Friday, May 3, 2013

Do antibiotics in cement reduce the risk of total joint infection?

We remember a meeting where a famous shoulder surgeon stated from the podium "in my country it is considered malpractice not to use antibiotics in cement".

Now, that belief may be called into question. See:

The Use of Erythromycin and Colistin-Loaded Cement in Total Knee Arthroplasty Does Not Reduce the Incidence of Infection: A Prospective Randomized Study in 3000 Knees

In this article the authors conducted a prospective randomized study with 2948 cemented total knee arthroplasties, in which bone cement without antibiotic was used in 1465 knees (the control group) and a bone cement loaded with erythromycin and colistin was used in 1483 knees (the study group). All patients received the same systemic prophylactic antibiotics. The rate of deep infection (1.4% in the control group and 1.35% in the study group) and the rate of superficial infection (1.2% and 1.8%, respectively) were similar in both groups. The factors related to a higher rate of deep infection in a multivariate analysis were male sex and an operating time of >125 minutes. In this series of surgeries antibiotics in the cement did not prove to be effective in lowering the infection rate.
In a second article

Risk Factors Associated with Deep Surgical Site Infections After Primary Total Knee Arthroplasty: An Analysis of 56,216 Knees

The authors conducted a retrospective review of 56,216 primary total knee arthroplasties recorded in a total joint replacement registry from 2001 to 2009 was conducted. Patient factors associated with deep surgical site infection included a BMI of ≥35, diabetes mellitus, male sex, an American Society of Anesthesiologists (ASA) score of ≥3, a diagnosis of osteonecrosis, and a diagnosis of posttraumatic arthritis. Surgical risk factors included quadriceps-release exposure and the use of antibiotic-laden cement. Operative time was a risk factor, with a 9% increased risk per fifteen-minute increment.

The authors concluded that the use of antibiotic irrigation should be encouraged, but antibiotic-laden cement may not be useful.


While these were articles about knees, not shoulders, we can suspect that the amount and duration of antibiotic delivered by antibiotic-laden cement is relatively small. Mixing antibiotics with cement may not provide much protection against infection and may compromise the strength of the cement.

Donald Roberts in his JBJS commentary on these articles states " In our institution, the difference between the costs of regular bone cement and tobramycin cement would pay the wages of the nursing staff caring for that patient throughout their stay in the operating room and recovery room." We need to make sure that the incremental cost creates incremental benefit for our patients - the value equation.

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