REVISION PEARLS: Static vs. Articulating Spacers for 2-Stage Revision TKA

    Editor’s Note: ICJR’s annual Revision Hip & Knee Course is one of the most popular continuing medical education activities we host. Due to the COVID-19 pandemic, however, the course – which would have started on Thursday, June 18 – had to be canceled this year. Although the course will not be held, this week we’ll be highlighting some of the highest-rated sessions from past meetings and offering a special discount for you to attend the course in 2021.

    A 2-stage revision total knee arthroplasty (TKA) for infection requires temporary implantation of a spacer in the first stage to allow local delivery of high-dose antibiotics. The question: Which type of spacer should be used, static or articulating?

    At ICJR’s annual Revision Hip & Knee Course, Tad M. Mabry, MD, and Michael J. Taunton, MD, both from Mayo Clinic in Rochester, Minnesota, reviewed the indications and contraindications for static (Dr. Mabry) and articulating (Dr. Taunton) spacers, as well as showed images and video of the technique for preparing and implanting both types of spacers.

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    As Dr. Mabry noted, the treatment goals for static and articulating spacers are the same:

    • Deliver local, high-dose antibiotics customized to the infecting organism
    • Stabilize the soft tissue envelope; an unstable spacer will lead to bone loss, which will make the reconstruction a challenge
    • Facilitate reimplantation of the final implant
    • Improve clinical outcomes of patients with an infected TKA

    He said that in his practice, bilaterally infected TKAs and contralateral limb issues, such as amputation or arthrodesis, are the only relative contraindications to the use of a static spacer. His indications include:

    • Severe bone loss, as these patients tend to do better with static than with articulating spacers
    • Compromised soft tissue, such as ligamentous instability, extensor mechanism disruption, and the need for flap coverage
    • Failed articulating spacer use
    • Host immune compromise
    • Virulent or atypical infecting organism
    • Anticipated arthrodesis

    Dr. Taunton agreed with these contraindications and indications, noting that he prefers to use an articulating space with patients who have:

    • An intact extensor mechanism
    • A reasonable soft tissue envelope
    • Adequate remaining bone

    An articulating spacer, he said, would not be appropriate or patients with:

    • Extensor mechanism disruption
    • A poor soft tissue envelope
    • Massive bone loss

    In general, orthopaedic surgeons at Mayo Clinic mix 3 to 4 grams of vancomycin and 3.6 to 4.8 grams of gentamicin or tobramycin into each 40-gram batch of Simplex cement they use to for their spacers. Dr. Mabry cautioned that surgeons should know what type of cement they’re using, as Palacos cement has different elution characteristics than Simplex cement.

    To find out more about spacers for infected TKAs, click here to watch Dr. Mabry’s presentation and here to watch Dr. Taunton’s presentation.

    Disclosures: Dr. Mabry has no disclosures relevant to this article. Dr. Taunton has disclosed that he is a consultant for and has a product development agreement with DJO Global.