Use of Cemented Spacer with a Handmade Stem to Treat Acute Periprosthetic Tibial Fracture Infection: A Case Report
An 85-year-old woman with hypertension, dementia and dependent for normal life activities presented after an accidental fall with a left periprosthetic tibial fracture around total knee arthroplasty (Alpina®, Biomet-France) implanted 9 years ago (Fig. ). The fracture was classified as type IIB according to the Felix classification [] (adjacent to the stem and with an unstable tibial component). To treat this lesion, areplacement of the tibial component by one with a long stem was performed (Fig. ). Although the patient was discharged two weeks later without clinical complications, she was readmitted 4 weeks after the intervention due to wound drainage. Acute prosthetic joint infection was suspected and a surgical debridement was performed. The intraoperative cultures were positive for extended-spectrum beta-lactamase (ESBL) producing Escherichia coli and ampicillin- and high\nlevel gentamicin-resistant Enterococcus faecium. Despite this surgical approach and parenteral antibiotherapy with vancomycin and imipenem, the clinical evolution was non-satisfactory, so after three days, all components were removed and a bone-cement spacer coated with clindamycin and gentamicin and a handmade stem with a metal core was implanted (Fig. ). The stem was made using the following\ntechnique: first, the cement was injected using a cement gun into a mold (although we used the tube used for cementing the femoral component of hip prosthesis, other molds, such as chest tubes, could be used) []. After this, a Kischner wire was inserted into the tube and buried in the cement leaving about an inch uncovered to allow for connecting it with the tibial plateau cement spacer. The limb was immobilized with knee extension with an orthosis for 4 weeks to control rotational forces at the level of the fracture focus. The wound evolution was correct except for a skin defect at the level of tibial tuberosity that required a neurocutaneous pedicled graft. Based on antibiogram, specific-parenteral antibiotherapy (imipenem 28 days + vancomycin 17 days followed by 11 days of linezolid) was prescribed. The patient was discharged with an articulated knee brace. Radiological signs of fracture consolidation were observed after 3 months of follow-up. Due to the previous health status of the patient and short life expectancy, it was decided to keep the spacer as definitive treatment. In the latest follow-up (24 months after surgery), the patient was able to sit without pain and to stand with help using a knee brace. There were no radiological (Fig. ), clinical (Fig. ), or blood analysis signs of infection.