Plain Bone Research Articles

Comparable bone penetration between antibiotic-loaded and plain bone cement in total knee arthroplasty.

One of the main concerns around the use of antibiotic-loaded bone cement (ALBC) is the potential reduction in the mechanical properties of the cement when antibiotics are admixed. The purpose of this study was to determine whether there is a difference between plain cement and ALBC in terms of radiological intrusion into the bone in total knee arthroplasties (TKAs). Prospective randomized study of 80 consecutive patients who underwent TKA. Depending on the cement used, patients were divided into two groups by a computer-generated randomization programme: the cement without antibiotic (Group 1) or the ALBC (Group 2). Cement intrusion was measured in postoperative radiographs in eight different regions in the tibial component and six regions in the femoral component. The average cement intrusion was similar in both groups (p = nonsignificance [n.s.]). Group 1 (plain cement) had an average cement intrusion in the femur of 1.4 mm (±0.4) and 2.4 mm (±0.4) in the tibia. In Group 2 (ALBC), the average cement intrusion in the femur came to 1.6 (±0.5) and 2.4 mm (±0.5) in the tibia. In 80% of the patients, the cement intrusion in the tibia averaged a minimum of 2 mm, being similar in both groups (p = n.s.). There are no differences in bone intrusion when comparing plain cement to ALBC. Therefore, the use of ALBC in primary TKA may be indicated, achieving optimal bone penetration. Level I.

Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement

Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Primary TKA with ALBC vs plain bone cement. The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.

Cost-Effectiveness of Bone Cement With and Without Antibiotics: A Broader Perspective

Background Periprosthetic joint infections (PJIs) and periprosthetic femur fractures (PFFs) increase total costs of care. Retrospective registry/institutional studies with selection bias and underpowered meta-analyses have corrupted the evidence base regarding antibiotic-laden bone cement (ALBC) use in total knee arthroplasties (TKAs). Clinical practice guidelines (CPGs) recommend using cement fixation of femoral components in hip fracture patients to prevent PFFs, but have no recommendations regarding ALBC. Hip osteoarthritis CPGs have no bone cement recommendations regarding prevention of PJIs or PFFs. ALBC is potentially cost-effective by reducing PJIs, PFFs, and reducing implant costs. Methods A systematic review was conducted to identify randomized controlled trials (RCTs), meta-analyses, and registry reports related to the efficacy of ALBC in reducing PJIs and cemented femoral fixation in reducing PFFs. Numbers needed to treat (NNT) are calculated. Cost-effectiveness margins per case are calculated. Results A pooled analysis of four TKA RCTs found ALBC reduces PJI by 0.94% (p=0.027), NNT 106. A total hip arthroplasty (THA) meta-analysis found ALBC reduces PJI by 0.58% (p<0.0001), NNT 172. A hip hemiarthroplasty (HH) RCT found high-dose dual-antibiotic ALBC reduces PJI by 2.35% (p=0.0474), NNT 43. A THA registry report found that cemented fixation compared to ingrowth fixation reduced PFFs by 0.44% (p<0.0001), NNT 229. A pooled analysis of three HH RCTs found that cemented femoral stem fixation reduced PFFs by 5.09% (p-0.0099), NNT 20. Mean PJI treatment costs are $80,000. Mean PFF treatment costs are $27,596. Mean HH cemented femoral stem cost reduction: $685. Using ALBC: TKA margin/case is $755; THA margin/case is $586; and HH margin/case is $3,925. Using plain bone cement: TKA margin/case is $0; THA margin/case is $121; and HH margin/case is $2,065. Conclusions A broader perspective demonstrates that ALBC provides significant financial margins in TKAs, THAs, and hip hemiarthroplasties. ALBC is cost-effective when including the additional costs of using ALBC in TKAs, THAs, and hip hemiarthroplasties. Hand-mixed ALBC is more cost-effective than pre-mixed ALBC in all scenarios.

Influence of the Type of Bone Cement Used in Two-Stage Exchange Arthroplasty for Chronic Periarticular Joint Infection on the Spacer Replacement and Reinfection Rate.

Antibiotic-loaded bone cement (ALBC) spacers are used in the first stage when treating periprosthetic joint infection (PJI). This study aimed to investigate whether a spacer made from commercial ALBC or plain bone cement with additional antibiotics could affect the spacer exchange rate before reimplantation. Patients undergoing two-stage exchange arthroplasty due to chronic PJI from January 2014 to August 2021 were retrospectively reviewed. The exclusion criteria included arthroplasty in the setting of septic arthritis, megaprosthesis, atypical pathogen infection, spacer placement unrelated to PJI, and spacer exchange due to mechanical complications. The patient demographics, brand of cement, and microbiology were recorded manually. The primary outcome was the incidence of spacer exchange due to persistent infection and the secondary outcome was the incidence of reinfection after reimplantation. A multivariate logistic regression analysis and Chi-square test were conducted to identify the effect of cement type on the spacer exchange. A total of 334 patients underwent two-stage exchange arthroplasty for PJI. The spacer exchange rates in the commercial and non-commercial ALBC groups were 6.4% and 25.1%, respectively (p = 0.004). After controlling for confounding factors, there were significant differences between the commercial group and non-commercial groups in the spacer exchange rate (adjusted OR = 0.25; 95% CI = 0.72-0.87, p = 0.029). The use of commercial ALBC was not associated with a lower reinfection rate after reimplantation (p = 0.160). In a two-stage exchange arthroplasty scenario, the spacer comprised of commercial ALBC resulted in a lower spacer exchange rate than the plain bone cement, both of which had additional antibiotics. However, the use of commercial ALBC was not associated with a lower incidence of reinfection following reimplantation.

Antibiotic-loaded bone cement vs. plain cement as an infection prophylaxis in primary elective shoulder arthroplasty

HypothesisThe use of antibiotic-loaded bone cement (ABC) in the setting of revision arthroplasty for deep infections is a broadly accepted practice. However, its use in the setting of primary arthroplasty continues to be controversial with few studies assessing the efficacy of ABC for primary total shoulder arthroplasty (TSA). The purpose of this study was to determine whether the use of ABC in primary TSA is associated with a difference in the risk of deep infections. MethodsA retrospective cohort study was conducted using data from a United States integrated health-care system’s shoulder arthroplasty registry. Patients aged ≥18 years who underwent primary elective anatomic TSA for osteoarthritis or reverse TSA (RTSA) for rotator cuff arthropathy with implanted cement information were included in the study (2009-2020). We compared patients that received ABC to those who received plain cement and are at risk of revision due to deep infection within 5 years of follow-up using Cox proportional hazard regression weighted with the inverse propensity score, stratified by procedure type. ResultsThe study sample included 6409 TSAs for osteoarthritis and 779 RTSAs for rotator cuff arthropathy performed by 198 surgeons at 58 hospitals. In the TSA group, 20% received ABC; the cumulative infection probability at 5 years of follow-up was 0.5% and 0.6% for the ABC and plain cement groups, respectively. After covariate adjustment, no significant difference in infection risk was found (hazard ratio = 0.72, 95% confidence interval = 0.43-1.21, P = .216). In the RTSA group, 19% received ABC; the cumulative infection probability at 5 years of follow-up was 2.7% and 0.9% for the ABC and plain cement groups, respectively. After covariate adjustment, no significant difference in infection risk was found between the 2 cement groups (hazard ratio = 1.47, 95% confidence interval = 0.66-3.26, P = .341). ConclusionIn this study of more than 7000 primary elective shoulder arthroplasties performed in patients with a standard risk of infection, antibiotic bone cement did not confer any risk-reduction for periprosthetic infection when compared to plain bone cement. Different at-risk pathogen profiles may develop with prolonged use of antibiotic bone cement.

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

PurposeAntibiotic-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. MethodsThe 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. ResultsEleven 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. ConclusionThe 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.

Low Incidence of Osteonecrosis in Childhood Acute Lymphoblastic Leukemia Treated with ALL-97 and ALL-02 Study of Japan Association of Childhood Leukemia Study Group

Purpose: Osteonecrosis (ON) is a serious complication of the treatment of childhood acute lymphoblastic leukemia (ALL). The incidence of ON varies (range, 2.0-18.0%) according to treatment strategy. Previous studies reported older age, female sex, dosage of corticosteroid, use of dexamethasone (DEX), combination therapy with DEX and L-asparaginase (L-Asp), and ethnicity were putative risk factors. However, most of these studies were mainly conducted in U.S.A. or European countries. Thus, the data relating to ON in Asian ALL patients are scarce. Herein, we performed a retrospective analysis of Japanese ALL patient cohorts uniformly treated with consecutive two clinical trials (ALL-97 and ALL-02) to clarify the incidence, clinical characteristics and risk factors of ON.Methods: In the ALL-97 study, various data on adverse events, including ON, were collected prospectively; however, in the ALL-02 study, there was no prospective collection of ON data. Thus, a questionnaire targeting ON was administered to all JACLS investigators in 2016. A total 1662 patients (635 patients treated with ALL-97, 1027 with ALL-02 protocol) were analyzed in this study. The total numbers of patients enrolled in the ALL-97 and ALL-02 studies were 635 and 1192 patients, respectively, and the majority of patients enrolled in both studies (100% in ALL-97 and 86.2% in ALL-02) were included in these analyses. The numbers of patients aged >10 years were 167/635 (26.3%) and 209/1027 (20.4%) in the ALL-97 and ALL-02 study, respectively. Clinical diagnosis of ON was defined as a symptomatic patient and positive findings on at least one imaging study, including plain bone X-ray, CT, or magnetic resonance imaging (MRI). Patients with ON diagnosed after hematopoietic stem cell transplantation were excluded. Patients with ON identified thorough these investigations were further examined for time of onset, sites involved, severity of symptoms, treatment, and outcome by questionnaire.Results: In total, 24 of 1662 patients suffered from ON, of which 12/635 (1.9%) and 12/1027 (1.2%) patients were treated with ALL-97 and ALL-02 protocols, respectively. Of these 24 patients, the median age at diagnosis of ALL was 13.0 ± 1.4 and 12.5 ± 3.0 in ALL-97 and ALL-02 study, respectively. Of patients with ON, only one patient was <10 years old, with the remaining 23 patients aged >10 years at onset of ALL. Most patients were diagnosed with ON by MRI, and the femoral head was the most frequent site of ON (10/12 patients in ALL-97; 7/12 patients in ALL-02). In 13 patients, ON became apparent during chemotherapy (seven patients in ALL-97; six patients in ALL-02), while nine patients (five patients in ALL-97; four patients in ALL-02) developed ON after completion of chemotherapy. On multivariate analysis, only age >10 years was a significant factor associated with ON development (hazard ratio = 27.8, 95% = CI 5.99-129.0, p < 0.001). Separate evaluation of patients >10 years indicated incidence rates of ON of 12/167 (7.2%) and 11/209 (5.3%) in the ALL-97 and ALL-02 protocols, respectively, which was lower than previous reports, despite total administration of dexamethasone (DEX) similar to that in comparable studies; however, concomitant administration of DEX and L-Asp was reduced in JACLS protocols. In JACLS ALL-97 and ALL-02, combined use of DEX and L-Asp was performed in induction therapy. DEX was administered on days 8 to 14 and L-Asp three times per week after day 15 of induction therapy in the JACLS protocol; thus we did not administer DEX and L-Asp simultaneously in any treatment period. By contrast, all previous studies administered DEX and L-Asp/Peg-Asp simultaneously during several treatment phases. Hence, only JACLS studies lacked simultaneous administration of DEX and L-Asp. In addition, the cumulative dosage of DEX in the treatment phases including both DEX and L-Asp was lower in the JACLS ALL-97 and -02 protocols than in those in other studies.Conclusions: We identified a low frequency of ON in the JACLS ALL-97 and -02 studies. Although the sole risk factor for ON was age (>10 years), even among high-risk patients, ON incidence was significantly lower than that reported in previous studies. These results suggest that, not only the total amount of DEX, but also how DEX and L-Asp are administered, which affects the clearance of DEX, may be associated with ON incidence in ALL patients. DisclosuresHiramatsu:Novartis Pharmaceuticals Corporation: Other: Clinical trials .

Risk factors associated with cervical spine lesions in patients with rheumatoid arthritis: an observational study

BackgroundFew reports have described the association between rheumatoid arthritis (RA) cervical lesions and osteoporosis, especially in patients with vertical subluxation (VS) that could be induced by the collapse of lateral masses in the upper cervical spine. Therefore, this study aimed to investigate the prevalence and risk factors for cervical lesions in patients with RA under current pharmacological treatments with biological agents, and to investigate the relationship between osteoporosis and VS development.Methods One hundred eighty-five consecutive patients with RA who underwent both cervical plain radiography and bone mineral density (BMD) scanning were enrolled. RA cervical lesions included atlantoaxial subluxation (AAS), VS, and subaxial subluxation (SAS). We assigned patients with AAS, VS, or SAS to the cervical-lesion group, and all other patients to the non-cervical-lesion group. Radiological findings, BMD, and clinical data on RA were collected. We used multivariate logistic regression analyses to assess the risk factors for cervical lesions in patients with RA.ResultsThe cervical-lesion and non-cervical-lesion groups included 106 and 79 patients, respectively. There were 79 patients with AAS, 31 with VS, and 41 with SAS. The cervical-lesion group had a younger age of RA onset, longer RA disease duration, higher RA stage, and lower femoral neck BMD than the non-cervical-lesion group. Multivariate analyses showed that the risk factors for RA cervical lesions were prednisolone usage, biological agent usage, and higher RA stage. Prednisolone usage and femoral neck BMD were the risk factors for VS.ConclusionsCervical lesions were confirmed in 57 % of the patients. Prednisolone usage, biological agent usage, and higher RA stage were significant risk factors for cervical lesions in patients with RA. The general status of osteoporosis might contribute to the development of VS.

Analysis of MRI Image-Assisted Diagnosis of Osteoarthritis Based on Support Vector Machine Algorithm

Objective: To discuss the diagnostic value of X-ray film and MRI of knee osteoarthritis by using support vector machine algorithm. Materials and Methods: The data of patients with osteoarthritis of the knee joint confirmed by open or arthroscopy surgery were collected in this paper. A total of 23 knee joints were performed in 23 cases, and plain films and MRI were performed before surgery. The support vector machine algorithm was used to retrospectively analyze its image performance and compare the positive rates of the two inspection methods. Results: The plain bone film showed better bone changes, and it could not show soft tissue lesions. MRI showed less changes in bone quality than plain films, and showed better changes in cartilage, meniscus degeneration, joint effusion, intra-articular free body, synovial thickening, bone marrow edema, and soft tissue swelling. Conclusion: MRI provides more positive signs than plain film, and the diagnosis accuracy of knee osteoarthritis is higher than plain film.

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

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). 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). 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). 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.

Antibiotic-Laden Bone Cement Use and Revision Risk After Primary Total Knee Arthroplasty in U.S. Veterans.

It is controversial whether the use of antibiotic-laden bone cement (ALBC) in primary total knee arthroplasty (TKA) affects periprosthetic joint infection (PJI) or revision rates. The impact of ALBC on outcomes of primary TKA have not been previously investigated in U.S. veterans, to our knowledge. The purposes of this study were to quantify utilization of ALBC among U.S. veterans undergoing primary TKA and to determine if ALBC usage is associated with differences in revision TKA rates. Patients who had TKA with cement from 2007 to 2015 at U.S. Veterans Health Administration (VHA) hospitals with at least 2 years of follow-up were retrospectively identified. Patients who received high-viscosity Palacos bone cement with or without gentamicin were selected as the final study cohort. Patient demographic and comorbidity data were collected. Revision TKA was the primary outcome. All-cause revisions and revisions for PJI were identified from both VHA and non-VHA hospitals. Unadjusted and adjusted regression analyses were performed to identify variables that were associated with increased revision rates. The study included 15,972 patients who had primary TKA with Palacos bone cement at VHA hospitals from 2007 to 2015. Plain bone cement was used for 4,741 patients and ALBC was used for 11,231 patients. Utilization of ALBC increased from 50.6% in 2007 to 69.4% in 2015. At a mean follow-up of 5 years, TKAs with ALBC had a lower all-cause revision rate than those with plain bone cement (5.3% versus 6.7%; p = 0.0009) and a lower rate of revision for PJI (1.9% versus 2.6%; p = 0.005). On multivariable regression, ALBC use was associated with a lower risk of all-cause revision compared with plain bone cement (hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.68 to 0.92; p = 0.0019). Seventy-one primary TKAs needed to be implanted with ALBC to avoid 1 revision TKA. The utilization of ALBC for primary TKAs performed at VHA hospitals has increased over time and was associated with a lower all-cause revision rate and a lower rate of revision for PJI. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

ASSESSMENT OF COXITIS PROGRESSION IN EARLY AXIAL SPONDYLOARTHRITIS

Recently, various visualization techniques have been used to study spondyloarthritis (SpA); indices are also being elaborated to assess the progression of radiographic changes in the spine and sacroiliac joints. Most studies dedicated to the problem of coxitis in SpA have shown that its progression parallels with a spinal inflammatory process; however, no indices for assessing the time course of changes in the hip joints (HJs) have been developed. Objective : to develop a method for assessing the radiographic progression of coxitis in early axial SpA (axSpA). Subjects and methods. Examinations were made in 175 patients (mean age, 28±6 years) with axSpA who met the 2009 ASAS criteria and had an inflammatory back pain duration of no more than 5 years. The analysis included 62 patients who had been followed up for at least 2 years and had plain pelvic bone X-ray films at the inclusion in the cohort and at 2 years after starting the follow-up. The sum of stages of radiographic coxitis (ssrC) was used to assess HJ injury progression. During the study, a formula was developed to assess the progression rate of radiographic coxitis. Results and discussion . The median difference in ssrC ( Δ ssrC) was 0.78 [0; 4] at baseline and at 2 years. During the study period, 63% of the patients showed no progression of ssrC; the latter increased by 1 score in 7 (11%) patients, by 2 scores in 11 (18%), by 3 scores in 1 (2%), and by 4 scores in 4 (6%). The ssrC averaged 0.54±0.79 at baseline and increased by 0.78 up to 1.32±1.34 (p=0.06) at 2 years. At baseline, the coxitis progression rate averaged 0.45 per year (it was conventionally accepted that the patients exhibited no signs of HJ injury at onset of the disease: ssrC was zero); that was 0.54 and 0.1 per year at 1 and 2 years of follow-up, respectively. Conclusion . The proposed calculation procedure is easily feasible and applicable in real practice, does not lead to additional investigations, and is economically feasible. This procedure allows monitoring the rate of radiographic coxitis progression in patients with axSpA throughout the course of the disease.

The cost-effectiveness of antibiotic-loaded bone cement versus plain bone cement following total and partial knee and hip arthroplasty

BackgroundPostoperative infection is one of the most prevalent complications following total joint arthroplasty (TJA). As such procedures become more prevalent, it is imperative that we develop new prophylactic methods to prevent the need for revision procedures. In recent years, surgeons have opted to use antibiotic-loaded bone cement (ALBC) rather than plain bone cement (PBC) in primary hip and knee replacements due to its theoretical potential of lowering infection rates. However, the cost-effectiveness of this intervention remains in question.Questions/Purposes: To determine the rate of infection and cost-effectiveness of antibiotic-loaded bone cement as compared to plain bone cement in hip and knee arthroplasty. Patients and methodsWe reviewed 4116 primary hip and knee arthroplasty cases performed between 2016 and 2018 at Morristown Medical Center in New Jersey. Data regarding demographics, complications, and any readmissions due to deep infection were collected retrospectively. During that time period there were a total of 4016 knee cases (423 ALBC, 3593 PBC) and 123 hip cases (63 ALBC, 60 PBC). The average cost for one bag of antibiotic-loaded bone cement and plain bone cement for hip and knee arthroplasty was $336.42 and $72.14, respectively. A statistical analysis was performed using Fisher's exact test; the National Healthcare Safety Network (NHSN) surgical site infection guidelines were used to distinguish between superficial and deep infections. ResultsTen patients were readmitted due to deep infection, all of whom had undergone total knee arthroplasty. Of those cases, plain bone cement was used for the index procedure in seven instances and antibiotic-loaded cement was used in three. This resulted in an infection rate of 0.19% and 0.62%, respectively, p = 0.103. There was no statistically significant difference in infection rates between the two groups. A total of 778 bags of ALBC were used in 423 knee surgeries, and 98 bags of ALBC were used in 63 hip cases. The total cost for ALBC in TKA and THA procedures was $261,734.76 (778*336.42) and $32,969.16 (98*336.42), respectively. If PBC had been used during all index procedures, it would have resulted in a total savings of $231,509.28. ConclusionsAntibiotic-loaded cement did not significantly reduce the rate of infection for either knee or hip arthroplasty. Thus, the routine use of antibiotic-loaded cement in primary hip and knee arthroplasty may be an unnecessary financial burden to the healthcare system. A larger sample size and a randomized controlled trial would help confirm our findings and would provide further information on the cost-effectiveness of ALBC cement versus PBC.Significance/Clinical Relevance: In this review of cases performed from 2016 to 2018 there was no statistically significant difference between the rate of infection and the need for revision surgeries for patients treated with ALBC versus PBC. As hospital systems continue to transition towards a bundled payment model, it becomes imperative for providers to reduce any unnecessary costs in order to increase quality and efficiency. We estimate that our hospital system could save nearly $120,000/year by using plain bone cement instead of antibiotic-loaded cement.

Does the Use of Antibiotic-Loaded Bone Cement Have an Effect on Deep Infection in Primary Total Knee Arthroplasty Practice?

Total knee arthroplasty (TKA) is performed to improve the quality of life by reducing knee arthralgia. One of the most destructive and expensive complications of TKA is deep infection. The primary purpose of this study was to evaluate the effect of using antibiotic-loaded bone cement (ALBC) on the incidence of deep infection after primary TKA. A total of 506 patients who underwent primary knee arthroplasty at the Antalya Training and Research Hospital between February 2009 and January 2016 were investigated retrospectively. The ALBC was used for 85 patients (16.7%), who constituted group 1. Plain bone cement was used for 421 patients (83.2%), who constituted group 2. Deep infection was observed in one patient (1.1%) in group 1 and in six patients (1.4%) in group 2, a difference that is not statistically significant. On average, the deep infection occurred six months after the surgery at the earliest and 19 months at the latest. Use of ALBC did not decrease the incidence of deep infection in TKA. Therefore, we prefer bone cement without any antibiotic.

EVALUATION OF THE PROGRESSION OF AXIAL SPONDYLOARTHRITIS IN THE EARLY STAGES OF THE DISEASE IN REAL CLINICAL PRACTICE: THE POSSIBILITIES OF USING THE SUMMARY SCORE OF RADIOGRAPHIC SACROILIITIS

The currently used methods for evaluating the progression of structural damages in early axial spondyloarthritis (axSpA) are little suitable to real practice since they require specially trained radiologists and increase a patient's exposure to radiation due to the need for radiography of three regions of the axial skeleton. In addition, the first radiological bone changes in the sacroiliac joints (SIJ) appear only many years after the onset of the disease, the overlying spine areas are involved in the pathological process. Objective: to develop a method for evaluating the radiographic progression of sacroiliitis (SI) in early axSpA for real clinical practice. Subjects and methods. The investigation enrolled patients from the early spondyloarthritis cohort (ESAC) formed at the V.A. Nasonova Research Institute of Rheumatology. The current ESAC comprised 164 patients; the analysis included 68 patients who had been followed up for at least 2 years and had plain pelvic bone films at the inclusion in the cohort and at 2-year follow-up. To evaluate disease progression, the investigators used the sum of radiographic SI stages in the left and right SIJs (the summary stage of radiographic SI (ssrSI), which was calculated at baseline and at 2-year follow-up. A formula for determining the rate of radiographic progression was derived. Results and discussion. At baseline and at 2-year follow-up, the median ssrSI difference (ΔssrSI) in 68 patients was 0 [0; 1.0]. During the study period, almost 60% of the patients had no progression of ssrSI, i.e. ΔssrSI was 0 in these patients, 1 and 2 scores in 12 (18%) and 13 (19%) patients, respectively, and there were singly cases, in which this figure was equal to 3, 4 and 7. The mean value of ssrSI was 3.5±1.6 at baseline and increased by 0.8, reaching 4.3±1.5 at 2 years (p = 0.006). Before included into the investigation, the patients had a progression rate of 1.75 during 1 year, which decreased to 0.4 per year in the active follow-up period. At the time of inclusion in the study, 40 (58.8%) of the 68 patients had ankylosing spondylitis (AS), and at 2 years their number increased to 51 (75.0%); i.e. 11 (39%) patients were observed to have progression of non-radiographic axSpA to AS. Conclusion. The proposed procedure to calculate ssrSI is easily feasible in real practice; it fails to lead to additional radiation exposure, is economically feasible, and allows one to monitor the rate of progression of axSpA in the early stage of the disease.

The Hidden Cost of Commercial Antibiotic-Loaded Bone Cement: A Systematic Review of Clinical Results and Cost Implications Following Total Knee Arthroplasty

BackgroundThe purpose of this systematic review is to compare deep prosthetic joint infections (PJIs) between total knee arthroplasty (TKA) patients treated with either antibiotic-loaded bone cement (ALBC) or plain bone cement, and to explore the potential cost implications of commonly used bone cement regimens. We hypothesized that ALBC would not substantially reduce PJIs and would thereby present an unnecessary cost to the healthcare system. MethodsUsing the PRISMA guidelines, we reviewed articles through May 2017 involving primary TKA patients with both ALBC cohort and plain bone cement cohort. A meta-analysis was performed comparing the prevalence of deep infections between cohorts. A cost comparison for a hypothetical setting with an annual volume of 1000 TKAs was performed to compare 3 commonly used cement regimens: 2 bags of ALBC used during each case, 1 bag of ALBC with 1 bag of plain cement, and 2 bags of plain cement. Pricing at our institution is $215/bag for commercial ALBC and $60/bag for plain cement. ResultsEight articles were included with a total of 34,664 patients. ALBC did not reduce the PJI (ALBC = 93/8189, 1.1% vs plain = 251/26,475, 0.9%; P = .09). The estimated costs for the 3 bone cement regimens per 1000 primary TKAs were as follows: 2 bags of ALBC = $430,000/y, 1 bag of ALBC +1 bag of plain cement = $275,000/y, and 2 bags of plain cement = $120,000/y. ConclusionALBC did not reduce the prevalence of PJI suggesting that ALBC may be an unnecessary cost to the healthcare system. Hospital systems that perform 1000 TKAs/y could save between $155,000 and $310,000/y by switching to plain cement.

The association between cement type and the subsequent risk of revision surgery in primary total hip replacement

Background and purpose — To further improve the success of joint replacement surgery, attention needs to be paid to variations associated with improved or worsened outcomes. We investigated the association between the type of bone cement used and the risk of revision surgery after primary total hip replacement.Methods — We conducted a prospective study of data from the National Joint Registry for England and Wales between April 1, 2003 and December 31, 2013. 199,205 primary total hip replacements performed for osteoarthritis where bone cement was used were included. A multilevel over-dispersed piecewise Poisson model was used to estimate differences in the rate of revision by bone cement type adjusted for implant type, head size, age, sex, ASA grade, and surgical approach.Results — The rate of revision was higher in DePuy CMW3 medium viscosity with gentamicin (IRR 2.0, 95% CI 1.5–2.7) and DePuy SmartSet high viscosity plain (IRR 2.7, 95% CI 1.1–5.5), and lower in DePuy CMW1 high viscosity plain (IRR 0.44, 95% CI 0.19–0.89) bone cements compared with Heraeus Palacos high viscosity with gentamicin. Revision rates were similar between plain and antibiotic-loaded bone cement.Interpretation — The majority of bone cements performed similarly well, excluding DePuy SmartSet high viscosity and CMW3 high viscosity with gentamicin, which both had higher revision rates. We found no clear differences by viscosity or antibiotic content.

Antibiotic-loaded bone cement reduces risk of infections in primary total knee arthroplasty? A systematic review.

Antibiotic-loaded bone cement has been widely used for the treatment of infected knee replacement, but its routine use in primary TKA remains controversial. The aim of this systematic review was to analyze the literature about the antimicrobial efficacy and safety of antibiotic-loaded bone cement for its prophylactic use in primary TKA. A detailed and systematic search of the Pubmed, Medline, Cochrane Reviews and Google Scholar databases had been performed using the keyword "total knee arthroplasty" "total knee replacement" "total knee prosthesis" and "antibiotic-loaded bone cement" with no limit regarding the year of publication. We used modified Coleman scoring methodology (mCMS) to identify scientifically sound articles in a reproducible format. The review was limited to the English-language articles. Six articles met inclusion criteria. In total, 6318 arthroplasties were included in our study. 3217 of these arthroplasties received antibiotic-loaded bone cement and 3101 arthroplasties served as the control. There was no statistical difference between the two groups in terms of the incidence of deep or superficial surgical site infection. The average mCMS score was 67.6, indicating good methodological quality in the included studies. Present review did not reveal any significant difference in terms of rate of deep or superficial surgical site infection in patients receiving antibiotic-loaded bone cement compared with the control (plain bone cement) during primary TKA. The clinical relevance of this study was that the use of antibiotic-loaded bone cement did not significantly reduce the risk of infection in primary TKA. III.

De novo bone formation underneath the sinus membrane supported by a bone patch: a pilot experiment in rabbit sinus model.

The objectives of this study were to evaluate bone regeneration beneath a newly devised bone substitute combined with collagen membrane (called a bone patch) lying over a concomitantly placed mini-implant following sinus floor elevation and verify its usefulness as a carrier system for recombinant human bone morphogenetic protein-2 (rhBMP-2) in rabbits. The sinus floor elevation procedure was performed bilaterally in five rabbits. Either a plain bone patch (control group) or an rhBMP-2-loaded patch (experimental group) was randomly placed beneath the elevated sinus membrane (SM) of both sinuses, where the mini-implants were concomitantly placed. Micro-computed tomographic and histologic analyses were performed at 4weeks post-surgery. In micro-computed tomography, the median values of the total augmented volume and the mineralized bone volume were significantly higher in the experimental group than in the control group (161 vs. 122mm3 [P<0.01] and 48 vs. 42mm3 [P<0.05], respectively). Histometric analysis revealed the same outcomes, with new bone areas of 6.41 and 2.97mm2 in the experimental and control groups, respectively (P<0.001), and bone-to-implant contact ratios of 22.6% and 5.2%, respectively (P<0.001). The newly devised bone patch in this study can support the elevated SM and facilitate bone regeneration from the basal bone with a reduced amount of biomaterial. The addition of rhBMP-2 may shorten the healing time for multidirectional bone regeneration toward the implant.

No decreased infection rate when using antibiotic-impregnated cement in primary total joint arthroplasty.

There has been much debate and controversy about the routine use of antibiotic-impregnated bone cement in primary total joint arthroplasty. The purpose of this study was to undertake a meta-analysis to determine whether the use of antibiotic-impregnated bone cement would reduce the incidence of infection after primary total joint arthroplasty. Of 313 citations identified for screening, 6 trials reporting 26,791 patients were eligible for data extraction and meta-analysis. The authors found no statistically significant difference between antibiotic-impregnated bone cement and plain bone cement in terms of the incidence of infection. The results indicated that the use of antibiotic-impregnated bone cement in primary total joint arthroplasty did not lead to a decrease in the rate of infection.