Graft Infections in Biologic Reconstructions in the Oncologic Setting: A Systematic Review of the Literature.

Background: Biologic graft infection (BGI) is one of the main complications in graft reconstructions. However, very little evidence exists regarding the epidemiology of BGI, as most of the data come from sparse reports. Moreover, most of the series did not detail the treatment and outcome of graft infections. The aim of this systematic review of the literature is to provide a comprehensive data collection on BGI after oncologic resections. Methods: Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Results: 139 studies met the inclusion criteria. A total of 9824 grafts were retrieved. Among these, 684 (6.9%) were in the humerus, 365 (3.7%) in the pelvis, 2041 (20.7%) in the femur and 1660 (16.8%) in the tibia. Most grafts were osteoarticular (2481, 26.7%) and intercalary 2112 (22.7%) allografts. In 461 (5.0%), vascularized fibula grafts (VFGs) were used in combination with recycled autografts. Recycled grafts were reported in 1573 (16.9%) of the cases, and allograft-prosthetic composites in 1673 (18.0%). The pelvis and the tibia had the highest incidence of BGI (20.4% and 11.0%, respectively). The most reported first treatment was debridement and implant retention (DAIR) in 187 (42.8%) cases and two-stage revision with graft removal in 152 (34.8%). Very little data are reported on the final outcome specified by site or type of graft. Conclusions: This systematic review of the literature confirms a high incidence of infections in biologic reconstructions after resections of primary bone tumors. Despite DAIR being a viable attempt, in most cases, a two-stage approach with graft removal and reconstruction with endoprosthesis presented the highest chance to overcome infection, guaranteeing a reconstruction. We emphasize the need for future multicentric studies to focus on the management of infections after biological reconstructions in bone sarcomas.

Does Patellar Height Influence Range of Motion and Anterior Knee Pain after Distal Femur Endoprosthesis Reconstruction?

Objectives: This study aims to evaluate the patellar height changes after distal femur (DF) endoprosthetic replacement (EPR) and its impact on anterior knee pain (AKP) and range of motion (ROM). Methods: A retrospective review of three institutions' databases was performed. The patellar height was determined using the modified Insall-Salvati ratio (MIS), the Blackburne-Peel (BP) and the Caton-Deschamps (CD) indexes. Data regarding AKP and ROM were collected. Results: A total of 199 patients were included. The mean age at presentation was 37.9 ± 23.1 years. The mean one-year follow-up MIS, BP and CD were 1.52 (sd: 0.41), 0.82 (sd: 0.33) and 0.93 (sd: 0.33). Patellar height decreased significantly compared to the pre-operative values according to all three scores (p < 0.001). AKP was reported by 34 (17.1%) patients at 1 year follow-up. Patients with patella baja (MIS < 1.2) or pseudo patella baja (CD < 0.6) had a higher incidence of AKP (p = 0.037 and p = 0.024, respectively). The mean flexion ROM was 91°, with a direct correlation with patellar height (MIS p = 0.020, BP p = 0.036 and CD p = 0.036). Conclusion: The restoration of the native position of the joint line in DF EPR is important to maintain optimal patellofemoral biomechanics. Despite surgeons' tendency toward a reduction in patellar height with respect to pre-operative values, an increase in patellar height might help to achieve better knee flexion and reduce AKP.

Soft Tissue Vascular Anomalies of the Extremities: A Proposed Diagnostic Approach.

This narrative review aims to summarise the classification of vascular anomalies, their clinical presentation, and their radiological features to propose a diagnostic algorithm to approach patients with suspected soft tissue vascular anomalies of the extremities. The management of vascular anomalies necessitates a multidisciplinary approach. Clinical presentation and physical examination are sufficient in most cases to achieve a correct diagnosis. This is especially true for small congenital lesions of the skin and subcutaneous tissue. Imaging is used for accurate characterization of these lesions, especially in cases of atypical or vague clinical presentation, and to assess extension in cases of lesions that are larger and localized in deeper tissues.

Personalizing Prophylactic Radiotherapy for Hip Heterotopic Ossification: An AMSTAR-2 Compliant Review of Meta-analyses.

BACKGROUND/AIM: Heterotopic ossification (HO) is a common complication following total hip arthroplasty. Various prophylactic treatments have been proposed, including radiotherapy (RT). This review summarizes the evidence from meta-analyses on the efficacy of RT in preventing hip HO. MATERIALS AND METHODS: A literature search was conducted on PubMed. The quality of the meta-analyses was assessed using the AMSTAR-2 tool. RESULTS: Seven meta-analyses were included. One meta-analysis reported a significant reduction in HO occurrence after RT compared to the control group. Comparing RT and non-steroidal anti-inflammatory drugs, one and two meta-analyses showed significantly greater efficacy of RT in preventing severe HO and better outcomes in patients receiving drugs, respectively. Regarding RT settings, the postoperative and preoperative RT were each supported by one meta-analysis. Furthermore, two meta-analyses showed an advantage of multi-fractionated RT over single fraction RT. The overall confidence rate of the meta-analyses was moderate, low, and critically low in one, three, and three meta-analyses, respectively. CONCLUSION: RT is a confirmed prophylactic intervention for HO. However, the precise optimization of timing, dosage, and fractionation requires elucidation. Future research should focus on the development of predictive models through large-scale data collection and advanced analytics to refine individualized treatment strategies and assess RT comparative effectiveness with drugs.

Total Ankle Replacement Infections: A Systematic Review of the Literature.

Periprosthetic infection (PJI) after TAR is a serious complication, often requiring further surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. This systematic review aims to summarize the current evidence on the management of TAR PJI and provide a comprehensive overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Seventy-one studies met the inclusion criteria, reporting on cases of TAR PJI. A total of 298 PJIs were retrieved. The mean incidence of PJI was 3.8% (range 0.2-26.1%). Furthermore, 53 (17.8%) were acute PJIs, whereas most of them (156, 52.3%) were late PJIs. Most of the studies were heterogeneous regarding the treatment protocols used, with a two-stage approach performed in most of the cases (107, 35.9%). While the prevalence of ankle PJI remains low, it is potentially one of the most devastating complications of TAR. This review highlights the lack of strong literature regarding TAR infections, thus highlighting a need for multicentric studies with homogeneous data regarding the treatment of ankle PJI to better understand outcomes.

Silver-Coated Distal Femur Megaprosthesis in Chronic Infections with Severe Bone Loss: A Multicentre Case Series.

Periprosthetic joint infections (PJI) and fracture-related infections (FRI) of the distal femur (DF) may result in massive bone defects. Treatment options include articulated silver-coated (SC) megaprosthesis (MP) in the context of a two-stage protocol. However, there is limited evidence in the literature on this topic. A retrospective review of the prospectively maintained databases of three Institutions was performed. Forty-five patients were included. The mean follow-up time was 43 ± 17.1 months. Eight (17.8%) patients had a recurrent infection. The estimated recurrence-free survival rate was 91.1% (93.5% PJI vs. 85.7% FRI) 2 years following MP implantation, and 75.7% (83.2% PJI vs. 64.3% FRI; p = 0.253) after 5 years. No statistically relevant difference was found according to the initial diagnosis (PJI vs. FRI). Among possible risk factors, only resection length was found to significantly worsen the outcomes in terms of infection control (p = 0.031). A total of eight complications not related to infection were found after reimplantation, but only five of them required further surgery. Above-the-knee amputation was performed in two cases (4.4%), both for reinfection. Articulated DF SC MP in a two-stage protocol is a safe and effective treatment for chronic knee infection with severe bone loss.

Management of periprosthetic joint infection of shoulder arthroplasty: Single-stage versus two-stage protocols. A systematic review and meta-analysis of the literature.

Background: The treatment of shoulder prosthetic joint infections (PJIs) requiring removal of the prosthesis is not well defined. This article aims to systematically review and compare the results of the literature in single-stage and two-stage protocols in the treatment of shoulder PJI. Methods: An in-depth search on PubMed/Scopus/Web of Science databases and cross-referencing search was carried out concerning the articles reporting detailed data on the topic. Results: A total of 486 shoulder PJIs were included: 137 treated with single-stage and 349 with two-stage procedure. A similar distribution between early and not-early infections (19.1% vs 80.9%) was found between the two groups. The overall rate of success in terms of PJI eradication was significantly higher in the single-stage group (95.6% vs 85.7%, p < 0.001). The non-infection-related complications rate was 13.8% in the single-stage group and 37.6% in the two-stage group (p < 0.001), the non-infection-related revision rate was 8% and 18.9%, respectively (p = 0.005). Discussion: The single-phase protocol showed a higher success rate in eradicating the infection and a lower complication rate. However, the low number of patients included, the low quality of the articles, the lack of data on clinical severity and bacteriological virulence suggest caution in conclusions.

Does Surgical Approach Influence Complication Rate of Hip Hemiarthroplasty for Femoral Neck Fractures? A Literature Review and Meta-Analysis.

Background: Femoral neck fractures are an epidemiologically significant issue with major effects on patients and health care systems, as they account for a large percentage of bone injuries in the elderly. Hip hemiarthroplasty is a common surgical procedure in the treatment of displaced femoral neck fractures. Several surgical approaches may be used to access the hip joint in case of femoral neck fractures, each with its own benefits and potential drawbacks, but none of them has consistently been found to be superior to the others. This article aims to systematically review and compare the different approaches in terms of the complication rate at the last follow-up. Methods: an in-depth search on PubMed/Scopus/Web of Science databases and a cross-referencing search was carried out concerning the articles comparing different approaches in hemiarthroplasty and reporting detailed data. Results: A total of 97,576 hips were included: 1030 treated with a direct anterior approach, 4131 with an anterolateral approach, 59,110 with a direct lateral approach, and 33,007 with a posterolateral approach. Comparing the different approaches, significant differences were found in both the overall complication rate and the rate of revision surgery performed (p < 0.05). In particular, the posterolateral approach showed a significantly higher complication rate than the lateral approach (8.4% vs. 3.2%, p < 0.001). Furthermore, the dislocation rate in the posterolateral group was significantly higher than in the other three groups considered (p < 0.026). However, the posterolateral group showed less blood loss than the anterolateral group (p < 0.001), a lower intraoperative fractures rate than the direct anterior group (p < 0.035), and shorter mean operative time than the direct lateral group (p < 0.018). Conclusions: The posterolateral approach showed a higher complication rate than direct lateral approach and a higher prosthetic dislocation rate than the other three types of surgical approaches. On the other hand, patients treated with posterolateral approach showed better outcomes in other parameters considered, such as mean operative time, mean blood loss and intraoperative fractures rate. The knowledge of the limitations of each approach and the most common associated complications can lead to choosing a surgical technique based on the patient's individual risk.

Mid-Term Results of Single-Stage Surgery for Patients with Chronic Osteomyelitis Using Antibiotic-Loaded Resorbable PerOssal® Beads.

This retrospective study reports on the treatment of chronic osteomyelitis with local debridement combined with PerOssal®. The diagnosis of chronic osteomyelitis was confirmed in all cases and classified according to the Cierny-Mader (C-M) classification. The primary outcome was the eradication of infection at a minimum of one year after surgery. A total of 93 patients (median age: 40 years) were included. The most represented sites were the femur (24, 25.8%) and tibia (52, 55.9%). Twenty-six patients (28.0%) had significant local or systemic comorbidities (C-M Class B hosts). According to anatomic type, 31 cases were type I, 13 type II, 21 type III and 28 type IV. Vancomycin was added to PerOssal® in most cases (80, 86.0%). In 24 (25.8%) cases, Vancomycin and Rifampicin were combined. In 32 (34.4%) cases, intraoperative cultures were negative. Staphylococcus aureus was isolated in 39 (63.9%) patients, and Gram-negative bacteria were isolated in 12 cases. The median follow-up was 21 months (range 12-84). A total of 21 (22.6%) patients developed an infection recurrence (IR) after a median follow-up of 11 months (range: 1-47). PerOssal® holds several practical advantages compared to other bone void fillers. Thus, due to its good biocompatibility and sufficient antibiotic release, it represents a viable adjuvant treatment in chronic osteomyelitis.

Megaprosthesis in Non-Oncologic Settings-A Systematic Review of the Literature.

Modular megaprostheses (MPs) are commonly used after bone-tumor resection, but they can offer a limb salvage solution in massive bone defects. The aim of this systematic review of the Literature is to provide a comprehensive data collection concerning the use of MPs in non-oncologic cases, and to provide an overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Sixty-nine studies met the inclusion criteria, reporting on cases of MP in non-oncologic cases. A total of 2598 MPs were retrieved. Among these, 1353 (52.1%) were distal femur MPs, 941 (36.2%) were proximal femur MPs, 29 (1.4%) were proximal tibia MPs and 259 (10.0%) were total femur MPs. Megaprostheses were most commonly used to treat periprosthetic fractures (1158 cases, 44.6%), in particular in the distal femur (859, 74.2%). Overall, complications were observed in 513 cases (19.7%). Type I (soft tissue failures) and type IV (infection) according to the Henderson classification were the most frequent (158 and 213, respectively). In conclusion, patients with severe post-traumatic deformities and/or significant bone loss who have had previous septic complications should be considered as oncologic patients, not because of the disease, but because of the limited therapeutic options available. The benefits of this treatment include relatively short operative times and immediate weight-bearing, thus making MP particularly attractive in the lower limb.

Differences in hip musculoskeletal loads between limbs during daily activities in patients with 3D-printed hemipelvic reconstructions following tumor surgery.

BACKGROUND: Anatomical custom-made prostheses, thanks to computer-aided design and 3D-printing technology, help improve osseointegration and reduce mechanical complications in bone reconstructions following bone tumors. A recent quantitative analysis of long-term recovery in patients with 3D-printed reconstructions following pelvic tumor surgery showed asymmetries in ground reaction forces between limbs during different motor activities, while standing very good motor performance and quality of life. RESEARCH QUESTION: We analyzed hip contact forces and muscle forces in that cohort of six patients with an innovative custom-made reconstruction of the hemipelvis, and we tested the hypothesis that asymmetries in ground reaction forces would result in more marked differences in musculoskeletal forces. METHODS: State-of-the-art musculoskeletal modeling in an optimization-based inverse-dynamics workflow was used to calculate hip contact forces and muscle forces during five motor activities, and the differences between limbs were statistically evaluated across the motor activity cycles and on the force peaks. RESULTS: The musculoskeletal loads were found to be not symmetric, as hip loads were generally higher in the contralateral limb. We found significant differences in considerable portions of the motor activities cycles except squat, load symmetry indices indicating a load increase (median up to 25%) on the contralateral limb, especially during stair descent and chair rise/sit, and significantly higher values in the contralateral limb at force peaks. SIGNIFICANCE: We confirmed the hypothesis that residual asymmetries found in ground reaction forces were amplified when hip musculoskeletal loads were investigated, reflecting a shift of the loads toward the intact limb. Despite the general trend of higher loads found in the contralateral hip, this cannot be considered a risk of overloading, as both hips supported loads in a physiological range or lower, indicating a likely optimal recovery.

Functional Outcome after Reimplantation in Patients Treated with and without an Antibiotic-Loaded Cement Spacers for Hip Prosthetic Joint Infections.

Purpose: A staged revision with placement of a temporary antibiotic-loaded cement spacer after removal of the implant is the "gold standard" for treatment of chronic prosthetic joint infection (PJI). It enables local delivery of antibiotics, maintenance of limb-length and mobility, easier reimplantation. However, bacterial colonization of spacers and mechanical complications can also occur. The aim of this study is to evaluate functional results and infection control in two-stage treatment of total hip arthroplasty (THA) PJI with and without a spacer. Materials and Methods: A retrospective review of 64 consecutive patients was conducted: 34 underwent two-stage revision using a cement spacer (group A), 30 underwent two-stage revision without a spacer (group B). At the final follow-up, functional evaluation of patients with a THA in site, without PJI recurrence, was performed using the Harris hip score (HHS). Measurement of limb-length and off-set discrepancies was performed using anteroposterior pelvic X-rays. Results: Most patients in group B were older with more comorbidities preoperatively. Thirty-three patients (97.1%) in group A underwent THA reimplantation versus 22 patients (73.3%) in group B (P<0.001). No significant differences in limb-length and off-set were observed. The results of functional evaluation performed during the final follow-up (mean, 41 months) showed better function in patients in group A (mean HHS, 76.3 vs. 55.9; P<0.001). Conclusion: The use of antibiotic-loaded cement spacer seems superior in terms of functional outcomes and reimplantation rate. Resection arthroplasty might be reserved as a first-stage procedure in patients who are unfit, who might benefit from a definitive procedure.

A descriptive case series of the relationship between maintenance of conservative PK/PD efficacy thresholds of dalbavancin over time and clinical outcome in long-term treatment of staphylococcal osteoarticular infections.

OBJECTIVE: To describe the relationship between maintenance of pharmacokinetic/pharmacodynamic (PK/PD) dalbavancin efficacy thresholds over time and clinical outcome in a case series of patients who underwent therapeutic drug monitoring (TDM) during long-term treatment of staphylococcal osteoarticular infections (OIs). METHODS: Patients who received two 1500-mg doses of dalbavancin 1 week apart for documented staphylococcal OIs, underwent TDM assessment, and had clinical outcome assessable at follow-up were included retrospectively. Dalbavancin concentrations ≥4.02 and/or ≥8.04 mg/L were identified as conservative PK/PD efficacy thresholds. The percentage of time of the overall treatment period with dalbavancin concentrations above these efficacy thresholds was calculated and correlated with clinical outcome. RESULTS: In total, 17 patients were included in this study. Long-term dalbavancin was used mainly for treating prosthetic joint infections (9/17, 52.9%). In 13/17 patients (76.5%), clinical outcome was assessable after at least 6 months of follow-up and was always successful (100.0%). In four of 17 patients (23.5%), clinical outcome is favourable after 3.7, 4.8, 5.1 and 5.3 months of follow-up, respectively. In most patients, both dalbavancin PK/PD efficacy thresholds were reached for most of the treatment period (%time ≥4.02 mg/L: 100% in 13 cases, 75-99.9% in two cases, 50-74.99% in two cases; %time ≥8.04 mg/L: 100% in eight cases, 75-99.9% in four cases, 50-74.99% in four cases, <50% in one case). CONCLUSIONS: These findings could support the idea that maintenance of conservative PK/PD efficacy thresholds of dalbavancin for the majority of the treatment period may represent a valuable approach in dealing efficaciously with long-term treatment of staphylococcal OIs.

A Planned Multidisciplinary Surgical Approach to Treat Primary Pelvic Malignancies.

The pelvic anatomy poses great challenges to orthopedic surgeons. Sarcomas are often large in size and typically enclosed in the narrow confines of the pelvis with the close proximity of vital structures. The aim of this study is to report a systematic planned multidisciplinary surgical approach to treat pelvic sarcomas. Seventeen patients affected by bone and soft tissue sarcomas of the pelvis, treated using a planned multidisciplinary surgical approach, combining the expertise of orthopedic oncology and other surgeons (colleagues from urology, vascular surgery, abdominal surgery, gynecology and plastic surgery), were included. Seven patients were treated with hindquarter amputation; 10 patients underwent excision of the tumor. Reconstruction of bone defects was conducted in six patients with a custom-made 3D-printed pelvic prosthesis. Thirteen patients experienced at least one complication. Well-organized multidisciplinary collaborations between each subspecialty are the cornerstone for the management of patients affected by pelvic sarcomas, which should be conducted in specialized centers. A multidisciplinary surgical approach is of paramount importance in order to obtain the best successful surgical results and adequate margins for achieving acceptable outcomes.

Porous tantalum acetabular cups for reconstructions after peri-acetabular resections of primary bone tumours.

INTRODUCTION: Periacetabular reconstruction after resection of primary bone tumour is a very demanding procedure. They are frequently associated with scarce functional results and a high rate of complications. We report a series of patients with periacetabular resections for primary bone tumours and reconstruction with a porous tantalum (PT) acetabular cup (AC). MATERIALS AND METHODS: 27 patients (median age 30 years) were included, being affected by primary bone tumours of the pelvis and treated with peri-acetabular resection and reconstruction with a PT AC. The diagnoses were 13 osteosarcomas, 7 chondrosarcomas and 7 Ewing sarcomas. Function was assessed with the Harris Hip Score and complications were classified according to Zeifang. RESULTS: The median follow-up was 70 months. 1 patient required removal of the PT AC because of implant associated infection 55 months after surgery. There was 1 hip dislocation and no case of aseptic loosening. At final follow-up, the median HHS was 81 points (range 48-92). CONCLUSIONS: The used PT AC had good medium-term survival rates and good functional results. This technique is a viable reconstructive option after resections of periacetabular primary bone sarcomas.

Mechanical complications of hip spacers: a systematic review of the literature.

INTRODUCTION: Temporary spacers used in the staged revision of a hip prosthetic joint infection (PJI) have been associated with several mechanical complications with very variable reported general complications rates up to 73%. The aim of this systematic review was to assess the mechanical complications associated with hip antibiotic-loaded spacers when treating periprosthetic hip PJI. METHODS: Through an electronic systematic search of PubMed, articles reporting mechanical complications of spacers used in the treatment of hip PJI were reviewed. Dislocations, spacer fracture, femoral fractures, and acetabular lysis rates were evaluated. RESULTS: Forty studies were included. Standardized molded spacers had a significantly higher weighted mean of total mechanical complication rates (37.2%) when compared to standardized preformed spacers (13.8%, p = 0.039), while no significant difference was found between molded spacers and manually shaped spacers. Spacer dislocation was the most frequent complication. No significant difference in mechanical complication rate was found between spacers with and without any metallic component. CONCLUSIONS: Spacer placement in chronic PJI of the hip with bone and soft-tissue defects is challenging and bears a high risk of mechanical failures and progressive bone loss during the interim period. A careful patient selection for spacer implantation is mandatory.

One-stage complete eradication and revision hip due to pseudotumor in metal-on-metal hip arthroplasty.

Background: The correct management and treatment of pseudotumors due to metal-on-metal (MOM) hip arthroplasty are still debated. The purpose of this study is to analyze the surgical treatment and the clinical and radiographic 3-year outcomes of MOM arthroplasty revisions due to pseudotumor treated with a strategy of excision and revision. Methods: Consecutive, retrospective series of 21 patients (8 males/13 females) with pseudotumor due to MOM hip arthroplasty was surgically treated at a single tertiary center. Demographic, clinical, radiological and implant-related features were collected pre-operatively. Post-revision clinical and radiographic parameters were evaluated. Chromium (Cr) and cobalt (Co) blood samples were collected before and after surgery. Results: Three patients (14.2%) with pseudotumor underwent a resection arthroplasty due to infection (perioperative finding) and could not be reimplanted due to septic relapses. Twenty (95.2%) pseudotumors were completely resected. Revisions [2 total hip reimplantations (11.1%) and 16 isolated component revisions (88.9%)] were performed with non-MOM couplings. A clinical improvement at a mean post-revision follow-up 3.3 years [standard deviation (SD), ±2.2 years] was observed, from 50.3 (SD, ±4.6) to 88.3 (SD, ±9.2) Harris hip score (HHS) points (P<0.001). Among revisions, there were 5 complications (23.8%): 1 dislocation, 1 psoas impingement, and 3 infections (14.2%). No re-revision was carried out. Three (14.2%) pseudotumors recurred: 1 was surgically treated, 1 was treated with selective arterial embolization, and 1 clinically followed. At the final follow-up, Cr and Co blood ions beyond the threshold decreased from 85.7% cases to 0% in the seven patients that could be evaluated. Conclusions: The one-stage strategy of radical excision and revision with non-MOM couplings in pseudotumors due to MOM hip arthroplasty achieved good 3-year outcomes. However, complications were frequent (23%). Recurrences were not rare (14%) and did not require implant re-revision.

Are Static Spacers Superior to Articulated Spacers in the Staged Treatment of Infected Primary Knee Arthroplasty? A Systematic Review and Meta-Analysis.

In the treatment of knee periprosthetic joint infection with a two-stage protocol, static spacers allow for the local delivery of high doses of antibiotics and help to preserve soft tissue tension. Articulated spacers were introduced to better preserve flexion after the reimplantation. The aim of this systematic review is to provide a comprehensive data collection of the results of these different spacers. An in-depth search on the main clinical databases was performed concerning the studies reporting data on the topic. A total of 87 studies and 4250 spacers were included. No significant differences were found both in pooling data analysis and meta-analysis of comparative studies about infection recurrences, complications, and clinical scores. Mean active knee flexion at last follow-up after total knee reimplantation was found to be significantly higher using articulated spacers (91.6° ± 7° for static spacers vs. 100.3° ± 9.9° for articulated spacers; p < 0.001). Meta-analysis also recognized this strong significant difference (p < 0.001). This review has confirmed that articulated spacers do not appear to be inferior to static spacers regarding all clinical outcomes, while they are superior in terms of active flexion. However, the low quality of the studies and the risk for selection bias with complex patients preferentially treated with static spacers need to be accounted for.