Depends on the duration of infection. If the infection is already ongoing for a long time I would propose to do a synovectomy together with an necrosectomy and administer antibiotics , and , as soon as the infection ist eradicated do the next necessary step. I would not propose to use a spacer

Thank you, Dr. Boehler, for your prompt answer. I also do not find a rationale for using a spacer in this case. I would like to ask you about the significance of the duration of infection that you mention. Would you please explain it ?

A complete as pssible debridement, bacteriologic  preoperative cultures and the use of cement spacer impregnated with antibiotics   is quite helpfull  if reimplantation  of a tkr is planned.

If you have an acute infection with a sensitive bacteria and no osteoarthritis we always were successful by doing an arthroscopic synovectomy and parallel antibiotic treatment.

In cases with osteoarthritis we carried out an open synovectomy as we expected, that there would be an chance to do a second operation ( TKA).

Dear Chanan, 

The case discussed on is primary septic gonitis (no previous TKR). I do not see the rationale for spacer in similar cases. I believe the tactics posted by Dr. Boehler is good and works. 

Dear Panayot I probaly misunderstood ,I was thinking of 1st stage revision TKR .I agree that  a spacer is unneccesary in plain septic arthritis of the kee.

1.knee aspiration and direkt microscopy to verifying the Dx

2. arthroscopic total synovectomy + biopsy .

3. Systemic antibiotic for 2 weeks then oral antibiotic for further 4 weeks

4. monitoring the effect of treatment clinically and by CRP & leucocyte measuring .In case of poor effect a new synovectomy to be considered(artroscopic or open)

Dr. Aldulaimi,

Your protocol seems to be concise, but I do not believe you can specify the bacterial type using only direkt microscopy (direct fluorescent microscopy is used to verify tuberculous bacteria). You need bacteriologal cultures and antibiogram to verify the bacterial sensitivity to antibiotics. Furthermore, if there are osteoarthritic changes, I do not believe a  synovectomy will be enough. A promp debridement with postoperative lavage and drainage is needed to eradicate the infection promptly if a TKR is to be done later.

Anyway, the question was do you use a spacer when treating a septic arthritis of the  knee (no previous TKR) in case of planning a later TKR ?

I think that the question is a little bit strange. There is no room in the knee for placing any spacers. Spacers are used after septic TKR. In the septic gonitis one can use local antibiotics like Garamycine Sponge that work similarly to spacers but do not need so much space in the knee.

A spacer, cement + antibiotics, is only indicated as a temporary substitute for an extracted knee prosthesis as a part of a 2-stage revision for an infected knee replacement.  In that situation it works well.

Thank you, Chanon, Wieslaw and Leif, for your clear answers. I agree entirely with your advices.

Regards,

Panayot

Dear friend debridement is for me the most important issue in septic arthritis, so I routinely do it. Besides I repeat surgical debridement in second-stage surgery. It is true that spacer acts as a foreign body, especially when antibiotic deliver function has gone, but nowadays is the best option for chronic arthritis.

The spacer keeps the distance and reduces the problems for reimplantation in gaining enough joint play. But it has disadvantages: the bone of the femoral condyle and tibia maybe compressed and as Dr. Silvestre said, yes, after a few days antibiotics are not delivered in adequate levels and the cement becomes a foreign body with the risk of germs adhering (esp. coag.neg. Staph).