Distal femur replacement for infected bone defects due to end-stage periprosthetic joint infection or trauma. A staged strategy protocol using the stemless CompressÒ device protected with a fast resorbable antibiotic-loaded hydrogel.

Distal femur replacement for infected bone defects due to end-stage periprosthetic joint infection or trauma. A staged strategy protocol using the stemless CompressÒ device protected with a fast resorbable antibiotic-loaded hydrogel. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Distal femur replacement for infected bone defects due to end-stage periprosthetic joint infection or trauma. A staged strategy protocol using the stemless CompressÒ device protected with a fast resorbable antibiotic-loaded hydrogel. Pablo S. Corona, Margalida H. Vicens, Rosa Fraile, Carles Amat, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5368805/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Distal femur replacement (DFR) with a stemmed megaprosthesis represents a challenge due to high rates of loosening and limited reconstructive options if the implant fails. Such an unfavourable scenario is even more complex where there are also infected bone defects. The Compress ® device was developed to provide an alternative to traditional intramedullary stems. We report on the outcomes of a staged protocol using the Compress ® DFR, protected with a vancomycin-gentamicin-loaded hydrogel, in infected non-oncological scenarios. Methods: Retrospective longitudinal cohort study including patients with infected defects of the distal femur following orthopaedic trauma or periprosthetic joint infection (PJI) and managed with the protocol described. Protocol features, microbiological data, radiological results, complications, infection control and implant survivorship were assessed. Minimum follow-up was 18 months or until implant removal. Results: 21 cases of Compress ® DFR were included. On average, patients had had 4.9 prior surgeries and 14.5 cm distal femur bone defects after pseudo-oncological resection. After median follow-up of 42 months (18-83 months), no infection recurrence occurred; limb salvage was achieved in all cases. Five patients experienced aseptic loosening, all within the first 7 postoperative months. Beyond this time threshold, no further implant failures were observed, resulting in a cumulative implant survival rate of 75 % at 1 and 5 years, and of 75% at final follow-up. Conclusion: Staged Compress ® DFR (protected with an antibiotic-loaded hydrogel) is a valid option for selected patients. It offers high rates of infection control, implant survivorship, and ease of revision, with aseptic failures occurring primarily in the initial postoperative months. Distal femur replacement Compress® device periprosthetic joint infection infected bone defect limb salvage DAC® hydrogel. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Infected bone defect is one of the most difficult conditions to treat following orthopaedic trauma or periprosthetic joint infection (PJI) . In cases of an infected distal femur with juxta-articular involvement, the challenges are even more formidable, due to limited limb salvage options (1). In recent years there has been increasing interest in distal femur replacement (DFR) in non-oncological scenarios (2). Stemmed DFR represents a particularly unfavourable biomechanical scenario, with a high complication rate. DFR after a failed total knee arthroplasty also shows significant failure rates, with a 47% aseptic loosening rate after 8 years. Revision-free survival is estimated at 62.5% at 3 years and 41% at 10 years (3) (4). Even more concerning are the limited reconstructive options if the implant fails, due to poor remaining bone stock. The increased risk of infection with such massive implants is widely recognized, with failed infection control rates ranging from 3% to more than 30% (5). The Compress ® compliant Pre-Stress (CPS) device (Zimmer-Biomet ® , Warsaw, Indiana, USA) is a fixation system with a very short intramedullary segment (stemless), designed to avoid some of the limitations of stemmed implants. Its primary stability is based on initial compression, with long-term stability achieved through implant osseointegration. Suggested advantages are greater bone stock preservation and longer implant survivorship, with series showing a survivorship rate of 80% at 10 years (6). Since 2015, a comprehensive two-stage limb-salvage strategy protocol has become the standard of care (7) in our specialty-dedicated unit, for managing end-stage knee PJI cases with massive distal femur bone loss or infected distal femur juxta-articular bone defects due to trauma: 1) Pseudo-oncological bone resection and temporary hand-made static spacer; 2) Stemless DFR using the Compress ® device 3) Mega-implant surface protection strategy using an antibiotic-loaded antibacterial hydrogel (Defensive Antibacterial Coating — DAC ® ; Novagenit, Mexxolombardo, Italy) (8). Considering all the aforementioned, we sought to study the outcomes of this limb-salvage strategy, focusing on: 1 ) infection control 2 ) Compress ® mid-term survivorship, 3) protocol-related complications, and 4 ) limb-salvage rate. Currently, there is a lack of scientific reports evaluating the usefulness of the Compress ® DFR in infected non-tumoral scenarios. Methods Following IRB approval, this study was conducted as a longitudinal cohort study. The institutional database was retrospectively reviewed to identify all patients with distal femur infected bone defects treated under this novel protocol between January 2015 and January 2022. Inclusion criteria : 1) Use of Compress ® DFR to manage infected bone defects (PJI or infected trauma defects) with a minimum post-surgical follow-up of 18 months. 2) Two-stage strategy 3) Use of DAC ® as an implant coating. Patients with no post-surgery tracking data, oncological cases, and cases which didn’t accomplished inclusion criteria. Outcome Variable : Primary endpoints were infection control rate and medium-term Compress ® implant survival rate. The following data were recorded from our institutional database: a ) demographics; b ) comorbidities; c ) previous surgeries; d ) first-stage intraoperative data; e) second-stage intraoperative data; e) postoperative data: Compress ® -related complications, unexpected reinterventions, radiological findings. Definitions : 1. Infection definition: post-traumatic cases with an established diagnosis of deep infection, according to international-consensus criteria (9). PJI cases with an established diagnosis of chronic PJI, according the 2021 EBJIS criteria definition (10). 2. Compress ® radiological evaluation: 1 point for narrowed interface contour, 2 points for unaltered contour, and 3 points for widened contour (11)(12). 3. Infection eradication, based on Delphi-method consensus criteria (13): a) healed wound without fistula or drainage and no infection recurrence caused by the same organism strain; b ) no subsequent surgical intervention for infection after reimplantation surgery; c ) no PJI-related mortality. Necessity for suppressive antibiotic treatment or onset of another PJI caused by a different microorganism were also deemed as treatment failures. Operative technique description : Limb-salvage was carried out following a two-stage surgical strategy with all surgeries performed by the senior author (P.C.). During the first stage a medial parapatellar approach is used, and extended through a tibial tubercle osteotomy when needed (16). Implant removal and radical bone debridement is performed following a pseudo-oncological approach, with segmental bone resection of distal femur. A temporary static spacer is used ( Figure 1A/B ) to fill dead space and stabilize the extremity (17). Antibiotic treatment is selected according to the susceptibility profile of the isolated bacteria. During the second stage the spacer is removed and a second aggressive debridement is performed, with sample collection. Indications for Compress ® implantation include > 2.5 mm cortical thickness of viable remaining proximal femur, without areas of cortical defect, and > 4 cm of residual subtrochanteric femur to accommodate the smaller anchor plug. The CPS is used in accordance with the manufacturer’s recommended technique, which can be found elsewhere (18), and attached to an OSS ® ( Orthopaedic Salvage System - Zimmer-Biomet ® , Warsaw, Indiana, USA) rotating hinge platform ( Figure 2 ). The system offers two anchor plug/spindle options: short Compress ® requires 45 mm of medullary placement, whereas standard Compress ® needs 80 mm. Coating protocol: DAC ® hydrogel is prepared intra-operatively according to the following protocol, developed by our unit. A vancomycin-gentamicin solution is prepared by diluting 1g of vancomycin powder in 20 cc distilled water. Then 5cc of this solution is combined with 3 ampoules of 80 mg liquid gentamicin. Next, 5 cc of this solution is mixed with 5 cc of DAC Ò powder and allowed to sit for 10 minutes before 20 cc of the resulting vancomycin-gentamicin-DAC Ò mixture is taken. The solution will remain stable for up to 5 hours. It is applied directly to the tibial stem and the extramedullary surfaces of the femoral component ( Figure 3 ). Follow-up and rehabilitation protocol : After discharge, patients were seen at 3 weeks, 6 weeks, 3 months, 6 months, and annually thereafter. Patients received a strict rehabilitation program, though the program was not begun until correct evolution of the surgical wound was confirmed. For the first 6 weeks, the program focused on passive knee motion, with no weightbearing allowed. A maximum of 50% weightbearing was then allowed for the subsequent 6 weeks, after which the patient progressed to full weightbearing as tolerated. Data Analysis Descriptive statistics were used to present patient demographics and surgical complications. Categorical variables were described by their absolute values and percentages. Continuous variables were presented by their measure of central tendency (mean or median) and range. Kaplan-Meier survival curve represented medium-term survivorship of the Compress ® device. Statistical analysis was conducted using Stata v.14.9 software. Results In our database review, there were identified 31 cases of DFR using the CPS device. After excluding ineligible cases, 21 cases with distal femur infected bone defects who had undergone the two-stage reconstruction protocol were finally included. Of these, 76.1% were males with an average age of 58 years (range:19-80); median follow-up in this series was 42 months (range:18-83). Reason for distal femur replacement:16 cases due to distal femur infected fractures; 5 cases due to end-stage PJI. The complexity of these cases is reflected in the number of previous procedures, prior to our index surgery. There was an average of 5.12 in our post-traumatic group, and 4.8 in PJI group. Patient demographics and specific comorbidities are shown in Table 1 . Table 1: Patient demographics and specific comorbidities Table 1 Summary of case characteristics Case Age Sex Risk factor ASA Fracture type/G-A Previous procedures 1 52 M None I Open/IIIA 8 2 41 M Smoker II Open/IIIA 2 3 61 F BMI>30 II Open/IIIA 3 4* 61 F BMI>30 II Aseptic loosening 4 5 75 M None II Closed 1 6 78 F DM II Closed 8 7 51 M None I Open/IIIB 4 8 56 M BMI>30 II Open/II 6 9 67 M Smoker, BMI>30 II Open/IIIA 2 10 53 M Smoker II Open/IIIA 2 11 48 M Smoker II Open/IIIA 8 12* 48 M Smoker II Aseptic loosening 8 13 67 M DM, BMI>30 III PJI 3 14 80 F DM II PJI 2 15 39 M None II Open/IIIA 14 16 19 M Smoker II Open/IIIA 5 17 69 M None II Open/IIIA 6 18 68 M None II PJI 3 19 60 M None II Closed 7 20 75 F None II PJI 5 21 50 M Smoker, BMI >30 III Open/IIIA 4 Legend : F=female, M=male, BMI=body mass index, ASA= American Anaesthesia Society scale, G-A: Gustilo-Anderson classification. *Revision Compress cases after Compress failure Characteristics of the first and second surgical steps are summarized in Table 2 . Regarding microbiological results, coagulase-negative Staphylococcus strains were the most frequent pathogens found in our series, isolated in 33.3 % of our cases. Eight cases presented negative cultures, despite unequivocal signs of infection. Further information on infection-causing microorganisms can be found in Table 2 . In this series, the mean distal femoral bone resection was 14.57 cm (range 8-23.5 cm). A static cement spacer was used in all cases without reported spacer-related complications. After the first stage, one patient experienced skin necrosis, which was resolved with a microsurgical ALT free flap. During the second stage, all microbiological cultures were negative; mean Compress ® -OSS ® reconstruction length was 15.85 cm. Detailed characteristics of CPS implant in Table 2 . Antibiotic-loaded hydrogel was used in all cases according to the described protocol, with no recorded intra-operative complication. Table 2 : First and second surgical features Table 2 Summary of case operative characteristics Case Bone defect (cm) Isolated microorganism Cement spacer TTO CPS-Plug Compression (lbs.) OSS length Local ATB 1 23.5 Polimicrobiane Dynamic Yes (2T) Standard 400 23 DAC 2 15 Negative Dynamic Yes (1,2T) Short 800 13 DAC 3 13 MRSA Static Yes (1,2T) Short 400 13 DAC 4* 16 Negative None Yes (2T) Short 400 17 DAC 5 14.5 CNS Dynamic Yes (1,2T) Short 400 16 DAC 6 18 Pseudomonas spp. Static No Short 400 18 DAC 7 15 MRSA Static No Short 600 13 DAC 8 8 CNS Static Yes (2T) Short 400 8 DAC 9 13 Negative Static Yes Short 800 18 DAC 10 12 CNS Static No Short 400 13 DAC 11 9 Pseudomonas spp. Static Yes (2T) Short 400 8 DAC 12* 14 Negative None Yes Short 600 15 DAC 13 12 CNS Static Yes (2t) Short 400 19 DAC 14 21 Negative Static No Short 400 24 DAC 15 20 Negative Static Yes (2T) Short 400 22 DAC 16 6 Negative Static Yes (2T) Short 600 8 DAC 17 5 Negative Static No Short 800 6 DAC 18 11.5 CNS Static Yes (2T) Short 800 17 DAC 19 20.5 CNS Static No Short 400 20 DAC 20 22 MRSA Static No Short 600 24 DAC 21 17 CNS Static Yes Short 800 18 DAC Legend : CNS=coagulase-negative Staphylococcus , MRSA = Methicillin-resistant Staphylococcus aureus ; TTO = tibial tubercle osteotomy. The cells highlighted in blue are from two cases of re-Compress ® As to the principal endpoint of our study, after a mean follow-up of 42 months we did not observe any infection relapse in this series of patients, with an overall infection control rate of 100% following our stringent infection control criteria. All cases achieved limb salvage. Regarding Compress ® device-related complications, during early follow-up, five cases experienced Compress ® fixation failure due to aseptic loosening, requiring isolated replacement of the femoral component (all cultures negative). Interestingly, all failures occurred in the first 7 months (range: 3-7); during the full weight-bearing step of the postoperative rehabilitation protocol no failures were reported (Table 3) . Beyond this time threshold, no further implant failures were observed, resulting in a cumulative implant survival rate of 75 % at 1 and 5 years, and of 75% at final follow-up ( Figure 4 ). Table 3: Features of Compress® Failures cases Table 3 Summary of Compress failure case characteristics Case Age Sex Risk Factors Pedestal Rx. score Cause FU Cultures IOP Revision Implant Histology 1 61 F BMI>30 No 1 Aseptic loosening 7 Negative Compress Chronic Inflammation changes 2 53 M Smoker, BMI>30 No 1 Aseptic loosening 4 Negative Cemented OSS Chronic Inflammation changes 3 48 M Smoker No 2 Implant Breakage 5 Negative Compress Foci of medullary necrosis 4 80 F DM No 2 Implant Breakage 3 Negative Cemented OSS Chronic Inflammation changes 5 75 F Non No 1 Implant Breakage 7 Negative TFA OSS Chronic Inflammation changes Legend : BMI = Body Mass Index, DM = Diabetes Mellitus; Rx Score = 3-points Groundland score; FU = Follow-up; IOP= intraoperative Regarding radiological evaluation, 71.4% showed bone hypertrophy on X-ray; all cases with bone hypertrophy scored 3 points ( Figure 5 ). All six cases without bone hypertrophy (scoring 1 or 2 points) experienced aseptic failures, except for one patient. This suggests a lack of bone osseointegration as the fundamental reason for failure. All failures required isolated revision of the femoral component: two new Compress ® devices, two cemented stemmed MPs, and one Total Femur Arthroplasty. Discussion In this series of 21 infections managed using the Compress ® DFR, we achieved a limb-salvage rate of 100%. Following our two-stage strategy and using an antibiotic-loaded resorbable hydrogel coating, we found no infection relapse after a median follow-up of 42 months. The 5-year Compress ® survivorship rate was 75%, with no failures presenting beyond 7 months after the index procedure. This is the largest reported series of its sort, in a non-oncological cohort. The risk of infection relapse in previously infected settings treated with megaprostheses is a major concern. The axiom “the larger the implant surface, the higher the risk of bacterial adhesion” may apply in this context. Surprisingly, there is limited literature on these scenarios, with reported infection rates ranging from 3-30% (5). DFR are even more concerning, with a relative risk for revision due to reinfection of 3.33 (p = .056) (4) In the current series we observed no infection relapse after a median follow-up of 42 months, following very stringent infection control criteria. Cases included had undergone a significant number of previous surgeries as detailed, a proven risk factor for failure due to potential deep osteomyelitis in the remaining bone and compromised soft tissue quality. This high infection control success rate can be attributed to several factors: (a) extensive bone resection enabled the elimination of potential osteomyelitis foci that could perpetuate the infection (b) use of a staged strategy, beneficial for the most complex cases, and (c) use of surface-coating technology to protect implant surfaces against bacterial seeding. Although a single-stage strategy may have a role in some infected cases, we believe a staged approach offers advantages in the most complex scenarios: it facilitates accurate microbiological diagnosis, allows monitoring of infection control and simplifies complication management. However, its most important advantage in such complex scenarios is its allowance for patient and soft tissue optimization, which in turn allows for reimplantation of a new megaimplant under better physiological conditions, reducing risk of recolonization. Recolonization risk plays a fundamental role. Efforts to minimize surface recolonization have led to a variety of surface modifications and coating technologies. Available coating options are limited, and their clinical efficacy remains controversial. Defensive Antibacterial Coating (DAC ® ) is a hydrogel composed of covalently linked hyaluronan and poly-D,L- lactide. Although originally designed as a stand-alone product to reduce perioperative bacterial adhesion (passive anti-folding effect) the gel can be loaded with different antibiotic (active antibacterial effect) concentrations (19). When mixed with antibiotics the compound can quickly deliver local antibiotics in amounts hundreds or thousands of times higher than the minimum inhibitory concentration for up to 72 hours, inhibiting biofilm formation on different substrates and planktonic bacterial growth in vitro (20). DAC ® is reabsorbed in 72 hours, with no observed deleterious effect on bone healing or implant osseointegration in animal models. Hydrogeleffectiveness and safety have been proven in two single-blind randomized controlled multicentre trials in the field of trauma and orthopaedics (8,20). Our high rate of infection control and the absence of hydrogel-related complications merits further investigation to establish the role of such a coating strategy. DFR represents a very unfavourable biomechanical scenario with a concerning rate of early aseptic loosening. Published series note aseptic failures as high as 18% after 5 years and 47% after only 8 years (3). Long stem length results in high bending stress coupled with rotational instability, leading to such early loosening. Even more troublesome is the fact that after revision of a long stem, the loss of bone stock can be so dramatic as to put at risk or rule out the possibility of further revision (21). The Compress ® was developed as an alternative to stemmed megaprostheses, aiming to overcome their limitations; it has primarily been used in oncological reconstructions. By leveraging Wolff’s Law, the implant promotes hypertrophy at the bone-implant interface (12) through axial compression and allows stable, high-pressure fixation. It requires shorter working lengths and less bone resection. Its potential advantages include greater bone stock preservation, reduced stress shielding and shorter working length. Compress ® is not, however, free of potential complications, including the possibility of mechanical failure. Our Compress ® distal femur replacement survivorship rate was 75% at 5 years,with all failures occurring in the first 7 months. Although long-term data is limited, similar studies have reported comparable outcomes. Healey demonstrated an overall Compress ® DFR survivorship rate of 85% at 5 years and 80% at 10 years (22). Studies comparing implant survivorship between Compress ® and stemmed implants have found no significant differences in this regard , although literature on the subject is limited. In a retrospective study (11) with matched groups, no difference in overall survivorship at 5 years was observed. However, significant differences were found in implant survivorship without necessity of surgical revision, favouring the study’s Compress ® group. Compress ® aseptic failures differ from those of stemmed implants, typically due to osseointegration deficiency at the host-bone interface. This highlights the importance of bone biology in implant fixation, as mechanical failure becomes inevitable if osseointegration is not achieved (21). Timing is the key distinction in aseptic failure between Compress ® and stemmed implants. Compress ® failures occur during the initial postoperative months, whereas stemmed megaprostheses tend to fail progressively over time. The aseptic failure rate ranges from 4%-25% (12), but once osseointegration is established, aseptic failure is unlikely to necessitate long-term revision. This conforms with our own findings, with all our failures occurring within the first 7 months after the index surgery and no failures observed beyond this time threshold. The radiographic parameters commonly used in assessing megaprostheses are not effective for predicting aseptic mechanical failure of Compress ® implants (23). Groundland (12) suggested a simpler 3-point scale based on host-bone reaction. Fifteen cases in our series demonstrated radiological pedestal, scoring 3 points each. Among the five patients who experienced aseptic failure, none scored as high as 3; 69% scored only 1. These findings suggest that such a radiological approach is suitable for assessing compressive osseointegration status and ruling out aseptic failure. We recognize the limitations of the present research. Retrospective’s nature, which rely on chart notes from which important data may be missing, increasing bias incidence. Another limitation is our lack of a comparison group; absence of a control group makes it impossible to compare results directly with cases where stemmed DFRs were used in the same clinical scenarios, or cases without DAC ® coating. Sample is relatively small, but comparable to other studies, and probably the largest in septic non-oncological scenarios. Finally, we recognize that all care was provided at a single, high-volume, specialized centre; being difficult to extrapolate these results to less-experienced units. Studies employing prospective data retrieval, larger sample and more extensive follow-up are undoubtedly needed. Conclusion DFR using the Compress ® device together with hydrogel coating has proven to be a valid treatment alternative in cases of massive infected bone defects. Our staged protocol and treatment strategy achieved infection control in all cases. Mid-term survivorship of the Compress ® DFR in this series was 75%, with all aseptic failures occurring within the initial months after implantation and due to osseointegration interface deficiency. Declarations Funding : This work received no financial support. The study was conducted as part of our institution’s routine work. Ethical Statement : All authors have participated in this paper, and we affirm that it has not been sent to any other journal. The Ethics Committee of our centre approved this study (Institutional Review Board — IRB approval). References Corona PS, Jurado M, Scott-Tennent A, Fraile R, Carrera L, Vicente M. Uniplanar versus biplanar monolateral external fixator knee arthrodesis after end-stage failed infected total knee arthroplasty: a comparative study. Eur. J. Orthop. Surg. Traumatol. 2020 Jul 1;30(5):815–25. Corona PS, Vicente M, Lalanza M, Amat C, Carrera L. Use of modular megaprosthesis in managing chronic end-stage periprosthetic hip and knee infections: Is there an increase in relapse rate? Eur. J. Orthop. Surg. Traumatol. 2018 May 1;28(4):627–36. Angers-Goulet M, Pelet S, Belzile EL, Bédard M. Total knee arthroplasty with distal femoral replacement is associated with an important complication rate. A case series. Knee. 2019 Oct 1;26(5):1080–7. Vertesich K, Puchner SE, Staats K, Schreiner M, Hipfl C, Kubista B. Distal femoral reconstruction following failed total knee arthroplasty is accompanied with risk for complication and reduced joint function. BMC Musculoskelet Disord. 2019 Jan 31;20(1). Calori GM, Colombo M, Malagoli E, Mazzola S, Bucci M, Mazza E. Megaprosthesis in post-traumatic and periprosthetic large bone defects: Issues to consider. Injury. 2014 Dec 1;45(S6):S105–10. Kramer MJ, Tanner BJ, Horvai AE, O’Donnell RJ. Compressive osseointegration promotes viable bone at the endoprosthetic interface: Retrieval study of Compress® implants. Int Orthop. 2008 Oct;32(5):567–71. Corona PS, Altayó M, Amat C, Vicente M, Velez R. Reconstruction of infected post-traumatic bone defects of the distal femur with the CompressⓇ implant. Preliminary results of a staged non-biological strategy. Injury. 2021 Mar 1;52(3):606–15. Malizos K, Blauth M, Danita A, Capuano N, Mezzoprete R, Logoluso N. Fast-resorbable antibiotic-loaded hydrogel coating to reduce post-surgical infection after internal osteosynthesis: a multicenter randomized controlled trial. Journal of Orthopaedics and Traumatology. 2017 Jun 1;18(2):159–69. Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, et al. Fracture-related infection: A consensus on definition from an international expert group. Injury. 2018 Mar 1;49(3):505–10. Mcnally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC. The EBJIS definition of periprosthetic joint infection. Bone Joint J. 2021;103(1):18–25. Pedtke AC, Wustrack RL, Fang AS, Grimer RJ, O’Donnell RJ. Aseptic failure: How does the compress® implant compare to cemented stems? Clin Orthop Relat Res; 2012. p. 735–42. Groundland J, Brown JM, Monument M, Bernthal N, Jones KB, Randall RL. What Are the Long-term Surgical Outcomes of Compressive Endoprosthetic Osseointegration of the Femur with a Minimum 10-year Follow-up Period? Clin Orthop Relat Res. 2022 Mar 1;480(3):539–48. Diaz-Ledezma C, Higuera CA, Parvizi J. Success after treatment of periprosthetic joint infection: A delphi-based international multidisciplinary consensus infection. Vol. 471, Clin Orthop Relat Res; 2013. p. 2374–82. Corona PS, Pérez M, Vicente M, Pujol O, Amat C, Carrera L. Sequential repeated tibial tubercle osteotomy in a two-stage exchange strategy: a superior approach to treating a chronically infected knee arthroplasty? Eur. J. Orthop. Surg. Traumatol. (2023) Corró S, Vicente M, Rodríguez-Pardo D, Pigrau C, Lung M, Corona PS. Vancomycin-Gentamicin Prefabricated Spacers in 2-Stage Revision Arthroplasty for Chronic Hip and Knee Periprosthetic Joint Infection: Insights Into Reimplantation Microbiology and Outcomes. Journal of Arthroplasty. 2020 Jan 1;35(1):247–54. Kagan R, Adams J, Schulman C, Laursen R, Espana K, Yoo J. What Factors Are Associated With Failure of Compressive Osseointegration Fixation? Clin Orthop Relat Res. 2017 Mar 1;475(3):698–704. Romanò CL, Malizos K, Capuano N, Mezzoprete R, D’arienzo M, Der C Van. Does an Antibiotic-Loaded Hydrogel Coating Reduce Early Post-Surgical Infection After Joint Arthroplasty? J Bone Jt Infect. 2016 Jul 19;1(1):34–41. Drago L, Boot W, Dimas K, Malizos K, Hänsch GM, Stuyck J, et al. Does Implant Coating With Antibacterial-Loaded Hydrogel Reduce Bacterial Colonization and Biofilm Formation in Vitro? Clin Orthop Relat Res. 2014 Oct 2;472(11):3311–23. Bhangu AA, Kramer MJ, Grimer RJ, O’Donnell RJ. Early distal femoral endoprosthetic survival: Cemented stems versus the Compress® implant. Int Orthop. 2006 Dec;30(6):465–72. Healey JH, Morris CD, Athanasian EA, Boland PJ. Compress ® knee arthroplasty has 80% 10-year survivorship and novel forms of bone failure knee. Clin Orthop Relat Res; 2013. p. 774–83. Kagan R, Parlee L, Beckett B, Hayden JB, Gundle KR, Doung YC. Radiographic parameter-driven decision tree reliably predicts aseptic mechanical failure of compressive osseointegration fixation. Acta Orthop. 2020 Mar 3;91(2):171–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Feb, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted Editorial decision: Revision requested 31 Dec, 2024 Reviews received at journal 27 Dec, 2024 Reviews received at journal 24 Dec, 2024 Reviewers agreed at journal 16 Dec, 2024 Reviewers agreed at journal 16 Dec, 2024 Reviewers invited by journal 16 Dec, 2024 Editor assigned by journal 05 Nov, 2024 Submission checks completed at journal 05 Nov, 2024 First submitted to journal 31 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5368805","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374415454,"identity":"772abc55-bb34-43b0-8a2e-566dea6267d7","order_by":0,"name":"Pablo S. Corona","email":"","orcid":"","institution":"Vall d'Hebron Hospital Universitari","correspondingAuthor":false,"prefix":"","firstName":"Pablo","middleName":"S.","lastName":"Corona","suffix":""},{"id":374415455,"identity":"b20e3a15-657e-490f-b01a-0099bb95f1dd","order_by":1,"name":"Margalida H. Vicens","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYDACCQjF2AAkDoBY/CAioYAULZIgVoIBkVrAwACsEY8W3dnNxz4X1NyR7ec/Y3jgR8Ude+PzqxM/PDBgkOcXO4BVi9mdY8mzZxx7Zjyz4YzBwZ4zzxK33Xi7WQLoMMOZsxOwa7mRY8zMw3Y4ccPBtoTDjG2HE8xunN0A0pJgcBuXlvzPzDz/DifuP8wG1PLvsL3xjLObf+DXksPMzNsGtIWN+cBhxobDjBv4e7cRsCXNmJm377DxjDPMBw72HDucOOMG7zaLBAMJPH5JfszM8+2wbH//weYPP2oO2/P3n91880eFjTy/NHYtWIAEWKUEscpBgP8AKapHwSgYBaNgBAAA/pNqj3vMqfsAAAAASUVORK5CYII=","orcid":"","institution":"Vall d'Hebron Hospital Universitari","correspondingAuthor":true,"prefix":"","firstName":"Margalida","middleName":"H.","lastName":"Vicens","suffix":""},{"id":374415456,"identity":"64daa9c1-7f45-49f3-803c-605c173f63f3","order_by":2,"name":"Rosa Fraile","email":"","orcid":"","institution":"Vall d'Hebron Hospital Universitari","correspondingAuthor":false,"prefix":"","firstName":"Rosa","middleName":"","lastName":"Fraile","suffix":""},{"id":374415457,"identity":"b943689f-6afb-4ae8-a6b0-618d7e83059d","order_by":3,"name":"Carles Amat","email":"","orcid":"","institution":"Vall d'Hebron Hospital Universitari","correspondingAuthor":false,"prefix":"","firstName":"Carles","middleName":"","lastName":"Amat","suffix":""},{"id":374415458,"identity":"92e8419b-7442-4f08-b4fe-393fa3ca1d4b","order_by":4,"name":"Matías Vicente","email":"","orcid":"","institution":"Vall d'Hebron Hospital Universitari","correspondingAuthor":false,"prefix":"","firstName":"Matías","middleName":"","lastName":"Vicente","suffix":""}],"badges":[],"createdAt":"2024-10-31 18:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5368805/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5368805/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00590-025-04177-9","type":"published","date":"2025-02-13T15:57:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70510389,"identity":"df2917c7-7d05-4f29-b23b-f2ee0a6af21f","added_by":"auto","created_at":"2024-12-04 00:30:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":416099,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Radiograph showing implant loosening as a consequence of a lack of osseointegration between implant and host bone; (b) Radiograph showing a temporary static spacer used to obliterate the dead space and stabilize the extremity during the first stage.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5368805/v1/d7dd4d52275b115ebddda3c2.png"},{"id":70510391,"identity":"e34db301-f58b-46c7-98a0-a5867e9b133c","added_by":"auto","created_at":"2024-12-04 00:30:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":854492,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Aggressive debridement is performed again; (b) Compress\u003csup\u003e®\u003c/sup\u003e system is implanted and attached to a rotating hinge prosthesis (Orthopaedic Salvage System, OSS\u003csup\u003e®\u003c/sup\u003e).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5368805/v1/4baa6cc4b324552ac61bc07b.png"},{"id":70510392,"identity":"721a749c-4126-4836-8f56-16934d750a14","added_by":"auto","created_at":"2024-12-04 00:30:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1202149,"visible":true,"origin":"","legend":"\u003cp\u003eThe Defensive Antibacterial Coating (DAC\u003csup\u003e®\u003c/sup\u003e) hydrogel coating is spread by direct application onto the extramedullary surface of the femoral implant and tibial stem during the second stage.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5368805/v1/b1b881edc219124f1a44423f.png"},{"id":70510387,"identity":"079b3ac2-aac0-49e3-8f18-619e8a384647","added_by":"auto","created_at":"2024-12-04 00:30:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":74924,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier Survival Curve\u003c/p\u003e\n\u003cp\u003eGraph of Kaplan-Meier survival curve for our series of Compress implants after infected bone defect resection of the distal femur, after a midterm follow-up of 5 years.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5368805/v1/f76b1f122f7b4e2247397dee.png"},{"id":70510388,"identity":"17cb34a3-f756-47a7-bd88-e9a842fe1bb6","added_by":"auto","created_at":"2024-12-04 00:30:08","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":342804,"visible":true,"origin":"","legend":"\u003cp\u003eAn AP radiograph (case #13) reveals bone hypertrophy in the interface host bone-implant which indicates a scoring of 3 points according to the Groundland radiographic Scale.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5368805/v1/106cca6b4f4769c6675d4e3d.png"},{"id":76487809,"identity":"7be37144-8239-490f-88b7-44d73021a9aa","added_by":"auto","created_at":"2025-02-17 16:12:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4900900,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5368805/v1/86faf13f-fcdb-4210-8871-4f24b1ebabb6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Distal femur replacement for infected bone defects due to end-stage periprosthetic joint infection or trauma. A staged strategy protocol using the stemless CompressÒ device protected with a fast resorbable antibiotic-loaded hydrogel.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInfected bone defect is one of the most difficult conditions to treat following orthopaedic trauma\u0026nbsp;or periprosthetic joint infection (PJI)\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eIn cases of an infected distal femur with juxta-articular involvement, the challenges are even more formidable, due to limited limb salvage options (1).\u0026nbsp;In recent years there has been increasing interest in distal femur replacement (DFR) in non-oncological scenarios (2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStemmed DFR represents a particularly unfavourable biomechanical scenario, with a high complication rate. DFR after a failed total knee arthroplasty also shows significant failure rates, with a 47% aseptic loosening rate after 8 years. Revision-free survival is estimated at 62.5% at 3 years and 41% at 10 years (3) (4). Even more concerning are the limited reconstructive options if the implant fails, due to\u0026nbsp;poor remaining bone stock. The increased risk of infection with such massive implants is widely recognized, with failed infection control rates ranging from 3% to more than 30% (5).\u003c/p\u003e\n\u003cp\u003eThe Compress\u003cem\u003e\u003csup\u003e®\u003c/sup\u003e\u003c/em\u003e compliant Pre-Stress (CPS) device\u0026nbsp;(Zimmer-Biomet\u003cem\u003e\u003csup\u003e®\u003c/sup\u003e\u003c/em\u003e, Warsaw, Indiana, USA) is a fixation system with a very short intramedullary segment (stemless), designed to avoid some of the limitations of stemmed implants.\u0026nbsp;Its primary stability is based on initial compression, with long-term stability achieved through implant osseointegration.\u0026nbsp;Suggested advantages are greater bone stock preservation and longer implant survivorship, with series showing a survivorship rate of 80% at 10 years (6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince 2015, a\u0026nbsp;comprehensive\u0026nbsp;two-stage limb-salvage strategy\u0026nbsp;protocol has become the standard of care (7)\u0026nbsp;in our specialty-dedicated unit, for managing end-stage knee PJI cases with massive distal femur bone loss or infected distal femur juxta-articular bone defects due to trauma: 1) Pseudo-oncological bone resection and temporary hand-made static spacer; 2) Stemless DFR using the Compress\u003cem\u003e\u003csup\u003e®\u003c/sup\u003e\u003c/em\u003e device 3) Mega-implant surface protection strategy using an antibiotic-loaded antibacterial hydrogel (Defensive Antibacterial Coating — DAC\u003csup\u003e®\u003c/sup\u003e; Novagenit, Mexxolombardo, Italy) (8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsidering all the aforementioned, we sought to study the outcomes of this limb-salvage strategy, focusing on: \u003cstrong\u003e1\u003c/strong\u003e) infection control \u003cstrong\u003e2\u003c/strong\u003e)\u0026nbsp;Compress\u003csup\u003e®\u0026nbsp;\u003c/sup\u003emid-term survivorship, \u003cstrong\u003e3)\u003c/strong\u003e protocol-related complications, and\u0026nbsp;\u003cstrong\u003e4\u003c/strong\u003e) limb-salvage rate.\u0026nbsp;Currently, there is a lack of scientific reports evaluating the usefulness of the Compress\u003csup\u003e®\u003c/sup\u003e DFR in infected non-tumoral scenarios.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFollowing IRB approval, this study was conducted as a longitudinal cohort study. The institutional database was retrospectively reviewed to identify all patients with distal femur infected bone defects treated under this novel protocol between January 2015 and January 2022.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInclusion criteria\u003c/em\u003e\u003c/strong\u003e: 1) Use of\u0026nbsp;Compress\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003eDFR\u0026nbsp;to manage infected bone defects (PJI or infected trauma defects) with a minimum post-surgical follow-up of 18 months. 2) Two-stage strategy 3)\u0026nbsp;Use of\u0026nbsp;DAC\u003csup\u003e\u0026reg;\u003c/sup\u003e as an implant coating.\u0026nbsp;\u0026nbsp;Patients with no post-surgery tracking data, oncological cases, and cases which didn\u0026rsquo;t accomplished inclusion criteria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOutcome Variable\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u003c/em\u003e Primary endpoints were infection control rate and medium-term Compress\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003eimplant survival rate. The following data were recorded from our institutional database: \u003cstrong\u003ea\u003c/strong\u003e) demographics;\u0026nbsp;\u003cstrong\u003eb\u003c/strong\u003e) comorbidities; \u003cstrong\u003ec\u003c/strong\u003e) previous surgeries; \u003cstrong\u003ed\u003c/strong\u003e) first-stage intraoperative data; \u003cstrong\u003ee)\u003c/strong\u003e second-stage intraoperative data;\u0026nbsp;\u003cstrong\u003ee)\u003c/strong\u003e postoperative data:\u0026nbsp;Compress\u003csup\u003e\u0026reg;\u003c/sup\u003e-related complications, unexpected reinterventions, radiological findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDefinitions\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e1.\u0026nbsp; \u0026nbsp;\u003c/em\u003e\u003c/strong\u003eInfection definition: post-traumatic cases with an established diagnosis of deep infection, according to international-consensus criteria (9). PJI cases with an established diagnosis of chronic PJI, according\u0026nbsp;the 2021 EBJIS criteria definition (10).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2. \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eCompress\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003eradiological evaluation:\u0026nbsp;1 point for narrowed interface contour, 2 points for unaltered contour, and 3 points for widened contour\u0026nbsp;(11)(12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3. \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eInfection eradication, based on Delphi-method consensus criteria (13): \u003cstrong\u003ea)\u003c/strong\u003e healed wound without fistula or drainage and no infection recurrence caused by the same organism strain; \u003cstrong\u003eb\u003c/strong\u003e) no subsequent surgical intervention for infection after reimplantation surgery; \u003cstrong\u003ec\u003c/strong\u003e) no PJI-related mortality. Necessity for suppressive antibiotic treatment or onset of another PJI caused by a different microorganism were also deemed as treatment failures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOperative technique description\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/em\u003eLimb-salvage was carried out following a two-stage surgical strategy with all surgeries performed by the senior author (P.C.).\u003c/p\u003e\n\u003cp\u003eDuring the first stage\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ea medial parapatellar approach is used, and extended through a tibial tubercle osteotomy when needed (16). Implant removal and radical bone debridement is performed following a pseudo-oncological approach, with segmental bone resection of distal femur. A temporary static spacer is used (\u003cstrong\u003eFigure 1A/B\u003c/strong\u003e) to fill dead space and stabilize the extremity\u0026nbsp;(17).\u0026nbsp;Antibiotic treatment is selected according to the susceptibility profile of the isolated bacteria.\u003c/p\u003e\n\u003cp\u003eDuring the second stage the\u0026nbsp;spacer is removed and a second aggressive debridement is performed, with sample collection. Indications for Compress\u003csup\u003e\u0026reg;\u003c/sup\u003e implantation include \u0026gt; 2.5 mm cortical thickness of viable remaining proximal femur, without areas of cortical defect, and \u0026gt; 4 cm of residual subtrochanteric femur to accommodate the smaller anchor plug. The CPS is used in accordance with the manufacturer\u0026rsquo;s recommended technique, which can be found elsewhere (18), and attached to an OSS\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003e(\u003cem\u003eOrthopaedic Salvage System -\u003c/em\u003e Zimmer-Biomet\u003cem\u003e\u003csup\u003e\u0026reg;\u003c/sup\u003e\u003c/em\u003e, Warsaw, Indiana, USA)\u0026nbsp;rotating hinge platform (\u003cstrong\u003eFigure 2\u003c/strong\u003e).\u0026nbsp;The system offers two anchor plug/spindle options: short Compress\u003csup\u003e\u0026reg;\u003c/sup\u003e requires 45 mm of medullary placement, whereas standard Compress\u003csup\u003e\u0026reg;\u003c/sup\u003e needs 80 mm.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCoating protocol:\u003c/strong\u003e DAC\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003ehydrogel is prepared intra-operatively according to the following protocol, developed by our unit. A vancomycin-gentamicin solution is prepared by diluting 1g of vancomycin powder in 20 cc distilled water. Then 5cc of this solution is combined with 3 ampoules of 80 mg liquid gentamicin. Next, 5 cc of this solution is mixed with 5 cc of DAC\u003csup\u003e\u0026Ograve;\u003c/sup\u003e powder and allowed to sit for 10 minutes before 20 cc of the resulting vancomycin-gentamicin-DAC\u003csup\u003e\u0026Ograve;\u003c/sup\u003e mixture is taken. The solution will remain stable for up to 5 hours. It is applied directly to the tibial stem and the extramedullary surfaces of the femoral component (\u003cstrong\u003eFigure 3\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFollow-up and rehabilitation protocol\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAfter discharge, patients were seen at 3 weeks, 6 weeks, 3 months, 6 months, and annually thereafter. Patients received a strict rehabilitation program, though the program was not begun until correct evolution of the surgical wound was confirmed. For the first 6 weeks, the program focused on passive knee motion, with no weightbearing allowed. A maximum of 50% weightbearing was then allowed for the subsequent 6 weeks, after which the patient progressed to full weightbearing as tolerated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to present patient demographics and surgical complications. Categorical variables were described by their absolute values and percentages. Continuous variables were presented by their measure of central tendency (mean or median) and range. Kaplan-Meier survival curve represented medium-term survivorship of the Compress\u003csup\u003e\u0026reg;\u003c/sup\u003e device. Statistical analysis was conducted using Stata v.14.9 software.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn our database review, there were identified 31 cases of DFR using the CPS\u003csup\u003e\u0026nbsp;\u003c/sup\u003edevice.\u0026nbsp;After excluding ineligible cases,\u0026nbsp;21 cases\u0026nbsp;with distal femur infected bone defects who had undergone the two-stage reconstruction protocol\u0026nbsp;were finally included.\u0026nbsp;Of\u0026nbsp;these, 76.1% were males with an average age of 58 years (range:19-80); median follow-up in this series was 42 months (range:18-83).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReason for distal femur replacement:16 cases due to distal femur infected fractures; 5 cases due to end-stage PJI. The complexity of these cases is reflected in the number of previous procedures, prior to our index surgery. There was an average of 5.12 in our post-traumatic group, and 4.8 in PJI group. Patient demographics and specific comorbidities are shown in \u003cstrong\u003eTable 1\u003c/strong\u003e. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003ePatient demographics and specific comorbidities\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"564\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003eSummary of case characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk factor\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFracture type/G-A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious procedures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eSmoker\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eBMI\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eBMI\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eAseptic loosening\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eClosed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eClosed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eBMI\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eSmoker, BMI\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e11\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eAseptic loosening\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eDM, BMI\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003ePJI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003ePJI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003ePJI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eClosed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003ePJI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8.15603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.2695%;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.73759%;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4043%;\"\u003e\n \u003cp\u003eSmoker, BMI \u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.97872%;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8085%;\"\u003e\n \u003cp\u003eOpen/IIIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.6454%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e: F=female, M=male, BMI=body mass index, ASA= American Anaesthesia Society scale, G-A: Gustilo-Anderson classification. \u0026nbsp; \u0026nbsp; *Revision Compress cases after Compress failure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCharacteristics of the first and second surgical steps are summarized in \u003cstrong\u003eTable 2\u003c/strong\u003e.\u0026nbsp;Regarding microbiological results, \u003cem\u003ecoagulase-negative Staphylococcus\u0026nbsp;\u003c/em\u003estrains were the most frequent pathogens found in our series, isolated in 33.3 % of our cases.\u0026nbsp;Eight cases presented negative cultures, despite unequivocal signs of infection.\u0026nbsp;Further\u0026nbsp;information on infection-causing microorganisms can be found in \u003cstrong\u003eTable 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eIn this series,\u0026nbsp;the mean distal femoral bone resection was 14.57 cm (range 8-23.5 cm). A static cement spacer was used in all cases without reported spacer-related complications. After the first stage, one patient experienced skin necrosis, which was resolved with a microsurgical ALT free flap.\u0026nbsp;During the second stage, all microbiological cultures were negative; mean Compress\u003cem\u003e\u003csup\u003e\u0026reg;\u003c/sup\u003e\u003c/em\u003e-OSS\u003cem\u003e\u003csup\u003e\u0026reg;\u003c/sup\u003e\u003c/em\u003e reconstruction length was 15.85 cm. Detailed characteristics of CPS implant in \u003cstrong\u003eTable 2\u003c/strong\u003e. Antibiotic-loaded hydrogel was used in all cases according to the described protocol, with no recorded intra-operative complication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e:\u0026nbsp;First and second surgical features\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"582\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 582px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eSummary of case operative characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBone defect (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIsolated microorganism\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCement spacer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTTO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCPS-Plug\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompression (lbs.)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOSS length\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal ATB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003ePolimicrobiane\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eDynamic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eStandard\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; DAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eDynamic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (1,2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eMRSA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (1,2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eCNS\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eDynamic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (1,2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003ePseudomonas spp.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eMRSA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eCNS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eCNS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003ePseudomonas spp.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eCNS\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (2t)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eCNS\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes (2T)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eCNS\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eMRSA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cem\u003eCNS\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003eShort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eDAC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 582px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e: CNS=coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e, MRSA = Methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e; TTO = tibial tubercle osteotomy. The cells highlighted in blue are from two cases of re-Compress\u003csup\u003e\u0026reg;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAs to the principal endpoint of our study, after a mean follow-up of 42 months we did not observe any infection relapse in this series of patients, with an overall infection control rate of 100% following our stringent infection control criteria. All cases achieved limb salvage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding Compress\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003edevice-related complications,\u0026nbsp;during early follow-up, five cases experienced\u0026nbsp;Compress\u003cem\u003e\u003csup\u003e\u0026reg;\u003c/sup\u003e\u003c/em\u003e fixation failure due to aseptic loosening,\u0026nbsp;requiring isolated replacement of the femoral component (all cultures negative). Interestingly, all failures occurred in the first 7 months (range: 3-7);\u0026nbsp;during the full weight-bearing step of the postoperative rehabilitation protocol no failures were reported \u003cstrong\u003e(Table 3)\u003c/strong\u003e.\u0026nbsp;Beyond this time threshold, no further implant failures were observed,\u0026nbsp;resulting in a cumulative implant survival rate of 75 % at 1 and 5 years, and of 75% at final follow-up (\u003cstrong\u003eFigure 4\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Features of Compress\u0026reg; Failures cases\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"617\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 617px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eSummary of Compress failure case characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk Factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePedestal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRx. score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCause\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFU\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultures IOP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRevision Implant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eBMI\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eAseptic loosening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eCompress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eChronic Inflammation changes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eSmoker, BMI\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eAseptic loosening\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eCemented OSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eChronic Inflammation changes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eImplant Breakage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eCompress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eFoci of medullary necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eDM\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eImplant Breakage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eCemented OSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eChronic Inflammation changes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eNon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eImplant Breakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eTFA OSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eChronic Inflammation changes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 617px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e: BMI = Body Mass Index, DM = Diabetes Mellitus; Rx Score = 3-points Groundland score; FU = Follow-up; IOP= intraoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Regarding radiological evaluation, 71.4% showed bone hypertrophy on X-ray; all cases with bone hypertrophy scored 3 points (\u003cstrong\u003eFigure 5\u003c/strong\u003e). All six cases without bone hypertrophy (scoring 1 or 2 points) experienced aseptic failures, except for one patient. This suggests a lack of bone osseointegration as the fundamental reason for failure.\u0026nbsp;All failures required isolated revision of the femoral component: two new Compress\u003cem\u003e\u003csup\u003e\u0026reg;\u0026nbsp;\u003c/sup\u003e\u003c/em\u003edevices, two cemented stemmed MPs, and one Total Femur Arthroplasty.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this series of 21 infections managed using the Compress\u003cem\u003e\u003csup\u003e®\u0026nbsp;\u003c/sup\u003e\u003c/em\u003eDFR, we achieved a limb-salvage rate of 100%. Following our\u0026nbsp;two-stage strategy and using an antibiotic-loaded\u0026nbsp;resorbable hydrogel coating,\u0026nbsp;we found no infection relapse\u0026nbsp;after a\u0026nbsp;median follow-up of 42 months. The 5-year Compress\u003csup\u003e®\u003c/sup\u003e survivorship rate was 75%, with no failures presenting beyond 7 months after the index procedure. This is the largest reported series of its sort, in a non-oncological cohort.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe risk of infection relapse in previously infected settings treated with megaprostheses is a major concern. The axiom “the larger the implant surface, the higher the risk of bacterial adhesion” may apply in this context. Surprisingly, there is limited literature on these scenarios, with reported infection rates ranging from 3-30% (5). DFR are even more concerning, with\u0026nbsp;a relative risk for revision due to reinfection of 3.33 (p = .056)\u0026nbsp;(4)\u003c/p\u003e\n\u003cp\u003eIn the current series we observed no infection relapse after a median follow-up of 42 months, following very\u0026nbsp;stringent infection\u0026nbsp;control\u0026nbsp;criteria.\u0026nbsp;Cases included had undergone a significant number of previous surgeries as detailed, a proven risk factor for failure due to potential deep osteomyelitis in the remaining bone and compromised soft tissue quality. This high infection control success rate can be attributed to several factors: (a) extensive bone resection enabled the elimination of potential osteomyelitis foci that could perpetuate the infection (b) use of a staged strategy, beneficial for the most complex cases, and (c) use of surface-coating technology to protect implant surfaces against bacterial seeding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough a single-stage strategy may have a role in some infected cases, we believe a staged approach offers advantages in the most complex scenarios: it facilitates accurate microbiological diagnosis, allows monitoring of infection control and simplifies complication management. However, its most important advantage in such complex scenarios is its allowance for patient and soft tissue optimization, which in turn allows for reimplantation of a new megaimplant under better physiological conditions, reducing risk of recolonization. \u0026nbsp;Recolonization risk plays a fundamental role. Efforts to minimize surface recolonization have led to a variety of surface modifications and coating technologies. Available coating options are limited, and their clinical efficacy remains controversial.\u0026nbsp;Defensive Antibacterial Coating (DAC\u003csup\u003e®\u003c/sup\u003e) is a hydrogel composed of covalently linked hyaluronan and poly-D,L- lactide. Although originally designed as a stand-alone product to reduce perioperative bacterial adhesion (passive anti-folding effect) the gel can be loaded with different antibiotic (active antibacterial effect) concentrations (19). When mixed with antibiotics the compound can quickly deliver local antibiotics in amounts hundreds or thousands of times higher than the minimum inhibitory concentration for up to 72 hours, inhibiting biofilm formation on different substrates and planktonic bacterial growth in vitro (20). DAC\u003csup\u003e®\u003c/sup\u003e is reabsorbed\u0026nbsp;in 72 hours, with no observed deleterious effect on bone healing or implant osseointegration in animal models. Hydrogeleffectiveness and safety have been proven in two single-blind randomized controlled multicentre trials in the field of trauma and orthopaedics (8,20). \u0026nbsp;Our high rate of infection control and the absence of hydrogel-related complications merits further investigation to establish the role of such a coating strategy.\u003c/p\u003e\n\u003cp\u003eDFR represents a very unfavourable biomechanical scenario with a concerning rate of early aseptic loosening. Published\u0026nbsp;series note aseptic failures as high as 18% after 5 years and\u0026nbsp;47% after only 8 years (3). Long stem length results in high bending stress coupled with rotational instability, leading to such early loosening. Even more troublesome is the fact that after revision of a long stem, the loss of bone stock can be so dramatic as to put at risk or rule out the possibility of further revision (21).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Compress\u003cem\u003e\u003csup\u003e®\u003c/sup\u003e\u003c/em\u003e was developed as an alternative to stemmed megaprostheses, aiming to overcome their limitations; it has primarily been used in oncological reconstructions. By leveraging Wolff’s Law, the implant promotes hypertrophy at the bone-implant interface (12) through axial compression and allows stable, high-pressure fixation. It requires shorter working lengths and less bone resection. Its potential advantages include greater bone stock preservation, reduced stress shielding and shorter working length. Compress\u003cem\u003e\u003csup\u003e®\u003c/sup\u003e\u003c/em\u003e is not, however, free of potential complications, including the possibility of mechanical failure.\u003c/p\u003e\n\u003cp\u003eOur Compress\u003csup\u003e®\u003c/sup\u003e distal femur replacement survivorship rate was 75% at 5 years,with all failures occurring in the first 7 months. Although long-term data is limited, similar studies have reported comparable outcomes. Healey demonstrated an overall Compress\u003csup\u003e®\u0026nbsp;\u003c/sup\u003eDFR survivorship rate of 85% at 5 years and 80% at 10 years (22). Studies comparing implant survivorship between Compress\u003csup\u003e®\u003c/sup\u003e and stemmed implants have found no significant differences in this regard\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003ealthough literature on the subject is limited. In a retrospective study (11) with matched groups, no difference in overall survivorship at 5 years was observed. However, significant differences were found in implant survivorship without necessity of surgical revision, favouring the study’s Compress\u003csup\u003e®\u003c/sup\u003e group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompress\u003csup\u003e®\u0026nbsp;\u003c/sup\u003easeptic failures differ from those of stemmed implants, typically due to osseointegration deficiency at the host-bone interface. This highlights the importance of bone biology in implant fixation, as mechanical failure becomes inevitable if osseointegration is not achieved (21). Timing is the key distinction in aseptic failure between Compress\u003csup\u003e®\u003c/sup\u003e and stemmed implants. Compress\u003csup\u003e®\u0026nbsp;\u003c/sup\u003efailures occur during the initial postoperative months, whereas stemmed megaprostheses tend to fail progressively over time. The aseptic failure rate ranges from 4%-25% (12), but once osseointegration is established, aseptic failure is unlikely to necessitate long-term revision. This conforms with our own findings, with all our failures occurring within the first 7 months after the index surgery and no failures observed beyond this time threshold.\u003c/p\u003e\n\u003cp\u003eThe radiographic parameters commonly used in assessing megaprostheses are not effective for predicting aseptic mechanical failure of Compress\u003csup\u003e®\u003c/sup\u003e implants (23). Groundland (12) suggested a simpler 3-point scale based on host-bone reaction. Fifteen cases in our series demonstrated radiological pedestal, scoring 3 points each. Among the five patients who experienced aseptic failure, none scored as high as 3; 69% scored only 1. These findings suggest that such a radiological approach is suitable for assessing compressive osseointegration status and ruling out aseptic failure.\u003c/p\u003e\n\u003cp\u003eWe recognize the limitations of the present research. Retrospective’s nature, which rely on chart notes from which important data may be missing, increasing bias incidence. Another\u0026nbsp;limitation is our lack of a comparison group;\u0026nbsp;absence of a control group makes it impossible to compare results directly with cases where stemmed DFRs were used in the same clinical scenarios, or cases without DAC\u003csup\u003e®\u003c/sup\u003e coating. Sample is relatively small, but comparable to other studies, and probably the largest in septic non-oncological scenarios. Finally, we recognize that all care was provided at a single, high-volume, specialized centre; being difficult to extrapolate these results to less-experienced units. Studies employing prospective data retrieval, larger sample and more extensive follow-up are undoubtedly needed.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDFR using the Compress\u003csup\u003e\u0026reg;\u003c/sup\u003e device together with hydrogel coating has proven to be a valid treatment alternative in cases of massive infected bone defects. Our staged protocol and treatment strategy achieved infection control in all cases. Mid-term survivorship of the Compress\u003csup\u003e\u0026reg;\u003c/sup\u003e DFR in this series was 75%, with all aseptic failures occurring within the initial months after implantation and due to osseointegration interface deficiency.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003eThis work received no financial support. The study was conducted as part of our institution’s routine work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical Statement\u003c/em\u003e\u003c/strong\u003e: All authors have participated in this paper, and we affirm that it has not been sent to any other journal. The Ethics Committee of our centre approved this study (Institutional Review Board — IRB approval).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCorona PS, Jurado M, Scott-Tennent A, Fraile R, Carrera L, Vicente M. Uniplanar versus biplanar monolateral external fixator knee arthrodesis after end-stage failed infected total knee arthroplasty: a comparative study. Eur. J. Orthop. Surg. Traumatol. 2020 Jul 1;30(5):815\u0026ndash;25.\u003c/li\u003e\n \u003cli\u003eCorona PS, Vicente M, Lalanza M, Amat C, Carrera L. Use of modular megaprosthesis in managing chronic end-stage periprosthetic hip and knee infections: Is there an increase in relapse rate? Eur. J. Orthop. Surg. Traumatol. 2018 May 1;28(4):627\u0026ndash;36.\u003c/li\u003e\n \u003cli\u003eAngers-Goulet M, Pelet S, Belzile EL, B\u0026eacute;dard M. Total knee arthroplasty with distal femoral replacement is associated with an important complication rate. A case series. Knee. 2019 Oct 1;26(5):1080\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eVertesich K, Puchner SE, Staats K, Schreiner M, Hipfl C, Kubista B. Distal femoral reconstruction following failed total knee arthroplasty is accompanied with risk for complication and reduced joint function. BMC Musculoskelet Disord. 2019 Jan 31;20(1).\u003c/li\u003e\n \u003cli\u003eCalori GM, Colombo M, Malagoli E, Mazzola S, Bucci M, Mazza E. Megaprosthesis in post-traumatic and periprosthetic large bone defects: Issues to consider. Injury. 2014 Dec 1;45(S6):S105\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003eKramer MJ, Tanner BJ, Horvai AE, O\u0026rsquo;Donnell RJ. Compressive osseointegration promotes viable bone at the endoprosthetic interface: Retrieval study of Compress\u0026reg; implants. Int Orthop. 2008 Oct;32(5):567\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eCorona PS, Altay\u0026oacute; M, Amat C, Vicente M, Velez R. Reconstruction of infected post-traumatic bone defects of the distal femur with the CompressⓇ implant. Preliminary results of a staged non-biological strategy. Injury. 2021 Mar 1;52(3):606\u0026ndash;15.\u003c/li\u003e\n \u003cli\u003eMalizos K, Blauth M, Danita A, Capuano N, Mezzoprete R, Logoluso N. Fast-resorbable antibiotic-loaded hydrogel coating to reduce post-surgical infection after internal osteosynthesis: a multicenter randomized controlled trial. Journal of Orthopaedics and Traumatology. 2017 Jun 1;18(2):159\u0026ndash;69.\u003c/li\u003e\n \u003cli\u003eMetsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, et al. Fracture-related infection: A consensus on definition from an international expert group. Injury. 2018 Mar 1;49(3):505\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003eMcnally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC. The EBJIS definition of periprosthetic joint infection. Bone Joint J. 2021;103(1):18\u0026ndash;25.\u003c/li\u003e\n \u003cli\u003ePedtke AC, Wustrack RL, Fang AS, Grimer RJ, O\u0026rsquo;Donnell RJ. Aseptic failure: How does the compress\u0026reg; implant compare to cemented stems? Clin Orthop Relat Res; 2012. p. 735\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eGroundland J, Brown JM, Monument M, Bernthal N, Jones KB, Randall RL. What Are the Long-term Surgical Outcomes of Compressive Endoprosthetic Osseointegration of the Femur with a Minimum 10-year Follow-up Period? Clin Orthop Relat Res. 2022 Mar 1;480(3):539\u0026ndash;48.\u003c/li\u003e\n \u003cli\u003eDiaz-Ledezma C, Higuera CA, Parvizi J. Success after treatment of periprosthetic joint infection: A delphi-based international multidisciplinary consensus infection. Vol. 471, Clin Orthop Relat Res; 2013. p. 2374\u0026ndash;82.\u003c/li\u003e\n \u003cli\u003eCorona PS, P\u0026eacute;rez M, Vicente M, Pujol O, Amat C, Carrera L. Sequential repeated tibial tubercle osteotomy in a two-stage exchange strategy: a superior approach to treating a chronically infected knee arthroplasty? Eur. J. Orthop. Surg. Traumatol. (2023)\u003c/li\u003e\n \u003cli\u003eCorr\u0026oacute; S, Vicente M, Rodr\u0026iacute;guez-Pardo D, Pigrau C, Lung M, Corona PS. Vancomycin-Gentamicin Prefabricated Spacers in 2-Stage Revision Arthroplasty for Chronic Hip and Knee Periprosthetic Joint Infection: Insights Into Reimplantation Microbiology and Outcomes. Journal of Arthroplasty. 2020 Jan 1;35(1):247\u0026ndash;54.\u003c/li\u003e\n \u003cli\u003eKagan R, Adams J, Schulman C, Laursen R, Espana K, Yoo J. What Factors Are Associated With Failure of Compressive Osseointegration Fixation? Clin Orthop Relat Res. 2017 Mar 1;475(3):698\u0026ndash;704.\u003c/li\u003e\n \u003cli\u003eRoman\u0026ograve; CL, Malizos K, Capuano N, Mezzoprete R, D\u0026rsquo;arienzo M, Der C Van. Does an Antibiotic-Loaded Hydrogel Coating Reduce Early Post-Surgical Infection After Joint Arthroplasty? J Bone Jt Infect. 2016 Jul 19;1(1):34\u0026ndash;41.\u003c/li\u003e\n \u003cli\u003eDrago L, Boot W, Dimas K, Malizos K, H\u0026auml;nsch GM, Stuyck J, et al. Does Implant Coating With Antibacterial-Loaded Hydrogel Reduce Bacterial Colonization and Biofilm Formation in Vitro? Clin Orthop Relat Res. 2014 Oct 2;472(11):3311\u0026ndash;23.\u003c/li\u003e\n \u003cli\u003eBhangu AA, Kramer MJ, Grimer RJ, O\u0026rsquo;Donnell RJ. Early distal femoral endoprosthetic survival: Cemented stems versus the Compress\u0026reg; implant. Int Orthop. 2006 Dec;30(6):465\u0026ndash;72.\u003c/li\u003e\n \u003cli\u003eHealey JH, Morris CD, Athanasian EA, Boland PJ. Compress \u0026reg; knee arthroplasty has 80% 10-year survivorship and novel forms of bone failure knee. Clin Orthop Relat Res; 2013. p. 774\u0026ndash;83.\u003c/li\u003e\n \u003cli\u003eKagan R, Parlee L, Beckett B, Hayden JB, Gundle KR, Doung YC. Radiographic parameter-driven decision tree reliably predicts aseptic mechanical failure of compressive osseointegration fixation. Acta Orthop. 2020 Mar 3;91(2):171\u0026ndash;6.\u003cstrong\u003e\u003cu\u003e\u003c/u\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Distal femur replacement, Compress® device, periprosthetic joint infection, infected bone defect, limb salvage, DAC® hydrogel.","lastPublishedDoi":"10.21203/rs.3.rs-5368805/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5368805/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Distal femur replacement (DFR) with a stemmed megaprosthesis represents a challenge due to high rates of loosening and limited reconstructive options if the implant fails. Such an unfavourable scenario is even more complex where there are also infected bone defects. The Compress\u003csup\u003e\u003cem\u003e®\u003c/em\u003e\u003c/sup\u003e device was developed to provide an alternative to traditional intramedullary stems. We report on the outcomes of a staged protocol using the Compress\u003csup\u003e\u003cem\u003e®\u003c/em\u003e\u003c/sup\u003e DFR, protected with a vancomycin-gentamicin-loaded hydrogel, in infected non-oncological scenarios.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Retrospective longitudinal cohort study including patients with infected defects of the distal femur following orthopaedic trauma or periprosthetic joint infection (PJI) and managed with the protocol described. Protocol features, microbiological data, radiological results, complications, infection control and implant survivorship were assessed. Minimum follow-up was 18 months or until implant removal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 21 cases of Compress\u003csup\u003e\u003cstrong\u003e®\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e \u003c/strong\u003eDFR\u003cstrong\u003e \u003c/strong\u003ewere included. On average, patients had had 4.9 prior surgeries and 14.5 cm distal femur bone defects after pseudo-oncological resection. After median follow-up of 42 months (18-83 months), no infection recurrence occurred; limb salvage was achieved in all cases. Five patients experienced aseptic loosening, all within the first 7 postoperative months. Beyond this time threshold, no further implant failures were observed, resulting in a cumulative implant survival rate of 75 % at 1 and 5 years, and of 75% at final follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Staged Compress\u003csup\u003e\u003cstrong\u003e®\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e \u003c/strong\u003eDFR (protected with an antibiotic-loaded hydrogel) is a valid option for selected patients. It offers high rates of infection control, implant survivorship, and ease of revision, with aseptic failures occurring primarily in the initial postoperative months.\u003c/p\u003e","manuscriptTitle":"Distal femur replacement for infected bone defects due to end-stage periprosthetic joint infection or trauma. A staged strategy protocol using the stemless CompressÒ device protected with a fast resorbable antibiotic-loaded hydrogel.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-04 00:30:03","doi":"10.21203/rs.3.rs-5368805/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-31T19:35:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-27T18:16:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-24T19:06:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138682802564055251197718371173795576802","date":"2024-12-16T20:56:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260524051133972126032709672033044186936","date":"2024-12-16T17:53:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-12-16T11:52:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-05T14:14:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-05T14:13:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Orthopaedic Surgery \u0026 Traumatology","date":"2024-10-31T18:49:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"041a8b25-6875-4aa6-a8c1-31a7efabd2ad","owner":[],"postedDate":"December 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:07:21+00:00","versionOfRecord":{"articleIdentity":"rs-5368805","link":"https://doi.org/10.1007/s00590-025-04177-9","journal":{"identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isVorOnly":false,"title":"European Journal of Orthopaedic Surgery \u0026 Traumatology"},"publishedOn":"2025-02-13 15:57:57","publishedOnDateReadable":"February 13th, 2025"},"versionCreatedAt":"2024-12-04 00:30:03","video":"","vorDoi":"10.1007/s00590-025-04177-9","vorDoiUrl":"https://doi.org/10.1007/s00590-025-04177-9","workflowStages":[]},"version":"v1","identity":"rs-5368805","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5368805","identity":"rs-5368805","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}