2-stage revision of 120 deep infected hip and knee prostheses using gentamicin-PMMA beads

Figures & data

Table 1. Baseline characteristics of patients and infections, with results of infection treatment

	Total	Success	Failure
	n = 120	n = 105	n = 15
Patient characteristics
Age	62 (30–82)	62 (30–82)	62 (44–80)
Sex: M/F	51/69	42/63	9/6
ASA-1	35	63	2
ASA-2	61	57	4
ASA-3	24	15	9
Morbidities
Smoking	24	22	2
Alcohol abuse	12	10	2
Diabetes mellitus	18	13	5
Inflammatory disease	4	3	1
Malignancy	9	8	1
Immunosuppression	1	1	0
Renal failure (dialysis)	7	3	4
Heart failure	22	18	4
Host score according to McPherson
A - Uncompromised	60	55	5
B - Compromised	54	47	7
C - Significantly compromised	6	3	3
Host score according Cierny
Uncompromised	43	39	4
Compromised	77	66	11
Prosthesis and infection characteristics
Total hip	95	84	11
Total knee	25	21	4
Indication index prosthesis
Primary arthroplasty	44	39	5
Aseptic revision	49	41	8
Septic revision	27	25	2
Infection period
Postoperative infections, n	114	100	14
joint age, weeks	108 (2–1,407)	117 (2–779)	46 (3–1,407)
Hematogenous infections, n	6	5	1
symptoms, days	41 (7–48)	46 (7–84)	(48)
Soft tissue
Not involved	73	63	10
Induration	2	2	0
Abscess or fistula	45	40	5
Infection score according to McPherson
Early postoperative (< 4 weeks)	4	2	2
Hematogenous infections	5	4	1
Late postoperative (> 4 weeks)	111	99	12
Local score according to McPherson
Grade 1 - Uncompromised	37	34	3
Grade 2 - Compromised	66	57	9
Grade 3 - Significantly compromised	17	14	3
Infection type according to Zimmerli
Early postop. + hematogenous ^a	9	4	5
Delayed exogenous ^b	45	37	8
Delayed hematogenous ^b	1	1	0
Late exogenous ^c	61	59	2
Late hematogenous ^c	4	4	0
Preoperative blood markers
ESR > 20 mm/h	103	88	15
CRP > 10 mg/L	91	79	12
Leucocytes > 11 x 10^9/L	16	13	3
Temperature ≥ 38.0°	24	21	3
Systemic antibiotics
Preoperatively, n	34	27	7
I.v. postoperatively, days	35 (2–132)	32 (2–132)	51 (20–125)
Oral postoperatively, days	76 (21–221)	76 (21–221)	78 (38–166)
Total days of postoperative therapy	104 (32–251)	101 (29–251)	128 (65–203)

a < 3 months; b 3–24 months; c > 2 years

Figure 1. 2-stage revision. A. Infected hip prosthesis in a 68-year-old woman. After extraction of the prosthesis, implantation of 360 gentamicin-PMMA beads for 2 weeks (B), then exchange to a spacer for 2 months (C). D. Puncture for culture, after 2 weeks of “antibiotic holiday”. E. After re-admission, extraction of the spacer and reimplantation of a total hip.

Figure 2. Diagram of treatments with data on reimplantation and healing of the infection.

Table 2. Causative microorganisms

Microorganism	Total	Success	Failure
CNS (ß-lactamase positive)	32	27	5
CNS (ß-lactamase negative)	14	14	0
Staphyloccus aureus (ß-lactamase positive)	18	14	4
Staphyloccus aureus (ß-lactamase negative)	8	8	0
MRSA	1	1	0
Streptococcus spp.	7	7	0
Enterococcus spp.	3	1	2
Enterobacter spp.	4	4	0
Pseudomonas aeruginosa	5	3	2
Propionibacterium acnes	4	4	0
Negative culture without antibiotics	8	8	0
Negative culture with antibiotics	2	2	0
Polymicrobial	14	12	2
Total	88	78	10

Table 3. Minimal inhibitory concentrations (MIC) of gentamicin with results of treatment

MIC gentamicin (μg/mL)	Total	Success	Failure
< 2	62	53	9
2–15	17	15	2
16–64	24	21	3
> 64	7	6	1
Negative cultures	10	10	0
	120	105	15

Figure 3. Kaplan-Meier curve depicting the time-to-event analysis with right-censoring, for healing of the infection. The event is healing for 6 months since the completion of the operative and antibiotic treatment.

Figure 4. Kaplan-Meier curves for infection healing with strata for ASA classifications.

Figure 5. Kaplan-Meier curves for infection healing with strata for the classification of type of infection according Zimmerli.

Table 4. Results in the literature of treatment of infected THR and TKR with hand-made or commercial antibiotic-loaded PMM beads

First author	Year	No. of prostheses	THR/TKR	Follow-up (years)	Healed (%)	Weeks to reconstruction	Beads
Hovelius	1979	3	THR	1.5	100	3–4	Septopal®
Walenkamp	1983	41	THR/TKR	1.1	85	2–4	Septopal^®
Scott	1993	7	TKR	?	100	6	hand-made
Garvin	1994	16	THR	5.7 (2–10)	100	?	hand-made
Lenoble	1995	32	THR	5 (2–11)	92	45–82	Septopal^®
Haddad	2000	50	THR	5.8	92	3–52	hand-made
Taggart	2002	33	THR/TKR	5.8 (5–9.3)	97	40 (9–156)	hand-made
Hsieh	2004	70	THR	4.9 (2–8)	93	?	hand-made
Hoad-Reddick	2005	38	TKR	4.7 (2–10)	89	?	hand-made
Stockley	2008	114	THR	6.2 (0.2–15)	88	28 (9–96)	hand-made
Chen	2009	48	THR	5.6 (2–14)	96	23 (9–104)	both
This series	2015	120	THR/TKR	5 (2–20)	88	4 (1.6–102)	Septopal^®

Figure 6. Proportions of short-term and long-term treatment in each 5-year period: increase in long-term treatment with time.

Figure 7. Intervals (months) of long-term treatment in four 5-year periods, with shorter intervals in more recent years.

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