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

Abstract

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.

PMMA Bone Cement: Antibiotic Elution and Mechanical Properties in the Context of Clinical Use

“…While this study reported similar morphologies of the cured cements, the elution rates of the manually loaded cement were 36% lower on average [ 35 ]. Because of these in part controversial results, some authors advise against the use of manually mixed ALBCs in general and argue that industrial antibiotic loading provides uniform release kinetics [ 36 ].…”

“…However, the influence of a vacuum mixing system on antibiotic elution depends on further factors, such as water solubility of the antibiotic, the diffusion gradient, and above all the choice of cement [ 36 ]. Meyer et al compared the effect of a vacuum mixing system on different commercially available gentamicin loaded bone cements.…”

Two-stage revision of infected hip prosthesis after post-operative antibiotic therapy: An observational study

“…Therefore, it prevents extensive scarring, preserves the quality of the bone and the length of the limb and facilitates final prosthesis implantation. [ 22 ]…”

“…Therefore, it prevents extensive scarring, preserves the quality of the bone and the length of the limb and facilitates final prosthesis implantation. [22] In this study, we determined the outcomes of patients underwent 2-staged THA after a course of antibiotic therapy.…”

Effects of bacteriophages on biofilms formed by Staphylococcus aureus isolated from patients with orthopedic infection

“…Инфекция протезированных суставов является важ ной проблемой современной медицины. По данным литературы, частота развития данного осложнения составляет от 2,5% после первичного эндопротезирова ния до 20% после ревизионных операций, при этом ле тальность от данного осложнения достигает 2,5% [1]. В случае выполнения ревизионной операции по поводу уже имеющейся инфекции, ее рецидивы развиваются в 25-67% [2].…”