Top

European Journal of Orthopaedic Surgery & Traumatology

Published in:

03-05-2023 | Gentamicin | Original Article

Does antibiotic bone cement reduce infection rates in primary total knee arthroplasty?

Authors: David Cieremans, Nishanth Muthusamy, Vivek Singh, Joshua C. Rozell, Vinay Aggarwal, Ran Schwarzkopf

Published in: European Journal of Orthopaedic Surgery & Traumatology | Issue 8/2023

Abstract

Introduction

Infection after total knee arthroplasty (TKA) impacts the patient, surgeon, and healthcare system significantly. Surgeons routinely use antibiotic-loaded bone cement (ALBC) in attempts to mitigate infection; however, little evidence supports the efficacy of ALBC in reducing infection rates compared to non-antibiotic-loaded bone cement (non-ALBC) in primary TKA. Our study compares infection rates of patients undergoing TKA with ALBC to those with non-ALBC to assess its efficacy in primary TKA.

Methods

A retrospective review of all primary, elective, cemented TKA patients over the age of 18 between 2011 and 2020 was conducted at an orthopedic specialty hospital. Patients were stratified into two cohorts based on cement type: ALBC (loaded with gentamicin or tobramycin) or non-ALBC. Baseline characteristics and infection rates determined by MSIS criteria were collected. Multilinear and multivariate logistic regressions were performed to limit significant differences in demographics. Independent samples t test and chi-squared test were used to compare means and proportions, respectively, between the two cohorts.

Results

In total, 9366 patients were included in this study, 7980 (85.2%) of whom received non-ALBC and 1386 (14.8%) of whom received ALBC. There were significant differences in five of the six demographic variables analyzed; patients with higher Body Mass Index (33.40 ± 6.27 vs. 32.09 ± 6.21; kg/m²) and Charlson Comorbidity Index values (4.51 ± 2.15 vs. 4.04 ± 1.92) were more likely to receive ALBC. The infection rate in the non-ALBC was 0.8% (63/7,980), while the rate in the ALBC was 0.5% (7/1,386). After adjusting for confounders, the difference in rates was not significant between the two groups (OR [95% CI]: 1.53 [0.69–3.38], p = 0.298). Furthermore, a sub-analysis comparing the infection rates within various demographic categories also showed no significant differences between the two groups.

Conclusion

Compared to non-ALBC, the overall infection rate in primary TKA was slightly lower when using ALBC; however, the difference was not statistically significant. When stratifying by comorbidity, use of ALBC still showed no statistical significance in reducing the risk of periprosthetic joint infection. Therefore, the advantage of antibiotics in bone cement to prevent infection in primary TKA is not yet elucidated. Further prospective, multicenter studies regarding the clinical benefits of antibiotic use in bone cement for primary TKA are warranted.

Aggarwal VK, Rasouli MR, Parvizi J (2013) Periprosthetic joint infection: current concept. Indian J Orthop 47(1):10–17. https://doi.org/10.4103/0019-5413.106884CrossRefPubMedPubMedCentral

Premkumar A, Kolin DA, Farley KX et al (2020) Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty. https://doi.org/10.1016/j.arth.2020.12.005CrossRefPubMed

Bistolfi A, Massazza G, Verné E et al (2011) Antibiotic-loaded cement in orthopedic surgery: a review. Int Sch Res Not. https://doi.org/10.5402/2011/290851CrossRef

Martínez-Moreno J, Merino V, Nácher A et al (2017) Antibiotic-loaded bone cement as prophylaxis in total joint replacement. Orthop Surg 9(4):331–341. https://doi.org/10.1111/os.12351CrossRefPubMedPubMedCentral

Bourne RB (2004) Prophylactic use of antibiotic bone cement: an emerging standard in the affirmative. J Arthroplasty 19:69–72CrossRefPubMed

Espehaug B, Engesaeter LB, Vollset SE et al (1997) Antibiotic prophylaxis in total hip arthroplasty: review of 10,905 primary cemented total hip replacements reported to the Norwegian arthroplasty register, 1987 to 1995. JBone Joint Surg. https://doi.org/10.1302/0301-620X.79B4.0790590CrossRef

Kunutsor SK, Wylde V, Whitehouse MR et al (2019) Influence of fixation methods on prosthetic joint infection following primary total knee replacement: meta-analysis of observational cohort and randomised intervention studies. J Clin Med 8(6):828. https://doi.org/10.3390/jcm8060828CrossRefPubMedPubMedCentral

Chiu FY, Chen CM, Lin CF et al (2002) Cefuroxime-impregnated cement in primary total knee arthroplasty: a prospective, randomized study of three hundred and forty knees. J Bone Joint Surg Am 84(5):759–762CrossRefPubMed

Hinarejos P, Guirro P, Puig-Verdie L et al (2015) Use of antibiotic-loaded cement in total knee arthroplasty. World J Orthop 6(11):877–885. https://doi.org/10.5312/wjo.v6.i11.877CrossRefPubMedPubMedCentral

10.

Leta TH, Gjertsen JE, Dale H et al (2021) Antibiotic-loaded bone cement in prevention of periprosthetic joint infections in primary total knee arthroplasty: a register-based multicentre randomised controlled non-inferiority trial (ALBA trial). BMJ Open 11(1):e041096. https://doi.org/10.1136/bmjopen-2020-041096CrossRefPubMedPubMedCentral

11.

Parvizi J, Tan TL, Goswami K et al (2018) The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty 33(5):1309-1314.e2. https://doi.org/10.1016/j.arth.2018.02.078CrossRefPubMed

12.

Iorio R, Yu S, Anoushiravani AA et al (2020) Vancomycin powder and dilute povidone-iodine lavage for infection prophylaxis in high-risk total joint arthroplasty. J Arthroplasty 35(7):1933–1936CrossRefPubMed

13.

Brown NM, Cipriano CA, Moric M et al (2012) Dilute betadine lavage before closure for the prevention of acute postoperative deep peri-prosthetic joint infection. J Arthroplasty 27:27–30CrossRefPubMed

14.

Schiavone Panni A, Corona K, Giulianelli M et al (2016) Antibiotic-loaded bone cement reduces risk of infections in primary total knee arthroplasty? A systematic review. Knee Surg Sports Traumatol Arthrosc 24:3168–3174. https://doi.org/10.1007/s00167-016-4301-0CrossRefPubMed

15.

Zhang J, Zhang XY, Jiang FL et al (2019) Antibiotic-impregnated bone cement for preventing infection in patients receiving primary total hip and knee arthroplasty. Medicine 98(49):e18068. https://doi.org/10.1097/MD.0000000000018068CrossRefPubMedPubMedCentral

16.

Sultan AA, Samuel LT, Umpierrez E et al (2019) Routine use of commercial antibiotic-loaded bone cement in primary total joint arthroplasty: a critical analysis of the current evidence. Ann Transl Med 7(4):73. https://doi.org/10.21037/atm.2018.11.50CrossRefPubMedPubMedCentral

17.

Bendich I, Zhang N, Barry JJ et al (2020) Antibiotic-laden bone cement use and revision risk after primary total knee arthroplasty in U.S. veterans. J Bone Joint Surg Am 102(22):1939–1947. https://doi.org/10.2106/JBJS.20.00102CrossRefPubMed

18.

Eveillard M, Mertl P, Tramier B et al (2003) Effectiveness of gentamicin-impregnated cement in the prevention of deep wound infection after primary total knee arthroplasty. Infect Control Hosp Epidemiol 24(10):778–780. https://doi.org/10.1086/502134CrossRefPubMed

19.

Anis HK, Sodhi N, Faour M et al (2019) Effect of antibiotic-impregnated bone cement in primary total knee arthroplasty. J Arthroplasty 34(9):2091-2095.e1. https://doi.org/10.1016/j.arth.2019.04.033CrossRefPubMed

20.

Wang H, Qiu GX, Lin J et al (2015) Antibiotic bone cement cannot reduce deep infection after primary total knee arthroplasty. Orthopedics 38(6):e462–e466CrossRefPubMed

21.

Namba RS, Chen Y, Paxton EW et al (2009) Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty 24(6 Suppl):44–47. https://doi.org/10.1016/j.arth.2009.05.007CrossRefPubMed

22.

Solarino G, Abate A, Vicenti G et al (2016) Reducing periprosthetic joint infection: what really counts? Joints 3(4):208–214PubMedPubMedCentral

23.

Greene KA, Wilde AH, Stulberg BN (1991) Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. J Arthroplasty 6:321–325CrossRefPubMed

24.

Pulido L, Ghanem E, Joshi A et al (2008) Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 466:1710–1715CrossRefPubMedPubMedCentral

25.

Kurtz SM, Ong KL, Lau E et al (2010) Prosthetic joint infection risk after TKA in the medicare population. Clin Orthop Relat Res 468:52–56CrossRefPubMed

26.

Kienzle A, Walter S, von Roth P et al (2020) High rates of aseptic loosening after revision total knee arthroplasty for periprosthetic joint infection. JB JS Open Access 5(3):e20.00026. https://doi.org/10.2106/JBJS.OA.20.00026CrossRefPubMedPubMedCentral

27.

Weaver F, Hynes D, Hopkinson W et al (2003) Preoperative risks and outcomes of hip and knee arthroplasty in the veterans health administration. J Arthroplasty 18:693–708. https://doi.org/10.1016/S0883-5403(03)00259-6CrossRefPubMed

28.

Silverstein P (1992) Smoking and wound healing. Am J Med 93(1A):22S-24S. https://doi.org/10.1016/0002-9343(92)90623-jCrossRefPubMed

29.

Bedard NA, DeMik DE, Owens JM et al (2019) Tobacco use and risk of wound complications and periprosthetic joint infection: a systematic review and meta-analysis of primary total joint arthroplasty procedures. J Arthroplasty 34(2):385-396.e4. https://doi.org/10.1016/j.arth.2018.09.089CrossRefPubMed

30.

Malinzak RA, Ritter MA, Berend ME et al (2009) Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 24:84–88CrossRefPubMed

31.

Chen J, Cui Y, Li X et al (2013) Risk factors for deep infection after total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg 133:675–687CrossRefPubMed

32.

Jämsen E, Nevalainen P, Eskelinen A et al (2012) Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am 94(14):e101. https://doi.org/10.2106/JBJS.J.01935CrossRefPubMed

33.

Nguyen NT, Nguyen XM, Lane J et al (2011) Relationship between obesity and diabetes in a US adult population: findings from the National health and nutrition examination survey, 1999–2006. Obes Surg 21(3):351–355. https://doi.org/10.1007/s11695-010-0335-4CrossRefPubMed

34.

Al-Goblan AS, Al-Alfi MA, Khan MZ (2014) Mechanism linking diabetes mellitus and obesity. Diabetes Metab Syndr Obes 7:587–591. https://doi.org/10.2147/DMSO.S67400CrossRefPubMedPubMedCentral

Title: Does antibiotic bone cement reduce infection rates in primary total knee arthroplasty?
Authors: David Cieremans
Nishanth Muthusamy
Vivek Singh
Joshua C. Rozell
Vinay Aggarwal
Ran Schwarzkopf
Publication date: 03-05-2023
Publisher: Springer Paris
Keywords: Gentamicin
Tobramycin
Antibiotic
Joint Infection
Published in: European Journal of Orthopaedic Surgery & Traumatology / Issue 8/2023
Print ISSN: 1633-8065
Electronic ISSN: 1432-1068
DOI: https://doi.org/10.1007/s00590-023-03557-3

At a glance: The STEP trials

Springer Medicine

Does antibiotic bone cement reduce infection rates in primary total knee arthroplasty?

Abstract

Introduction

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 8/2023

The learning curve to ROSA: cases needed to match the surgery time between a robotic-assisted and a manual primary total knee arthroplasty

Platelet-rich plasma in chronic Achilles tendinopathy

Does a hip fracture mean we should we operate on a concomitant proximal humerus fracture?

Does the distal nail position impact the rates of misalignment and bone union in distal tibial fractures?

Outcomes of supra-acetabular pin placement with and without fluoroscopic assisted: a prospective randomized controlled trial

Outcomes of medicaid patients undergoing TJA with previous positive urine toxicology screens