Use of antibiotic-loaded cement in total knee arthroplasty

Abstract

Bone cement has the capacity to release antibiotic molecules if any antibiotic is included in it, and these elution properties are improved as cement porosity is increased. In vitro studies have shown high local antibiotic concentration for many hours or few days after its use. Antibiotic loaded bone cement (ALBC) is helpful when treating an infection in total knee arthroplasty (TKA) revision surgery. The purpose of this paper was to review the evidence for the routine use of ALBC in TKA in the literature, its pros and cons. Many authors have recommended the use of ALBC also in primary TKA for infection prophylaxis, but the evidence based on data from National Registries, randomized clinical trials and meta-analysis suggest a protective effect of ALBC against infection when used in hips, but not (or only mild) in knees. A possible explanation to this finding is that the duration and quantity of locally elevated antibiotic levels after surgery are smaller in TKA, due to the smaller amount of cement used for fixation in TKA-only a layer in the bone surface. There are some concerns about the routine use of ALBC in primary TKA as prophylaxis against infection: Firstly, there is a risk of hypersensivity or toxicity even when the chance is highly improbable. Secondly, there is a reduction in the mechanical properties of the cement, but this can be probably neglected if the antibiotic is used in low doses, not more than 1 g per 40 g cement package. Another significant concern is the increased economic cost, which could be overlooked if there were enough savings in treating fewer prosthetic infections. Finally, there is also a risk of selection of antibiotic-resistant strains of bacteria and this could be the main concern. If used, the choice of the antibiotic mixed in ALBC should consider microbiological aspects (broad antimicrobial spectrum and low rate of resistant bacteria), physical and chemical aspects (thermal stability, high water solubility), pharmacological characteristics (low risk to allergic reactions or toxicity) and economic aspects (not too expensive). The most commonly used antibiotics in ALBC are gentamicin, tobramycin and vancomycin. In conclusion, there is a paucity of randomized clinical trials in the use of ALBC in primary TKAs and the actual evidence of the effect of ALBC in reducing the risk of infection is insufficient. This, in addition to concerns about patient safety, risks of increase in the antibiotic resistance of microorganisms and the increase in costs in the procedure, lead us to recommend a cautious use of ALBC, perhaps only in high-risk patients (immunocompromised, morbidly obese, diabetic and patients with previous history of fracture or infection around the knee) unless the benefits of ALBC use were fully proven. Meanwhile, the rigorous use of peri-operative prophylactic systemic antibiotics and adoption of efficient antiseptic procedures and improved surgical techniques must be considered the gold standard in infection prevention in TKA surgery.

Keywords: Antibiotic loaded cement, Antibiotic toxicity, Total knee arthroplasty, Infection, Prophylaxis, Economic cost, Antimicrobial resistance

Core tip: The bone cement capacity to release antibiotic molecules has been helpful in the treatment of prosthetic infections. Many authors have recommended the use of antibiotic loaded bone cement (ALBC) in total knee arthroplasty (TKA) for infection prophylaxis, but the actual evidence suggests a minimal, if any, protective effect against infection in TKA. There are some concerns against its routine use in primary TKA: The risk of toxicity, possible mechanical properties reduction, a significant increase in the cost of the cement, and the risk of selection of antibiotic-resistant bacteria. We recommend a cautious use of ALBC, perhaps only in high-risk patients, unless its benefits were better proven.