Guidelines for Complications of Cancer Treatment Vol VIII Part B

considered to be two-stage revision arthroplasty includingremoval of the prosthesis and cement, thorough débridement,placement of an antibiotic-impregnated cement spacer, a courseof intravenous antibiotics, and a delayed second-stage revisionarthroplasty 16-21,23 . Two-stage revision surgery was firstdescribed in 1983 by Insall et al., who demonstrated thenecessity of removing the implants as well as the cement andof introducing antibiotic therapy for definitive treatment 24 .Bengston et al 25 showed the advantages of a two stageprocedure. One-stage procedures were not successful and oneor two attempts to control the infection by leaving theintramedullary component of the prosthesis in situ also wereunsuccessful. Donati and Biscaglia 26 experienced similarresults and recommended removal of the prosthesis and useof a cement spacer in all chronic infections.Garvin and Hanssen 27 reviewed twenty-nine studies and foundthat two-stage procedures without antibiotic-loaded cementhad a better success rate (82% of 158 joints) than one-stageexchange arthroplasties (58% of sixty joints), althoughsystemic antibiotics were used for both procedures 27 . Withthe addition of antibiotic cement, the rates of successfuleradication of the infection increased to 91% (385 of 423joints) for the two stage technique and 82% (976 of 1189 joints)for the one-stage revision. Two-stage revision arthroplastywithout the use of spacers allows complete removal of foreignmaterials, with later reimplantation after eradication of theinfection. However, this procedure has several disadvantagesas soft-tissue contractures and joint instability may developand the patient will have difficulty with mobility. From atechnical perspective, the disadvantage of the procedure isthat it makes reimplantation during the second-stage operationmore difficult as a result of arthrofibrosis and the loss of tissueplanes. Antibiotic-impregnated cement spacers provide directlocal delivery of antibiotics while preserving patient mobility108