Skip to main content
SpringerLink
Log in

Articulating Spacers Used in Two-stage Revision of Infected Hip and Knee Prostheses Abrade with Time

  • Basic Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Articulating spacers used in two-stage revision surgery of infected prostheses have the potential to abrade and subsequently induce third-body wear of the new prosthesis.

Questions/purposes

We asked whether particulate material abraded from spacers could be detected in the synovial membrane 6 weeks after implantation when the spacers were removed for the second stage of the revision.

Patients and Methods

Sixteen hip spacers (cemented prosthesis stem articulating with a cement cup) and four knee spacers (customized mobile cement spacers) were explanted 6 weeks after implantation and the synovial membranes were removed at the same time. The membranes were examined by xray fluorescence spectroscopy, xray diffraction for the presence of abraded particles originating from the spacer material, and analyzed in a semiquantitative manner by inductively coupled plasma mass spectrometry. Histologic analyses also were performed.

Results

We found zirconium dioxide in substantial amounts in all samples, and in the specimens of the hip synovial lining, we detected particles that originated from the metal heads of the spacers. Histologically, zirconium oxide particles were seen in the synovial membrane of every spacer and bone cement particles in one knee and two hip spacers.

Conclusions

The observations suggest cement spacers do abrade within 6 weeks. Given the presence of abrasion debris, we recommend total synovectomy and extensive lavage during the second-stage reimplantation surgery to minimize the number of abraded particles and any retained bacteria.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2A–B
Fig. 3
Fig. 4A–C
Fig. 5A–B

Similar content being viewed by others

References

  1. Affatato S, Mattarozzi A, Taddei P, Robotti P, Soffiatti R, Sudanese A, Toni A. Investigations on the wear behaviour of the temporary PMMA-based hip Spacer-G. Proc Inst Mech Eng H. 2003;217:1–8.

    PubMed  CAS  Google Scholar 

  2. Ammann AA. Inductively coupled plasma mass spectrometry (ICP MS): a versatile tool. J Mass Spectrom. 2007;42:419–427.

    Article  PubMed  CAS  Google Scholar 

  3. Burch RE, Hahn HK. Trace elements in human nutrition. Med Clin North Am. 1979,63:1057–1068.

    PubMed  CAS  Google Scholar 

  4. Burnett RS, Kelly MA, Hanssen AD, Barrack RL. Technique and timing of two-stage exchange for infection in TKA. Clin Orthop Relat Res. 2007;464:164–178.

    PubMed  Google Scholar 

  5. Calton TF, Fehring TK, Griffin WL. Bone loss associated with the use of spacer blocks in infected total knee arthroplasty. Clin Orthop Relat Res. 1997;345:148–154.

    Article  PubMed  Google Scholar 

  6. Caravia L. Dowson D, Fisher J, Jobbins B. The influence of bone and bone cement debris on counterface roughness in sliding wear tests of ultra-high molecular weight polyethylene on stainless steel. Proc Inst Mech Eng H. 1990;204:65–70.

    Article  PubMed  CAS  Google Scholar 

  7. Cui Q, Mihalko WM, Shields JS, Ries M, Saleh KJ. Antibiotic-impregnated cement spacers for the treatment of infection associated with total hip or knee arthroplasty. J Bone Joint Surg Am. 2007;89:871–882.

    Article  PubMed  Google Scholar 

  8. Donath K, Breuner G. A method for the study of undecalcified bones and teeth with attached soft tissues: the Säge-Schliff (sawing and grinding) technique. J Oral Pathol. 1982;11:318–326.

    Article  PubMed  CAS  Google Scholar 

  9. Evans RP. Successful treatment of total hip and knee infection with articulating antibiotic components: a modified treatment method. Clin Orthop Relat Res. 2004;427:37–46.

    Article  PubMed  Google Scholar 

  10. Fehring TK, Odum S, Calton TF, Mason JB. Articulating versus static spacers in revision total knee arthroplasty for sepsis: the Ranawat Award. Clin Orthop Relat Res. 2000;380:9–16.

    Article  PubMed  Google Scholar 

  11. Fink B, Grossmann A, Fuerst M, Schäfer P, Frommelt L. Two-stage cementless revision of infected hip endoprostheses. Clin Orthop Relat Res. 2009;467:1848–1858.

    Article  PubMed  Google Scholar 

  12. Fitzgerald RH Jr. Infected total hip arthroplasty: diagnosis and treatment. J Am Acad Orthop Surg. 1995;3:249–262.

    PubMed  Google Scholar 

  13. Freeman MG, Fehring TK, Odum SM, Fehring K, Griffin WL, Mason JB. Functional advantage of articulating versus static spacers in 2-stage revision for total knee arthroplasty infection. J Arthroplasty. 2007;22:1116–1121.

    Article  PubMed  Google Scholar 

  14. Garvin KL, Evans BG, Salvati EA, Brause BD. Palacos gentamicin for the treatment of deep periprosthetic hip infections. Clin Orthop Relat Res. 1994;298:97–105.

    PubMed  Google Scholar 

  15. Garvin KL, Hanssen AD. Infection after total hip arthroplasty: past, present, and future. J Bone Joint Surg Am. 1995;77:1576–1588.

    PubMed  CAS  Google Scholar 

  16. Goldman RT, Scuderi GR, Insall JN. 2-stage reimplantation for infected total knee replacement. Clin Orthop Relat Res. 1996;331:118–124.

    Article  PubMed  Google Scholar 

  17. Goldstein WM, Kopplin M, Wall R, Berland K. Temporary articulating methylmethacrylate antibiotic spacer (TAMMAS): a new method of intraoperative manufacturing custom articulating spacer. J Bone Joint Surg Am. 2001;83(suppl 2, pt 2):92–97.

    Google Scholar 

  18. Haddad FS, 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;82:807–812.

    Article  PubMed  CAS  Google Scholar 

  19. Haddad FS, Muirhead-Allwood SK, Manktelow AR, Bacarese-Hamilton I. Two-stage uncemented revision hip arthroplasty for infection. J Bone Joint Surg Br. 2000;82:689–694.

    Article  PubMed  CAS  Google Scholar 

  20. Hahn M. Quantitative analysis of the histological reactions at the interface and the surrounding bone tissue following the implantation of hip endoprostheses. In: Barbosa MA, Campilho A, eds. Imaging Techniques in Biomaterials. Amsterdam, The Netherlands: North-Holland/Elsevier Science Publishers; 1994:325–340.

  21. Hahn M, Vogel M, Delling G. Undecalcified preparation of bone tissue: report of technical experience and development of new methods. Virchows Arch A Pathol Anat Histopathol 1991;418:1–7.

    Article  PubMed  CAS  Google Scholar 

  22. Hanssen AD, Osmon DR. Evaluation of a staging system for infected hip arthroplasty. Clin Orthop Relat Res. 2002;403:16–22.

    Article  PubMed  Google Scholar 

  23. Hofmann AA, Goldberg TD, Tanner AM, Cook TM. Ten-year experience using an articulating antibiotic cement hip spacer for the treatment of chronically infected total hip. J Arthroplasty. 2005;20:874–879.

    Article  PubMed  Google Scholar 

  24. Hofmann AA, Kane KR, Tkach TK, Plaster RL, Camargo MP. Treatment of infected total knee arthroplasty using an articulating spacer. Clin Orthop Relat Res. 1995;321:45–54.

    PubMed  Google Scholar 

  25. Hook GR, Hosseini JM, Elin RJ. Analytical approaches for biomedical elemental analysis. J Am Coll Nutr. 1985;4:599–612.

    PubMed  CAS  Google Scholar 

  26. Huotari K, Lyytikäinen O; Hospital Infection Surveillance Team. Impact of postdischarge surveillance on the rate of surgical site infection after orthopedic surgery. Infect Control Hosp Epidemiol. 2006;27:1324–1329.

    Article  PubMed  Google Scholar 

  27. Irifune T, Kurio A, Sakamoto S, Inoue T, Samiya H. Materials: ultrahard polycrystalline diamond from graphite. Nature. 2003;421:599–600.

    Article  PubMed  CAS  Google Scholar 

  28. Isaac GH, Atkinson JR, Dowson D, Kennedy PD, Smith MR. The causes of femoral head roughening in explanted Charnley hip prostheses. Eng Med. 1987;16:167–173.

    Article  PubMed  CAS  Google Scholar 

  29. Keen CE, Philip G, Brady K, Spencer JD, Levison DA. Histopathological and microanalytical study of zirconium dioxide and barium sulphate in bone cement. J Clin Pathol. 1992;45:984–989.

    Article  PubMed  CAS  Google Scholar 

  30. Kesteris U, Carlsson L, Haraldsson C, Lausmaa J, Lidgren L, Onnerfält R, Wingstrand H. Contamination of polyethylene cups with polymethyl methacrylate particles: an experimental study. J Arthroplasty. 2001;16:905–908.

    Article  PubMed  CAS  Google Scholar 

  31. Lerouge S, Huk O, Yahia LH, Sedel L. Characterization of in vivo wear debris from ceramic-ceramic total hip arthroplasties. J Biomed Mater Res. 1996;32:627–633.

    Article  PubMed  CAS  Google Scholar 

  32. Lewis G. Alternative acrylic bone cement formulations for cemented arthroplasties: present status, key issues, and future prospects. J Biomed Mater Res Part B: Appl Biomater. 2008;84:301–319.

    Article  Google Scholar 

  33. Lieberman JR, Callaway GH, Salvati EA, Pellicci PM, Brause BD. Treatment of the infected total hip arthroplasty with a two stage reimplantation protocol. Clin Orthop Relat Res. 1994;301:205–212.

    PubMed  Google Scholar 

  34. Masri BA, Panagiotopoulos KP, Greidanus NV, Garbuz DS, Duncan CP. Cementless two-stage exchange arthroplasty for infection after total hip arthroplasty. J Arthroplasty. 2007;22:72–78.

    Article  PubMed  Google Scholar 

  35. Meek RM, Masri BA, Dunlop D, Garbuz DS, Greidanus NV, McGraw R, Duncan CP. Patient satisfaction and functional status after treatment of infection at the site of a total knee arthroplasty with use of the PROSTALAC articulating spacer. J Bone Joint Surg Am. 2003;85:1888–1892.

    Article  PubMed  Google Scholar 

  36. Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001;392:15–23.

    Article  PubMed  Google Scholar 

  37. Phillips JE, Crane TP, Noy M, Elliott TS, Grimer RJ. The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. J Bone Joint Surg Br. 2006;88:943–948.

    Article  PubMed  CAS  Google Scholar 

  38. Pitto RP, Castelli CC, Ferrari R, Munro J. Pre-formed articulating knee spacer in two-stage revision for the infected total knee arthroplasty. Int Orthop. 2005;29:305–308.

    Article  PubMed  CAS  Google Scholar 

  39. Rahil-Khazen R, Bolann BJ, Myking A, Ulvik RJ. Multi-element analysis of trace element levels in human autopsy tissues by using inductively coupled atomic emission spectrometry technique (ICP-AES). J Trace Elem Med Biol. 2002;16:15–25.

    Article  PubMed  CAS  Google Scholar 

  40. Riedel F, Hönle W, Göske J, Kachler W, Holzwarth U, Schuh A. [Examination of granuloma of revised cemented or cementless total hip arthroplasties using inductively coupled plasma atomic emission spectrometry (ICP-OES)] [in German]. Biomed Tech (Berl). 2006;51:15–20.

    Article  CAS  Google Scholar 

  41. Sabokbar A, Fujikawa Y, Murray DW, Athanasou NA. Radio-opaque agents in bone cement increase bone resorption. J Bone Joint Surg Br. 1997;79:129–134.

    Article  PubMed  CAS  Google Scholar 

  42. Schuh A, Thomas P, Kachler W, Göske J, Holzwarth U. [Characterisation of histologic sections of granulomas of revised total hip arthroplasties using a scanning electron microscope (SEM)] [in German]. Biomed Technik. 2005;50(suppl):1577–1578.

    Google Scholar 

  43. Villa T, Carnelli D. Experimental evaluation of the biomechanical performances of the PMMA-based knee spacer. Knee. 2007;14:145–153.

    Article  PubMed  Google Scholar 

  44. Widmer AF, Gaechter A, Ochsner PE, Zimmerli W. Antimicrobial treatment of orthopedic implant-related infections with rifampin combinations. Clin Infect Dis. 1992;14:1251–1253.

    PubMed  CAS  Google Scholar 

  45. Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA. 1998;279:1537–1541.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We thank Matthias Schnabelrauch PhD and Christian Schrader PhD (Innovent e.V. Technologieentwicklung) for performing the XRF and XRD measurements.

Author information

Authors and Affiliations

  1. Clinic of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706, Markgröningen, Germany

    Bernd Fink MD

  2. INNOVENT e.V. Technologieentwicklung, Prüssingstraße 27 B, 07745, Jena, Germany

    Annett Rechtenbach PhD

  3. Heraeus Medical GmbH, Philipp-Reis-Str. 8/13, 61273, Wehrheim, Germany

    Hubert Büchner PhD & Sebastian Vogt PhD

  4. Center of Biomechanics, University Clinic Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany

    Michael Hahn PhD

Authors
  1. Bernd Fink MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Annett Rechtenbach PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hubert Büchner PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sebastian Vogt PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michael Hahn PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bernd Fink MD.

Additional information

One or more of the authors (AR) received funding from Heraeus Medical GmbH for the XRF and XRD analyses and the ICP-MS analyses.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at the Orthopaedic Clinic Markgröningen gGmbH.

About this article

Cite this article

Fink, B., Rechtenbach, A., Büchner, H. et al. Articulating Spacers Used in Two-stage Revision of Infected Hip and Knee Prostheses Abrade with Time. Clin Orthop Relat Res 469, 1095–1102 (2011). https://doi.org/10.1007/s11999-010-1479-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-010-1479-1

Keywords

Search

Navigation