The Impact of Antibiotic-Loaded Bone Cement on Antibiotic Resistance in Periprosthetic Knee Infections

Antimicrobial Regimens in Cement Spacers for Periprosthetic Joint Infections: A Critical Review

Antibiotic-loaded cement spacers (ALCSs) are essential for treating periprosthetic joint infections (PJIs) by providing mechanical support and local antibiotic delivery. The purpose of this review is to comprehensively examine the various types of spacers utilised in the management of periprosthetic joint infections (PJIs), including both static and articulating variants and to analyse the fundamental principles underlying spacer use, their clinical benefits, the selection and administration of antimicrobial agents, appropriate dosages, and potential adverse effects. Articulating spacers, which allow joint mobility, often yield better outcomes than static ones. Spacer pharmacokinetics are vital for maintaining therapeutic antibiotic levels, influenced by cement porosity, mixing techniques, and the contact area. Antibiotic choice depends on heat stability, solubility, and impact on cement's mechanical properties. Mechanical properties are crucial, as spacers must withstand physical stresses, with antibiotics potentially affecting these properties. Complications, such as tissue damage and systemic toxicity, are discussed, along with mitigation strategies. Future advancements include surface modifications and novel carriers to enhance biofilm management and infection control.

Patients at a high risk of PJI: Can we reduce the incidence of infection using dual antibiotic-loaded bone cement?

Prosthetic joint infection (PJI) is one of the most devastating complications of orthopedic surgery. However, not all patients are equally at the risk of severe infection. The incidences of PJI vary with the host and surgery-related risk factors. It is now generally accepted that some important medical comorbidities may predispose the patients to a high risk of PJI. Time-consuming and invasive surgical procedures, such as revision arthroplasties, are also associated with a high incidence of PJI, presumably due to the increased risk of surgical site contamination. Effective infection-preventing strategies should begin with identifying and optimizing the patients at a high risk of infection prior to surgery. Optimizing the operating room environment and antibiotic prophylaxis are also essential strategies that help minimize the overall incidence of infection in orthopedic surgery. The ideal antibiotic prophylaxis is still under debate, and discussions have emerged about whether variations or adjustments to the standard protocol are justified in patients at a high risk of infection. This also includes evaluating the possible benefits and risks of using high-dose dual antibiotic-loaded bone cement instead of low-dose single antibiotic-loaded bone cement in arthroplasty. This review summarizes the evidence showing that the combination of two local antibiotics in bone cement exerts a strong and longer-lasting antimicrobial effect against PJI-associated pathogens. This conclusion is consistent with the preliminary clinical studies showing a low incidence of PJI in high-risk patients undergoing cemented hemiarthroplasty, cemented revision, and primary arthroplasty if dual ALBC is used. These results may encourage clinicians to consolidate this hypothesis in a wider clinical range.

Worse outcome of debridement, antibiotics, and implant retention in acute hematogenous infections than in postsurgical infections after total knee arthroplasty: a multicenter study

Background

We sought to determine (1) the success rate of debridement, antibiotics, and implant retention (DAIR) for acute periprosthetic joint infection (PJI) of the knee in patients with acute postsurgical infection and in those with acute hematogenous infection via a multicenter study, (2) the factors related to the failure of DAIR for overall acute PJI and acute hematogenous PJI via subgroup analysis, and (3) whether the PJI recurrence patterns differed between the two groups over time after DAIR.

Methods

This retrospective multicenter study included 101 acute knee PJI. Acute postsurgical PJI was defined as PJI diagnosed < 3 months following initial knee arthroplasty surgery. DAIR was performed for 34 cases of acute postsurgical PJIs (postsurgical group) and 67 cases of acute hematogenous PJIs (hematogenous group). The success rates between groups were compared, and factors related to DAIR failure were analyzed.

Results

The overall success rate of DAIR was 77%. The success rate tended to be higher in the postsurgical group than in the hematogenous group (p = 0.060). However, there was no significant factor related to DAIR failure in the subgroup analysis of acute hematogenous PJIs. In the postsurgical group, the recurrence of PJI occurred until 3 months, whereas in the hematogenous group, recurrence occurred for up to 2 years.

Conclusions

The failure rate tended to be higher in the acute hematogenous PJI group than in the acute postsurgical PJI group. Since acute hematogenous infections may recur for a longer period than postsurgical infections, careful follow-up is required after DAIR.

Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Continued Call for a Prospective Randomized Trial

BACKGROUND

Periprosthetic joint injection (PJI) is a rare, but life-altering complication of total joint arthroplasty (TJA). Though intrawound vancomycin powder (IVP) has been studied in other orthopedic subspecialties, its efficacy and safety in TJA has not been established.

METHODS

PubMed and MEDLINE databases were used to identify studies utilizing IVP in primary and revision total hip (THA) and knee arthroplasty (TKA). Postoperative PJI data were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Studies were weighted by the inverse variance of their effect estimates.

RESULTS

Overall, 16 of the 1871 studies identified were pooled for final analysis, yielding 33,731 patients totally. Of these, 17 164 received IVP. In aggregate, patients who received IVP had a decreased rate of PJI (OR 0.46, P < .05). Separately, TKA and THA patients who received IVP had lower rates of PJI (OR 0.41, P < .05 and OR 0.45, P < .05, respectively). Aggregate analysis of primary TKA and THA patients also revealed a decreased PJI rate (OR 0.44, P < .05). Pooled revision TKA and THA patients had a similar decrease in PJI rates (OR 0.30, P < .05). Although no publication bias was appreciated, these findings are limited by the low-quality evidence available.

CONCLUSION

While IVP may reduce the risk of PJI in primary and revision TJA, its widespread use cannot be recommended until higher-quality data, such as that obtained from randomized control trials, are available. This study underscores the continued need for more rigorous studies before general adoption of this practice by arthroplasty surgeons.

The Fate of Antibiotic Impregnated Cement Space in Treatment for Forefoot Osteomyelitis

Forefoot osteomyelitis can be an extremely challenging problem in orthopedic surgery. Unlike conventional methods, such as amputations, antibiotic impregnated cement space (ACS) was recently introduced and perceived as a substitute for amputation. The purpose of this study was to compare clinical features between diabetic and non-diabetic groups and to evaluate the efficacy of ACS in the treatment of forefoot osteomyelitis, by identifying the clinical characteristics of ACS. We inserted ACS into the forefoot osteomyelitis patients and regularly checked up on them, then analyzed the clinical features of the patients and failure reasons, if ACS had to be removed. Average survival rate of ACS was 60% (21 out of 35 cases) and main failure reason was recurrence of infection. There was no significant clinical difference between diabetic and non-diabetic groups. We concluded that ACS could be a possible way of avoiding amputation if infection is under control. ACS seems to be an innovative method with promising results for foot osteomyelitis, but widely accepted indications need to be agreed upon.

Connections between Orthopedic Conditions and Oxidative Stress: Current Perspective and the Possible Relevance of Other Factors, Such as Metabolic Implications, Antibiotic Resistance, and COVID-19

The general opinion in the literature is that these topics remain clearly understudied and underrated, with many unknown aspects and with controversial results in the respective areas of research. Based on the previous experience of our groups regarding such matters investigated separately, here we attempt a short overview upon their links. Thus, we summarize here the current state of knowledge regarding the connections between oxidative stress and: (a) orthopedic conditions; (b) COVID-19. We also present the reciprocal interferences among them. Oxidative stress is, of course, an interesting and continuously growing area, but what exactly is the impact of COVID-19 in orthopedic patients? In the current paper we also approached some theories on how oxidative stress, metabolism involvement, and even antibiotic resistance might be influenced by either orthopedic conditions or COVID-19. These manifestations could be relevant and of great interest in the context of this current global health threat; therefore, we summarize the current knowledge and/or the lack of sufficient evidence to support the interactions between these conditions.

A novel open synovectomy technique using an arthroscopy shaver blade in revision surgery to treat infected total knee arthroplasty: a technical note

Background

This article introduces a novel open synovectomy technique using an arthroscopy shaver blade to effectively remove intra-articular synovitis during revision surgery for infected primary total knee arthroplasty.

Methods (techniques)

Open synovectomy is performed using a 4.2-mm arthroscopy shaver blade, and the handpiece is connected to suction drainage. Suction is supplied through the central cylinder of the shaver blade to bring the debrided fragments of soft tissue into the window. Grossly inflamed, reddened, diseased synovium is debrided to reveal yellowish, healthy synovium. The inflamed tissues of the knee joint (suprapatellar pouch, medial and lateral gutters, and peripatellar area) are debrided. Then, with maintaining full flexion of the knee joint, a shaver equipped with a longer bar can be used to easily access the medial and lateral posterior compartments, which are generally difficult to access.

Results

During a mean of 13.5-month follow-up, there was no recurrent infection in either group; however, patients who underwent the novel technique improved significantly faster in terms of acute serological markers during the first period.

Conclusions

This technique yielded favorable outcomes compared with the conventional technique. In particular, it may facilitate the approach to the posterior joint space, which is difficult to access.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03024-5.

Current Concepts on the Application, Pharmacokinetics and Complications of Antibiotic-Loaded Cement Spacers in the Treatment of Prosthetic Joint Infections

Prosthetic joint infection (PJI) is a devastating complication of total joint replacement surgery. It affects about 2% of primary total joint replacements. Treatment aims at infection eradication and restoration of patient's mobility. Two-stage revision arthroplasty with an interim application of an antibiotic-loaded cement spacer (ALCS) is the widely accepted treatment for PJI. Spacers are powerful local carriers of antibiotics at the site of infection, effective against biofilm-protected microbes. On the other hand, spacers permit some mobility of the patient and facilitate final prosthesis implantation. ALCS's are either commercially available or prepared intraoperatively on prefabricated or improvised molds. Antibiotic elution from the spacer depends on the amount of the antibiotic used for cement impregnation, at the expense of mechanical stiffness of the spacer. The antibiotic should not exceed 4g per 40g of bone cement to preserve the mechanical properties of the cement. Spacers are frequently accompanied by local or systemic complications. The spacer may break, dislocate and compress vessels or nerves of the limb. Systemic complications are the result of excess elution of antibiotic and include nephrotoxicity, hepatotoxicity, ototoxicity, allergic reactions or neutropenia. Elderly patients with comorbidities are at risk to present such complications. Microbial resistance is a potential risk of long-lasting spacer retention. Persisting infection may require multiple spacer replacements.

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.

Feasibility of Loop-Mediated Isothermal Amplification for Rapid Detection of Methicillin-Susceptible and Methicillin-Resistant Staphylococcus aureus in Tissue Samples

Background

Methods

Results

Conclusions

Cement Loaded With High-Dose Gentamicin and Clindamycin Reduces the Risk of Subsequent Infection After One-Stage Hip or Knee Arthroplasty Exchange for Periprosthetic Infection: A Preliminary Study

BACKGROUND

The use of antibiotic-loaded acrylic cement for treating periprosthetic joint infections remains controversial. We hypothesized that the raw rate of surgical site infection (SSI) is lower after using cement loaded with high-dose gentamicin and clindamycin than after using cement loaded with standard-dose gentamicin for implant fixation during 1-stage hip and knee revision arthroplasty for infection.

METHODS

One hundred seventy-one continuous patients operated by 2 experienced surgeons during a 2-year period were included in the study. All patients were followed for 24 months. The primary endpoint was the raw rate of SSI after 2 years of follow-up time.

RESULTS

The raw rate of SSI after 2 years of follow-up time was significantly lower in the study group (13%) than in the control group (26%) (P = .03) with an odds ratio of 0.42 (P = .03). These SSIs were new infections rather than a recurrence/persistence of the initial infection.

CONCLUSION

The cement used in the study group significantly reduced the risk of SSI relative to the cement used in the control group. Routine use of this high-dose dual antibiotic-loaded cement can be considered during 1-stage knee or hip revision arthroplasty for infection.

Intra-articular administration of vancomycin and tobramycin during primary cementless total knee arthroplasty : determination of intra-articular and serum elution profiles

AIMS

Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA.

METHODS

A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml.

RESULTS

A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin.

CONCLUSION

Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702-1708.

Antibiotics- and Heavy Metals-Based Titanium Alloy Surface Modifications for Local Prosthetic Joint Infections

Prosthetic joint infection (PJI) is the second most common cause of arthroplasty failure. Though infrequent, it is one of the most devastating complications since it is associated with great personal cost for the patient and a high economic burden for health systems. Due to the high number of patients that will eventually receive a prosthesis, PJI incidence is increasing exponentially. As these infections are provoked by microorganisms, mainly bacteria, and as such can develop a biofilm, which is in turn resistant to both antibiotics and the immune system, prevention is the ideal approach. However, conventional preventative strategies seem to have reached their limit. Novel prevention strategies fall within two broad categories: (1) antibiotic- and (2) heavy metal-based surface modifications of titanium alloy prostheses. This review examines research on the most relevant titanium alloy surface modifications that use antibiotics to locally prevent primary PJI.

The combination of medical devices and medicinal products revisited from the new European legal framework

Medical devices and medicinal products have many similarities in their nature, scope or specific medical purposes, and despite the differences in their principal means of action, they are often used in combination. Indeed, many medicinal products depend on medical devices for their administration, and it is increasingly common for medical devices to contain medicinal substances to support their action. Therefore, the combination of medicinal products and medical devices provides additional benefits for patients. However, their higher technical complexity requires a strengthening of their authorisation and certification requirements. In this regard, more comprehensive requirements and classification rules are introduced by a new European regulation on medical devices that fully applies from May 26^th 2021. On account of their therapeutic significance, this review aims at gaining insight into the borderline between medical devices and medicinal products in this new 2021 regulatory framework. For the first time, any item containing a medical device and a medicinal product will have both parts evaluated. Through exemplification of both marketed and investigational devices incorporating medicinal substances and drug-device combinations, the new European requirements and their implications are thoroughly illustrated herein.

The Role of Chitosan and Graphene Oxide in Bioactive and Antibacterial Properties of Acrylic Bone Cements

Acrylic bone cements (ABC) are widely used in orthopedics for joint fixation, antibiotic release, and bone defect filling, among others. However, most commercially available ABCs exhibit a lack of bioactivity and are susceptible to infection after implantation. These disadvantages generate long-term loosening of the prosthesis, high morbidity, and prolonged and expensive treatments. Due to the great importance of acrylic bone cements in orthopedics, the scientific community has advanced several efforts to develop bioactive ABCs with antibacterial activity through several strategies, including the use of biodegradable materials such as chitosan (CS) and nanostructures such as graphene oxide (GO), with promising results. This paper reviews several studies reporting advantages in bioactivity and antibacterial properties after incorporating CS and GO in bone cements. Detailed information on the possible mechanisms by which these fillers confer bioactive and antibacterial properties to cements, resulting in formulations with great potential for use in orthopedics, are also a focus in the manuscript. To the best of our knowledge, this is the first systematic review that presents the improvement in biological properties with CS and GO addition in cements that we believe will contribute to the biomedical field.