Arch Orthop Trauma Surg (2012) 132:719–724

DOI 10.1007/s00402-012-1461-3

HIP ARTHROPLASTY

Temporary cement tectoplasty: a technique to improve prefabricated hip spacer stability in two-stage surgery for infected hip arthroplasty

X. Flores · P. S. Corona · J. Cortina · E. Guerra · C. Amat

Received: 14 November 2011 / Published online: 19 January 2012© Springer-Verlag 2012

Abstract This technical note describes an intraopera-tively custom-made, antibiotic-loaded bone cement roof,used in conjunction with a prefabricated hip spacer toimprove component stability, as part of the Wrst stage of atwo-stage procedure for an infected hip implant. This tech-nique was successfully used in seven cases who presentedwith extensive superior and/or posterio-superior acetabulardefect, which created a risk of spacer dislocation. With thistechnique we were able to avoid any further dislocation inthese seven cases. We believe that the technique mayreduce postoperative spacer dislocation in cases with exten-sive acetabular defects, while improving clinical outcomes.

Keywords Total joint arthroplasty · Infection · Spacer · Dislocation

Introduction

Currently, among the diVerent options available (suppres-sion treatment, resection arthroplasty, one- or two-stagereplacement, etc.) the most common approach for manage-ment of chronic periprosthetic joint infection (PJI) is atwo-stage replacement. The success rate for this techniqueexceeds 90% when an antibiotic-impregnated cement

spacer is used during the period between stages [1]. Suchspacers provide direct local delivery of antibiotics whilepreserving the joint space and facilitating the second-stagereimplantation surgery [2].

Prosthesis-like mobile spacers (dynamic hip spacers)oVer advantages over a static block. They allow weightbearing and joint motion that could improve both functionaloutcome, and quality of life during the period between thetwo procedures. Probably the most important, though, isthat dynamic spacers make the second-stage surgery easierto perform. One problem with the use of dynamic spacers,however, is that the risk of dislocation has been reported ashigh as 7% [3].

Some authors [4, 5] suggest that relative contraindica-tions to placement of a mobile hip spacer may include anyimportant acetabular insuYciency [6]. To deal with suchcases, we use a technique that involves fashioning a newacetabular roof using antibiotic-loaded bone cement, duringthe Wrst-stage procedure. This “tectoplasty” augments theacetabular surface and results in a better match with thespacer’s head, providing an improved biomechanical sce-nario, possibly reducing the risk of spacer dislocation.

This technical note describes the details and beneWts ofthe method, which we have named temporary cement tec-toplasty (TCT).

Technical description

The infected components are removed in a standard fash-ion. The residual socket space defect is assessed. In caseswith extensive superior or posterior–superior bone loss, ifthere is any doubt about acetabular containment or aboutdynamic spacer stability, a TCT is performed.

Depending upon the residual acetabular defect and theresidual femur geometry, the size of the prefabricated

X. Flores · P. S. Corona · J. Cortina · E. Guerra · C. AmatReconstruction and Septic Division, Department of Orthopedic Surgery, Hospital Universitario Vall d�Hebron, Barcelona 08035, Spain

P. S. Corona (&)Department of Orthopedic Surgery, Hospital de Traumatología y Rehabilitación Vall d�Hebron, Passeig Vall d�Hebron 119-129, 08035 Barcelona, Spaine-mail: pcorona@vhebron.net

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dynamic hip spacer is selected. We use the Vancogenx-SpaceHip System (TECRES S.P.A.; Sommacampagna, Italy) avail-able in both standard and extra-long versions, with three sizeoptions for each. They are preloaded with Vancomycin andGentamycin. Depending upon the shape of the spacer’s head,three to Wve 6.5 mm cancellous screws (short thread) areplaced at the posterio-superior rim of the residual ilium,between the 11 o’clock and 2 o’clock positions (Fig. 1). Thescrews are placed with 10°–15° of caudo-cranial slope and indiVerent degrees of ante-retroversion, to increase the strengthand stability of the construction. About 15–20 mm of eachscrew is left outside the bone. This is necessary because thescrews will provide a “scaVold” to hold the new acetabularroof, to be fabricated using antibiotic-impregnated bonecement (Fig. 2). A hand mixing technique without vacuum isused, to increase porosity and so improve antibiotic elution[7]. We add high doses of a thermostable antibiotic, selectedon the basis of sensitivity pattern displayed in cultured sam-ples taken preoperatively through percutaneous biopsy.

The antibiotic-impregnated bone cement, in a doughystate, is placed around the screws to form a bulky cementroof with a hemispherical shape, so as to reconstruct theposterior–superior defect, provide a larger contact area, andimprove spacer containment. The spacer head is then usedas a mold, to achieve a congruent hemispherical articula-tion. It is important to avoid Wlling the screw slots withcement, since the screws must be removed during the sec-ond-stage reimplantation procedure. Filling the slots withbone wax is useful to prevent accidental blockage bycement. A wet glove wrapped around the head of the spaceris used to prevent cement interdigitation, and to achieve assmooth a surface as possible.

After cement polymerization, the chosen dynamic hipspacer is placed, and stability and range of motion areassessed (Fig. 3).

Results

We report here the Wrst seven cases where this techniquewas performed. We present on Wve women and two menwith an average age at time of surgery of 50.5 (range 32–78). The demographic and operative variables of thepatients are presented in Table 1.

In four cases of chronic hip prosthesis infection withextensive superior acetabular defect, the technique wasused in a prophylactic fashion—as a guard against spacerdislocation. In each of these four cases, at the Wrst-stagesurgery, the surgeon judged that spacer stability was a con-cern due to the socket defect, and decided to perform a TCTto diminish the risk of postoperative dislocation. In theremaining three cases, TCT was chosen as a solution toalready-existing spacer dislocation. In six out of the sevencases, the socket defect was classiWed as type III-A,according to the Paprosky classiWcation system [6]. In theremaining case, the defect was considered to be type III-B.

Fig. 1 Three to Wve 6.5 mm cancellous screws (short thread) areplaced at the posterio-superior rim of the residual ilium, between the11 o’clock and 2 o’clock positions, in order to conform the scaVoldwhere attach the bone cement

Fig. 2 Reconstruction of superior acetabular margin using acryliccement and screws to create a new roof

Fig. 3 After bone cement polymerization, the deWnitive spacer isimplanted and Wnal stability is checked

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Six out of the seven cases studied were deemed eligible forthe second-stage procedure. Each did well clinically fol-lowing the Wrst-stage procedure, while awaiting the secondstage. Wait time averaged 25 weeks (range 12–64 weeks).During the waiting period no spacer dislocation occurred.Further, we did not observe any wound healing diYculties,nor any case of tectoplasty or spacer breakage. In casesreported in the modern literature [3], frequency of dynamichip spacer breakage is approximately 2%.

According to our protocol, the second-stage proce-dure is to be done only after a minimum of 12 weeksunder oral systemic antibiotic treatment, and when CRP/ESR levels have returned to normal. Intraoperative anal-ysis of frozen sections is used routinely for identiWca-tion of infection at the time of revision arthroplasty [8,9]. In our institution, intraoperative subcutaneouswound closing culture samples are not usually per-formed [10]. Our study patient number 2 (Table 1)waited 64 weeks for the second-stage procedure, inaccordance with the patient’s wishes. During the waitingperiod, no TCT-related incident occurred. At the second-stage procedure, the tectoplasty was easily removed,revealing a polished inner surface, free from wear andwith no evident foreign-body reaction at the surgicalsite. The tectoplasty did not alter the planned technicalapproach (Table 1) in the second stage. Our case number3 had originally presented with a fungal infection, andso was not a candidate for the second-stage procedurewithin the same waiting period as our other studypatients because the prolonged antifungal systemic treat-ment. After 84 weeks, however, no complications wereobserved (Fig. 4).

In our hands, this technique has proved to be a very use-ful technique for the most challenging of cases and is nor-mally performed in every case with concern about thespacer stability.

Illustrative case

Four years after a cementless total hip arthroplasty, a 78-year-old woman presented to our institution with pain andseptic loosening, and the arthroplasty was revised. A biopsy[11] found a chronic Propionibacterium acnes infection, anda two-stage revision was selected. The Wrst-stage mobilespacer failed due to severe superior segmental bone loss andinadequate support for the spacer’s head, resulting in spacerdislocation. This was re-revised using the technique reportedin this article. The second-stage procedure was carried outafter 12 weeks under oral antibiotic treatment (Clinda-macin), at which point the wound had healed, the CRP hadreturned to normal, and surgery was medically feasible. TheTCT was removed without complications. We performed anacetabular reconstruction using a non-cemented tantalumacetabular cup (Trabecular Metal™ Acetabular RevisionSystem; Zimmer, USA) with a cranial tantalum augment(Trabecular Metal Buttress Augment, Zimmer, USA) to dealwith a very large superior defect. On the femoral side, a cus-tom-made total femur prosthesis (Link, Germany) was theoption selected—extensive femoral bone loss and the pres-ence of a stem in the distal part of the femur ruled out otheroptions. Intraoperative culture samples and histologicalanalysis were negative for infection (Fig. 5).

After 13 months of follow-up, no complications and norecurrence of infection were reported.

Discussion

There are several reports in the modern literature on theadvantages of a two-stage procedure using an antibiotic-loaded dynamic hip spacer [1–3]. The use of a stagedapproach is probably safer with regard to infection [1] and adynamic spacer oVers the patient improved quality of life

Table 1 Demographic and operative variables

Patient Side Age Sex Germen Paprosky classif. TCT indication TCT time Type of reconstruction

1 L 78 F P. Acnes IIIA Dislocation 12 weeks Socket: Trabecular Metal Buttress AugmentFemur: Total Femur Arthroplasty

2 R 37 M MRSE IIIA Dislocation 64 weeks Socket: Allograft reconstructionFemur: Revitan revision stem

3 R 32 F C. Albicans IIIB Prophylactic 84 weeks Still awaiting second procedure

4 L 46 M MRSA IIIA Dislocation 13 weeks Socket: Trabecular Metal Acetabular Revision SystemFemur: Revitan Revision Stem

5 L 70 F Pseudo.A. IIIA Prophylactic 16 weeks Socket: Trabecular Metal Acetabular Revision SystemFemur: Revitan Revision stem

6 R 41 F MRSE IIIA Prophylactic 20 weeks Socket: Allograft reconstructionFemur: Revitan Revision stem

7 L 76 F MRSE IIIA Prophylactic 13 weeks Socket: Trabecular Metal Acetabular Revision SystemFemur: Proximal femur megaimplant (Mega-C)

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during the period between procedures [3] since it maintainsleg length and joint motion, and allows the patient to mobi-lize. Further, by maintaining soft tissue status, it facilitatesthe second stage, which is likely the primary advantage.Use of a two-stage reconstructive procedure withoutemployment of a temporary spacer has been also reported[12, 13]. Takigami et al. recently reported the use of antibi-otic-loaded hydroxyapatite (HA) blocks during the Wrststage. The advantage here is improved antibiotic releasecapacity and the excellent biocompatibility with bone tissueoVered by HA blocks. We believe maintenance of limblength and soft tissue tension during the interim period is ofparamount importance, so that failure to use a dynamicspacer could be a drawback. Patient quality of life is also aconcern.

If there is severe superior and/or posterior–superior bonedefect in the socket, with inadequate support, it becomesdiYcult to achieve stability of the hip spacer in the acetabu-lum, and increases the risk of dislocation [4–6]. Such prob-lems do not change with the use of other commerciallyavailable systems, such as prostheses of antibiotic-loadedacrylic cement (PROSTALAC; Depuy, Warsaw, IN). In thepresence of such defects, the stability of the cementedPROSTALAC polyethylene socket is also compromised.

One ongoing criticism regarding prefabricated dynamichip spacer systems is that the incorporated antibiotic dosagemay be inadequate for treatment of a chronically infectedarthroplasty [3, 4]. An added value of the TCT technique is

that the surgeon is able to customize the cement, incorpo-rating the most appropriate antibiotic type and dosage.

Other criticisms of prefabricated spacers include the lim-ited range of available sizes, which makes it diYcult tomatch the residual defect properly and which may alsoincrease the risk of spacer dislocation [4]. Yet anotheradvantage of the TCT technique is that it enables the sur-geon to create a superior match between the chosen headsize and the residual socket space. This solves the problemof the limited size range of prefabricated spacers, and fur-ther reduces the risk of dislocation.

Among our seven study cases, no technique-relatedcomplications have been observed. No patient suVered anew episode of dislocation following the initial procedure.We experienced no problems in the second-stage proce-dure, in terms of cement roof removal or in performing thereconstructive procedure as planned.

A point of concern regarding the use of polymethyl-methacrylate spacers in a two-stage replacement proce-dure is the risk of production of abraded particles [14–16].The risk here is that cement particles in the joint canembed in bearing surfaces and create scratches, with therisk of wear and decreased survival of the implant. Ofthese cement particles, those composed of zirconium diox-ide seem to be the most problematic due to their extremehardness. In a very recent paper, Fink et al. [16] pointedout that abraded particles can be founded even during ashort, 6-week period after implantation of a cement spacer.

Fig. 4 A 27-year-old woman with a fungal THA infection and a massive acetabular and femoral bone defect (a) The patient was able to walk withthe TCT with no complications, during prolonged antifungal systemic treatment (14 months) (b, c)

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To our knowledge there is no current evidence suggestingthat prostheses have lower survival rates after septic two-stage revision than after aseptic loosening, or that suchparticles could be deleterious from the point of view ofinfection. Further studies are required in order to conWrmthese observations.

It is logical to expect cement debris particles to bereleased from the cement-on-cement interface. In order tominimize the risk related to such particles, and also toensure elimination of residual organisms, it is of paramountimportance to perform an aggressive debridement andextensive lavage at the time of reimplantation. In our series,the cement-on-cement interface performed well during thetime the TCT was in place, and no wear-related complica-tions were observed. After 11.2 months of follow-up (range7–18 months) no relapse infection was recorded.

A similar technique has been described by Baker et al.[17] for the management of superior acetabular bone loss.They describe the use of cancellous screws and an acryliccement crescent or buttress to reconstruct the superior ace-tabular margin and allow cementing of a PROSTALACpolyethylene socket.

Summary

We consider TCT a useful tool in cases of PJI and extensiveacetabular bone loss, allowing the use of a dynamic hipspacer and oVering our patients better quality of life duringthe period between the Wrst- and second-stage procedures.

TCT is technically easy to perform during the Wrst-stagesurgery and allows the use of a prefabricated articulatinghip spacer in scenarios where high risk of dislocation maybe present.

Acknowledgments We thank Russ Williams from Roundly Wordedfor his editorial recommendations and Nuria Guitart Garcia for his bib-liographic support.

ConXict of interest The authors declare that there is no conXict ofinterest.

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Fig. 5 A 78-year-old woman with a chronic-PJI. She underwent a two-stage replacement with a postoperative spacer dislocation due to lack ofsuperior socket support (a). A TCT was performed (b). A total femur reconstruction was done at the second stage (c)

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