0g of vancomycin (VCM) powder (0.5g �� 4vials) and 40g of a cement with a lower polymerization selleckchem Ruxolitinib temperature (Cemex RX; Exactech, Gainesville, FL, USA) [10]. To prevent breakage, the spacer was reinforced with an Ender nail wrapped with a soft steel wire. When the causative bacterium was unidentifiable, 2.0g VCM and 1200mg GM were mixed with 40g cement.Since March 2005, ��-TCP has been preferred because it was reported to generate no heat during polymerization and to allow the gradual release of the antibiotic embedded in the spacer [11]. Because FHP-type spacers composed of only ��-TCP, which has low strength and frequently collapsed, antibiotic-impregnated ��-TCP spacers were developed for separate placement on the femoral and acetabular sides. However, this precluded correction of leg length discrepancy during the waiting period.

For this reason, new spacers using a combination of PMMA cement and ��-TCP were developed and have been used since February 2008.(3) Creation of a New Type of Handmade Antibiotic-Impregnated Spacer. The new type of spacer was prepared similarly to the spacer made of a combination of PMMA cement and ��-TCP, by winding a soft steel wire around an Ender nail to prevent the nail from breaking, which makes it difficult to remove the distal spacer (Figure 2(a)). The amounts of antibiotics used were 0.5g of VCM and 60mg (1.5mL) of GM to 12g of ��-TCP powder (Figure 2(b)). The core part of the femoral head was formed from 48g of ��-TCP containing 2g of VCM and 240mg of GM (Figure 2(c)) and placed at the tip of an Ender nail (Figure 2(d)).

The part of femoral head was prepared by wrapping PMMA bone cement containing 2g of VCM with ��-TCP and shaping it by using an appropriately sized ladle (Figures 2(e) and 2(f)). The stem needed to be prepared carefully with PMMA cement so that it did not become too thick (Figure 2(g)), although the neck part should be somewhat thick to prevent fractures (Figure 2(h)). After completion of the spacer, a pore reaching the ��-TCP core of the femoral head was made by using an surgical airdrill to create a channel for efficient gradual release of the antibiotics (Figures 2(i) and 2(j)).Figure 2Steps in the making of the new type of handmade antibiotic-impregnated spacer.To improve the results of spacer placement, advance trial reposition was performed to check whether the femoral head would fit the acetabulum.

An excessively large femoral head of the spacer can restrict hip mobility, as well as hip repositioning, postoperatively. To fill the dead space and enhance gradual antibiotic release, antibiotic-impregnated ��-TCP was added to the neck part after placement and repositioning of the spacer. The excised portions of the greater trochanter and femoral stem were temporarily fixed by performing tension-band wiring and wiring, respectively, until the next Carfilzomib surgery.(4) Systemic Administration of Antibiotics after the First Surgical Stage.