Clinical bottom line
Local antibiotic-loaded bone cement (ALBC) remains a valuable adjunct in preventing prosthetic joint infection (PJI), particularly in high-risk primary and revision arthroplasty. Evidence supports that ALBC delivers high local antibiotic concentrations with minimal systemic exposure, reducing infection rates without significantly increasing antibiotic resistance risk. Dual antibiotic-loaded cements may offer enhanced efficacy and cost-effectiveness over single-agent formulations in aseptic revision knee arthroplasty. However, standardized protocols regarding antibiotic choice, dosage, and cement type are lacking, and concerns about resistance and mechanical properties warrant cautious application (Sabater-Martos et al., 2023; Sanz-Ruiz et al., 2020).
What the evidence shows
Sabater-Martos et al. (2023) provide a comprehensive review of antimicrobials incorporated into polymethylmethacrylate (PMMA) bone cement, outlining principles of antibiotic elution kinetics, spectrum of activity, and clinical applications from prophylaxis to treatment of established PJI. They emphasize that ALBC achieves local antibiotic concentrations exceeding minimum inhibitory concentrations for common pathogens, effectively reducing infection risk.
Sanz-Ruiz et al. (2020) conducted a cost-effectiveness analysis comparing dual versus single antibiotic-loaded bone cement in aseptic revision knee arthroplasty. Their data suggest that dual-loaded cements significantly reduce PJI incidence and associated costs, supporting broader use in revision settings.
Anagnostakos et al. (2017) discuss therapeutic applications of ALBC in hip and knee joint infections, highlighting its role in delivering high local antibiotic doses during two-stage revision procedures with favorable outcomes.
Berberich et al. (2022) address concerns regarding antibiotic resistance triggered by ALBC use. Their analysis indicates that while local antibiotic delivery may select for resistant strains in vitro, clinical evidence of widespread resistance impacting PJI treatment remains limited.
Kühn et al. (2018) review mechanical and handling properties of ALBC, noting that high antibiotic loads may compromise cement strength, necessitating balance between antimicrobial efficacy and implant fixation integrity.
Caveats and uncertainty
Heterogeneity in study designs, patient populations, and antibiotic regimens complicates direct comparisons.
Long-term surveillance data on resistance patterns related to ALBC are sparse.
Optimal antibiotic combinations, dosages, and cement formulations remain to be standardized.
Potential mechanical weakening of cement with high antibiotic loads may increase implant loosening risk.
Cost-effectiveness findings may vary by healthcare system and patient risk profiles.
How this may change practice
Surgeons should consider ALBC use in patients at elevated risk for PJI, especially in revision arthroplasty.
Dual antibiotic-loaded cements may be preferentially selected in aseptic revision knees to enhance prophylaxis.
Preoperative risk stratification and microbiological data should guide antibiotic selection in cement.
Monitoring for emerging resistance and mechanical complications is advised.
Multidisciplinary collaboration between surgeons, microbiologists, and pharmacists can optimize ALBC protocols.