Arthroplasty infection rates in fractured neck of femur: single vs dual antibiotic cement

Use of local treatment in managing infections: Focus on antimicrobial locks, beads, and cement

PURPOSE

The purpose of this review is to describe important considerations with local antimicrobial therapies such as locks, beads, and cement for adjunctive infection management or prevention.

SUMMARY

Local delivery of antimicrobials with locks, beads, and cement has been used for infection management with retained devices in an effort to improve clinical success. However, their use has been controversial due to conflicting clinical data and logistical issues. Antimicrobial lock therapy (ALT) has been used for both adjunctive treatment and prevention of catheter-related bloodstream infections for certain pathogens and based on patient-specific scenarios. ALT has been a controversial method for sterilizing the catheter lumen by delivering high concentrations of antibiotics with or without heparin into the catheter for prolonged durations. Studies differ regarding the selection and concentrations of antibiotics, dwell duration, presence of heparin in the ALT, clinical outcomes/definitions, and use for prevention or treatment of catheter-related bloodstream infections. Antibiotic beads and cement have been used for various surgical procedures but are predominately considered in orthopedic surgeries. Despite the widespread use of the antibiotic-loaded bone cement in orthopedics, studies differ regarding the selection and concentrations of antibiotics, clinical outcomes/definitions, and use for prevention or treatment of infections.

CONCLUSION

Although antimicrobial locks, beads, and cement are commonly used for adjunctive treatment or prevention of infections, more data are needed to support their use to provide clinical efficacy and safety with consistent antimicrobial selection and logistics.

Spacers in two-stage strategy for periprosthetic infection

In two-stage revision of infected implants, the first stage involves removing the implant and implanting a joint spacer, and the second stage involves implanting a new prosthesis at least 6 weeks later. Spacers have two main functions: local administration of high-dose antibiotics, and preservation of the joint space by reducing soft tissue retraction and improving patient comfort until reimplantation. The present review aims to detail the necessary characteristics of antibiotics added to cement to achieve good joint diffusion, to describe the steps of two-stage revision, and to present the types of spacer available according to the joint and complications. The antibiotic used in the spacer must be heat-resistant, water-soluble and chemically stable in the cement. Gentamicin and vancomycin are generally preferred. We recommend at least 3 months' systematic antibiotic therapy for periprosthetic joint infection. Reimplantation is performed either at 6 weeks without antibiotic washout or 3 months after 2 weeks' washout Spacers may be static (non-articulating) or dynamic (articulating). Static spacers are mainly used in the knee or hip in cases of severe bone defect or risk of soft-tissue lesions. An articulating spacer enables some joint functions to be preserved in the knee, hip or shoulder. The most frequent complications are the dislocation of dynamic spacers and the breakage of static or dynamic spacers. To optimize efficacy and minimize complications, the biomechanical and bacteriological characteristics of spacers must be considered. LEVEL OF EVIDENCE: Expert opinion.

Efficacy and Safety of Dual vs Single Antibiotic-Loaded Cement in Bone Fracture Management: A Systematic Review and Meta-Analysis

Bone fractures often require arthroplasty, which carries the risk of surgical site infections (SSIs) and prosthetic joint infections (PJIs). Antibiotic-loaded bone cement (ALBC) is commonly used to reduce these risks. Dual antibiotic-loaded cement (DALC) has been proposed as a more effective option compared to single antibiotic-loaded cement (SALC). This systematic review and meta-analysis aimed to compare the efficacy and safety of DALC and SALC in preventing infections and related outcomes in arthroplasty. We conducted a systematic review and meta-analysis comparing DALC and SALC in patients undergoing hip or knee arthroplasty for fractures. The primary outcome was infection rate (SSI and PJI), with secondary outcomes including re-revision rates and mortality. Databases searched included PubMed, Cochrane Library, Scopus, and Google Scholar. Data synthesis was performed using Review Manager Software (RevMan 5.4, Cochrane Methods, London, UK), and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Nine studies comprising 55,672 patients were included. Eight studies focused on hip arthroplasty, and four included knee surgeries. In hip arthroplasty, DALC significantly reduced infection rates compared to SALC (OR, 0.64; 95% CI, 0.49 to 0.83; P = 0.001), with moderate heterogeneity (I² = 52%). However, no significant difference was found in knee arthroplasty (OR, 1.21; 95% CI, 0.87 to 1.70; P = 0.26). Overall, DALC showed a significant reduction in infection rates (OR, 0.81; 95% CI, 0.66 to 1.00; P = 0.05). DALC also significantly reduced deep surgical site infections in hip surgeries (OR, 0.46; 95% CI, 0.33 to 0.66; P < 0.001). No significant differences were observed in re-revision rates for either hip or knee arthroplasty. Mortality rates were also not significantly different between DALC and SALC. DALC appears to reduce infection rates, particularly in hip arthroplasty, compared to SALC. However, no significant differences were found in re-revision or mortality rates. These findings suggest that DALC may offer better prophylaxis in hip surgeries, but further research is needed to explore its broader benefits and cost-effectiveness.

A Low Rate of Periprosthetic Infections after Aseptic Knee Prosthesis Revision Using Dual-Antibiotic-Impregnated Bone Cement

AIM

The incidence of periprosthetic joint infections (PJI) following aseptic knee revision arthroplasty lies between 3% and 7.5%. The aim of this study was to verify the hypothesis that the use of dual-antibiotic-impregnated cement in knee revision arthroplasty leads to a lower rate of periprosthetic joint infections.

METHODS

We retrospectively reviewed 403 aseptic revision knee arthroplasties performed between January 2013 and March 2021 (148 revisions of a unicompartmental prosthesis, 188 revisions of a bicondylar total knee arthroplasty (TKA), 41 revisions of an axis-guided prosthesis, and 26 revisions of only one component of a surface replacement prosthesis). The bone cement Copal G+C (Heraeus Medical, Wertheim, Germany) with two antibiotics-gentamycin and clindamycin-was used for the fixation of the new implant. The follow-up period was 53.4 ± 27.9 (4.0-115.0) months.

RESULTS

Five patients suffered from PJI within follow-up (1.2%). The revision rate for any reason was 8.7%. Survival for any reason was significantly different between the types of revision (p = 0.026, Log-Rank-test), with lower survival rates after more complex surgical procedures. The 5-year survival rate with regard to revision for any reason was 91.3% [88.2-94.4%] and with regard to revision for PJI 98.2% [98.7-99.9%], respectively.

CONCLUSION

The use of the dual-antibiotic-impregnated bone cement Copal G+C results in a lower rate of periprosthetic infections after aseptic knee prosthesis replacement than that reported in published prosthesis revisions using only one antibiotic in the bone cement.

High-dose dual-antibiotic loaded cement for hip hemiarthroplasty in the UK (WHiTE 8): a randomised controlled trial

BACKGROUND

Hip fracture is the most common injury requiring treatment in hospital. Controversy exists regarding the use of antibiotic loaded bone cement in hip fractures treated with hemiarthroplasty. We aimed to compare the rate of deep surgical site infection in patients receiving high-dose dual-antibiotic loaded cement versus standard care single-antibiotic loaded cement.

METHODS

We included people aged 60 years and older with a hip fracture attending 26 UK hospitals in this randomised superiority trial. Participants undergoing cemented hemiarthroplasty were randomly allocated in a 1:1 ratio to either a standard care single-antibiotic loaded cement or high-dose dual-antibiotic loaded cement. Participants and outcome assessors were masked to the treatment allocation. The primary outcome was deep surgical site infection at 90 days post-randomisation as defined by the US Centers for Disease Control and Prevention in an as-randomised population of consenting participants with available data at 120 days. Secondary outcomes were quality of life, mortality, antibiotic use, mobility, and residential status at day 120. The trial is registered with ISRCTN15606075.

FINDINGS

Between Aug 17, 2018, and Aug 5, 2021, 4936 participants were randomly assigned to either standard care single-antibiotic loaded cement (2453 participants) or high-dose dual-antibiotic loaded cement (2483 participants). 38 (1·7%) of 2183 participants with follow-up data in the single-antibiotic loaded cement group had a deep surgical site infection by 90 days post-randomisation, as did 27 (1·2%) of 2214 participants in the high-dose dual-antibiotic loaded cement group (adjusted odds ratio 1·43; 95% CI 0·87-2·35; p=0·16).

INTERPRETATION

In this trial, the use of high-dose dual-antibiotic loaded cement did not reduce the rate of deep surgical site deep infection among people aged 60 years or older receiving a hemiarthroplasty for intracapsular fracture of the hip.

FUNDING

Heraeus Medical. Supported by the UK National Institute for Health and Care Research Oxford Biomedical Research Centre.

Infection after intracapsular femoral neck fracture - does antibiotic-loaded bone cement reduce infection risk after hemiarthroplasty and total hip arthroplasty?

Aims

The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture.

Methods

Data collection was performed using the German Arthroplasty Registry (EPRD). In HA and THA following femoral neck fracture, fixation method was divided into cemented and uncemented prostheses and paired according to age, sex, BMI, and the Elixhauser Comorbidity Index using Mahalanobis distance matching.

Results

Overall in 13,612 cases of intracapsular femoral neck fracture, 9,110 (66.9%) HAs and 4,502 (33.1%) THAs were analyzed. Infection rate in HA was significantly reduced in cases with use of antibiotic-loaded cement compared with uncemented fixated prosthesis (p = 0.013). In patients with THA no statistical difference between cemented and uncemented prosthesis was registered, however after one year 2.4% of infections were detected in uncemented and 2.1% in cemented THA. In the subpopulation of HA after one year, 1.9% of infections were registered in cemented and 2.8% in uncemented HA. BMI (p = 0.001) and Elixhauser Comorbidity Index (p < 0.003) were identified as risk factors of periprosthetic joint infection (PJI), while in THA cemented prosthesis also demonstrated an increased risk within the first 30 days (hazard ratio (HR) = 2.73; p = 0.010).

Conclusion

The rate of infection after intracapsular femoral neck fracture was statistically significantly reduced in patients treated by antibiotic-loaded cemented HA. Particularly for patients with multiple risk factors for the development of a PJI, the usage of antibiotic-loaded bone cement seems to be a reasonable procedure for prevention of infection.

Management of Periprosthetic Joint Infections After Hemiarthroplasty of the Hip: A Critical Analysis Review

➢

Periprosthetic joint infection (PJI) following hip hemiarthroplasty (HA) is a devastating complication, incurring immense health-care costs associated with its treatment and placing considerable burden on patients and their families. These patients often require multiple surgical procedures, extended hospitalization, and prolonged antimicrobial therapy.

➢

Notable risk factors include older age, higher American Society of Anesthesiologists (ASA) score, inadequate antibiotic prophylaxis, non-antibiotic-loaded cementation of the femoral implant, longer duration of the surgical procedure, and postoperative drainage and hematoma.

➢

Although the most frequent infecting organisms are gram-positive cocci such as Staphylococcus aureus, there is a higher proportion of patients with gram-negative and polymicrobial infections after hip HA compared with patients who underwent total hip arthroplasty.

➢

Several surgical strategies exist. Regardless of the preferred surgical treatment, successful management of these infections requires a comprehensive surgical debridement focused on eradicating the biofilm followed by appropriate antibiotic therapy.

➢

A multidisciplinary approach led by surgeons familiar with PJI treatment and infectious disease specialists is recommended for all cases of PJI after hip HA to increase the likelihood of treatment success.

Materials-driven fibronectin assembly on nanoscale topography enhances mesenchymal stem cell adhesion, protecting cells from bacterial virulence factors and preventing biofilm formation

Post-operative infection is a major complication in patients recovering from orthopaedic surgery. As such, there is a clinical need to develop biomaterials for use in regenerative surgery that can promote mesenchymal stem cell (MSC) osteospecific differentiation and that can prevent infection caused by biofilm-forming pathogens. Nanotopographical approaches to pathogen control are being identified, including in orthopaedic materials such as titanium and its alloys. These topographies use high aspect ratio nanospikes or nanowires to prevent bacterial adhesion but these features also significantly reduce MSC adhesion and activity. Here, we use a poly (ethyl acrylate) (PEA) polymer coating on titanium nanowires to spontaneously organise fibronectin (FN) and to deliver bone morphogenetic protein 2 (BMP2) to enhance MSC adhesion and osteospecific signalling. Using a novel MSC-Pseudomonas aeruginosa co-culture, we show that the coated nanotopographies protect MSCs from cytotoxic quorum sensing and signalling molecules, enhance MSC adhesion and osteoblast differentiation and reduce biofilm formation. We conclude that the PEA polymer-coated nanotopography can both support MSCs and prevent pathogens from adhering to a biomaterial surface, thus protecting from biofilm formation and bacterial infection, and supporting osteogenic repair.

Dual antibiotic loaded bone cement in patients at high infection risks in arthroplasty: Rationale of use for prophylaxis and scientific evidence

In view of the demographic changes and projected increase of arthroplasty procedures worldwide, the number of prosthetic joint infection cases will naturally grow. Therefore, in order to counteract this trend more rigid rules and a stricter implementation of effective preventive strategies is of highest importance. In the absence of a “miracle weapon” priorities should lie in evidence-based measures including preoperative optimization of patients at higher infection risks, the fulfilment of strict hygiene rules in the operating theatre and an effective antibiotic prophylaxis regimen. Instead of a “one size fits all” philosophy, it has been proposed to adjust the antibiotic prophylaxis protocol to major infection risks taking into account important patient- and procedure-related risk factors. A stronger focus on the local application mode via use of high dose dual antibiotic-loaded bone cement in such risk situations may have its advantages and is easy to apply in the theatre. The more potent antimicrobial growth inhibition in vitro and the strong reduction of the prosthetic joint infection rate in risk for infection patients with aid of dual antibiotic-loaded bone cement in clinical studies align with this hypothesis.

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.

Is Dual Antibiotic-Loaded Bone Cement More Effective and Cost-Efficient Than a Single Antibiotic-Loaded Bone Cement to Reduce the Risk of Prosthetic Joint Infection in Aseptic Revision Knee Arthroplasty?

BACKGROUND

Higher rates of prosthetic joint infections (PJIs) are related to patient risk factors and/or to special surgical procedures such as revision total knee arthroplasty (rTKA). Among the measures discussed to better protect those patients from the higher infection risks use of dual antibiotic-loaded bone cement has emerged as a further prophylactic option.

METHODS

This retrospective study included 246 patients undergoing strictly aseptic revision knee arthroplasty at our institution in the time period 2015-2018. Based on the type of bone cement used for the cementation of the revision prosthesis, 2 groups were defined. In total, 143 patients received the low-dose single antibiotic-loaded bone cement (SALBC) PALACOS R+G and 103 patients received the high-dose dual antibiotic-loaded bone cement (DALBC) COPAL G+C. The number of PJI cases in each group over a follow-up time of minimum 1 year was compared and the extra costs for the DALBC use calculated against the economic savings per each avoided PJI case on basis of 3 different assumptions (treatment costs and amount of cement use).

RESULTS

Use of DALBC in aseptic rTKA was associated with a significant reduction in PJI cases (relative risk = 57%, PJI rate in the SALBC group 4.1% vs 0% in the DALBC group, P = 0.035). The calculated total savings per patient was $1367. Depending on the economic assumptions the range of savings was between $1413 (less favorable calculation model) and $3661 (most favorable calculation model).

CONCLUSION

The use of DALBC in rTKA has been found to be more effective in preventing PJI and proved cost-efficient in all our cost-calculation models.

Infection Risk-Adjusted Antibiotic Prophylaxis Strategies in Arthroplasty: Short Review of Evidence and Experiences of a Tertiary Center in Spain

There is growing body of evidence that important patient-, procedure- and pathogen-related factors are linked to higher risks for prosthetic joint infections (PJI) following arthroplasty surgeries. The prior identification and optimization of such risk factors is considered paramount to minimize the incidence of these infections. Without any doubt, antibiotic prophylaxis remains one of the cornerstones among all preventive measures. However, the ideal antibiotic prophylaxis is still in debate and discussions have emerged, whether certain situations deserve adjustments or variations of the standard protocol taking into account antibiotic resistance surveillance data and patient risk factors for infections. This review aims to provide the reader with an overview of possible antibiotic prophylaxis strategies in response to these risks and discusses the clinical experiences so far obtained. We further present preliminary evidence that the use of a reinforced local antibiotic prophylaxis regimen with high-dose dual antibiotic-loaded bone cement may be an effective and easy-to-apply option in patients at high infection risks.

Antibiotic Choice: The Synergistic Effect of Single vs Dual Antibiotics

INTRODUCTION

This review summarizes single vs dual antibiotic cement literature, evaluating for synergistic activity with dual antibiotics.

METHODS

A systematic review was performed for literature regarding dual antibiotics in cement, identifying 13 studies to include for review.

RESULTS

Many in vitro studies reported higher elution from cement and/or improved bacteria inhibition with dual antibiotics, typically at higher dosages with a manual mixing technique. Limited clinical data from hip hemiarthroplasties and spacers demonstrated that dual antibiotics were associated with improved infection prevention and higher intra-articular antibiotic concentrations.

CONCLUSION

In addition to broader pathogen coverage, several studies document synergy of elution and increased antibacterial activity when dual antibiotics are added to cement. Limited clinical evidence suggests that dual antibiotic cement may be associated with reduced infection rates.