Efficacy of antibiotic-impregnated cement in total hip replacement

Extended oral antibiotics in primary and revision total joint arthroplasty: An update

Periprosthetic joint infections (PJI) are a significant healthcare and economic burden after joint replacement surgery. Extended oral antibiotic prophylaxis (EOAP) has been highlighted as a safe, efficacious, and cost-effective measure to mitigate the risk of infection against the increasing demands for total joint arthroplasty (TJA). Several studies have demonstrated substantial reductions in PJI rates, particularly among high-risk populations receiving a 7-day course of antibiotics, mainly with use of cefadroxil. Conversely, other studies have found no significant differences or even increased infection rates, highlighting concerns over antimicrobial resistance, Clostridium difficile infections (CDI), and other antibiotic-related adverse events. Additionally, recent trends show a substantial rise in EOAP utilization across the United States, demonstrating need for clear and evidence-based guidelines. There is a need for high quality randomized controlled trials to help identify optimal patient selection criteria, antibiotic type, and duration to effectively balance the benefits of EOAP against potential risks. Although there is limited evidence of significant antibiotic associated complications with the use of EOAP, care should be utilized prior to widespread adoption with antibiotic stewardship in mind.

Antibiotic-Loaded Polymer-Calcium Phosphate Scaffold for Treating Orthopedic Device-Related Infection in a Rabbit Segmental Bone Defect Model

Treatment of orthopedic device-related infection (ORDI) generally requires a combination of medical and surgical interventions for successful treatment outcomes. Many cases are treated with a two-stage revision, whereby contaminated implants and necrotic tissues are removed, and dead space is managed with a temporary, non-resorbable polymethyl methacrylate (PMMA) spacer loaded with antibiotics. Weeks later, this is replaced with a bone graft or similar material to aid bone healing. However, this two-stage approach is quite a burden for the patient, and infection may still recur. The use of a 3D-printed, absorbable, antibiotic-releasing material that also promotes bone healing would be a promising alternative that produces the exact geometry of the missing bone and eliminates the need for a second surgery. In this study, we investigated whether a novel 3D-printed, antibiotic-loaded, osteoconductive calcium phosphate scaffold (CPS) is effective in the single-stage revision of an infected segmental bone defect model in rabbits. A 5-mm segmental defect of the radius of female New Zealand White rabbits (n = 64), stabilized with cerclage wire, was inoculated with Staphylococcus aureus. After 4 weeks, the infected bone fragment was removed, the site debrided, and the bone defect was either left empty (Control group) or filled with a PMMA spacer with gentamicin, CPS loaded with rifampicin or non-loaded CPS. The animals were also managed with systemic cefazolin for 4 weeks. An additional group received vancomycin-loaded CPS without adjunctive systemic antibiotic therapy. All animals were euthanized 8 weeks after revision and assessed by quantitative bacteriology or semiquantitative histopathology. The antibiotic-loaded scaffolds (PMMA-Genta and CPS-Rif) in the animals receiving systemic antibiotic treatment resulted in a reduction in bacterial count at euthanasia compared to controls (rabbits receiving systemic antibiotic alone and in which the defect was left empty). The PMMA-Genta induced a significant CFU reduction (p = 0.0486) compared to controls. The infection rate was also reduced from 80% in the control group to 50% for the groups receiving local and systemic antibiotics. The CPS-Vanco group for local delivery without adjunctive systemic antibiotic therapy resulted in a lower infection rate, but the CFUs in these samples at euthanasia were comparable with those of the control group. The findings show that treating an ODRI with PMMA-Genta yields the best results for infection eradication; however, it does not provide the reconstruction opportunity that the antibiotic-loaded CPS does. Even though it is not comparable to the PMMA-Genta, the antibiotic-loaded CPS showed a reduction in infection rates. The use of local antibiotics alone is insufficient to eradicate the infection.

The application of antibiotic-loaded bone cement in preventing periprosthetic joint infection: an umbrella review

OBJECTIVES

The purpose of this study was to provide thorough, understandable and precise evidence for the clinical use of antibiotic-loaded bone cement (ALBC) in preventing periprosthetic joint infection (PJI).

METHODS

We evaluated the effectiveness of ALBC in preventing PJI by conducting an umbrella review of existing meta-analysis. Four databases, PubMed/MEDLINE, Cochrane Library, Embase and Web of Science, were searched until May 2024. Two reviewers were reviewers for literature screening, and data were extracted independently. AMSTAR 2 guideline and GRADE were also used for quality evaluation. The clinical outcomes were evaluated for effectiveness by several indicators, including surface infection rate (SIR), deep infection rate (DIR), total infection rate (TIR), unadjusted/adjusted all-cause revision rate, and revision rate for PJI.

RESULTS

We synthesized the results of ten meta-analyses. Two meta-analyses had high AMSTAR 2 scores, two had moderate AMSTAR 2 ratings, three had critically low AMSTAR 2 scores, and the remaining meta-analyses had low AMSTAR 2 ratings. In terms of postoperative surgical site infection and revision rate, SIR (OR 1.50, 95% CI 1.14, 1.99, P = 0.004, I2 = 0%), unadjusted all-cause revision rate (RR 1.44, 95% CI 1.08, 1.90, P = 0.011, I2 = 91.8%) and adjusted all-cause revision rate (HR 1.21, 95% CI 1.12, 1.31, P < 0.001, I2 = 0%) in ALBC group were significantly higher than those in non-antibiotic-loaded bone cement (NALBC) group. ALBC group was significantly lower than NALBC group in DIR (OR 0.53, 95% CI 0.39, 0.70, P < 0.0001, I2 = 57%), (RR 0.506, 95% CI 0.341, 0.751, P = 0.001, I2 = 0%) and revision for PJI (RR 0.721, 95% CI 0.628, 0.828, P = 0, I2 = 53%). There was no statistical difference in total infection rate (TIR) between the ALBC group and the NALBC group (OR 0.81, 95% CI 0.51, 1.28, P = 0.37, I2 = 73%).

CONCLUSIONS

On the basis of the results of our analysis, we do not believe that ALBC is more effective than NALBC in preventing PJI after primary total joint arthroplasty (PTJA). No statistically significant difference was found on TIR between the two groups, although it was lower in the ALBC group. In addition, the DIR and revision for PJI are significantly lower in the ALBC group, but the results are of low quality, which calls for high-quality and large-sample studies in the future.

Cutting through infection risk: robotic-assisted vs. conventional total knee replacement surgery - a meta-analysis

BACKGROUND

Surgical site infections (SSI) following knee replacement pose significant challenges, often attributed to microorganism contamination during surgery. Robotic-assisted total knee replacement (RA-TKR) offers potential advantages but may also raise concerns regarding infection risk. This systematic review and meta-analysis aimed to evaluate infection rates following RA-TKR compared to Conventional Total knee replacement (C-TKR) within the first-year post-implantation.

MATERIALS AND METHODS

A systematic search of major databases was conducted from 2005 to November 2023. Eligible studies reported primary C-TKR and RA-TKR interventions, documented SSI incidence, and had a follow-up period of at least 12 months. Data on deep, superficial, and pin-site infections were extracted, and the risk of bias was assessed using the Cochrane Risk of Bias Tool. Summary estimates were generated using a random-effects model.

RESULTS

Eight studies were included, comprising 758,453 knees (6724 RA-TKR, 751,729 C-TKR). The overall SSI rate was 1.57% in conventional TKR and 1.29% in RA-TKR. Deep infection rates were 0.96% and 0.66% in conventional and robotic procedures, respectively, with no significant variation between them (Odds Ratio [OR] 1.27 [95% Confidence Interval [CI], 0.93 to 1.73], I2 = 0%, P-value = 0.13). Superficial and pin-site infection rates were comparable between both procedures (0.61% vs. 0.62%) with no significant difference (OR 1.21 [95% CI, 0.86 to 1.70], I2 = 0%, P-value = 0.28).

CONCLUSION

This meta-analysis shows low SSI rates for both RA-TKR and C-TKR within the first year post-implantation. Both techniques are viable with low SSI incidence, and further research should investigate longer-term outcomes and different robotic systems to refine infection risk understanding in knee arthroplasty.

Does the use of topical vancomycin during primary hip or knee arthroplasty protect from infections?

BACKGROUND

Infection is one of the main complications of hip and knee arthroplasties. Topical application vancomycin to prevent postoperative infections is efficient in spine surgery, and is spreading in prosthetic surgery. However, its clinical relevance and safety are still under debate. Thus, we conducted the present study to (1) assess whether topical vancomycin reduces peri-prosthetic infection rate, and (2) investigate its influence on surgical wound complications.

HYPOTHESIS

Our hypothesis was that topical administration of diluted vancomycin during arthroplasty would reduce infection rate within the first postoperative year.

MATERIAL AND METHODS

In total, 1900 hip and knee arthroplasties were performed between 2014 and 2021 in a single hospital. From July 2018 and December 2021, 910 prostheses were implanted with intra-articular instillation of vancomycin and tranexamic acid. From November 2014 to June 2018, 990 prostheses were set up without vancomycin. During a follow-up of minimum 12 months, we reported periprosthetic infections occurring during the first postoperative year, as well as vancomycin-induced general or cutaneous complications.

RESULTS

We observed periprosthetic infections in 9/990 cases (0.91%) of the control group and 10/910 cases (1.1%) of the vancomycin group (p = 0.82). In parallel, we observed wound complications (erythema, seroma, hematoma, dehiscence and delay in wound healing) in 19/990 (1.9%) and 10/910 cases (1.1%) of the control and vancomycin group, respectively (p = 0.19). There were no general complications resulting from the application of vancomycin.

DISCUSSION

Topical diluted vancomycin does not reduce periprosthetic infection risk, and has no effect on the occurrence of surgery wound complications. Considering the present findings, the use of vancomycin cannot be recommended in current practice to prevent infections following hip and knee arthroplasties. Finally, its use does not induce any specific complications, whether local (cicatrisation) or general (related to ototoxicity or nephrotoxicity).

LEVEL OF EVIDENCE

III; case control study.

Local antimicrobial delivery systems for prophylaxis and treatment of periprosthetic traumatological infections

Infections associated with implants are the most serious complications in joint replacement surgeries and can jeopardize the functionality of orthopedic implants. Local antimicrobial delivery could enable antibiotics to attain concentrations above the minimum inhibitory concentration (MIC) threshold at the joint replacement site while preventing systemic side effects. Therefore, there is a dire need for the development of improved biomaterial-based delivery systems for local antibiotic administration in prosthetic infections. In this context, this review highlights the latest breakthroughs in the design of biomaterial-based formulations intended for the prophylaxis and treatment of prosthetic infections. Delivery systems for distinct forms of administration (i.e., direct intra-articular administration, loading into bone cements, coating of implant surfaces, or loading into hydrogels) are here comprehensively compiled with a focus on the design of microparticles and nanosystems for local antimicrobial administration and their impact on distinct in vitro and in vivo models of implant infections.

The 'Japanese paradox' of total hip arthroplasty: where are we going?

INTRODUCTION

There is a worldwide trend toward 'revisiting' cemented total hip arthroplasty (THA). In Japan, however, cemented THAs accounts for 11%, and the percentage of cemented hemiarthroplasty is estimated to be less than 10%. This review was designed to reconsider the option of cemented THA and to encourage policy changes in Japan to support the best possible care for patients.

AREA COVERED

In this article, we reviewed the history of THA and the current situations of the world, based on past reports and nationwide registries. Merits and demerits of cemented THA were evaluated from various perspectives.

EXPERT OPINION

Cemented THA had great advantages, including establishment of the acetabular cup, diversity of the femoral stem, antibiotic-loaded acrylic cement, revision, low incidence of periprosthetic fracture, and hemiarthroplasty. In patients older than 75 years of age, cemented THA resulted in the lowest risk of revision. Guidelines for femoral neck fracture recommended the use of cemented hemiarthroplasty in many countries because of low incidence of periprosthetic fracture. Numerous contradictions regarding implant price and cost of operations have also been noted in Japan. For the patients, we need to rethink what is truth and what is fiction.

The Epidemiology of the Revision Total Hip Arthroplasty in the United States From 2016 to 2022

Background

The number of revision total hip arthroplasties (THAs) is projected to reach 572,000 cases annually by 2030 in the United States. This may be attributed to the successes of primary THAs combined with an aging population, patients desire to remain active, and expanded indications for younger patients. Given the evolving nature of revision THAs, an epidemiological analysis of (1) etiologies; (2) demographics, including age and region; and (3) lengths of stay (LOSs) may minimize the gap between appropriate understanding and effective intervention.

Methods

From 2016 to 2022, a national, all-payer database was queried. Incidences and indications were analyzed for a total of 102,476 patients who had revision THA procedures. Patients were stratified according to etiology of failure, age, US census region, primary payor class, and mean LOS.

Results

The most common etiologies for revision THA procedures were dislocation (16.7%) and infection (12.7%), followed by periprosthetic fracture (6.9%). The largest age group was 65-74 years (30.9%), followed by >75 years (28.6%), then 55-64 (26.5%). The South had the largest total procedure cohort (36.9%), followed by the Midwest (27.5%), then the Northeast (19.7%), and the West (15.9%). The mean LOS was 4.10 days (range, 1.0-20.0).

Conclusions

Dislocation and infection remain leading indications for revision THA. These findings can properly guide surgeons toward appropriate management as well as toward active steps to minimizing these outcomes.

High-concentration continuous local antibacterial perfusion therapy: safety and potential efficacy for acute and chronic periprosthetic knee joint infection

BACKGROUND

Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) are among the most challenging pathologies to manage. Recently, continuous local antibiotic perfusion (CLAP) therapy has been introduced for treating musculoskeletal infections in orthopedics. This study aimed to determine the outcomes and risks of CLAP therapy combined with conventional treatment for PJIs after TKA.

METHODS

We retrospectively evaluated 14 patients with PJIs. For acute PJIs, CLAP therapy was performed alongside debridement, intravenous antibiotics, and implant retention. For chronic PJIs, a two-stage revision with CLAP therapy and intravenous antibiotics was performed. Implants were replaced with a cement mold incorporating CLAP therapy, followed by revision surgery after 3 months. For all patients, 120 mg/day of gentamicin (GM) was locally administered into the knee joint for 2 weeks as part of CLAP therapy, in combination with perioperative intravenous antibiotics.

RESULTS

Five patients developed acute PJIs, and nine developed chronic PJIs after TKA. The mean follow-up period was 18.4 (15.2-21.1) months. All five patients with PJIs treated with one-stage surgery (debridement and insert exchange only) successfully preserved their implants. Among the nine patients with chronic PJIs, seven underwent CLAP therapy combined with two-stage revision surgery, resulting in successful treatment without relapse, whereas the remaining two patients were initially treated with one-stage surgery and CLAP therapy but failed to retain their implants, and subsequently required additional two-stage revision surgery, which ultimately succeeded. No adverse effects from GM were reported.

CONCLUSIONS

Our results suggest that CLAP therapy is safe and may be effective for treating acute and most chronic PJIs after TKA.

Bone allograft impregnated with tobramycin and vancomycin delivers antibiotics in high concentrations for prophylaxis against bacteria commonly associated with prosthetic joint infections

Local delivery of antibiotics as prophylaxis for prosthetic joint infections (PJIs) is frequently used during total hip replacement surgery. Morselized bone allograft impregnated with vancomycin and tobramycin (TobraVanc) could provide effective prophylaxis against bacteria commonly associated with PJIs. In this study, the concentrations of antibiotics released by bone allograft impregnated with TobraVanc were determined by using an in vitro bioassay system entailing measuring inhibition zone diameters caused by antibiotic-impregnated bone chips cast in agar against standard curves. The concentrations were determined in samples of TobraVanc-impregnated bone graft taken before and after the application of the bone graft in the patients undergoing acetabular revision surgery. Antibiotic-impregnated bone grafts, sampled prior to application in the patient, delivered antibiotics in the concentration ranges of 730-9,800 mg/L for tobramycin and 1,300-11,000 mg/L for vancomycin. Samples taken after application in the patient released lower concentrations of tobramycin (490-1,900 mg/L; P < 0.01) and vancomycin (3,000-5,100 mg/L; P < 0.05); however, these concentrations remained well above the tobramycin minimum inhibitory concentrations (MICs) for investigated, highly tobramycin-resistant Staphylococcus epidermidis strains (MICs > 256 mg/L). At the tested concentrations, bone graft material mixed with TobraVanc delivered antibiotics in potent concentrations above the MICs for bacteria causing PJIs. Clinical trials are needed to evaluate the efficacy and risk of TobraVanc-impregnated bone graft as a prophylactic agent for patients undergoing hip replacement surgery.IMPORTANCEAntibiotic prophylaxis is the cornerstone of successful joint replacement surgery, reducing the risk for the dreaded complication of prosthetic joint infection (PJI) to roughly 0.5%-2% in standard total hip replacement (THR). In addition to systemic antibiotics, antibiotics added locally have the potential to reduce the PJI risk even further, because of the high concentrations that can be achieved in the joint with limited risk for systemic toxicity. The results in the current study show that bone chips impregnated with a combination of tobramycin and vancomycin (TobraVanc) release antibiotics in concentrations that are potent against common bacteria causing PJIs. Especially in high-risk patients, our results support the prophylactic use of TobraVanc in hip replacement surgery requiring the use of a bone graft. A clinical study testing the efficacy of TobraVanc-impregnated bone graft in reducing the incidence of PJI in hip replacement surgery is currently ongoing (EudraCT: 2021-001708-14).

A review on the promising antibacterial agents in bone cement-From past to current insights

Antibacterial bone cements (ABCs), such as antibiotic-loaded bone cements (ALBCs), have been widely utilized in clinical treatments. Currently, bone cements loaded with vancomycin, gentamicin, tobramycin, or clindamycin are approved by the US Food and Drug Administration. However, traditional ALBCs exhibit drawbacks like burst release and bacterial resistance. Therefore, there is a demand for the development of antibacterial bone cements containing novel agents to address these defects. In this review, we provide an overview and prospect of the new antibacterial agents that can be used or have the potential to be applied in bone cement, including metallic antibacterial agents, pH-switchable antibacterial agents, cationic polymers, N-halamines, non-leaching acrylic monomers, antimicrobial peptides and enzymes. Additionally, we have conducted a preliminary assessment of the feasibility of bone cement containing N-halamine, which has demonstrated good antibacterial activities. The conclusion of this review is that the research and utilization of bone cement containing novel antibacterial agents contribute to addressing the limitations of ALBCs. Therefore, it is necessary to continue expanding the research and use of bone cement incorporating novel antibacterial agents. This review offers a novel perspectives for designing ABCs and treating bone infections.

Number of Doses of Systemic Antibiotic Prophylaxis May Be Reduced in Cemented Primary Knee Arthroplasty Irrespective of Use of Antibiotic in the Cement: A Multiregistry-Based Meta-Analysis

Background

The use of systemic antibiotic prophylaxis (SAP) and antibiotic-loaded bone cement (ALBC) is the accepted practice to reduce the risk of periprosthetic joint infection (PJI) in primary total knee arthroplasty (pTKA). However, practice varies internationally. This study's primary aim was to compare the risk of PJI revision after pTKA with ALBC + SAP vs. plain bone cement (PBC) + SAP, and the secondary aim was to assess whether the risk of PJI revision varies with the number of SAP doses.

Methods

Cohort of 289,926 pTKAs for osteoarthritis from arthroplasty registries in Denmark, New Zealand, Norway, Romania, and United States registered from 2010 to 2020. One-year revision for PJI following pTKA with ALBC + SAP vs. PBC + SAP, and single vs. multiple SAP doses was compared. We computed cumulative percent revision (1 minus Kaplan-Meier) using distributed analysis method and adjusted hazard rate ratios (HRRs) using Cox regression analyses within each registry. Advanced distributed meta-analysis was performed to summarize HRRs from all countries.

Results

Among all pTKAs, 64.4% were performed with ALBC + SAP. Each registry reported a 1-year cumulative percent revision for PJI of <1.00% for both pTKAs with ALBC + SAP (0.34%-0.80%) and with PBC + SAP (0.54%-0.69%). The distributed meta-analysis showed HRR = 1.21; (95% confidence interval [CI], 0.79-1.87) for ALBC + SAP compared with PBC + SAP. Similar risk of PJI revision was observed between pTKAs with ALBC + single vs. multiple doses of SAP: 2 doses (0.95; 95% CI, 0.68-1.33), 3 doses (1.09; 95% CI, 0.64-1.87), and 4 doses (1.23; 95% CI, 0.69-2.21). Comparable results were found for the PBC + SAP group except for higher risk of PJI revision with 4 doses of SAP (2.74; 95% CI, 1.11-6.75).

Conclusions

ALBC and PBC entailed similar risk of PJI revision when patients received SAP in pTKA, regardless of number of SAP doses. ALBC or PBC used in combination with SAP in pTKAs, with one single preoperative dose of SAP may be sufficient without compromising the patient safety.

Level of evidence

Level III. See Instructions for Authors for a complete description of levels of evidence.

In Vivo Intra-Articular Antibiotic Concentrations at 24 Hours After TKA Fall Below the Minimum Inhibitory Concentration for Most Bacteria: A Randomized Study of Commercially Available Bone Cement

BACKGROUND

The use of antibiotic-loaded bone cement (ALBC) to help reduce the risk of infection after primary total knee arthroplasty (TKA) is controversial. There is a paucity of in vivo data on the elution characteristics of ALBC. We aimed to determine whether the antibiotic concentrations of 2 commercially available ALBCs met the minimum inhibitory concentration (MIC) and minimum biofilm eradication concentration (MBEC) for common infecting organisms.

METHODS

Forty-five patients undergoing TKA were randomized to receive 1 of the following: bone cement without antibiotic (the negative control; n = 5), a commercially available formulation containing 1 g of tobramycin (n = 20), or a commercially available formulation containing 0.5 g of gentamicin (n = 20). Intra-articular drains were placed, and fluid was collected at 4 and 24 hours postoperatively. An automated immunoassay measuring antibiotic concentration was performed, and the results were compared against published MIC and MBEC thresholds.

RESULTS

The ALBC treatment groups were predominantly of White (65%) or Black (32.5%) race and were 57.5% female and 42.4% male. The mean age (and standard deviation) was 72.6 ± 7.2 years in the gentamicin group and 67.6 ± 7.4 years in the tobramycin group. The mean antibiotic concentration in the tobramycin group was 55.1 ± 37.7 μg/mL at 4 hours and 19.5 ± 13.0 μg/mL at 24 hours, and the mean concentration in the gentamicin group was 38.4 ± 25.4 μg/mL at 4 hours and 17.7 ± 15.4 μg/mL at 24 hours. Time and antibiotic concentration had a negative linear correlation coefficient (r = -0.501). Most of the reference MIC levels were reached at 4 hours. However, at 24 hours, a considerable percentage of patients had concentrations below the MIC for many common pathogens, including Staphylococcus epidermidis (gentamicin: 65% to 100% of patients; tobramycin: 50% to 85%), methicillin-sensitive Staphylococcus aureus (gentamicin: 5% to 90%; tobramycin: 5% to 50%), methicillin-resistant S . aureus (gentamicin: 5% to 65%; tobramycin: 50%), Streptococcus species (gentamicin: 10% to 100%), and Cutibacterium acnes (gentamicin: 10% to 65%; tobramycin: 100%). The aforementioned ranges reflect variation in the MIC among different strains of each organism. Gentamicin concentrations reached MBEC threshold values at 4 hours only for the least virulent strains of S . aureus and Escherichia coli. Tobramycin concentrations did not reach the MBEC threshold for any of the bacteria at either time point.

CONCLUSIONS

The elution of antibiotics from commercially available ALBC decreased rapidly following TKA, and only at 4 hours postoperatively did the mean antibiotic concentrations exceed the MIC for most of the pathogens. Use of commercially available ALBC may not provide substantial antimicrobial coverage following TKA.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Cemented Calcar-Guided Short-Stem Prostheses in Geriatric Patients: Short-Term Results from a Prospective Observational Study

Both cementless and cemented stems have exhibited favorable long-term outcomes in total hip arthroplasty. Nonetheless, in elderly patients, cemented hips offer an advantage due to their reduced risk of periprosthetic fractures. This study aimed to assess the initial outcomes of 28 patients who underwent unilateral cemented total hip arthroplasty utilizing a calcar-guided A2 stem (ARTIQO GmbH, Lüdinghausen, Germany). Various types of antibiotic-loaded bone cement were employed. During follow-up, we recorded demographic data and comorbidities and employed standardized clinical assessment tools, including the Harris Hip Score. Radiographic assessments included preoperative, postoperative, and follow-up imaging to evaluate subsidence, osteolysis, and bone resorption. The results indicated that among the 28 patients, 5 withdrew consent and 2 patients passed away from unrelated causes. Additionally, one prosthesis was explanted due to the undersizing of the cement stopper, which resulted in an inadequate cement mantle. As a result, 20 patients underwent a 1-year follow-up, revealing noteworthy enhancements in clinical scores, with no instances of radiolucent lines or osteolysis. No infections were detected. In summary, our short-term experience with this particular cemented short-stem design yielded promising results, exhibiting excellent functional outcomes, no aseptic loosening attributable to the stem, and no infections. Further clinical studies and registry data are essential to corroborate these findings.

Evidence for cemented TKA and THA based on a comparison of international register data

BACKGROUND

Hip and knee implants can either be fixed without cement, press-fit, or with bone cement. Real-world data from arthroplasty registers, as well as studies provide a broad database for the discussion of cemented versus uncemented arthroplasty procedures.

OBJECTIVE

What does current evidence from international arthroplasty registries and meta-analyses recommend regarding cemented or cementless fixation of hip and knee implants?

METHODS

A recommendation is generated by means of direct data comparison from the arthroplasty registries of eight countries (USA, Germany, Australia, UK, Sweden, Norway, New Zealand, Netherlands), the comparison of 22 review studies and meta-analyses based on registry data, as well as an evaluation of recommendations of healthcare systems from different nations. For this purpose, reviews and meta-analyses were selected where the results were statistically significant, as were the annual reports of the arthroplasty registries that were current at the time of writing.

RESULTS

For knee arthroplasties, long survival time as well as lower risk of revision can be achieved with the support of cemented fixation with antibiotic-loaded bone cement. In patients aged 70 years and older, cemented fixation of hip stem implants significantly reduces risk of intraoperative or postoperative periprosthetic fracture (quadruple). This applies both to elective total hip arthroplasties and to hemiarthroplasty after femoral neck fractures. Antibiotic-loaded bone cement significantly (p = 0.041) reduces the risk of periprosthetic infection, especially in patients with femoral neck fractures.

CONCLUSION

Total knee replacement with antibiotic-loaded bone cement is well established internationally and is evidence-based. Registry data and meta-analyses recommend cemented fixation of the hip stem in older patients. In Germany, USA and Australia these evidence-based recommendations still must be transferred to daily practice.

Cement loaded with high-dose gentamicin and clindamycin does not reduce the risk of subsequent infection after aseptic total hip or knee revision arthroplasty: a preliminary study

PURPOSE

The aim of this study was to quantify the prophylactic effect of high-dose gentamicin and clindamycin antibiotic-loaded bone cement (ALBC) during revision total hip (rTHA) or knee (rTKA) arthroplasty for aseptic reasons. The hypothesis was that the raw surgical site infection (SSI) rate is lower when this particular cement is used in comparison with cement loaded with standard-dose gentamicin during rTHA or rTKA for aseptic reasons.

METHODS

This retrospective study included 290 consecutive patients undergoing aseptic rTHA or rTKA. Two consecutive cohorts were defined: the first (control group) involved 145 patients where ALBC with gentamicin only was used; the second (study group) involved 145 patients where ALBC with high-dose gentamicin and clindamycin was used. The primary endpoint was the raw SSI rate after 24 months.

RESULTS

The raw SSI rate was 8/145 (6%) in the control group and 13/145 (9%) in the study group (odds ratio 0.62, p = 0.26). There was a significant impact of the presence of any risk factor on the SSI rate (15/100 versus 6/169, odds ratio = 4.25, p = 0.002), but no significant impact of any individual risk factor. No complication or side effect related to ALBC was observed in either group.

CONCLUSION

These results do not support the routine use of gentamicin and clindamycin ALBC for fixation of revision implants after rTHA and rTKA for aseptic reasons.

Vancomycin powder in the prevention of infection in primary knee and hip arthroplasty: Case-control study with 1151 arthroplasties

BACKGROUND AND OBJECTIVE

Vancomycin powder (VP) has been positively used in spinal surgery to reduce the rate of infections. Hardly any data have been published on hip and knee joint replacement surgery, and its usefulness is questioned. Our objective was to investigate the effectiveness of VP in reducing prosthetic infection and its possible complications.

METHODS

Primary hip (THA) and knee (TKA) arthroplasties were reviewed, performed by five surgeons in one hospital center, between 2017 and 2018. 1g of VP was used on the implant prior to surgical closure based on the surgeon's preferences. With a 5-year follow-up in which the infection rate and local complications were analyzed.

RESULTS

One thousand one hundred and fifty one arthroplasties were performed, 748 were TKA and 403 were THA. Nine patients were diagnosed with prosthetic infection, of which five received VP and four did not (P=.555). Likewise, another 15 patients suffered wound complications, of which 11 received VP and 4 did not (P=.412). There were no differences, either, in the rest of the complications depending on the use or not of VP (P=.101). Likewise, the number of patients who needed reintervention was similar (P=.999). No systemic complications were detected due to the use of VP.

CONCLUSIONS

It has not been possible to demonstrate that the use of VP reduces the rates of prosthetic infection in the hip and knee, so we cannot recommend its use.

[Translated article] Vancomycin powder in the prevention of infection in primary knee and hip arthroplasty: Case-control study with 1151 arthroplasties

BACKGROUND AND OBJECTIVE

Vancomycin powder (VP) has been positively used in spinal surgery to reduce the rate of infections. Hardly any data have been published on hip and knee joint replacement surgery, and its usefulness is questioned. Our objective was to investigate the effectiveness of VP in reducing prosthetic infection and its possible complications.

METHODS

Primary hip (THA) and knee (TKA) arthroplasties were reviewed, performed by five surgeons in one hospital centre, between 2017 and 2018. One gram of VP was used on the implant prior to surgical closure based on the surgeon's preferences. With a 5-year follow-up in which the infection rate and local complications were analysed.

RESULTS

One thousand one hundred and fifty-one arthroplasties were performed, 748 were TKA and 403 were THA. Nine patients were diagnosed with prosthetic infection, of which five received VP and four did not (p=0.555). Likewise, another 15 patients suffered wound complications, of which 11 received VP and 4 did not (p=0.412). There were no differences, either, in the rest of the complications depending on the use or not of VP (p=0.101). Likewise, the number of patients who needed reintervention was similar (p=0.999). No systemic complications were detected due to the use of VP.

CONCLUSIONS

It has not been possible to demonstrate that the use of VP reduces the rates of prosthetic infection in the hip and knee, so we cannot recommend its use.

[Register data on cemented arthroplasty : A proof for cementless fixation?]

BACKGROUND

Hip and knee implants can be either fixated without cement, press-fit, or with bone cement. Real-world data from arthroplasty registers, as well as studies, provide a broad database for the discussion of cemented versus uncemented arthroplasty procedures.

OBJECTIVES

What is the recommendation for cemented or cementless anchorage of hip and knee implants based on the current evidence from international arthroplasty registries and meta-analyses?

METHODS

A recommendation is generated by means of a direct comparison of data from the arthroplasty registries of eight different countries (USA, Germany, Australia, UK, Sweden, Norway, New Zealand, and The Netherlands), the comparison of 22 review studies and meta-analyses based on registry data, as well as the evaluation of the recommendation of healthcare systems of different nations. For this purpose, reviews and meta-analyses whose results were statistically significant were selected, as were the annual reports of the arthroplasty registries that were current at the time of writing.

RESULTS

For knee endoprostheses, a long survival time, as well as a lower risk of revision can be achieved with the help of cemented anchorage with antibiotic-laden bone cement. In patients aged 70 years and older, cemented anchorage of the hip stem implant significantly reduces the risk of intraoperative or postoperative periprosthetic fracture (times four), this applies both to elective total hip arthroplasties (TEPs) and to hemiarthroplasty after femoral neck fractures. Antibiotic-loaded bone cement significantly (p = 0.041) reduces the risk of periprosthetic infection, especially in patients with femoral neck fractures.

CONCLUSIONS

Total knee replacement with antibiotic-loaded bone cement is well established in Germany and evidence based. Registry data and meta-analyses recommend cemented fixation of the hip stem in older patients-in Germany the evidence-based recommendations must still be transferred to daily practice.

The Effect of Povidone-Iodine Irrigation on the Efficacy of Antibiotic Cement In Vitro

Povidone-iodine is a common antiseptic demonstrating success in reducing infection rates in primary arthroplasty; however, recent data suggest that its use in revision arthroplasty may increase infection rates. This study evaluated the effect of povidone-iodine solution on antibiotic cement and investigated the connection between povidone-iodine and increased infection rates in revision arthroplasty. Sixty antibiotic cement samples (ACSs) were formed using gentamicin-impregnated cement. The ACSs were divided into three groups: group A (n=20) was subject to a 3-minute povidone-iodine soak followed by a saline rinse; group B (n=20) underwent a 3-minute saline soak; and group C (n=20) underwent only a saline rinse. The antimicrobial activity of the samples was tested using a Kirby-Bauer-like assay using Staphylococcus epidermidis. The zone of inhibition (ZOI) was measured every 24 hours for 7 days. All groups possessed the greatest antimicrobial activity at 24 hours. Group C displayed a mass-corrected ZOI of 395.2 mm/g, which was statistically greater than the group B ZOI (313.2 mm/g, P<.05) but not the group A ZOI (346.5 mm/g, P>.05). All groups demonstrated a decrease in antimicrobial activity at 48 through 96 hours, with no significant difference at any time point. Prolonged soaking of antibiotic cement in a povidone-iodine or saline solution results in elution of the antibiotic into the irrigation solution, blunting initial antibiotic concentration. When using antibiotic cement, antiseptic soaks or irrigation should be focused prior to cementation. [Orthopedics. 2024;47(1):10-14.].

Utilization of Antibiotic Bone Cement in Spine Surgery: Pearls, Techniques, and Case Review

Vertebral osteomyelitis (VO) encompasses a spectrum of spinal infections ranging from isolated mild vertebral osteomyelitis to severe diffuse infection with associated epidural abscess and fracture. Although patients can often be treated with an initial course of intravenous antibiotics, surgery is sometimes required in patients with sepsis, spinal instability, neurological compromise, or failed medical treatment. Antibiotic bone cement (ABC) has been widely used in orthopedic extremity surgery for more than 150 years, both for prophylaxis and treatment of bacterial infection. However, relatively little literature exists regarding its utilization in spine surgery. This article describes ABC utilization in orthopedic surgery and explains the technique of ABC utilization in spine surgery. Surgeons can choose from multiple premixed ABCs with variable viscosities, setting times, and antibiotics or can mix in antibiotics to bone cements themselves. ABC can be used to fill large defects in the vertebral body or disc space or in some cases to coat instrumentation. Surgeons should be wary of complications such as ABC extravasation as well as an increased difficulty with revision. With a thorough understanding of the properties of the cement and the methods of delivery, ABC is a powerful adjunct in the treatment of spinal infections.

Rank-Ordered List of Cost-effective Strategies for Preventing Prosthetic Joint Infection in Total Joint Arthroplasty in an Academic US Hospital

Although the overall rate of prosthetic joint infection (PJI) is low, it remains a major complication associated with total joint arthroplasty (TJA). PJI represents a significant economic burden to the health care system that is projected to increase commensurate with increasing joint replacement volumes. This review provides a rank-ordered list of cost-effective strategies that are performable intraoperatively and have data supporting their efficacy at preventing PJI after TJA. This study may be helpful in assisting surgeons, ambulatory surgery center owners, and hospital acquisition committees to make reasonable and cost-conscious decisions in the face of changing reimbursement. [Orthopedics. 2023;46(6):327-332.].

Nanocomposite orthopaedic bone cement combining long-acting dual antimicrobial drugs

Antibiotic loaded bone cements are widely used in total joint replacement (TJR); despite many limitations such as a burst release which leads to antibiotic concentration below inhibitory levels and possibly contributing to the selection of antibiotic resistant strains. In order to address such limitations and to simultaneously address antibiotic resistance and short-term antimicrobial activity, we developed a nanocomposite bone cement capable of providing a controlled release of antimicrobial agents from bone cement to act as prophylaxis or treatment against prosthetic joint infections (PJIs). Gentamicin and chlorhexidine were loaded in combination on silica nanoparticles surface using layer-by-layer coating technique (LbL) combining hydrolysable and non-hydrolysable polymers. The drug release from the nanocomposite continued for >50 days at concentrations higher than the commercial formulation containing the same amount of antimicrobial drugs, where burst release for few days were observed. Moreover, the nanocomposite bone cement showed superior antimicrobial inhibition without adversely affecting the mechanical properties or the ability of osteoblasts to grow. In vivo experiments with an infected bone lesion model along with mass-spectrometric analysis also provided further evidence of efficacy and safety of the implanted nanocomposite material as well as its prolonged drug eluting profile. The developed nanocomposite bone cement has the potential to reduce PJIs and enable treatment of resistant established infections; moreover, the newly developed LbL based nano-delivery system may also have wider applications in reducing the threat posed by antimicrobial resistance.

Evaluating the Translational Potential of Bacteriocins as an Alternative Treatment for Staphylococcus aureus Infections in Animals and Humans

Antibiotic resistance remains a global threat to human and animal health. Staphylococcus aureus is an opportunistic pathogen that causes minor to life-threatening infections. The widespread use of antibiotics in the clinical, veterinary, and agricultural setting combined with the increasing prevalence of antibiotic-resistant S. aureus strains makes it abundantly clear that alternatives to antibiotics are urgently needed. Bacteriocins represent one potential alternative therapeutic. They are antimicrobial peptides that are produced by bacteria that are generally nontoxic and have a relatively narrow target spectrum, and they leave many commensals and most mammalian cells unperturbed. Multiple studies involving bacteriocins (e.g., nisin, epidermicin, mersacidin, and lysostaphin) have demonstrated their efficacy at eliminating or treating a wide variety of S. aureus infections in animal models. This review provides a comprehensive and updated evaluation of animal studies involving bacteriocins and highlights their translational potential. The strengths and limitations associated with bacteriocin treatments compared with traditional antibiotic therapies are evaluated, and the challenges that are involved with implementing novel therapeutics are discussed.

Robotic-assisted knee replacement surgery & infection: A historical foundation, systematic review and meta-analysis

Background

An increasing proportion of Knee arthroplasty is performed using robotic-assisted surgical techniques. This study sought to use a meta-analytical approach to establish summary rates of surgical site infection in robotic-assisted procedures and compare the rate of deep infections to those seen in conventional knee arthroplasty.

Methods

This study performed a literature search across four online databases to establish a summary rate of surgical site infection across two categories: deep infection and superficial and pin-site infections. This was processed with the aid of a bespoke data-extraction tool. Risk of Bias analysis was performed using the Cochrane RoB2 tool. Meta-analysis was then performed with tests for heterogeneity and a DerSimonian-Laird random effects model.

Results

A total of 17 studies were identified as appropriate for inclusion in the meta-analysis. The summary rate of overall surgical site infections within one year of robotic knee arthroplasty was found to be 0.568% (SE = 0.183, 95% CI = 0.209-0.927). Deep infections fell to 0.154% (SE = 0.069, 95% CI = 0.018-0.290) and to 0.347% (SE = 0.109, 95% CI = 0.133-0.561) in superficial and pin-site infections.

Conclusion

The surgical site infection rates were found to be low across robotic knee arthroplasty. Further research is required to prove its superiority compared to the conventional, non-robotic technique.

Evidence for Local Antibiotics in the Prevention of Infection in Orthopaedic Trauma

Prevention of fracture-related infection (FRI) remains a substantial challenge in orthopaedic trauma care. There is evolving evidence to support the use of local antibiotics for both the prevention and treatment of musculoskeletal infection. Local antibiotics can achieve higher local tissue concentrations with a lower risk of systemic complications compared to intravenously administered antibiotics. These antibiotics may be administered in powder or liquid form without carrier, or if sustained release is desired, using a carrier. Polymethylmethacrylate (PMMA), ceramics, and hydrogels are examples of antibiotic carriers. Unlike PMMA, ceramics and hydrogels have the advantage of not requiring a second surgery for removal. The VANCO trial supported the use of powdered vancomycin in high-risk fracture cases for the reduction of Gram-positive infections; although, data is limited. Future studies will evaluate the use of aminoglycoside antibiotics to address Gram-negative infection prevention. While theoretical concerns exist with the use of local antibiotics, available studies suggest local antibiotics are safe with a low-risk of adverse effects.

Strategies to Mitigate and Treat Orthopaedic Device-Associated Infections

Orthopaedic device implants play a crucial role in restoring functionality to patients suffering from debilitating musculoskeletal diseases or to those who have experienced traumatic injury. However, the surgical implantation of these devices carries a risk of infection, which represents a significant burden for patients and healthcare providers. This review delineates the pathogenesis of orthopaedic implant infections and the challenges that arise due to biofilm formation and the implications for treatment. It focuses on research advancements in the development of next-generation orthopaedic medical devices to mitigate against implant-related infections. Key considerations impacting the development of devices, which must often perform multiple biological and mechanical roles, are delineated. We review technologies designed to exert spatial and temporal control over antimicrobial presentation and the use of antimicrobial surfaces with intrinsic antibacterial activity. A range of measures to control bio-interfacial interactions including approaches that modify implant surface chemistry or topography to reduce the capacity of bacteria to colonise the surface, form biofilms and cause infections at the device interface and surrounding tissues are also reviewed.

Diagnosis and treatment of periprosthetic infection after hip replacement (a review)

Introduction. The frequency of hip arthroplasty is steadily increasing throughout the world and, although this operation has become routine, the likelihood of postoperative complications reaches 4.3 % [1]. The most dangerous of them are infectious lesions in the area of the endoprosthesis and adjacent tissues. At the same time, in addition to the threat of generalization of the infectious process, there are functional disorders in the joint area and a general deterioration in the quality of life of the patient. Timely diagnosis and treatment of the infectious process and related disorders can minimize the adverse effects of infection.

Target. The purpose of this review is to analyze modern methods for diagnosing and treating periprosthetic infection resulting from hip replacement.

Materials and methods. The subject literature was searched using the PubMed and Google Sholar databases.

Results. The main methods for diagnosing periprosthetic infection include histological and bacteriological examination of the biopsy specimen, determination of sensitivity to antibiotics, blood, and synovial fluid analysis for the content of leukocytes, IL-6, CRP, PCR diagnostics of infectious agents. Treatment consists of re-intervention and/or antibiotic therapy.

Conclusion. The most optimal method for diagnosing periprosthetic infection is a bacteriological study of biopsy specimens taken intraoperatively. The preferred method of treatment is determined by the severity of the infection, the degree of involvement of tissues adjacent to the prosthesis, the comorbid background, the nature of the infectious agent, and includes repeated revision surgery.

Comprehensive meta-analysis of antibiotic-impregnated bone cement versus plain bone cement in primary total knee arthroplasty for preventing periprosthetic joint infection

PURPOSE

Antibiotic-loaded bone cement (ALBC) was usually used to prevent periprosthetic joint infection (PJI) in primary total knee arthroplasty (PTKA), but whether to use ALBC or plain bone cement in PTKA remains unclear. We aimed to compare the occurrence rate of PJI using two different cements, and to investigate the efficacy of different antibiotic types and doses administered in preventing surgical site infection (SSI) with ALBC.

METHODS

The availability of ALBC for preventing PJI was evaluated by using a systematic review and meta-analysis referring to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Existing articles until December 2021 involving PTKA patients with both ALBC and plain bone cement cohorts were scanned by searching "total knee arthroplasty", "antibiotic-loaded cement", "antibiotic prophylaxis", "antibiotic-impregnated cement" and "antibiotic-laden cement" in the database of PubMed/MEDLINE, Embase, Web of Science and the Cochrane Library. Subgroup analysis included the effectiveness of different antibiotic types and doses in preventing SSI with ALBC. The modified Jadad scale was employed to score the qualities of included articles.

RESULTS

Eleven quantitative studies were enrolled, including 34,159 knees undergoing PTKA. The meta-analysis results demonstrated that the use of prophylactic ALBC could significantly reduce the prevalence of deep incisional SSI after PTKA, whereas there was no significant reduction in the rate of superficial incisional SSI. Moreover, gentamicin-loaded cement was effective in preventing deep incisional SSI, and the use of high-dose ALBC significantly reduced the rate of deep incisional SSI after PTKA. Besides, no significant adverse reactions and complications were stated during the use of ALBC in PTKA.

CONCLUSION

The preventive application of ALBC during PTKA could reduce the rates of deep PJI. Furthermore, bone cement containing gentamicin and high-dose ALBC could even better prevent deep infection after PTKA. However, the existing related articles are mostly single-center and retrospective studies, and further high-quality ones are needed for confirmation.

The Cost-Effectiveness of Extended Oral Antibiotic Prophylaxis for Infection Prevention After Total Joint Arthroplasty in High-Risk Patients

BACKGROUND

Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients.

METHODS

Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT).

RESULTS

Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates.

CONCLUSION

The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition.

Femoral Stem Cementation in Primary Total Hip Arthroplasty

➢

Femoral stem cementation has undergone considerable investigation since bone cement was first used in arthroplasty, leading to the evolution of modern femoral stem cementation techniques.

➢

Although there is a worldwide trend toward the use of cementless components, cemented femoral stems have shown superiority in some studies and have clear indications in specific populations.

➢

There is a large evidence base regarding cement properties, preparation, and application techniques that underlie current beliefs and practice, but considerable controversy still exists.

➢

Although the cementing process adds technical complexity to total hip arthroplasty, growing evidence supports its use in certain cohorts. As such, it is critical that orthopaedic surgeons and investigators have a thorough understanding of the fundamentals and evidence underlying modern cementation techniques.

Prevention of Orthopedic Prosthetic Infections Using Evidence-Based Surgical Site Infection Care Bundles: A Narrative Review

Background: The number of primary/revision total joint replacements (TJR) are expected to increase substantially with an aging population and increasing prevalence of comorbid conditions. The 30-day re-admission rate, in all orthopedic specialties, is 5.4% (range, 4.8%-6.0%). A recent publication has documented that the surgical site infection (SSI) infection rate associated with revision total knee (rTKR, 15.6%) and revision total hip (rTHR, 8.6%) arthroplasties are four to seven times the rate of the primary procedures (2.1%-2.2%). These orthopedic infections prolong hospital stays, double re-admissions, and increase healthcare costs by a factor of 300%. Methods: A search of PubMed/MEDLINE, EMBASE and the Cochrane Library publications, which reported the infection risk after TKR and THR, was undertaken (January 1, 1995 to December 31, 2021). The search also included documentation of evidence-based practices that lead to improved post-operative outcomes. Results: The evidence-based approach to reducing the risk of SSI was grouped into pre-operative, peri-operative, and post-operative periods. Surgical care bundles have existed within other surgical disciplines for more than 20 years, although their use is relatively new in peri-operative orthopedic surgical care. Pre-admission chlorhexidine gluconate (CHG) showers/cleansing, staphylococcal decolonization, maintenance of normothermia, wound irrigation, antimicrobial suture wound closure, and post-operative wound care has been shown to improve clinical outcome in randomized controlled studies and meta-analyses. Conclusions: Evidence-based infection prevention care bundles have improved clinical outcomes in all surgical disciplines. The significant post-operative morbidity, mortality, and healthcare cost, associated with SSIs after TJR can be reduced by introduction of evidence-based pre-operative, intra-operative, and post-operative interventions.

When and How Should I Use Antibiotic Cement in Primary and Revision Joint Arthroplasty?

Periprosthetic joint infections (PJIs) remain one of the most challenging and devastating complications associated with total joint arthroplasty. Therefore, prevention and the ability to effectively treat PJIs are critical. One such tool for both the prevention and treatment of PJIs is the use of antibiotic-loaded bone cement (ALBC). ALBC provides an effective local delivery method of antibiotics. Low dose (<2 g per 40-g batch) is commonly used for prophylaxis, while high dose (>3.6 g per 40-g batch) is used for the treatment of PJIs. This review focuses on the efficacy, safety, and cost-effectiveness of ALBC for both the prevention as well as the treatment of PJIs.

Lyophilized Human Bone Allograft as an Antibiotic Carrier: An In Vitro and In Vivo Study

Background: Antibiotics delivered from implanted bone substitute materials (BSM) can potentially be used to prevent acute infections and biofilm formation, providing high concentrations of antibiotics at the surgical site without systemic toxicity. In addition, BSM should allow osteoconductivity supporting bone healing without further surgery. Promising results have been achieved using lyophilized bone allografts mixed with antibiotics. Methods: In this study specially prepared human bone allografts were evaluated as an antibiotic carrier in vitro and in vivo. The efficacy of different antibiotic-impregnated bone allografts was measured by drug release tests in vitro and in vivo and bacterial susceptibility tests using four bacterial species usually responsible for implant-associated infections. Results: The loading procedures of allograft bone substitutes with antibiotics were successful. Some of the antibiotic concentrations exceeded the MIC90 for up to 7 days in vitro and for up to 72 h in vivo. The susceptibility tests showed that S. epidermidis ATCC 12228 was the most susceptible bacterial species in comparison to the other strains tested for all antibiotic substances. Vancomycin and rifampicin showed the best results against standard and patient-isolated strains in vitro. In vivo, new bone formation was comparable in all study groups including the control group without antibiotic loading. Conclusions: Human bone allografts showed the capacity to act as customized loaded antibiotic carriers to prevent acute infections and should be considered in the management of bone infections in combination with systemic antimicrobial therapy.

Antibiotic Cement Utilization for the Prophylaxis and Treatment of Infections in Spine Surgery: Basic Science Principles and Rationale for Clinical Use

Antibiotic bone cement (ABC) is an effective tool for the prophylaxis and treatment of osteomyelitis due to the controlled, sustained release of local antibiotics. ABC has been proven to be effective in the orthopedic fields of arthroplasty and extremity trauma, but the adoption of ABC in spine surgery is limited. The characteristics of ABC make it an optimal solution for treating vertebral osteomyelitis (VO), a serious complication following spine surgery, typically caused by bacterial and sometimes fungal and parasitic pathogens. VO can be devastating, as infection can result in pathogenic biofilms on instrumentation that is dangerous to remove. New techniques, such as kyphoplasty and novel vertebroplasty methods, could amplify the potential of ABC in spine surgery. However, caution should be exercised when using ABC as there is some evidence of toxicity to patients and surgeons, antibiotic allergies, bone cement structural impairment, and possible development of antibiotic resistance. The purpose of this article is to describe the basic science of antibiotic cement utilization and review its usage in spine surgery.

The use of antibiotic-loaded bone cement does not increase antibiotic resistance after primary total joint arthroplasty

PURPOSE

One of the preventive strategies for periprosthetic joint infection (PJI) is the use of antibiotic-loaded bone cement (ALBC) in primary total joint arthroplasty (TJA). Even though it is widely used, there are concerns about the development of antibacterial resistance. The aim of the study was to investigate whether using ALBC in primary TJA increases the antibiotic-resistant PJI. The hypothesis was that the regular use of ALBC does not increase the rate of resistant PJI.

METHODS

Patients with confirmed PJI who had revision surgery from year 2010 to 2019 were included in this international multicenter study. The ALBC group was compared to the non-ALBC TJA group from the same time period. Medical records were used to collect clinical (age, gender, body mass index, comorbidities), TJA-related (type of operation, implant type and survival) and PJI-related (cultured microorganism, antibiogram) data. Resistance to gentamicin, clindamycin and vancomycin were recorded from the antibiograms. Multiple logistic regression model was used to identify risk factors and account for the potential confounders.

RESULTS

218 patients with PJI were included in the study: 142 with gentamicin-loaded bone cement and 76 in the non-ALBC group. The average age in the ALBC group was 71 ± 10 years and 62 ± 12 years in the comparison group (p < 0.001). Coagulase negative Staphylococci (CONS) were the most common (49%) isolated pathogens. The use of ALBC did not increase the rate of any resistant bacteria significantly (OR = 0.79 (0.42-1.48), p = 0.469). The presence of CONS was associated with higher risk of antibiotic resistance.

CONCLUSIONS

The current study demonstrates no increase in antibiotic resistance due to ALBC after primary TJA. Thus, the use of ALBC during primary TJA should not be feared in the context of antimicrobial resistance.

LEVEL OF EVIDENCE

III.

"Smart" Polylactic Acid Films with Ceftriaxone Loaded Microchamber Arrays for Personalized Antibiotic Therapy

Bacterial infections are a severe medical problem, especially in traumatology, orthopedics, and surgery. The local use of antibiotics-elution materials has made it possible to increase the effectiveness of acute infections treatment. However, the infection prevention problem remains unresolved. Here, we demonstrate the fabrication of polylactic acid (PLA) “smart” films with microchamber arrays. These microchambers contain ceftriaxone as a payload in concentrations ranging from 12 ± 1 μg/cm² to 38 ± 8 μg/cm², depending on the patterned film thickness formed by the different PLA concentrations in chloroform. In addition, the release profile of the antibiotic can be prolonged up to 72 h in saline. At the same time, on the surface of agar plates, the antibiotic release time increases up to 96 h, which has been confirmed by the growth suppression of the Staphylococcus aureus bacteria. The efficient loading and optimal release rate are obtained for patterned films formed by the 1.5 wt % PLA in chloroform. The films produced from 1.5 and 2 wt % PLA solutions (thickness—0.42 ± 0.12 and 0.68 ± 0.16 µm, respectively) show an accelerated ceftriaxone release upon the trigger of the therapeutic ultrasound, which impacted as an expansion of the bacterial growth inhibition zone around the samples. Combining prolonged drug elution with the on-demand release ability of large cargo amount opens up new approaches for personalized and custom-tunable antibacterial therapy.

Antibiotic cement coating in orthopedic surgery: a systematic review of reported clinical techniques

Background

Antibiotic-containing cement and bone graft substitute-coated orthopedic implants provide the advantages of simultaneous local antibiotic delivery and internal stable fixation, aiding in both infection eradication and osseous healing. Standardized protocols pertaining to implant coating techniques in various clinical and particularly intraoperative settings are scarce, and available literature is limited. This systematic review aims to provide a summary of the available current literature reporting on custom-made coating techniques of orthopedic implants, indications, outcomes, and associated complications in clinical use.

Methods

A systematic search of the literature in PubMed, Medline, Embase, and Cochrane Library databases was performed in accordance with PRISMA guidelines. Articles reporting specifically on custom-made coating techniques of orthopedic implants in a clinical setting were eligible.

Results

A total of 41 articles with a cumulative total number of 607 cases were included. Indications for treatment mostly involved intramedullary infections after previous plate osteosynthesis or nailing. A variety of implants ranging from intramedullary nails, plates, wires, and rods served as metal cores for coating. Polymethylmethacrylate (PMMA) bone cement was most commonly used, with vancomycin as the most frequently added antibiotic additive. Chest tubes and silicone tubes were most often used to mold. Common complications are cement debonding and breakage of the metallic implant.

Conclusion

Adequate coating techniques can reduce the burden of treatment and be associated with favorable outcomes. Lack of general consensus and heterogeneity in the reported literature indicate that the perfect all-in-one implant coating method is yet to be found. Further efforts to improve implant coating techniques are warranted.

Level of evidence

III.

Novel dual-functional implants via oxygen non-thermal plasma and quaternary ammonium to promote osteogenesis and combat infections

OBJECTIVE

Implant-related infections are a primary reason for implant failures that affect millions of patients. It is of paramount importance to develop novel implants that possess the dual functions of osteogenesis-promotion and antibacterial activity. The objectives of this study were to: (1) develop novel dual-functional titanium (Ti) implants by combining oxygen non-thermal plasma and covalent bonding of antibacterial organosilicon quaternary ammonium monomers; (2) investigate the physicochemical properties, bioactivity and antibacterial effects of the modified implants for the first time.

METHODS

Surface characteristics of the modified Ti surfaces were tested. Adherence and viability of rat bone marrow-derived stem cells (rBMSCs) on the surface were evaluated. Metabolic activity of biofilm on the surfaces were measured. The stability of the dual-function after 5000 thermal cycles was also evaluated.

RESULTS

The presence of chemical bonding between Ti and organosilicon monomers demonstrated covalent immobilization of the antibacterial agents. The water contact angle of the treated Ti surfaces decreased from 70.98 ± 3.68° to 59.86 ± 4.91°. The adhesion and proliferation of rBMSCs on the modified Ti were increased by 40%, compared to control group (P < 0.05). The metabolic level of biofilms on modified Ti were reduced by more than half, compared to control (P < 0.05). The modified Ti implants exhibited cell-promotion and antibacterial stability after thermal cycles.

SIGNIFICANCE

The new dual-functional Ti implant is promising to promote osteogenesis while simultaneously preventing infections. Furthermore, the novel surface modification and processing methods have applicability to enhancing a wide range of other implants to improve bioactivity and combat infections.

PMMA bone cement containing long releasing silica-based chlorhexidine nanocarriers

Prosthetic joint infections (PJI) are still an extremely concerning eventuality after joint replacement surgery; growing antibiotic resistance is also limiting the prophylactic and treatment options. Chlorhexidine (a widely used topical non-antibiotic antimicrobial compound) coatings on silica nanoparticles capable of prolonged drug release have been successfully developed and characterised. Such nanocarriers were incorporated into commercial formulation PMMA bone cement (Cemex), without adversely affecting the mechanical performance. Moreover, the bone cement containing the developed nanocarriers showed superior antimicrobial activity against different bacterial species encountered in PJI, including clinical isolates already resistant to gentamicin. Cytocompatibility tests also showed non inferior performance of the bone cements containing chlorhexidine releasing silica nanocarriers to the equivalent commercial formulation.

Influence of Tranexamic Acid on Elution Characteristics and Compressive Strength of Antibiotic-Loaded PMMA-Bone Cement with Gentamicin

PURPOSE

The topical application of tranexamic acid (TXA) into the joint space during total joint arthroplasty (TJA) with no increase of complications, has been widely reported. We investigated the influence of TXA on antibiotic release, activity of the released antibiotic against a clinical isolate of S. aureus, and compressive strength of a widely used commercially prepared gentamicin-loaded cement brand (PALACOS R + G).

METHOD

12 bone cement cylinders (diameter and height = 6 and 12 mm, respectively) were molded. After curing in air for at least 1 h, six of the cylinders were completely immersed in 5 mL of fetal calf serum (FCS) and the other six were completely immersed in a solution consisting of 4.9 mL of FCS and 0.1 mL (10 mg) of TXA. Gentamicin elution tests were performed over 7 d. Four hundred µL of the gentamicin eluate were taken every 24 h for the first 7 d without renewing the immersion fluid. The gentamicin concentration was determined in a clinical analyzer using a homogeny enzyme immuno-assay. The antimicrobial activity of the eluate, obtained after day 7, was tested. An agar diffusion test regime was used with Staphylococcus aureus. Bacteria were grown in a LB medium and plated on LB agar plates to get a bacterial lawn. Fifty µL of each eluate were pipetted on 12-mm diameter filter discs, which were placed in the middle of the agar gel. After 24 h of cultivation at 37 °C, the zone of inhibition (ZOI) for each specimen was measured. The compressive strength of the cements was determined per ISO 5833.

RESULTS

At each time point in the gentamicin release test, the difference in gentamicin concentration, obtained from specimens immersed in the FCS solution only and those immersed in the FCS + TXA solution was not significant (p = 0.055-0.522). The same trend was seen in each of the following parameters, after 7 d of immersion: (1) Cumulative gentamicin concentration (p < 0.297); (2) gentamicin activity against S. aureus (strongly visible); (3) ZOI size (mostly > 20 mm) (p = 0.631); and (4) compressive strength (p = 0.262).

CONCLUSIONS

For the PALACOS R + G specimens, the addition of TXA to FCS does not produce significant decreases in gentamicin concentration, in the activity of the gentamicin eluate against a clinical isolate of S. aureus, the zone of inhibition of S. aureus, and in the compressive strength of the cement, after 7 d of immersion in the test solution.

Cold-Injection Molded Gentamicin-Impregnated Polymethyl Methacrylate Implants for Cranioplasty

BACKGROUND

Cranioplasty can be carried out using either fresh, frozen autologous bone or synthetic substitutes. Ordering artificial 3 dimensional (3D) implants is challenging and time consuming depending on geographical location. In this article, we share our experience using a streamlined process of producing 3D computer-assisted design (CAD) implants using commercially available 3D printers and silicone molds that can be easily replicated with consistent results and are associated with good outcomes.

OBJECTIVE

To develop patient-specific implants for patients with cranial defects that are accurate, consistent, low cost, and easy to replicate while reducing operator-dependent factors.

METHODS

We present data from 15 patients who underwent cranioplasty with 3D CAD-designed gentamicin-impregnated bone cement implants that were molded using the cold injection technique.

RESULTS

The technique was consistent in result production, required little postdemolding manipulation, and showed no dimensional variation in design. Postoperative computed tomography scans showed excellent implant fit, and patients had a low complication rate.

CONCLUSION

We have demonstrated a technique of mold preparation that is efficient and that produces a reliable result. Polymethyl methacrylate implants molded using this technique showed better reproducibility, higher accuracy, and precision than other types of implants and required minimal postdemolding clean-up.

Influence of Antibiotic-Loaded Acrylic Bone Cement Composition on Drug Release Behavior and Mechanism

Periprosthetic joint infection (PJI) is a devastating complication after total joint replacement with considerable morbidity and large economic burdens. Antibiotic-Loaded Bone Cement (ALBC) has been developed as a valuable tool for local administration and is becoming one of the most effective methods for the prevention and treatment of orthopedic infections. Controlling antibiotic release from ALBC is critical to achieve effective infection control, however, the antibiotic elution rates are generally low, and the mechanisms are poorly understood. Thus, the present study aims to investigate the effects of the basic acrylic bone cement components, including liquid/powder (monomer-to-polymer) ratios, radiopacifier, initiator, and doses of antibiotics on the porosity, antibiotic elution rates and mechanical properties of polymethylmethacrylate (PMMA) based ALBC. The obtained results from the in vitro studies suggested that a reduction in the liquid/powder ratio and an increase in the radiopacifier ratio and gentamicin doses led to increased porosity and release of antibiotic, while the initiator ratio exerted no effect on elution rates. In conclusion, we hope that by varying the composition of ALBC, we could considerably enhance the antibiotic elution rates by increasing porosity, while maintaining an adequate mechanical strength of the bone cements. This finding might provide insights into controlling antibiotic release from ALBC to achieve effective infection control after total joint replacement surgery.

Is serum gentamicin concentration modified with autologous cell-saved blood transfusion after total knee arthroplasty using tranexamic acid? A randomised control trial

BACKGROUND

Self-transfusion has been proven as an effective management of blood loss after total knee arthroplasty (TKA). Considering that the high local concentration of antibiotic from bone cement is delivered intravenously through the self-transfusion process, systematic toxicity has never been evaluated. In addition, the effectiveness of self-transfusion with the routine concomitant use of other modern blood-salvage strategies, like tranexamic acid, should also be assessed. Therefore, we performed a randomised study to assess: 1) the safety of self-transfusion in TKA by comparing the gentamicin concentrations resulting from the use or not of autologous blood transfusion; 2) the efficacy of self-transfusion in TKA, with the concomitant administration of tranexamic acid.

HYPOTHESIS

Self-transfusion in TKA elevates the serum gentamicin concentration and the potential risk of nephrotoxicity.

METHODS

The serum concentration of aminoglycosides was measured in two groups of 20 patients each, after TKA, according to the use of self-transfusion. Hemoglobin, renal function and calculated blood loss were compared at several points in time between groups.

RESULTS

The only time where there was a statistically significant difference in serum gentamicin, was at 48h postoperatively between groups [0.3 ug/mL±0.21, range: 0.15 to 0.72 vs. 0.14ug/mL±0.1, range: 0 to 0.35 (p=0.02)]. There were no significant differences in total blood loss [1341mL±501, range: 830 to 2230 vs. 1263mL±459 range: 840 to 2480 (p=0.67)] and need of allogeneic blood transfusion [3 units vs. 2 units] between groups.

CONCLUSION

The use of autologous blood transfusion was found to be safe, in terms of nephrotoxicity of aminoglycosides after TKA, but it seemed to be ineffective as a blood salvage strategy, when used concomitantly with the administration of tranexamic acid.

LEVEL OF EVIDENCE

II; low-powered randomised study. CLINICALTRIALS.

GOV REGISTRATION NUMBER

NCT04505748.

Periprosthetic Joint Infection Prophylaxis in the Elderly after Hip Hemiarthroplasty in Proximal Femur Fractures: Insights and Challenges

We review antibiotic and other prophylactic measures to prevent periprosthetic joint infection (PJI) after hip hemiarthroplasty (HHA) surgery in proximal femoral fractures (PFFs). In the absence of specific guidelines, those applied to these individuals are general prophylaxis guidelines. Cefazolin is the most widely used agent and is replaced by clindamycin or a glycopeptide in beta-lactam allergies. A personalized antibiotic scheme may be considered when colonization by a multidrug-resistant microorganism (MDRO) is suspected. Particularly in methicillin-resistant Staphylococcus aureus (MRSA) colonization or a high prevalence of MRSA-caused PJIs a glycopeptide with cefazolin is recommended. Strategies such as cutaneous decolonization of MDROs, mainly MRSA, or preoperative asymptomatic bacteriuria treatment have also been addressed with debatable results. Some areas of research are early detection protocols in MDRO colonizations by polymerase-chain-reaction (PCR), the use of alternative antimicrobial prophylaxis, and antibiotic-impregnated bone cement in HHA. Given that published evidence addressing PJI prophylactic strategies in PFFs requiring HHA is scarce, PJIs can be reduced by combining different prevention strategies after identifying individuals who will benefit from personalized prophylaxis.

Increasing but levelling out risk of revision due to infection after total hip arthroplasty: a study on 108,854 primary THAs in the Norwegian Arthroplasty Register from 2005 to 2019

Background and purpose - Focus on prevention, surveillance, and treatment of infection after total hip arthroplasty (THA) in the last decade has resulted in new knowledge and guidelines. Previous publications have suggested an increased incidence of surgical revisions due to infection after THA. We assessed whether there have been changes in the risk of revision due to deep infection after primary THAs reported to the Norwegian Arthroplasty Register (NAR) over the period 2005-2019.Patients and methods - Primary THAs reported to the NAR from January 1, 2005 to December 31, 2019 were included. Adjusted Cox regression analyses with the first revision due to deep infection after primary THA were performed. We investigated changes in the risk of revision as a function of time of primary THA. Time was stratified into 5-year periods. We studied the whole population of THAs, and the subgroups: all-cemented, all-uncemented, reverse hybrid (cemented cup), and hybrid THAs (cemented stem). In addition, we investigated factors that were associated with the risk of revision, and changes in the time span from primary THA to revision.Results - Of the 108,854 primary THAs that met the inclusion criteria, 1,365 (1.3%) were revised due to deep infection. The risk of revision due to infection, at any time after primary surgery, increased through the period studied. Compared with THAs implanted in 2005-2009, the relative risk of revision due to infection was 1.4 (95% CI 1.2-1.7) for 2010-2014, and 1.6 (1.1-1.9) for 2015-2019. We found an increased risk for all types of implant fixation. Compared to 2005-2009, for all THAs, the risk of revision due to infection 0-30 days postoperatively was 2.2 (1.8-2.8) for 2010-2014 and 2.3 (1.8-2.9) for 2015-2019, 31-90 days postoperatively 1.0 (0.7-1.6) for 2010-2014 and 1.6 (1.0-2.5) for 2015-2019, and finally 91 days-1 year postoperatively 1.1 (0.7-1.8) for 2010-2014 and 1.6 (1.0-2.6) for 2015-2019. From 1 to 5 years postoperatively, the risk of revision due to infection was similar to 2005-2009 for both the subsequent time periodsInterpretation - The risk of revision due to deep infection after THA increased throughout the period 2005-2019, but appears to have levelled out after 2010. The increase was mainly due to an increased risk of early revisions, and may partly have been caused by a change of practice rather than a change in the incidence of infection.

A randomized clinical trial of low dose single antibiotic-loaded cement versus high dose dual antibiotic-loaded cement in patients receiving a hip hemiarthroplasty after fracture: A protocol for the WHiTE 8 COPAL study

AIMS

Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture.

METHODS

The WHiTE 8 Copal Or Palacos Antibiotic Loaded bone cement trial (WHiTE 8 COPAL) is a multicentre, multi-surgeon, parallel, two-arm, randomized clinical trial. The pragmatic study will be embedded in the World Hip Trauma Evaluation (WHiTE) (ISRCTN 63982700). Participants, including those that lack capacity, will be allocated on a 1:1 basis stratified by recruitment centre to either a low dose single antibiotic-loaded bone cement or a high dose dual antibiotic-loaded bone cement. The primary analysis will compare the differences in deep SSI rate as defined by the Centers for Disease Control and Prevention within 90 days of surgery via medical record review and patient self-reported questionnaires. Secondary outcomes include UK Core Outcome Set for hip fractures, complications, rate of antibiotic prescription, resistance patterns of deep SSI, and resource use (more specifically, cost-effectiveness) up to four months post-randomization. A minimum of 4,920 patients will be recruited to obtain 90% power to detect an absolute difference of 1.5% in the rate of deep SSI at 90 days for the expected 3% deep SSI rate in the control group.

CONCLUSION

The results of this trial will provide evidence regarding clinical and cost-effectiveness between low dose single and high dose dual antibiotic-loaded bone cement, which will inform policy and practice guidelines such as the National Institute for Health and Care Excellence guidance on management of hip fractures. Cite this article: Bone Jt Open 2021;2(2):72-78.

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)

INTRODUCTION

The current evidence on the efficacy of antibiotic-loaded bone cement (ALBC) in reducing the risk of periprosthetic joint infections (PJI) after primary joint reconstruction is insufficient. In several European countries, the use of ALBC is routine practice unlike in the USA where ALBC use is not approved in low-risk patients. Therefore, we designed a double-blinded pragmatic multicentre register-based randomised controlled non-inferiority trial to investigate the effects of ALBC compared with plain bone cement in primary total knee arthroplasty (TKA).

METHODS AND ANALYSIS

A minimum of 9,172 patients undergoing full-cemented primary TKA will be recruited and equally randomised into the ALBC group and the plain bone cement group. This trial will be conducted in Norwegian hospitals that routinely perform cemented primary TKA. The primary outcome will be risk of revision surgery due to PJI at 1-year of follow-up. Secondary outcomes will be: risk of revision due to any reason including aseptic loosening at 1, 6, 10 and 20 years of follow-up; patient-related outcome measures like function, pain, satisfaction and health-related quality of life at 1, 6 and 10 years of follow-up; risk of changes in the microbial pattern and resistance profiles of organisms cultured in subsequent revisions at 1, 6, 10 and 20 years of follow-up; cost-effectiveness of routine ALBC versus plain bone cement use in primary TKA. We will use 1:1 randomisation with random permuted blocks and stratify by participating hospitals to randomise patients to receive ALBC or plain bone cement. Inclusion, randomisation and follow-up will be through the Norwegian Arthroplasty Register.

ETHICS AND DISSEMINATION

The trial was approved by the Western Norway Regional Committees on Medical and Health Research Ethics (reference number: 2019/751/REK vest) on 21 June 2019. The findings of this trial will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04135170.

The effect of antibiotic-loaded bone cement on risk of revision following hip and knee arthroplasty

AIMS

This study aimed to compare the effect of antibiotic-loaded bone cement (ALBC) versus plain bone cement (PBC) on revision rates for periprosthetic joint infection (PJI) and all-cause revisions following primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

MEDLINE, Embase, Web of Science, and Cochrane databases were systematically searched for studies comparing ALBC versus PBC, reporting on revision rates for PJI or all-cause revision following primary elective THA or TKA. A random-effects meta-analysis was performed. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42018107691).

RESULTS

Nine studies and one registry report were identified, enabling the inclusion of 371,977 THA and 671,246 TKA. Pooled analysis for THA demonstrated ALBC was protective against revision for PJI compared with PBC (relative risk (RR) 0.66, 95% confidence interval (CI) 0.56 to 0.77; p < 0.001), however, no differences were seen for all-cause revision rate (RR 0.62, 95% CI 0.35 to 1.09; p = 0.100). For TKA, there were no significant differences in revision rates for PJI or all causes between ALBC and PBC (RR 0.92, 95% CI 0.59 to 1.45; p = 0.730, and RR 0.73, 95% CI 0.53 to 1.02; p = 0.060, respectively).

CONCLUSION

ALBC demonstrated a protective effect against revision for PJI compared with PBC in THA with no difference in all-cause revisions. No differences in revision rates for PJI and all-cause revision between ALBC and PBC for TKA were observed. Cite this article: Bone Joint J 2021;103-B(1):7-15.

Antimicrobial Resistance, the COVID-19 Pandemic, and Lessons for the Orthopaedic Community

Antimicrobial resistance (AMR) is widely regarded as one of the most important global public health challenges of the twenty-first century. The overuse and the improper use of antibiotics in human medicine, food production, and the environment as a whole have unfortunately contributed to this issue. Many major international scientific, political, and social organizations have warned that the increase in AMR could cost the lives of millions of people if it is not addressed on a global scale. Although AMR is already a challenge in clinical practice today, it has taken on a new importance in the face of the coronavirus disease 2019 (COVID-19) pandemic. While improved handwashing techniques, social distancing, and other interventional measures may positively influence AMR, the widespread use of antibiotics to treat or prevent bacterial coinfections, especially in unconfirmed cases of COVID-19, may have unintended negative implications with respect to AMR. Although the exact number of bacterial coinfections and the rate at which patients with COVID-19 receive antibiotic therapy remain to be accurately determined, the pandemic has revived the discussion on antibiotic overuse and AMR. This article describes why the COVID-19 pandemic has increased our awareness of AMR and presents the immense global impact of AMR on society as a whole. Furthermore, an attempt is made to stress the importance of tackling AMR in the future and the role of the orthopaedic community in this worldwide effort.