Comparing the Efficacy of Articulating Spacer Constructs for Knee Periprosthetic Joint Infection Eradication: All-Cement vs Real-Component Spacers

Published:January 20, 2021DOI:



      The most common treatment for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a 2-stage revision. Few studies have compared different articulating spacer constructs. This study compares the outcomes of real-component and all-cement articulating spacers for TKA PJI treatment.


      This retrospective observational study examined the arthroplasty database at 3 academic hospitals for articulating spacers placed for TKA PJIs between April 2011 and August 2020. Patients were categorized as receiving a real-component or an all-cement articulating spacer. Data on demographics, surgical information, and outcomes were collected.


      One-hundred sixty-four spacers were identified: 72 all-cement and 92 real-component spacers. Patients who received real-component spacers were older (67 ± 10 vs 63 ± 12 years; P = .04) and more likely to be former smokers (50.0% vs 28.6%; P = .02). Real-component spacers had greater range of motion (ROM) after Stage 1 (84° ± 28° vs 58° ± 28°; P < .01) and shorter hospital stays after Stage 1 (5.8 ± 4.3 vs 8.4 ± 6.8 days; P < .01). There was no difference in time to reimplantation, change in ROM from pre-Stage 1 to most recent follow-up, or reinfection. Real-component spacers had shorter hospital stays (3.3 ± 1.7 vs 5.4 ± 4.9 days; P < .01) and operative times during Stage 2 (162.2 ± 47.5 vs 188.0 ± 66.0 minutes; P = .01).


      Real-component spacers had improved ROM after Stage 1 and lower blood loss, shorter operative time, and shorter hospital stays after Stage 2 compared to all-cement articulating spacers. The 2 spacer constructs had the same ultimate change in ROM and no difference in reinfection rates, indicating that both articulating spacer types may be safe and effective options for 2-stage revision TKA.

      Level of Evidence

      III, retrospective observational analysis.


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        • Boddapati V.
        • Fu M.C.
        • Mayman D.J.
        • Su E.P.
        • Sculco P.K.
        • McLawhorn A.S.
        Revision total knee arthroplasty for periprosthetic joint infection is associated with increased postoperative morbidity and mortality relative to noninfectious revisions.
        J Arthroplasty. 2018; 33: 521-526
        • Kurtz S.M.
        • Lau E.
        • Watson H.
        • Schmier J.K.
        • Parvizi J.
        Economic burden of periprosthetic joint infection in the United States.
        J Arthroplasty. 2012; 27: 61-65.e1
        • Delanois R.E.
        • Mistry J.B.
        • Gwam C.U.
        • Mohamed N.S.
        • Choksi U.S.
        • Mont M.A.
        Current epidemiology of revision total knee arthroplasty in the United States.
        J Arthroplasty. 2017; 32: 2663-2668
        • Spivey J.C.
        • Guild 3rd, G.N.
        • Scuderi G.R.
        Use of articulating spacer technique in revision total knee arthroplasty complicated by sepsis: a systematic meta-analysis.
        Orthopedics. 2017; 40: 212-220
        • Cohen J.C.
        • Hozack W.J.
        • Cuckler J.M.
        • Booth R.E.J.
        Two-stage reimplantation of septic total knee arthroplasty. Report of three cases using an antibiotic-PMMA spacer block.
        J Arthroplasty. 1988; 3: 369-377
        • Booth R.E.J.
        • Lotke P.A.
        The results of spacer block technique in revision of infected total knee arthroplasty.
        Clin Orthop Relat Res. 1989; 248: 57-60
        • Cui Q.
        • Mihalko W.M.
        • Shields J.S.
        • Ries M.
        • Saleh K.J.
        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
        • Haddad F.S.
        • Masri B.A.
        • Campbell D.
        • McGraw R.W.
        • Beauchamp C.P.
        • Duncan C.P.
        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
        • Zamora T.
        • Garbuz D.S.
        • Greidanus N.V.
        • Masri B.A.
        An articulated spacer made of new primary implants in two-stage exchange for infected total knee arthroplasty may provide durable results.
        Bone Joint J. 2020; 102-B: 852-860
        • Hofmann A.A.
        • Goldberg T.
        • Tanner A.M.
        • Kurtin S.M.
        Treatment of infected total knee arthroplasty using an articulating spacer: 2- to 12-year experience.
        Clin Orthop Relat Res. 2005; 430: 125-131
        • Siddiqi A.
        • Nace J.
        • George N.E.
        • Buxbaum E.J.
        • Ong A.C.
        • Orozco F.R.
        • et al.
        Primary total knee arthroplasty implants as functional prosthetic spacers for definitive management of periprosthetic joint infection: a multicenter study.
        J Arthroplasty. 2019; 34: 3040-3047
        • Emerson R.H.J.
        • Muncie M.
        • Tarbox T.R.
        • Higgins L.L.
        Comparison of a static with a mobile spacer in total knee infection.
        Clin Orthop Relat Res. 2002; 404: 132-138
        • Choi H.-R.
        • Malchau H.
        • Bedair H.
        Are prosthetic spacers safe to use in 2-stage treatment for infected total knee arthroplasty?.
        J Arthroplasty. 2012; 27: 1474-1479.e1
        • Goltz D.E.
        • Sutter E.G.
        • Bolognesi M.P.
        • Wellman S.S.
        Outcomes of articulating spacers with autoclaved femoral components in total knee arthroplasty infection.
        J Arthroplasty. 2018; 33: 2595-2604
        • Karas V.
        • Rutherford R.W.
        • Herschmiller T.A.
        • Plate J.F.
        • Bolognesi M.P.
        • Joyce M.J.
        • et al.
        Flash sterilization and component reimplantation is a viable option for articulating antibiotic spacers in periprosthetic knee infections.
        J Knee Surg. 2020;
        • Warth L.C.
        • Hadley C.J.
        • Grossman E.L.
        Two-stage treatment for total knee arthroplasty infection utilizing an articulating prefabricated antibiotic spacer.
        J Arthroplasty. 2020; 35: S57-S62
        • Qiu X.-S.
        • Sun X.
        • Chen D.-Y.
        • Xu Z.-H.
        • Jiang Q.
        Application of an articulating spacer in two-stage revision for severe infection after total knee arthroplasty.
        Orthop Surg. 2010; 2: 299-304
        • Lyons S.
        • Downes K.
        • Habeck J.
        • Whitham Z.
        • Werger M.
        • Stanat S.
        Early to midterm results of “low-friction” articulating antibiotic spacers for septic total knee arthroplasty.
        Arthroplast Today. 2019; 5: 221-225
        • Yu Q.
        • Luo M.
        • Wu S.
        • Lai A.
        • Sun Y.
        • Hu Q.
        • et al.
        Comparison of infection eradication rate of using articulating spacers containing bio-inert materials versus all-cement articulating spacers in revision of infected TKA: a systematic review and meta-analysis.
        Arch Orthop Trauma Surg. 2019; 139: 695-707
        • Kalore N.V.
        • Maheshwari A.
        • Sharma A.
        • Cheng E.
        • Gioe T.J.
        Is there a preferred articulating spacer technique for infected knee arthroplasty? A preliminary study.
        Clin Orthop Relat Res. 2012; 470: 228-235
        • Woon C.Y.L.
        • Nguyen J.
        • Kapadia M.
        • Russell C.A.
        • Henry M.
        • Miller A.
        • et al.
        Temporary new implant spacers increase post-reimplantation total knee prosthesis survival after periprosthetic joint infection.
        Knee Surg Sports Traumatol Arthrosc. 2020;
        • Parvizi J.
        • Tan T.L.
        • Goswami K.
        • Higuera C.
        • Della Valle C.
        • Chen A.F.
        • et al.
        The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria.
        J Arthroplasty. 2018; 33: 1309-1314.e2
        • Harvey I.A.
        • Barry K.
        • Kirby S.P.
        • Johnson R.
        • Elloy M.A.
        Factors affecting the range of movement of total knee arthroplasty.
        J Bone Joint Surg Br. 1993; 75: 950-955
        • Lizaur A.
        • Marco L.
        • Cebrian R.
        Preoperative factors influencing the range of movement after total knee arthroplasty for severe osteoarthritis.
        J Bone Joint Surg Br. 1997; 79: 626-629
        • Wang Q.
        • Goswami K.
        • Kuo F.-C.
        • Xu C.
        • Tan T.L.
        • Parvizi J.
        Two-stage exchange arthroplasty for periprosthetic joint infection: the rate and reason for the attrition after the first stage.
        J Arthroplasty. 2019; 34: 2749-2756
        • Gomez M.M.
        • Tan T.L.
        • Manrique J.
        • Deirmengian G.K.
        • Parvizi J.
        The fate of spacers in the treatment of periprosthetic joint infection.
        J Bone Joint Surg Am. 2015; 97: 1495-1502
        • Antony S.
        • Farran Y.
        Prosthetic joint and orthopedic device related infections. The role of biofilm in the pathogenesis and treatment.
        Infect Disord Drug Targets. 2016; 16: 22-27
        • Rosman M.
        • Rachminov O.
        • Segal O.
        • Segal G.
        Prolonged patients’ In-Hospital Waiting Period after discharge eligibility is associated with increased risk of infection, morbidity and mortality: a retrospective cohort analysis.
        BMC Health Serv Res. 2015; 15: 246
        • Sud M.
        • Yu B.
        • Wijeysundera H.C.
        • Austin P.C.
        • Ko D.T.
        • Braga J.
        • et al.
        Associations between short or long length of stay and 30-day readmission and mortality in hospitalized patients with heart failure.
        JACC Hear Fail. 2017; 5: 578-588
        • Nikkel L.E.
        • Kates S.L.
        • Schreck M.
        • Maceroli M.
        • Mahmood B.
        • Elfar J.C.
        Length of hospital stay after hip fracture and risk of early mortality after discharge in New York State: retrospective cohort study.
        BMJ. 2015; 351: h6246
      1. Hospital adjusted expenses per inpatient day. San Francisco.
        ([accessed 30.11.20])