotator cuff tendon tears, infection eradication can be challenging to achieve and the functional outcome is often not satisfying even after successful infection eradication. In such cases a two-stage approach with initial resection of the native infected articular surfaces, implantation of a cement spacer before final treatment with a total shoulder arthroplasty in a second stage is gaining popularity in recent years with the data in literature however being still limited.

To evaluate the results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint.

We retrospectively included five consecutive patients over a five-year period and evaluated the therapeutic management and the clinical outcome assessed by disability of the arm, shoulder and hand (DASH) score and subjective shoulder value (SSV). All procedures were performed through a deltopectoral approach and consisted in a debridement and synovectomy, articular surface resection and insertion of a custom made antibiotic enriched cement spacer. Shoulder arthroplasty was performed in a second stage.

Mean age was 61 years (range, 47-70 years). Four patients had previous surgeries ahead of the septic arthritis. All patients had a surgical debridement ahead of the index procedure. Mean follow-up was 13 mo (range, 6-24 mo). Persistent microbiological infection was confirmed in all five cases at the time of the first stage of the procedure. The shoulder arthroplasties were performed 6 to 12 wk after insertion of the antibiotic-loaded spacer. There were two hemi and three reverse shoulder arthroplasties. Infection was successfully eradicated in all patients. The clinical outcome was satisfactory with a mean DASH score and SSV of 18.4 points and 70% respectively.

Short interval two-stage approach for septic shoulder arthritis is an effective treatment option. It should nonetheless be reserved for selected patients with advanced disease in which lavage and debridement have failed.

• Septic arthritis
• Shoulder
• Arthroplasty
• Spacer
• Antibiotic
• Enriched
• Infection
• Native joint

The treatment strategy for evolutive septic arthritis (SA) with coexistent degenerative joint disease is not well established. The purposes of this study were to 1) investigate treatment outcome and potential risk factors of treatment failure in patients with evolutive SA following two-stage procedure, including insertion of an antibiotic-loaded spacer at the first stage and subsequent implantation of a new prosthesis; and 2) determine the performance of serum erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and Interleukin-6 (IL-6) in predicting persisting infection at second-stage procedure.

We retrospectively reviewed 74 patients with evolutive SA of hips and knees who underwent a two-stage TJA between 2008 and 2015. The treatment success was defined according to the modified Delphi criteria and Kaplan-Meier survivorship curves were constructed to determine treatment success. A Cox regression model was performed to identify risk factors for treatment failure. Receiver operating characteristic (ROC) curves were generated to determine the prognostic value of ESR, CRP, and IL-6 in predicting persistent infection before second-stage prostheses implantation.

Overall, the treatment success rate was 93% for hips and 100% for knees after the first-stage surgery. The treatment success rate was 89% for hips and 84% for knees after second-stage prosthesis implantation with a mean follow-up of 4.7 (range, 2.2 to 10.8) years. Older age (Hazard ratio [HR] [per 10-year increase], 1.20; 95% confidential interval [CI], 1.11 to 1.62), higher preoperative CRP level (HR [per 1-mg/dL increase], 1.15; 95% CI, 1.04 to 1.28) and resistant organism (HR, 13.96; 95% CI, 3.29 to 19.20) were associated with an increased risk of treatment failure. All serologic tests presented limited values in predicting persisting infection, with the area under ROC curve of ESR, CRP, IL-6 and combination of the three markers was 57.8, 61.6, 60.3, and 62.1%, respectively.

Two-stage TJA is an adequate management of infection control in patients with evolutive SA. The three potential risk factors (old age, high preoperative CRP, and resistant organism profile) may predict treatment failure following a two-stage procedure for evolutive SA. Additionally, serum ESR, CRP, and IL-6 had no benefit in predicting persisting infection before second-stage prostheses implantation. These findings may be useful when treating patients with evolutive SA.

• C-reactive protein
• Erythrocyte sedimentation rate
• Interleukin-6
• Septic arthritis
• Total joint arthroplasty

Antibiotic-impregnated articulating cement spacers can maintain interim joint motion with the potential to enhance functional status and improve patient satisfaction. Articular surfaces with cement against cement have raised concerns regarding mechanical complications and cement debris during knee motion. However, long-term clinical conditions regarding these concerns are not well addressed.

We report a case in which articulating cement spacers were maintained in situ for 7 years. The patient had severe left knee pain with an ankylosing knee and severe tricompartmental arthritis due to tuberculous infection. We planned to perform one- or two-stage primary total knee arthroplasty (TKA), depending on the presence of infection. Persistent osteomyelitis was found intraoperatively. The second-stage TKA was delayed on the patient’s request. As the patient was satisfied with the improved knee function and pain relief after using articulating cement spacers. No symptom or sign that suggested recurrent infection or systemic toxicity was found during the 7-year follow-up. However, it seemed that the bone loss progressed insidiously. At the 7-year follow-up, a broken articulating cement spacer and medial femoral condylar fracture were found. The second-stage TKA was performed, and a considerable amount of bone loss surrounded by dense granulation tissue was observed intraoperatively. Excisional biopsy of the tissue revealed chronic foreign body reaction with infiltration of giant cells and macrophages.

Although the articular spacers were maintained for 7 years without major complications, regular observation of the development and progress of bone loss was required. Surgeons should take considerable bone loss into account during conversion TKA in patients with a prolonged retention of articulating cement spacers.

• Articulating spacer
• Infection
• Retention
• Total knee arthroplasty

• C-reactive protein (CRP)
• active septic arthritis
• arthroscopy
• aseptic failure
• erythrocyte sedimentation rate (ESR)
• fungal arthritis
• joint arthroplasty
• joint infection risk
• osteomyelitis
• outpatient arthroplasty
• outpatient total joint arthroplasty
• periprosthetic joint infection (PJI) risk
• preoperative screening
• prior arthroscopy
• septic arthritis
• surgical site infection (SSI) risk
• total hip arthroplasty
• total knee arthroplasty
• tubercular arthritis

• Outcome
• Periprosthetic joint infection
• Quality of life
• Spacer
• Total knee arthroplasty
• Two-stage revision

• Infection
• Periprosthetic joint infection
• Sonication
• Total knee arthroplasty

• Arthroplasty, Replacement, Hip
• Arthroplasty, Replacement, Knee
• Humans
• Joint Prosthesis/microbiology
• Prognosis
• Prosthesis-Related Infections

• Candida
• arthroplasty
• methicillin-resistant Staphylococcus aureus
• prosthetic joint infection

• Antibiotic-impregnated cement spacer
• Colistin
• Infected arthritic knee
• Two-stage approach
• Vancomycin-resistant Pseudomonas aeruginosa

• Mycobacterium abscessus
• Non-tuberculous mycobacteria
• Prosthetic joint infection
• Rapidly growing mycobacteria

• Arthroplasty
• Drug Resistance
• Joint
• Microbial
• Prosthesis-Related Infections
• Revision
• Total Hip Arthroplasty
• Total Knee Arthroplasty

• Knee
• Septic osteoarthritis
• Short interval
• TKR
• Total knee arthroplasty
• Total knee replacement
• Two-stage TKA

Total joint arthroplasty is one of the most frequent and effective surgeries today. However, despite improved surgical techniques, a significant number of implant-associated infections still occur. Suitable in vitro models are needed to test potential approaches to prevent infection. In the present study, we aimed to establish an in vitro co-culture setup of human primary osteoblasts and S. epidermidis to model the onset of implant-associated infections, and to analyze antimicrobial implant surfaces and coatings.

For initial surface adhesion, human primary osteoblasts (hOB) were grown for 24 hours on test sample discs made of polystyrene, titanium alloy Ti6Al4V, bone cement PALACOS R^®, and PALACOS R^® loaded with antibiotics. Co-cultures were performed as a single-species infection on the osteoblasts with S. epidermidis (multiplicity of infection of 0.04), and were incubated for 2 and 7 days under aerobic conditions. Planktonic S. epidermidis was quantified by centrifugation and determination of colony-forming units (CFU). The quantification of biofilm-bound S. epidermidis on the test samples was performed by sonication and CFU counting. Quantification of adherent and vital primary osteoblasts on the test samples was performed by trypan-blue staining and counting. Scanning electron microscopy was used for evaluation of topography and composition of the species on the sample surfaces.

After 2 days, we observed approximately 10⁴ CFU/ml biofilm-bound S. epidermidis (10³ CFU/ml initial population) on the antibiotics-loaded bone cement samples in the presence of hOB, while no bacteria were detected without hOB. No biofilm-bound bacteria were detectable after 7 days in either case. Similar levels of planktonic bacteria were observed on day 2 with and without hOB. After 7 days, about 10⁵ CFU/ml planktonic bacteria were present, but only in the absence of hOB. Further, no bacteria were observed within the biofilm, while the number of hOB was decreased to 10% of its initial value compared to 150% in the mono-culture of hOB.

We developed a co-culture setup that serves as a more comprehensive in vitro model for the onset of implant-associated infections and provides a test method for antimicrobial implant materials and coatings. We demonstrate that observations can be made that are unavailable from mono-culture experiments.

• Antibiotics
• Biomaterials
• Drug delivery
• Osteomyelitis
• Staphylococcus aureus

• Cement
• Infection
• Revision total knee arthroplasty
• Spacer
• Treatment