Use Of Antibiotic-impregnated Cement Research Articles

The Use of Antibiotic-Impregnated Cement for Infection or Mechanical Support in Diabetic Foot Osteomyelitis A Systematic Review and Meta-Analysis

Background Diabetic foot infections are difficult to eradicate and could lead to serious complications such as multiple surgeries, amputation and mortality. Culture-based IV antibiotics and particularly amputation are usually the available options. Only few studies articles reported the use of cement impregnated with antibiotics to fill temporarily or permanently a bone defect, but with no evidence synthesis yet. Therefore, this study aims at assessing the outcomes of the use of antibiotic-impregnated cement for infection or mechanical support in diabetic foot osteomyelitis. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. We searched multiple electronic databases using the terms “osteomyelitis AND cement AND diabetic AND foot.” The quality of the included studies was evaluated using the Joanna Briggs Institute Appraisal Tool. Results Six studies met the inclusion criteria combining 82 patients with 85 procedures. With a mean follow-up period of 22 ±14.6 months, the meta-analytical results were as follows: (1) the weighted healing rate was 85.2%, (2) 63.6% of cement were kept in place, (3) 8.2% of cement had to be exchanged, (4) 24.4% of placed cement had to be removed, (5) minor amputation following cement placement was 13.4%, and (6) the rate of secondary surgery was 18.7%, with arthrodesis being the most common (94%). Conclusion There are limited studies available detailing the outcomes of cement use in diabetic foot osteomyelitis. In the case of the difficult-to-heal osteomyelitis of the diabetic foot and whenever a peripheral bone rim could be preserved, filling the void within to deliver local infection control and to assure mechanical resistance for ambulation could be a non-radical limb preserving option. Level of Evidence Level IV

High Incidence of Acute Kidney Injury Following Antibiotic-Loaded Spacer Insertion for Periprosthetic Joint Infection: An Updated Review of the Literature

BackgroundThe use of antibiotic-impregnated cement during 2-stage revision arthroplasty for periprosthetic joint infection poses a risk of renal complications following spacer insertion. This systematic review aimed to investigate the rate of acute kidney injury (AKI) following antibiotic-loaded spacer insertion and to identify risk factors associated with this complication. MethodsA systematic review was performed using PubMed, Cochrane Central, and Scopus databases. All clinical studies that documented renal complications following antibiotic-loaded spacer insertion for periprosthetic knee (total knee arthroplasty [TKA]) or hip (total hip arthroplasty [THA]) infection were included. Articles that combined THA and TKA outcomes were also included and labeled “THA + TKA.” Descriptive statistics were analyzed when data were available. ResultsThere were 24 studies (9 THA, 7 TKA, 8 THA + TKA) included. The mean incidences of spacer-related AKI across THA, TKA, and THA + TKA cohorts were 4.2 (range, 0 to 10%), 14 (range, 0 to 19%), and 27% (range, 0 to 35%), respectively. The most common patient-related risk factors for AKI were underlying chronic kidney disease or high baseline creatinine, low preoperative hemoglobin, and blood transfusion requirement. Spacer-related risk factors included high antibiotic dosage (>3.6 g/cement batch) and antibiotic type. While most recovered without complication, select patients required hemodialysis for acute management (2 THA, 18 THA + TKA) and/or developed chronic kidney disease (8 TKA, 8 THA). ConclusionThe rate of AKI following spacer insertion was high and likely under-reported in the literature. Surgeons should be cognizant of this devastating complication and should closely monitor at-risk patients for AKI following antibiotic-loaded spacer insertion.

The Antibiotic Cement Bead Rouleaux: A Technical Trick to Maximize the Surface Area to Volume Ratio of Cement Beads to Improve the Elution of Antibiotics.

The use of antibiotic-impregnated cement as a local antibiotic delivery system is well-established as an adjunctive treatment for chronic osteomyelitis. Because the elution of antibiotics is a surface area phenomenon, the geometry of the cement is an important consideration. The antibiotic cement bead rouleaux technique is a simple and efficient method of bead fabrication that requires only 10 minutes of preparation time and readily available operating room supplies. The discoid structure of the beads provides 3 times the surface-area-to-volume ratio of a spherical bead, which facilitates antibiotic elution. Given the speed and ease of fabrication, along with optimized geometry, the antibiotic cement bead rouleaux is a useful addition to the surgeon's repertoire.

Should Antibiotic-Impregnated Cement Be Used During Primary Total Ankle Arthroplasty (TAA)?

Unknown. There is insufficient evidence for the routine use of antibiotic-impregnated cement during primary total ankle arthroplasty (TAA). Consensus. Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Trends in the Use of High-Viscosity Cement in Patients Undergoing Primary Total Knee Arthroplasty in the United States

BackgroundAseptic loosening remains the most common mode of failure following total knee arthroplasty (TKA). Although the risk of loosening is multifactorial, recent studies reported early failure via debonding at the tibial implant-cement interface and a potential association with high viscosity cement (HVC). The purpose of this study is to determine the type of cement used by surgeons performing elective, primary TKA in the United States. MethodsA retrospective cohort study was performed using data reported to the American Joint Replacement Registry from 2012 to 2017. The primary variable assessed was the type of cement used in each primary TKA, categorized as HVC, medium viscosity cement, or low viscosity cement based on the manufacturer’s specifications. The use of antibiotic-impregnated cement was also assessed. ResultsA total of 554,935 primary TKA procedures were reviewed over the 7-year period. The use of HVC steadily increased from 46.0% of TKAs in 2012 to 61.3% of TKAs in 2017. Conversely, the use of low viscosity cement decreased in use from 47.9% of TKAs in 2012 to 30.9% in 2017. The percentage of TKAs performed using antibiotic-impregnated cement also decreased from 44.2% in 2012 to 34.5% in 2017. ConclusionThis study demonstrates that the percentage of TKAs performed using HVC has continued to increase over the most recent 7 years for which the American Joint Replacement Registry has data. The risk of aseptic loosening is clearly multifactorial, but close monitoring is necessary to determine whether this change in surgeon preference will affect component survivorship.

Antibiotic Prophylaxis and the Risk of Surgical Site Infections following Total Hip Arthroplasty: Timely Administration Is the Most Important Factor

Surgical site infections (SSIs) following total hip arthroplasty can lead to prolonged hospitalization, increased morbidity and mortality, and high costs. This article analyzes the effect of various parameters of surgical antibiotic prophylaxis on the risk of SSI following total hip arthroplasty. Data about SSI and potential prophylaxis-, patient-, and procedure-related risk factors were prospectively collected for 1922 patients who underwent elective total hip arthroplasty in 11 hospitals that participated in the Dutch intervention project, Surgical Prophylaxis and Surveillance. Multivariate logistic regression analysis was performed to correct for random variation among hospitals. SSIs (superficial and deep) occurred in 50 patients (2.6%). The highest odds ratios for SSI were found in patients who received prophylaxis after incision (2.8, 95% confidence interval [CI], 0.9-8.6; P=.07), had an American Society of Anesthesiology score that was >2 (2.8, 95% CI, 0.8-9.2; P=.09), and experienced a duration of surgery that was >75th percentile (2.5; 95% CI, 1.1-5.8; P=.04). Prolonged prophylaxis after the end of surgery and the use of antibiotic-impregnated cement did not contribute to fewer SSIs in this study. This study suggests that intervention programs in search of amendable factors to prevent SSI should focus on timely administration of antibiotic prophylaxis.

Use of antibiotic-impregnated cement in total joint arthroplasty.

The use of antibiotic-impregnated cement in revision of total hip arthroplasty procedures is widespread, and a substantial body of evidence demonstrates its efficacy in infection prevention and treatment. However, it is not clear that it is necessary or desirable as a routine means of prophylaxis in primary total joint arthroplasty. In the management of infected implant sites, antibiotic-impregnated cement used in one-stage exchange arthroplasties has lowered reinfection rates. In two-stage procedures, use of beads and either articulating or nonarticulating antibiotic-impregnated cement spacers also has lowered reinfection rates. In addition, spacers reduce "dead space," help stabilize the limb, and facilitate reimplantation. Problems associated with antibiotic-impregnated cement in total joint arthroplasty include weakening of the cement and the generation of antibiotic-resistant bacteria in infected implant sites.

The use of antibiotic-impregnated cement in infected reconstructions after resection for bone tumours.

We have studied 35 patients with infected reconstructions after segmental resection for bone tumours. Two different regimes of treatment were employed both of which entailed debridement and the use of cement impregnated with antibiotic. In 25 patients gentamicin-PMMA beads were used and in ten an antibiotic-impregnated cement spacer. Better results were achieved with the second procedure in terms of cases healed, the number of operations, time of healing, time of recovery and the functional score. The use of vancomycin in the cement spacer gave better local control.

The use of antibiotic-impregnated cement in infected reconstructions after resection for bone tumours

We have studied 35 patients with infected reconstructions after segmental resection for bone tumours. Two different regimes of treatment were employed both of which entailed debridement and the use of cement impregnated with antibiotic. In 25 patients gentamicin-PMMA beads were used and in ten an antibiotic-impregnated cement spacer. Better results were achieved with the second procedure in terms of cases healed, the number of operations, time of healing, time of recovery and the functional score. The use of vancomycin in the cement spacer gave better local control.

New uses for gentamicin-impregnated polymethyl methacrylate spacers in two-stage revision hip arthroplasty

The use of antibiotic-impregnated cement as a bone spacer in two-stage revision hip surgery has been well described. Two additional placements for spacers are described: within the trochanteric osteotomy and overlying the greater trochanter. These spacers have been found to dramatically facilitate exposure at the second-stage procedure and are now being incorporated into all two-stage revision hip arthroplasties at The General Infirmary at Leeds.

Antibiotic-impregnated cement and beads for orthopedic infections.

There is a long history of local antibiotic use for the treatment of orthopedic infections (13, 19, 25, 34). During World War I, Alexander Fleming observed that locally applied antiseptics failed to sterilize chronically infected wounds, but they did reduce the burden of bacteria. He also appreciated that leukocytes and tissue fluids were important factors in creating a physiological environment for promoting resolution (19). The sulfonamides were the first antimicrobial agents available for clinical use. In 1939, the instillation of sulfanilamide crystals, along with thorough debridement, hemostasis, primary closure, and immobilization, resulted in a reduced infection rate for open fractures (25). As additional systemic antimicrobial agents became available, interest in the topical treatment of wounds waned, but the management of established osteomyelitis remained problematic. In the 1960s, the method of closed wound irrigation-suction was popularized as a method which could be used to deliver high concentrations of an antibiotic after debridement. The high flow rate of hypertonic solutions by this technique eliminated hematoma accumulation and promoted the influx of leukocytes and tissue fluids. Primary closure could be accomplished to reduce cross contamination (13). An alternative method for delivering high concentrations of an antibiotic to sites of lower extremity osteomyelitis was isolation perfusion. After thorough debridement, cannulae were inserted into the appropriate artery and vein, a tourniquet was placed proximally, and oxygenated blood containing high concentrations of antibiotic was pumped through the limb (34). The antibiotics available for the prevention and treatment of bone infections in the early 1960s were limited. Those that were used primarily included penicillin G, chloramphenicol and the tetracyclines; streptomycin and vancomycin were perceived to be toxic. The cumbersome methods of closed wound irrigation-suction and isolation perfusion were largely abandoned with the subsequent development of new systemic antibiotics which were more potent against the staphylococci and gram-negative bacilli causing orthopedic infections. Included were the antistaphylococcal and broad-spectrum penicillins, cephalosporins, lincosamides, and aminoglycosides and, more recently, the carbapenems and fluoroquinolones. Additionally, vancomycin preparations were purified, and vancomycin was no longer perceived to be highly toxic. The local use of antibiotics to prevent and treat skeletal infections was revived in Germany with the widespread use of prosthetic joint replacement, a situation in which infections were not an anticipated consequence of trauma or sepsis but a devastating complication of elective surgery. In 1970, Buchholz and Engelbrecht (8) reported that penicillin, erythromycin, and gentamicin incorporated into the cement used to attach total hip joint prostheses diffused out into the surrounding tissues over a period of months, thereby providing prolonged concentrations of local antibiotic. On the basis of the success noted in reducing early postoperative arthroplasty infections (8), interest developed in applying antibiotic-impregnated cement as a therapy for osteomyelitis. In 1979, as an alternative to introducing large deposits of antibiotic-impregnated cement at sites of chronic osteomyelitis, Klemm (29) formed gentamicin-impregnated cement into beads and used them to temporarily fill in the dead space created after the debridement of infected bone. Among 128 patients so treated for chronic osteomyelitis, he reported a 91.4% cure rate. Currently, antibiotic-impregnated cement is used to prevent infections primarily in arthroplasties, in which materials with adhesive properties are required; systemic perioperative prophylactic antibiotics are often given as well. Beads are used to temporarily (usually weeks to months) provide high local antibiotic concentrations and fill the dead space after debridement in patients with chronic osteomyelitis or compound fractures; again, systemic antibiotics may be given as well. After granulation tissue forms, the beads are removed and a bone graft is place (17). Despite high initial interest in the use of antibiotic-impregnated cement and beads, controversies remain regarding their indications because of limited proof of efficacy and concerns regarding the consistency and safety of the various products available. In a 1992 survey (17), only 90 (27%) of 336 U.S. hospitals responding to the survey indicated that their physicians used antibiotic-impregnated bone cement or beads, and their use in most hospitals was only occasional. Nearly all of the 90 hospitals used the cement, but less than half used the beads.

Use of antibiotic-impregnated cement during hip and knee arthroplasty in the United States

A survey of practicing orthopaedists regarding their use of antibiotic(s) in bone—cement (ABC) was carried out. The initial sampling of 2,139 orthopaedists spanned the continental United States. Responses that passed fail—edit criteria were obtained from 1,015 physicians. Clinical practice patterns are highly variable. Adult reconstructive orthopaedic practitioners' belief in antibiotic(s) in bone—cement for the treatment of patients with previous sepsis is favorable. This opinion can be supported at the guideline level. Guidelines suggesting that liquid antibiotics should not be used as additions to polymethyl methacrylate are also supportable. The need for careful scientific inquiry and cost-effectiveness evaluation of the benefits and risks relating to the use of antibiotic additions to polymethyl methacrylate cement in joint arthroplasty exists. On the basis of such inquiry, educational dissemination to reduce practice variation would be indicated.

Primary semiconstrained total elbow arthroplasty. Survival analysis of 113 consecutive cases

We used survival analysis to evaluate 113 consecutive semiconstrained total elbow arthroplasties (TEAs) in 95 patients at a maximum follow-up of 99 months. Our criteria for failure were mechanical malfunction, revision for any reason, and deep infection. The primary diagnosis was inflammatory arthritis in 86 elbows, post-traumatic arthritis in 6, supracondylar nonunion or fracture in 12, osteoarthritis in 2 and other causes in 3. Seven failures were due to deep infection, and five of these had a primary diagnosis of inflammatory arthritis. Eight failures were revised or had revision recommended for aseptic loosening, and six of these were in patients with post-traumatic arthritis or supracondylar nonunion. The cumulative survival for TEAs performed for post-traumatic arthritis, fractures or supracondylar nonunion was 73% at three years and 53% at five years, significantly worse than the cumulative three- and five-year survivals of 92% and 90%, respectively, for patients with inflammatory arthritis. TEA with a semiconstrained prosthesis appears to have a satisfactory survival in selected patients with arthritic disorders. The incidence of deep infection was reduced by improvements in surgical technique and postoperative management, and the routine use of antibiotic-impregnated cement. The incidence of aseptic loosening was low, except in patients with supracondylar nonunion or post-traumatic arthritis.

Effect of hand mixing tobramycin on the fatigue strength of Simplex P

In a recent study, we showed that the presence of gentamicin in Palacos R or erythromycin plus colistin in Simplex P bone cement did not significantly decrease the fatigue strength of the cement. [J.P. Davies, D.O. O'Connor, D.W. Burke, and W.H. Harris, "Influence of antibiotic impregnation on the fatigue life of Simplex P and Palacos R acrylic bone cements, with and without centrifugation," J. Biomed. Mater. Res., 23, 379-397 (1989)] However, the commercially prepared Palacos R with Gentamicin and AKZ (Simplex P with colistin and erythromycin) which were tested are not approved by the FDA for use in the United States. Because of this, many surgeons in the United States hand mix tobramycin with the cement in the operating room if a case calls for the use of antibiotic-impregnated cement. In this study, we determined the effect of adding 1.2 g of tobramycin to one pack (40 g) of Simplex P powder on the fatigue strength of the cement. The effect of centrifugation on the fatigue strength of Simplex P with the tobramycin added was also assessed. Simplex P was prepared according to the manufacturer's instructions with and without the addition of 1.2 g tobramycin per 40-g pack and with and without centrifugation. Fifteen specimens of each of the four cement preparations were tested in fully reversed tension-compression fatigue at +/- 15 MPa, 2 Hz. The fatigue strength of the uncentrifuged and centrifuged Simplex P was not significantly reduced by the tobramycin. Centrifugation significantly increased the fatigue life of Simplex P both with and without the addition of tobramycin. The fatigue life of the Simplex P with tobramycin was increased by a factor of 8 by centrifugation.

The use of acrylic bone cement for cervical fusion in patients with rheumatoid arthritis.

We report on 14 patients with instability of the cervical spine secondary to rheumatoid arthritis treated by fusion using a combination of traditional bone grafting techniques and methylmethacrylate bone cement. Successful fusion was achieved in all cases with few complications. The high infection rate reported by other authors was avoided by reducing the bulk of the cement mass and the use of antibiotic impregnated cement. We recommend this method of fusion to all orthopaedic surgeons involved in the treatment of patients with rheumatoid arthritis.