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Use of Static or Articulating Spacers for Infection Following Total Knee ArthroplastyA Systematic Literature Review
Pramod B. Voleti, MD1; Keith D. Baldwin, MD, MSPT, MPH1; Gwo-Chin Lee, MD1
1 Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104. E-mail address for G.-C. Lee: Gwo-Chin.Lee@uphs.upenn.edu
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Investigation performed at the Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Sep 04;95(17):1594-1599. doi: 10.2106/JBJS.L.01461
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Abstract

Background: 

The so-called gold standard for treatment of periprosthetic joint infection following total knee arthroplasty is two-stage reimplantation. However, it is unclear whether use of static or articulating antibiotic-impregnated spacers during the interim period between these two stages is superior. The purpose of this study was to compare the outcomes of static and articulating spacers in the treatment of infection following total knee arthroplasty.

Methods: 

A systematic review of the peer-reviewed literature indexed by MEDLINE and Embase was performed to identify studies reporting the outcomes of antibiotic spacers in the treatment of infection following total knee arthroplasty. Seven Level-III comparative studies and thirty-two Level-IV case series remained following the screening process. The data in these studies were extracted and aggregated to compare the reinfection rate, range of knee motion, functional scores, and complication rates between static and articulating spacers.

Results: 

The two types of spacers demonstrated similar reinfection rates (7% for articulating and 12% for static, p = 0.2). However, the articulating spacers resulted in significantly greater range of knee motion after reimplantation (101° for articulating and 91° for static, p = 0.0002). Despite this difference in ultimate knee motion, functional scores in the treatment groups were similar. Rates of wound-related and spacer-related complications were similarly low with both types of spacers.

Conclusions: 

Our review failed to identify a significant difference in the ability of static or articulating spacers to eradicate periprosthetic infection following total knee arthroplasty. Compared with static spacers, articulating spacers provided improved knee motion following reimplantation, although functional scores were similar in the two treatment groups. We encourage arthroplasty surgeons to consider both static and articulating spacers in the treatment of infection following total knee arthroplasty and to tailor treatment on the basis of patient-related factors.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Mustafa Citak*, Thorsten Gehrke*, Javad Parvizi** and Daniel Kendoff*
    Posted on December 02, 2013
    Outcomes of two-stage-exchange arthroplasty in the treatment of infected knee prostheses
    *Department of Orthopaedics, Helios ENDO-Klinik Hamburg, Germany and **Department of Orthopaedics, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA

    We congratulate Voleti and colleagues on the publication of their paper and respect that it is a well-conducted systematic literature review. In their meta-analysis, the authors included 39 published articles (7 Level III and 32 Level IV) including a total number of 1526 cases. The authors found a similar reinfection rate between articulating and non-articulating spacers with reinfection rates of 8% and 12%, respectively. They found, however, a significant higher range of motion (ROM) with a mean of 101° with the use of an articulating spacer compared to the use of non-articulating spacers with a mean of 91°.

    Prior to the International Consensus Meeting on periprosthetic joint infection (Thomas Jefferson University, Philadelphia, USA, July 31st- August 1st 2013), we performed also among others a meta-analysis on the results of articulating and non-articulating spacers in the treatment of periprosthetic knee infection and created a preliminary draft of the consensus statement. In our literature review, we included an overall number of 46 original articles (excluding case reports, review articles, and technical reports) including 4 level 2, 8 level 3, and 34 level 4 studies related to the use of knee spacers[1-46].

    More than 300 delegates from 54 countries voted on the questions/consensus statements on August 1st 2013 in Philadelphia, USA. The voting process was conducted using electronic keypads, where one could agree with the consensus statement, disagree with the consensus statement, or abstain from voting. The strength of the consensus was judged by the following scale: 1) Simple Majority: No Consensus (50.1-59% agreement), 2) Majority: Weak Consensus (60-65% agreement), 3) Super Majority: Strong Consensus (66-99% agreement) and 4) Unanimous: 100% agreement.

    Regarding infection control, approximately 90 % of the delegates agreed to our following consensus statement: "The type of spacer does not influence the rate of infection eradication in two-stage exchange arthroplasty of the knee". This statement was classified as a "strong consensus". Analyzing the infection control, we included 1,557 cases treated with articulating spacers and 601 cases treated with non-articulating spacers. The eradication rate using an articulating spacer was 91.5% (132 cases of reinfection), while infection control could be achieved in 87.0% (78 cases of reinfection) using a non-articulating spacer.

    Regarding function, our consensus statement differs from the study results by Voleti and colleagues. Our defined consensus statement "There is a non-significant trend in range of motion improvement with articulating compared to non-articulating spacers, but the panels believes that this is still of value to the patient" was validated by the delegates as a "strong consensus" (82 % agreed). Analyzing the function, we included a total of 1669 cases (articulating spacer n=1195; non-articulating spacer n=474) with a mean follow-up of 44.3 months for articulating and 51.6 months for non-articulating spacers.

    In summary, we congratulate again Voleti and colleagues for their terrific work. However, based on our results, there is a non-significant trend in range of motion improvement with articulating compared to non-articulating spacers in the treatment of an infected knee prosthesis. We also conclude that the type of spacer does not influence the infection control as found by Voleti and colleagues. The strength of our data is the validation of the results from more than 300 experts in this field from 54 countries. However, it must be noted that the level of evidence of the current literature on the outcomes of two-stage-exchange arthroplasty in the treatment of infected knee prostheses is still terrifying. Further studies with higher levels of evidence are warranted to elucidate the optimal treatment protocol for periprosthetic joint infection following total knee arthroplasty..

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