Total Femur Antibiotic Spacers: Effective Salvage for Complex Periprosthetic Joint Infections

Abstract Introduction A simultaneous periprosthetic joint infection (PJI) of an ipsilateral hip and knee arthroplasty is a challenging complication of total hip and knee arthroplasties. We evaluated the use of total femur antibiotic-impregnated polymethylmethacrylate (PMMA) bone cement spacers in the staged treatment of such limb-threatening PJIs. Methods Thirteen patients were treated with a total femur antibiotic spacer. The mean age at the time of spacer placement was 65 years. Nine patients had polymicrobial PJIs. All spacers incorporated vancomycin (3.0g/40g PMMA) and gentamicin (3.6g/40g PMMA), while 8 also included amphotericin (150mg/40g PMMA). Eleven spacers were bi-articular. Twelve spacers were implanted through one longitudinal incision, while 8 of 12 reimplantations occurred through two smaller, separate hip and knee incisions. Mean follow-up after reimplantation was 3 years. Results Twelve (92%) patients underwent reimplantation of a total femur prosthesis at a mean of 26 weeks. One patient died of medical complications 41 days after spacer placement. At latest follow-up, 3 patients had experienced PJI recurrence managed with irrigation and debridement. One required acetabular component revision for instability. All 12 reimplanted patients retained the total femur prosthesis with no amputations. Eleven (91%) were ambulatory, and 7 (58%) remained on suppressive antibiotics. Conclusion Total femur antibiotic spacers are a viable, but technically demanding, limb-salvage option for complex PJIs involving the ipsilateral hip and knee. In the largest series to-date, there were no amputations and 75% of reimplanted patients remained infection-free. Radical debridement, antimicrobial diversity, prolonged spacer retention, and limiting recurrent soft-tissue violation are potential tenets of success. Level of Evidence IV