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Intramedullary knee spacer in 2-stage revision knee surgery with segmental bone loss: a technical note involving 6 cases.

Schrøder HM, Petersen MM - Acta Orthop (2012)

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery U-2162, Rigshospitalet, University Hospital of Copenhagen, Denmark.

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In 2-stage revision knee surgery ending with a tumor prosthesis, the bone loss is so large that in the interim period the patient can be treated with (1) rest in bed with or without skeletal traction, (2) external fixation, or (3) a custom-made spacer... Between 2006 and 2008, we operated 6 selected patients with this new spacer technique. 5 of the patients had an infected revision knee arthroplasty (Figure 1) and 1 had a posttrauma-infected distal femoral pseudarthrosis (Figure 2)... The patient was reoperated, but the spacer fractured again and the knee was left with considerable shortening in a plaster for 2.5 months before successful implantation of a tumor prosthesis... This heavy male patient did not respect our advice not to bear full weight and for a period was considered a candidate for amputation... Apart from the patient with a fractured spacer, no reoperations were needed before reimplantation; 5 patients had a GMRS tumor prosthesis (Stryker) and 1 had a MEGA-C tumor prosthesis (Valdemar Link). 2 patients died: 1 died 5 weeks postoperatively and 1 died 5 years postoperatively... Both were free of infection and died because of cardiac disease. 4 patients are still alive (as of December 2011) and free of infection. 2 patients have been reoperated after reimplantation, both after about 1 year (1 aseptic loosening of the femoral stem and 1 breakage of a femoral stem connection)... We consider the present spacer technique to be safe, as all infections were cured... Amputation is sometimes considered in patients with persistent periprosthetic or posttraumatic infection of the knee despite several operations, and is indeed an effective operation regarding cure of infection... However, mobility decreases, and a tumor prosthesis actually gives good functional results (Berend and Lombardi 2010) and even seems to be cost effective compared to amputation... On the basis of our early experience, we recommend that the 2 nails be inserted in press-fit without the use of locking screws... The connection of the free ends of the nails can be reinforced with 1 or 2 screws before applying cement, but can also be connected with wires... The trick is to secure the leg length before cementing... In conclusion, the present intramedullary knee spacer appears to be an effective, safe, and patient-friendly method at the first stage of 2-stage revisions, where bone loss is so large that a tumor prosthesis will be needed at stage 2.

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A 37-year-old man with an infected pseudartrosis. A. Preoperatively; pseudarthrosis of the distal femur. B. Spacer inserted after revision, with resection of all infected and dead bone. C. After stage 2 (one year postoperatively), with tumor prosthesis inserted.
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Figure 2: A 37-year-old man with an infected pseudartrosis. A. Preoperatively; pseudarthrosis of the distal femur. B. Spacer inserted after revision, with resection of all infected and dead bone. C. After stage 2 (one year postoperatively), with tumor prosthesis inserted.

Mentions: A thigh tourniquet was used if possible. An anterior incision extending proximally was done, extending the old incision. After thorough debridement with removal of hardware, all infected and/or necrotic bone was resected. Remaining tibial and femoral canals were reamed and sized with pulse lavage irrigation before and after reaming. Retrograde femoral IM nails (AO) were inserted by press-fit in the full lengths of the femoral and tibial canals under fluoroscopic guidance. In the first 2 cases, 1 of the nails was locked; in the last 4 cases, no locking screws were used. Thereafter, the assistant pulled the leg into maximum possible length while the free ends of the nails were cemented together using 3–5 portions of bone cement as a spacer between the femur and tibia. In 4 cases, the nails inserted were so long that the free ends could be connected with 1 or 2 screws through the locking holes before cementing. After cementing, all metal between the bony ends of the femur and tibia was covered with cement, but no cement was put into the canals. The spacer was thus made of 2 retrograde intramedullary nails, preferably connected with 1 or 2 screws or wires, and the “free ends” of the nails were embedded in cement (Refobacin Revision; Biomet) (Figures 1 and 2), which contained clindamicin and gentamicin. Amphotericin B was added in a patient with candida infection. The patients were mobilized with 2 crutches and toe-touch weight bearing. A softcast cylinder was optional during mobilization.


Intramedullary knee spacer in 2-stage revision knee surgery with segmental bone loss: a technical note involving 6 cases.

Schrøder HM, Petersen MM - Acta Orthop (2012)

A 37-year-old man with an infected pseudartrosis. A. Preoperatively; pseudarthrosis of the distal femur. B. Spacer inserted after revision, with resection of all infected and dead bone. C. After stage 2 (one year postoperatively), with tumor prosthesis inserted.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3369161&req=5

Figure 2: A 37-year-old man with an infected pseudartrosis. A. Preoperatively; pseudarthrosis of the distal femur. B. Spacer inserted after revision, with resection of all infected and dead bone. C. After stage 2 (one year postoperatively), with tumor prosthesis inserted.
Mentions: A thigh tourniquet was used if possible. An anterior incision extending proximally was done, extending the old incision. After thorough debridement with removal of hardware, all infected and/or necrotic bone was resected. Remaining tibial and femoral canals were reamed and sized with pulse lavage irrigation before and after reaming. Retrograde femoral IM nails (AO) were inserted by press-fit in the full lengths of the femoral and tibial canals under fluoroscopic guidance. In the first 2 cases, 1 of the nails was locked; in the last 4 cases, no locking screws were used. Thereafter, the assistant pulled the leg into maximum possible length while the free ends of the nails were cemented together using 3–5 portions of bone cement as a spacer between the femur and tibia. In 4 cases, the nails inserted were so long that the free ends could be connected with 1 or 2 screws through the locking holes before cementing. After cementing, all metal between the bony ends of the femur and tibia was covered with cement, but no cement was put into the canals. The spacer was thus made of 2 retrograde intramedullary nails, preferably connected with 1 or 2 screws or wires, and the “free ends” of the nails were embedded in cement (Refobacin Revision; Biomet) (Figures 1 and 2), which contained clindamicin and gentamicin. Amphotericin B was added in a patient with candida infection. The patients were mobilized with 2 crutches and toe-touch weight bearing. A softcast cylinder was optional during mobilization.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery U-2162, Rigshospitalet, University Hospital of Copenhagen, Denmark.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

In 2-stage revision knee surgery ending with a tumor prosthesis, the bone loss is so large that in the interim period the patient can be treated with (1) rest in bed with or without skeletal traction, (2) external fixation, or (3) a custom-made spacer... Between 2006 and 2008, we operated 6 selected patients with this new spacer technique. 5 of the patients had an infected revision knee arthroplasty (Figure 1) and 1 had a posttrauma-infected distal femoral pseudarthrosis (Figure 2)... The patient was reoperated, but the spacer fractured again and the knee was left with considerable shortening in a plaster for 2.5 months before successful implantation of a tumor prosthesis... This heavy male patient did not respect our advice not to bear full weight and for a period was considered a candidate for amputation... Apart from the patient with a fractured spacer, no reoperations were needed before reimplantation; 5 patients had a GMRS tumor prosthesis (Stryker) and 1 had a MEGA-C tumor prosthesis (Valdemar Link). 2 patients died: 1 died 5 weeks postoperatively and 1 died 5 years postoperatively... Both were free of infection and died because of cardiac disease. 4 patients are still alive (as of December 2011) and free of infection. 2 patients have been reoperated after reimplantation, both after about 1 year (1 aseptic loosening of the femoral stem and 1 breakage of a femoral stem connection)... We consider the present spacer technique to be safe, as all infections were cured... Amputation is sometimes considered in patients with persistent periprosthetic or posttraumatic infection of the knee despite several operations, and is indeed an effective operation regarding cure of infection... However, mobility decreases, and a tumor prosthesis actually gives good functional results (Berend and Lombardi 2010) and even seems to be cost effective compared to amputation... On the basis of our early experience, we recommend that the 2 nails be inserted in press-fit without the use of locking screws... The connection of the free ends of the nails can be reinforced with 1 or 2 screws before applying cement, but can also be connected with wires... The trick is to secure the leg length before cementing... In conclusion, the present intramedullary knee spacer appears to be an effective, safe, and patient-friendly method at the first stage of 2-stage revisions, where bone loss is so large that a tumor prosthesis will be needed at stage 2.

Show MeSH
Related in: MedlinePlus