Antibiotic-loaded vs. plain bone cement yield similar revision rates for PJI after TKA

F. Johannes Plate, MD, PhD, FAAOS

Routine use of antibiotic-laden cement for primary total knee arthroplasty remains controversial with inconclusive recommendations. Antibiotic-laden cement is routinely used outside the U.S. for its purported effectiveness in reducing periprosthetic joint infection after TKA and subsequent cost savings from averted revisions.

Tesfaye H. Leta, PhD, and colleagues assessed consolidated international registry data with more than 2.1 million cases (93% with antibiotic-laden cement) and reported similar rates for revision due to PJI and all-cause revision at 1 year, recommending against routine use of antibiotic-laden cement. The study used mostly European, Australian and New Zealand data with only minor contribution from a U.S. database (Kaiser Permanente Total Joint Replacement Registry, 6%) and did not include patient comorbidities or surgical factors.

Blake O. Nourie, MD, and colleagues assessed 109,242 Medicare patients (25% with antibiotic-laden cement) from the American Joint Replacement Registry and found no difference in revision for PJI at 1-year between antibiotic-laden cement and plain cement. The study used logistic regression analysis, including patient demographics, comorbidities and surgical factors, to determine what patients received antibiotic-laden cement.

Antibiotic-laden cement is preferentially being used in patients with a higher number of comorbidities, greater BMI, U.S. veterans and with regional variation possibly related to surgeon preference or hospital policy. The potential for subsequent cost savings from prevented revision with use of antibiotic-laden cement in high-risk patients has been argued; however, in a study of 2,511 consecutive TKAs (43% with antibiotic-laden cement), cases with antibiotic-laden cement had higher overall costs without a significant decreased incidence of PJI.

Antibiotic-laden cement use in “high-risk” patients remains ill-defined and would require level-1 data with a large number of patients to show a meaningful decrease in PJI rate of 1%. Current evidence does not support the use of antibiotic-laden cement for primary TKA in the prevention of PJI, and the increased cost of antibiotic-laden cement is not justified.

References:

Bendich I, et al. J Bone Joint Surg Am. 2020;doi:10.2106/JBJS.20.00102.

Cieremans D, et al. Eur J Orthop Surg Traumatol. 2023;doi:10.1007/s00590-023-03557-3.

Leta TH, et al. Acta Orthop. 2023;doi:10.2340/17453674.2023.17737.

Nourie BO, et al. J Arthroplasty. 2024;doi:10.1016/j.arth.2024.01.068.

Ricciardi BF, et al. J Am Acad Orthop Surg. 2024;doi:10.5435/JAAOS-D-23-00434.

Sanz-Ruiz P, et al. J Arthroplasty. 2017;doi:10.1016/j.arth.2016.11.012.

Yayac M, et al. J Arthroplasty. 2019;doi:10.1016/j.arth.2019.04.043.

Michael J. Dunbar, MD, FRCSC, PhD, FCAHS

There are few complications as devastating after total knee arthroplasty as a periprosthetic joint infection. In response to this, surgeons in many jurisdictions internationally utilize antibiotic-laden bone cement despite the lack of consensus in the literature and the added costs. Because the incidence of PJI is low, conventional randomized controlled trials are difficult to perform. National joint replacement registries are increasingly viewed as a potential source of clarity for such difficult epidemiological questions.

The paper by Tesfaye H. Leta, PhD, and colleagues is remarkable in that it represents an international effort to combine data from 14 national joint replacement registries to investigate the effect of antibiotic-laden bone cement on 1-year PJI rates in TKA. More than 2 million TKA cases were included in the analyses, representing one of the largest outcomes studies of any kind on TKA in the literature. The authors concluded that there is no statistically significant difference in PJI rates at 1 year in TKA whether antibiotic-laden bone cement is utilized.

There are limitations with all registry studies in that revision is the endpoint and, subsequently, PJIs that do not result in a revision would not be recorded. There can also be selection biases as to which patients receive antibiotic-laden bone cement in the noncontrolled nature of registry studies. Still, given that revision for PJI is the most consequential outcome to be avoided and given the fact that many registries included had close to or 100% utilization rates of antibiotic-laden bone cement use, I feel these concerns do not substantially detract from the message of this paper.

This paper should drive discussions about the extra costs associated with antibiotic-laden bone cement in increasingly strained health care systems. However, regardless, these should not distract from the most important initiatives to maintain rigorous control over maintaining a sterile environment when performing TKA — something that I feel often is under appreciated and overlooked.