The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 83, Issue 2 suppl 2

Scientific Article | November 01, 2001

Temporary Articulating Methylmethacrylate Antibiotic Spacer (TAMMAS) : A New Method of Intraoperative Manufacturing of a Custom Articulating Spacer

Wayne M. Goldstein, MD; Matthew Kopplin, MD; Robin Wall, MSPA-C; Kimberly Berland, CST-FA

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Wayne M. Goldstein, MD
Robin Wall, MS, PA-C
Kimberly Berland, CST-FA
The Center for Orthopaedic Surgery, Illinois Bone and Joint Institute, 150 North River Road, Suite 100, Des Plaines, IL 60016

Matthew Kopplin, MD
Department of Orthopaedics, University of Illinois at Chicago, 209 Medical Sciences South, 901 South Wolcott Avenue, Chicago, IL 60612-7342

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from DePuy. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2001 Nov 01;83(2 suppl 2):S92-97

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Abstract

Abstract

A temporary articulating antibiotic-impregnated cement spacer for use during the first stage of a two-stage revision of a total knee replacement that had failed because of infection was developed by one of us (W.M.G.). It is simply a knee prosthesis made of methylmethacrylate and antibiotics that is manufactured intraoperatively with use of instruments, medications, and supplies that are already available at most hospitals. This construct allows for motion of the knee during treatment of the infection, thereby reducing the risk of loss of motion after subsequent revision. The technique has been successfully utilized in five patients since 1999 and has now become our standard treatment method.

Figures in this Article

Introduction

Introduction | Methods | Results | Conclusion | References

It has become standard practice to treat patients with an infection at the site of a total knee arthroplasty with a two-stage procedure. The prosthesis is removed, osseous and soft tissues are debrided, and a temporary antibiotic-delivering spacer is placed at the site of removal. After the infection has resolved, a revision total knee arthroplasty is performed. Traditionally, spacers are molded by hand to the thickness of the extension space. They are frequently a single block anchored by a molded tibial stem. Also, additional methylmethacrylate is often placed between the patella and the anterior aspect of the femur to prevent adherence of the extensor mechanism. Unfortunately, shifting of the spacer can cause bone loss. More importantly, motion can be lost as the knee is held in continuous extension during the treatment period. The results of the revision procedure, after the infection has resolved, have been less satisfactory than the results of revisions for aseptic failure. A major contributing factor to unsatisfactory outcomes is limited range of motion¹.

Strategies to maintain motion have been introduced by many authors. Hofmann et al. reported good results, with preservation of motion, after use of a temporary articulating system composed of a metal femoral component, polyethylene tibial and patellar components, and antibiotic-impregnated methylmethacrylate¹. Haddad et al. described the results of a two-stage procedure involving the use of special, small femoral and tibial implants made of metal and polyethylene, respectively, in combination with antibiotic-loaded cement². In forty-one of forty-five patients, the infection was eradicated and motion was maintained. However, both of these approaches leave foreign material in the infected joint space to which bacteria may adhere. Although the results of the above procedures have been good, a technique that preserves motion without leaving behind foreign material that might compromise the eradication of the infection would be superior.

McPherson et al. utilized a temporary articulating system consisting entirely of antibiotic-impregnated cement³. No metallic or polyethylene foreign material was left in the joint. No outcomes were reported. This approach requires technical perfection. As premature cement placement could result in interdigitation of the cement into the cancellous bone, waiting until the cement is sufficiently thick may result in poor conformity of the implant and a loose fit. Only with perfect cement technique is bone loss minimized. Improvements in this technique would allow better conformity while preventing interdigitation of cement.

Fehring et al. measured no appreciable bone loss in thirty consecutive infected knees treated with an antibiotic-impregnated articulating spacer⁴. They also found that the spacers facilitated reimplantation without an added risk of infection.

With these experiences in mind, we set out to improve intraoperative techniques in order to optimize the production of an articulating spacer.

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Fig. 1:: Molding of the foil over the distal part of the femur.

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Fig. 2:: Application of the cement to the femoral foil.

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Fig. 3:: Shaping of the cement on the femoral foil.

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Fig. 4:: Molding of the femoral condyles with use of a tibial insert.

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Fig. 5:: Final femoral TAMMAS in place.

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Fig. 6:: Measuring the thickness of the tibial TAMMAS compared with the trial insert.

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Fig. 7:: Trimming of excess cement from the tibial TAMMAS.

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Fig. 8:: Final femoral and tibial TAMMAS components in place.

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Color Map for Figs. 7 and 8

Methods

Introduction | Methods | Results | Conclusion | References

The knee is prepared by obtaining fluid and tissue specimens for culture, removing the prosthesis and all foreign material, performing a synovectomy, and finally performing copious lavage with saline solution. Conforming of sterilized, heavy aluminum foil to the distal part of the femur creates a femoral spacer, which includes all osseous defects (Fig. 1). The foil prevents interdigitation of the cement and bone, minimizing later bone loss. The foil is then coated with a sterile lubricant to facilitate easy separation from the cement. Palacos-brand cement is used because of its superior antibiotic elution characteristics. Antibiotic-impregnated cement is applied to the foil and formed in the shape of a femoral component, approximately 10 mm thick (Figs. 2 and 3). A plastic trial tibial insert is then used to mold the cement, forming an articulating surface (Fig. 4). After the cement hardens, the foil is removed, and the spacer is fitted onto the distal part of the femur (Fig. 5). A tibial component is formed in a similar fashion, creating a thickness appropriate to maintain soft-tissue tension (Fig. 6). When the cement hardens, the foil is removed, the spacer is trimmed if necessary (Fig. 7), and the implant is placed in the knee (Fig. 8 (color map)). Stability is checked, and motion is allowed to approximately 45° of flexion.

Results

Introduction | Methods | Results | Conclusion | References

This technique has been used in five two-stage revision total knee procedures. The implant does not shift within the knee because of the femoral spacer’s congruity with the distal part of the femur and its articulation with the tibial spacer. This technique allows motion, touch-down weight-bearing, and preservation of bone stock.

Conclusion

Introduction | Methods | Results | Conclusion | References

The temporary articulating methylmethacrylate antibiotic spacer (TAMMAS) is a simple alternative to conventional methylmethacrylate spacers. The TAMMAS allows knee motion, improving the final outcome. All required materials are readily available in most hospitals, and the procedure can be performed without the use of molds or special implants. No metallic foreign body that might compromise eradication of infection is retained.

References

Introduction | Methods | Results | Conclusion | References

HofmannAA, Kane KR, Tkach TK, Plaster RL,Camargo MP. Treatment of infected total knee arthroplasty using an articulating spacer. Clin Orthop,1995;321: 45-54. 32145 1995 [PubMed]

HaddadFS, Masri BA, Campbell D, McGraw RW, Beauchamp CP,Duncan CP. The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Prosthesis of antibiotic-loaded acrylic cement. J Bone Joint Surg Br,2000;82: 807-12. 82807 2000 [PubMed]

McPhersonEJ, Lewonowski K,Dorr LD. Techniques in arthroplasty. Use of an articulated PMMA spacer in the infected total knee arthroplasty. J Arthroplasty,1995;10: 87-9. 1087 1995 [PubMed]

FehringTK, Odum S, Calton TF,Mason JB. Articulating versus static spacers in revision total knee arthroplasty for sepsis. Clin Orthop,2000;380: 9-16. 3809 2000 [PubMed]

Topics

antibiotics ; femur ; methylmethacrylate ; infection ; antibiotics, implantable ; spacer device

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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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Wayne M. Goldstein, Matthew Kopplin, Robin Wall, Kimberly Berland; Temporary Articulating Methylmethacrylate Antibiotic Spacer (TAMMAS) A New Method of Intraoperative Manufacturing of a Custom Articulating Spacer. The Journal of Bone & Joint Surgery. 2001 Nov;83(2_suppl_2):S92-97.

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