Two-stage approach to total knee arthroplasty using colistin-loaded articulating cement spacer for vancomycin-resistant Pseudomonas aeruginosa infection in an arthritic knee

Moon Jong Chang, Min Kyu Song, Jae Hoon Shin, Chan Yoon, Chong Bum Chang, Seung-Baik Kang

A two-stage approach to total knee arthroplasty (TKA) using an antibiotic-impregnated articulating cement spacer is an option for an infected arthritic knee. Vancomycin combined with broad-spectrum antibiotics can be used to make an antibiotic-impregnated articulating cement spacer. Causative organisms are sometimes not confirmed before surgery. Joint infections of multidrug-resistant organisms are increasing. Therefore, routine combinations of antibiotics may not be effective. We present a case of a patient who developed vancomycin-resistant Pseudomonas aeruginosa infection in an arthritic knee. A 71-year-old man was initially diagnosed with pyogenic arthritis caused by Staphylococcus aureus. He underwent arthroscopic debridement elsewhere. However, the infection persisted. He was referred to our hospital, and we performed a two-stage TKA using a vancomycin-based antibiotic-impregnated articulating cement spacer. Vancomycin-resistant P. aeruginosa was identified after surgery. Intravenous colistin was added. However, this failed, either because vancomycin was not effective against P. aeruginosa, or because insufficient systemic colistin due to colistin-induced acute kidney injury. Therefore, debridement was repeated, and colistin-loaded cement spacer was inserted. The spacer delivered high concentrations of colistin to the infected joint with decreased systemic effects. Thus, less systemic colistin was used. The infection was controlled without recurrent acute kidney injury. One year after surgery, conversion to TKA was successfully performed. A two-stage approach to TKA using a colistin-loaded articulating cement spacer can be used for an arthritic knee infected by vancomycin-resistant P. aeruginosa. Furthermore, local administration of colistin using a cement spacer can reduce the systemic side effects of colistin.