BACKGROUND. High-dose antibiotic cement spacers are commonly used to treat prosthetic joint infections following knee arthroplasties. Several clinical studies have shown a high success rate with antibiotic cement spacers, however there is little data on the systemic complications of high-dose antibiotic spacers, particularly acute kidney injury (AKI). This study aims to determine the incidence of AKI and identify risk factors predisposing patients undergoing staged revision arthroplasty with antibiotic cement spacers. METHODS. A single-institution, retrospective review was used to collect and analyze clinical and demographic data for patients who underwent staged revision total knee arthroplasty with placement of an antibiotic-impregnated cement spacer from 2006 to 2016. A search was made through specific procedure (DRG) and diagnostic (CD) codes. Baseline descriptive data were collected for all patients including age, sex, medical comorbidities, type and quantity of antibiotics used in the cement spacer, pre- and postoperative hemoglobin (Hg), BMI, smoking status, peak creatinine levels, and random vancomycin levels. Acute kidney injury was defined as a more than 50% rise in serum creatinine from a preoperative baseline within 90 days postoperatively. RESULTS. A total of 54 staged revision TKA surgeries performed by 5 different surgeons between 2006 and 2016. The total incidence of AKI was 31% (n=17). There was a significant positive association between change in creatinine level and use of oral/intravenous antibiotics (p=0.03, Spearman's rho=0.33) and a significant positive association between AKI and the use of tobramycin cement (p=0.01, Spearman's rho=0.38). Factors that were not significantly associated with AKI include presence of preexisting hypertension (p = 0.26), hyperlipidemia (p = 0.83), coronary artery disease (p = 0.86), chronic kidney disease (p=0.56), and smoking status (p=.35). There was a trend towards increased risk of AKI in patients with diabetes mellitus (p= 0.12), however this was not significant. CONCLUSION. In single staged revision knee arthroplasty there is a significant association between acute kidney injury and type of oral/intravenous antibiotic used in the treatment. Both the use of intravenous vancomycin and tobramycin cement are independently associated with higher rates of AKI. Preexisting medical comorbidities are not independent risk factors for development of AKI. Serum creatinine and measurement of serum aminoglycoside and vancomycin levels should be performed after placement of an aminoglycoside-containing antibiotic cement spacer in a staged revision arthroplasty

Introduction. Objective was to assess clinical results of treatment of Infected Non Union (INU) of long bones, using Antibiotic Cement Impregnated Nail (ACIN), a single or two staged approach, Stage 1 - Debridement, eradication of infection, primary stabilization with (ACIN). 2nd Stage - Definitive stabilization and early rehabilitation. Methods. 185 cases of infected non-union of long bones from Jan 2002 to Jan 2009 were treated in this hospital. 46 females and 139 males, age varied from 17–65 years (Avg. 40). Tibia was the commonest bone to be affected, followed by femur & humerus. The control of infection was by debridement, antibiotic cement impregnated K-nail (ACIN) insertion with or without Ilizarov ring fixator application, second stage treatment by definitive internal fixation and bone grafting was done if required. Average duration of follow up, was 26 months (14–58 months). Main outcome measurements were assessment of bone healing, functional outcome, healing time and complications. Results. Out of the 185 cases treated in our institute 174 (93.7%) patients achieved union at an average of 8 months. 2 limbs with non union tibia fractures were amputed on demand by patients, 2 limbs developed severe edema, 7 patients did not achieve union, inspite of repeated procedures. Infection was controlled early especially in Type 1 non unions. 5 patients had persistent infection though mild inspite of 2 or 3 surgeries of exploration and curettage. Discussion and conclusion. The two staged procedure described gives satisfactory results. Antibiotic and cement impregnated nails and beads achieve good infection control without any complications and reduce the healing time. Ilizarov fixator helps in stabilization, compression, deformity correction at the same time and plays a significant role in the path to union. Fixator should be removed as early as possible to avoid restriction of movements

INTRO. Two-stage revision arthroplasty for PJI may make use of an antibiotic-loaded cement spacer (ACS), as successful long- term prevention of reinfection have been reported using this technique.[i] However, there is little data on systemic complications of high-dose antibiotic spacers. Acute kidney injury (AKI) is of clinical significance, as the drugs most commonly utilized, vancomycin and aminoglycosides, can be nephrotoxic. We intended to determine the incidence of AKI in patients that underwent staged revision arthroplasty with an ACS, as well as to identify potential predisposing risk factors for the disease. METHODS. Local databases of six different orthopaedic surgeons were retrospectively reviewed for insertion of either a static or articulating antibiotic cement spacer by from 2007–2017. Dose of antibiotic powder implanted, as well as IV antibiotic used, was collected from operative records. Demographics, comorbidities, and preoperative and postoperative creatinine and hemoglobin values were recorded from the EHR. AKI was defined by a more than 50% rise in serum creatinine from preoperative baseline to at least 1.4 mg/dL, as described by Menge et al.[ii] Variables were analyzed for the primary outcome of AKI within the same hospital stay as insertion of the ACS. Categorical variables were analyzed with Chi-Square test, and continuous variables with univariate logistic regression. RESULTS. 75 patients (39 M, 36 F) receiving an ACS were identified, with a mean age of 70.0 (SD=10.6) and a mean BMI of 31.3 (SD=7.3). Incidence of in-hospital AKI was 13.3%. Patients reached AKI at a mean 6.7 days (SD=4.5), during a median length of stay of 13.5 days (IQR=21.8). No significant correlation was found between AKI and the variables of age (p=.430), BMI (p=.569) or gender (p=.181). AKI was also not associated with increased dose of vancomycin (p=.416), tobramycin (p=.440), or gentamycin (p=.846) within the cement spacer, or the comorbidities of hypertension (p=.094), diabetes (p=.146), coronary artery disease (p=1.00) and renal disease (p=.521). However, decreased baseline hemoglobin showed significantly increased risk for AKI (OR=1.67, p =.049), and increased creatinine showed a trend (OR=2.9, p=.059). Percentage of hemoglobin decrease (preoperative to postoperative) did not increase odds for AKI (p=.700). CONCLUSION. The incidence of acute kidney injury in patients that receive antibiotic cement spacers is relatively high when compared to the data reported in primary TKA. ii,[iii]. Our results suggest that patient related risk factors, such as low preoperative hemoglobin, may be involved in the etiology of AKI in this population. Therefore, it may be clinically appropriate to monitor anemic patients for AKI when implanting an ACS

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients. Cite this article: Bone Joint J 2014; 96-B:783–8

Introduction:. The developing world often lacks the resources to effectively treat the most serious injuries, potentially resulting in severe complications of orthopaedic trauma, including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are now a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide. Aims:. This project studied the effectiveness of locally made antibiotic beads, analysing their effectiveness after being gas sterilised, packaged and kept in storage. Methods:. Different antibiotic beads were manufactured locally using Simplex cement and tested against MRSA bacteria grown from a case of osteomyelitis. Each antibiotic was tested before and after a process of gas sterilisation as well as later being tested after storage in packaging up to 42 days. Results:. The gentamicin, vancomycin, amikacin and ceftriaxone beads all inhibited growth of the MRSA on the TSB and agar plates, both before and after gas sterilisation. All four antibiotics continued to show similar zones of inhibition after 42 days of storage, with slight fluctuations from week to week. Conclusion:. The four antibiotic beads manufactured using limited resources and in the austere environment were all effective in inhibiting bacterial growth. The growth of MRSA was inhibited by the antibiotic beads. Gas sterilisation or storage at room temperature for up to 42 days did not adversely deteriorate the efficacy of the beads. The results show significant promise to produce beads with locally obtainable ingredients in an austere environment and improve cost effectiveness by storing them in a sterilised condition

The purpose of this study is to present the preliminary results after treatment of shoulder sepsis with prolonged implantation of an antibiotic-loaded cement spacer in a selected group of compromised patients.

The current study included 11 patients (9 males and 2 females) with a mean age of 64 years (range: 36–79 years). All patients were treated with radical debridement, implantation of an antibiotic-impregnated polymethylmethacrylate spacer, and 6 weeks of antibiotic therapy. The subjective complaints, range of motion of the shoulder, functional outcome (mini-DASH score), and radiographic findings were evaluated. Nine patients at a mean follow-up time of 21 months (range: 13–18 months) were free of infection with pain relief and adequate shoulder function for activities of daily living. Radiographic evaluation revealed no loosening or fracture of the spacer and no progressive degenerative changes involving the glenoid.

Prolonged implantation of the spacer may be a useful alternative in selected patients with poor general condition.

Antibiotic bone cement as a form of prophylaxis against deep infection for total hip joint replacements is widely used; however its efficacy has not been proven. This study aims to determine if the use of prophylactic antibiotic cement for primary total hip joint replacements in New Zealand reduces the risk of deep infection requiring revision. Data from January 1999 to December 2007 were recovered from the New Zealand National Joint Registry. Proportional hazards regression analysis was used to study the relative revision risks or failure rates between those THJR which utilised antibiotic bone cement and those using plain bone cement. Of the 32,646 hips included in the study 1376 were revised. The overall use of antibiotic and plain cement through this time period is relatively equal, with 18,863 (54.7%) receiving ABC compared to 16,295 (46.3%) hips receiving plain cement. The presence of antibiotics in bone cement was not found to affect whether the hip went on to get revised for deep infection (p =0.16). Nor was the type of operating theatre (p=0.13), the use of space suits (p=0.97), and the operative time (p=0.55). Younger age was found to be the most significant indicator for the need for revision for infection (p value 0.00014). The induction of antibiotic resistance and the significant additional costs associated with antibiotic bone cement cannot be denied. While the literature supports the prophylactic use of antibiotic bone cement for patients at high risk of infection, the routine use in patients who have a low risk of infection may not be justified

Introduction: While the incidence of infection associated with hip and knee prosthesis is low, with the increasing number of arthroplasties being carried out, the total number of such cases is increasing. Also increasing is the number of multi-resistant organisms. These factors have raised questions regarding the optimal antibiotic impregnated cement for use in both spacers and in cemented revisions. While gentamycin, erythromycin, cefotaxime and vanomycin have a proven record as effective thermostatic antibiotics, newer antibiotics teicoplanin (although used in clinical practice) are as yet untested. Aim: To investigate the effectiveness of teicoplanin impregnated cement against a Staph Aureus. Method: A pure culture of Staphlococcus Aureus with known antibiotic sensitivities was obtained. Six batches of Palacos cement were mixed without under sterile conditions. One batch contained cement alone. The other 5 batches were mixed with one of gentamycin, vancomycin, erythromycin, cefotaxime and teicoplanin. Group 1: A pure culture of over 60 colonies was grown on 5 Columbian blood agar plates. A 1cm spherical sample of each batch of the cement was placed on each plate at regular intervals and allowed to heat and harden. Group 2: A further 1cm spherical ball of cement from each batch were placed on a further 5 blood agar plates which were then inoculated with the Staph Aureus and the cement was allowed to heat and harden. Group 3: 24 hours later, the cement was placed on a further 5 blood agar plates which were then inoculated with the Staph Aureus. Results: Group 1: None of the cement groups had any effect on the established colonies of Staph Aureus. Groups 2 & 3: The cement without antibiotic had no effect on the growth of the antibiotic even when allowed to heat on the plate. All the other groups including the teicoplanin impregnated cement both initially and after 24 hours, caused a zone of inhibition, ie prevented bacterial growth. Conclusion:. Heat alone did not affect the growth of the bacteria. None of the antibiotic impregnated cement batches had any effect on an established growth of Staph Aureus indicating the effect of antibiotic impregnated cement may be bacteriostatic rather than bacteriocidal. Teicoplanin is thermosable and is effective in the short term at least at halting the growth of Staph Aureus. Addition of antibiotics to cement may change the biomechanical properties of the cement. It was noted that it took on average twice as long for the teicoplanin-impregnated cement to harden. Further investigations into this are ongoing

Aim. The incidence of fractured neck of femur (FNOF) is increasing yearly. Many of these patients undergo hip hemiarthroplasty. High dose dual-antibiotic cement (HDDAC) has been shown to reduce rates of deep surgical site infection (SSI) when compared to the current standard low dose single-antibiotic cement (LDSAC) in a quasi-randomised controlled trial. Some concerns exist regarding the use of HDDAC and the development of resistance. We reviewed cases of infection in LDSAC and HDDAC bone cement with regard to causative organism and resistance profile. Method. A retrospective analysis was undertaken of all hemiarthroplasties within our trust from April 2008 to December 2014. We identified all patients in this time period who acquired a deep SSI from the trust SSI surveillance database. The infecting organisms and susceptibility patterns were collated for each cement. Results. We identified 1941 hemiarthroplasties. There were 36 deep surgical site infections representing an infection rate of 3.1% in LDSAC patients and 1.2% in HDDAC patients. A wider variety of organisms were seen in the LDSAC compared to HDDAC. Staphylococcus epidermidis accounted for the majority of infections in both LDSAC and HDDAC patients. Infection with Corynebacterium species and Staphylococcus aureus was eliminated completely in HDDAC. There was minimal change in the proportion of Gram-negative and Gram-positive bacteria. A change in resistance was not demonstrated amongst infections caused by Gram-negative bacteria. In Gram-positive bacteria, resistance to a number of antibiotics increased using HDDAC compared to LDSAC, most notably to clindamycin and gentamicin within the coagulase negative staphylococci. However, levels of resistance remained low to teicoplanin, vancomycin, daptomycin, linezolid and rifampicin. Conclusions. A lower infection rate was seen in HDDAC. Direct comparison demonstrated changes in resistance profiles caused by Gram-positive organisms. 24,000 patients undergo hip hemiarthroplasty annually. Extrapolating our results to this cohort would demonstrate 744 infections in LDSAC and 288 infections in HDDAC. Of these, resistance to both clindamycin and gentamicin would be seen in 180 patients with LDSAC and 177 patients with HDDAC. Overall, this review supports the continued use of HDDAC in FNOF patients. High dose dual antibiotic cement = Copal G+C, Heraeus Medical, UK. Low dose single antibiotic cement = Palacos R+G, Heraeus Medical, UK

Based on the first implementation of mixing antibiotics into bone cement in the 1970s, the Endo-Klinik has used one stage exchange for prosthetic joint infection (PJI) in over 85% of cases. Looking carefully at current literature and guidelines for PJI treatment, there is no clear evidence that a two stage procedure has a higher success rate than a one-stage approach. A cemented one-stage exchange potentially offers certain advantages, mainly based on the need for only one operative procedure, reduced antibiotics and hospitalisation time. In order to fulfill a one-stage approach, there are obligatory pre-, peri- and post-operative details that need to be meticulously respected, and are described in detail. Essential pre-operative diagnostic testing is based on the joint aspiration with an exact identification of any bacteria. The presence of a positive bacterial culture and respective antibiogram are essential, to specify the antibiotics to be loaded to the bone cement, which allows a high local antibiotic elution directly at the surgical side. A specific antibiotic treatment plan is generated by a microbiologist. The surgical success relies on the complete removal of all pre-existing hardware, including cement and restrictors and an aggressive and complete debridement of any infected soft tissues and bone material. Post-operative systemic antibiotic administration is usually completed after only ten to 14 days.

Cite this article: Bone Joint J 2013;95-B, Supple A:77–83.

Despite the prophylactic use of antibiotics and hygienic strategies, surgical site infection following total joint arthroplasty (TJA) is still a severe and unsolved complication. Since antibiotic-loaded bone cement (ALBC) was introduced by Buchholz in the 1970s, the use of ALBC has been increasingly used for the prevention and treatment of periprosthetic infection (PPI). However, the routine use of ALBC during primary TJA remains controversial. Recent clinical studies have found that ALBC is effective in reducing the risk of PJI following primary TJA. Although ALBC having the advantage of reducing the risk of PJI, the main disadvantages are the possible development of toxicity, antibiotic resistance, allergic reaction, and possible reduction of the mechanical properties of bone cement. Nevertheless, a recent published article demonstrated, that the use of high dose dual-antibiotic impregnated cement reduce significantly the rate of surgical site infections compared to standard low dose single ALBC in the setting of a hip fracture treating with hemiarthroplasty. Furthermore, Sanz-Ruiz et al. presented that the use of ALBC in TJA has favorable cost-efficiency profile. In this context, reasons why surgeons should use antibiotic-loaded bone cement during primary TJA are demonstrated.

Periprosthetic infection after total joint replacement is a catastrophic complication. Current rates of infection have been decreasing and in most centers now are in the range of 0.1–1%. Peri-operative intravenous antibiotic therapy is used routinely in total hip arthroplasty patients at this time. With rates this low and mixed evidence that antibiotics in bone cement for routine total hip replacement are beneficial at reducing joint infection, routine use of this practice seems unnecessary and has potential disadvantages. Cost of antibiotics being added to cement on a routine basis will increase the cost of the arthroplasty $300–$500. Although small addition of bone cement also has a negative effect on the mechanical properties of the cement. The major disadvantage remains the danger of resistant bacterial strains from excessive use of antibiotics particularly vancomycin resistant organisms when it is used routinely. Although rare with the aminoglycosides, allergic reactions may occur if cephalosporins are used as prophylaxis. Use of antibiotics in bone cement should be considered in high risk patients for infection undergoing total hip replacement but not routinely because of cost, emergence of resistant organism and possible allergic reaction.

Purpose: Prophylactic use of antibiotic-laden bone cement (ALBC) has been proposed to decrease the incidence of deep infections. We asked if the use of antibiotic laden bone cement decreased the deep infection rate following primary total knee replacement (TKA) as compared to plain bone cement (PBC).

Method: We surveyed 1,625 consecutive patients undergoing cemented, primary knee replacement with either ALBC or PBC. Relevant covariates including age, body mass index (BMI), gender, education, and medical comorbidity were collected. Joint pain and functional status were assessed at baseline and at 1 year follow up with the respective Western Ontario McMaster University Osteoarthritis Index (WOMAC) scores. The incidence of deep infection at 1 year follow up was recorded.

Results: There were 811 (49.9%) patients in the ALBC group and 814(50.1%) in the PBC group. There were no differences in age, gender, BMI, education or comorbidity between groups at baseline (p> 0.05). We found a deep infection rate of 3.1% in the ALBC group and 2.2% in the PBC group (p=0.27). Adjusted analysis showed that ALBC was not predictive of a lower infection rate at 1 year (p=0.84).

Conclusion: ALBC did not reduce the incidence of deep infection following primary TKA at 1 year follow up. Further studies are needed to define any high risk groups for which ALBC might be beneficial.

Aim. Studies have shown that retention of antibiotic cement spacer in selected elderly patients with low functional demand represents a viable option for periprosthetic joint infections (PJI) treatment. 1,2. . The aim of this study is to compare the efficacy in infection treating among modular taylored preformed and hand-made antibiotic spacers. Our hypothesis is that modular tailored preformed spacer provides a better rate of infection resolution, better radiological and functional outcomes compared to hand-made spacers. Materials and methods. We identified 48 patients treated with antibiotic cement spacer for shoulder chronic infection between 2015 and 2021 in our institution; (13 hand-made spacers and 35 modular tailored preformed spacers). We collected data about comorbidities, associated microorganism, infection resolution, clinical and radiographic evaluation. Results. The mean age at surgery was 63.2 years, (45.8% female − 54.2% male), mean BMI 28.3. The mean time of infection diagnosis after first surgery was 30 months; (31.2% infection after ORIF in proximal humeral fractures, 68.8% PJI after shoulder arthroplasty). The main pathogens were Propionibacterium Acnes (37.5%), Staphylococcus Epidermidis (29.2%), Staphylococcus Aureus (16.7%), negative intraoperative coltures (14.6%), Enterococcus (4.17%), Pseudomonas Aeruginosa (4.17%). The mean time of antibiotic spacer retention was 18 months: 23 patients (47.9%) underwent second stage surgery for prosthesis implantation; 2 removed the spacer because of spacer dislocation, 2 died during follow up; while 21 patients still hold the antibiotic spacer (17 patients in treatment with prefabricated spacers and 4 with self-constructed spacer). The mean value for clinical assessment for patients with modular tailored preformed spacer were: Constant Score 34 – QuickDASH 40 – SST 33 – ASES Score 66 – VAS 2. Patients treated with hand-made spacer registered the following scores: Constant Score 20 – QuickDASH 51 – SST 25 – ASES Score 38 – VAS 6. Two patients presented fracture of the spacer (one hand-made spacer and one tailored preformed). Conclusions. According to our data patients treated with modular tailored preformed antibiotic spacer show better functional outcomes. Patients are more likely to retain the spacer as a permanent implant, avoiding the risks of a second stage surgery in those low-demanding patients, achieving a reasonable satisfying quality of shoulder motion without pain

Fracture related infection, in particular chronic osteomyelitis, requires complex management plans. Meta analyses and systematic reviews have not found a gold standard of treatment for this disease. In 2017 an alternative treatment protocol was undertaken in our institution; whereby staged surgery with the use of cheaply manufactured tailored antibiotic cement rods was used in the treatment of chronic osteomyelitis, secondary to traumatic long bone fractures. Short term outcomes for this protocol demonstrated a 75.7% microbiological resolution to a negative culture and a good clinical outcome of 84.2% overall was demonstrated in terms of sinus resolution, skin changes, pain and function. Our aim now was to assess the long term outcomes of this treatment strategy. A cross-sectional study of patients who had previously undergone the set treatment protocol was performed. Patient satisfaction, effects on activities of daily living, return to work and clinical improvement at 5 years following the intervention were assessed using a patient questionnaire and the validated AAOS lower limb score. The average AAOS lower limb score was 88 which was en par to other similar studies. 80% of patients had returned to some form of work. Ongoing mild pain was a persistent problem for 50% of the patients however 98% of the patients were overall satisfied with the treatment satisfaction at 5 years. Only 1 patient required further treatment. 8 patients could not be located for follow up. Chronic osteomyelitis remains a complex disease to treat. This treatment protocol demonstrates favourable microbiological, serological and clinical short term outcomes and favourable patient satisfaction and functional long term outcomes at 5 years. Our study highlights antibiotic targeted cement rods as a feasible treatment option in managing chronic osteomyelitis

The April 2024 Research Roundup. 360. looks at: Prevalence and characteristics of benign cartilaginous tumours of the shoulder joint; Is total-body MRI useful as a screening tool to rule out malignant progression in patients with multiple osteochondromas?; Effects of vancomycin and tobramycin on compressive and tensile strengths of antibiotic bone cement: a biomechanical study; Biomarkers for early detection of Charcot arthropathy; Strong association between growth hormone therapy and proximal tibial physeal avulsion fractures in children and adolescents; UK pregnancy in orthopaedics (UK-POP): a cross-sectional study of UK female trauma and orthopaedic surgeons and their experiences of pregnancy; Does preoperative weight loss change the risk of adverse outcomes in total knee arthroplasty by initial BMI classification?

Antibiotic-laden bone cement is an important strategy of treatment for an established bone infection. It was aimed to find the safe antibiotic dose intervals of the antibiotic cements soaked in Phosphate Buffered Saline solution and to determine whether there was a difference in terms of mechanical strength between the prepared samples. This study was done in our institute Microbiology and Metallurgy laboratories. All samples were prepared using manual mixing technique using 40 g radiopaque Biomet® Bone cement (Zimmer Biomet, Indiana, USA) under sterile conditions at 19 ± 2 ºC. In this study, vancomycin (4 groups − 0.5, 2, 4, 6 g), teicoplanin (4 groups − 0.8, 1.2, 2, 2.4 g), daptomycin (4 groups − 1, 2, 2.5, 3 g), piperacillin-tazobactam (4 groups − 0.125, 0.5, 1, 2 g) and meropenem (4 groups − 0.5, 2, 4, 6 g) were measured in a assay balance and added to the cement powder. Antibiotic levels ranged from the lowest 0.625% to the highest 15%. 80×10×4 mm rectangle prism-shaped sample for mechanical measurements in accordance to ISO 5833 standart and 12×6×1 mm disc-shaped samples for microbiological assesments were used. Four sample for each antibiotic dose and control group was made. Prepared samples were evaluated macroscopically and faulty samples were excluded from the study. Prepared samples were kept in Phosphate Buffered Saline solution renewed every 24 hours at 37 ºC. At the end of 6 weeks, all samples were tested with Instron ® 3369 (Norwood Massachusetts, USA) four point bending test. Staphylococcus aureus (ATCC 29213) strain was used for samples of antibiotics containing vancomycin, teicoplanin and daptomycin after the samples prepared for antibiotic release were maintained under sterile conditions and kept in Phosphate Buffered Saline solution as appropriate. For samples containing meropenem and piperacillin - tazobactam antibiotics, Pseudomonas aeruginosa (ATCC 27853) strain was used. The addition of more than 5% antibiotics to the cement powder was significantly reduced mechanical strength in all groups(p <0.05) however the power of significance was changed depending on the type of antibiotic. In general, adding antibiotics with 2.5% and less for cement amount was not cause significant changes in mechanical measurements. There was a negative correlation between the increase in the amount of antibiotics mixed with cement and the durability of the cement (p: <0.001, r: −0.883 to 0.914). In this study, especially the antibacterial effects of piperacillin-tazobactam, containing 0.25 gr and 0.5 gr antibiotic doses, were found to be low. There was no bacterial growth in all other groups for 21 days. Considering the mechanical properties of groups containing meropenem, vancomycin, daptomycin and teicoplanin, it was observed that all antibiotic cements remained above the limit value of 50 MPa in the bending test at concentrations containing 2.5% and less antibiotics. This was not achieved for the piperacillin-tazobactam group. The findings of the study showed that each antibiotic has different MPa values at different doses. Therefore, it could be concluded that not only the antibiotic dose but also the type oould change the mechanical properties. In the light of these findings, mixing more than 2.5% antibiotics in cement for the antibiotic types included in the study was ineffective in terms of antibacterial effect and mechanically reduces the durability of cement below the standard value of 50 MPa

The rate of periprosthetic joint infections (PJI) after primary total hip arthroplasty (THA) is approximately 1%. As the number of THAs performed each year continue to increase (550,000 by 2030), a corresponding increase in the number of hip PJI cases is likely to occur. A chronic deep infection may be treated by either chronic suppression, irrigation and debridement, single-stage exchange, or two-stage exchange. In the United States, the gold standard for chronic PJI continues to be a two-stage exchange. The benefit of an antibiotic impregnated cement is that they produce higher local concentrations of antibiotics than systemic intravenous administration. Hip spacers may be either static or articulating. Static spacers are reserved for cases of massive acetabular bone loss in which an articulating spacer is not feasible. A static spacer consists of a block of antibiotic cement in the native acetabulum and antibiotic coated rod in the femoral canal. Limb shortening, loss of soft tissue planes, and disuse osteopenia and muscle atrophy are all limitations of static spacers. In contrast, articulating spacers fulfill the goals of the interim construct during two-stage exchange which is to enhance eradication of the infecting organism through drug elution, to maintain limb length, to facilitate exposure during revision surgery, and to improve functional mobilization. Articulating spacers may be divided into three general categories based on method of spacer creation: Handmade custom spacers, prefabricated spacers, custom molded spacers (hemiarthroplasty molds and molded stem with cemented all-polyethylene cup). Handmade custom spacers are usually created with K-wire or rush rods coated with antibiotic cement. Handmade spacers are relatively simple to make, they are economical, and the amount and type of antibiotics incorporated can be customised for the infecting organism. Commercially available hemiarthroplasty spacers can be either prefabricated (Spacer G, Exactech, Gainesville. FL) or made intraoperatively (Stage One, Zimmer Biomet, Warsaw, IN) are available in several head and stem sizes. The advantage of prefabricated spacers is that they do not require additional time to mold in the operating room. The downside of prefabricated spacers is that the antibiotic concentration and type is predetermined. A custom molded stem with cemented all-polyethylene cup can be made with off the shelf implants or used as part of a commercially available spacer (PROSTALAC, DePuy Synthes, Warsaw, IN). A common antibiotic/cement combination includes Tobramycin (3.6 g/40 g of cement) and vancomycin (1.5 g/40 g of cement). In all of these spacer constructs, the principles of using a high-elution cement mixed without a vacuum and with high doses of heat stable antibiotics are consistent. Tobramycin works synergistically to improve Vancomycin elution properties and is usually added in higher doses. Overall infection eradication is similar between all categories of spacers and range between 90–97%. Complications after placement of an articulating spacer are often specific to the type of spacer used. Handmade spaces that have K-wires for support are at risk for spacer cement fracture. Spacer dislocation is also a common complication in up to 15% of cases with all types of spacers. In addition, periprosthetic fractures can occur postoperatively in up to 10% of patients. Overall, despite this complication profile, articulating antibiotic spacers have excellent rates of infection eradication and offer improved mobilization in the interim two stage period and reduce operative time, complexity, and morbidity during reimplantation

Aims. The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol. Methods. The study involved a retrospective review of our prospectively collected database from which we identified all patients who underwent an intended two-stage revision for PJI of the hip. All patients had a diagnosis of PJI according to the major criteria of the Musculoskeletal Infection Society (MSIS) 2013, a minimum five-year follow-up, and were assessed using the MSIS working group outcome-reporting tool. The outcomes were grouped into ‘successful’ or ‘unsuccessful’. Results. A total of 299 two-stage revision THAs in 289 patients met the inclusion criteria, of whom 258 (86%) proceeded to second-stage surgery. Their mean age was 68.1 years (28 to 92). The median follow-up was 10.7 years (interquartile range (IQR) 6.3 to 15.0). A 91% success rate was seen in those patients who underwent reimplantation, decreasing to 86% when including those who did not proceed to reimplantation. The median duration of postoperative systemic antibiotics following the first stage was five days (IQR 5 to 9). There was no significant difference in outcome between those patients who were treated with antibiotics for ≤ 48 hours (p = 0.961) or ≤ five days (p = 0.376) compared with those who were treated with longer courses. Greater success rates were seen for Gram-positive PJIs (87%) than for Gram-negative (84%) and mixed-Gram PJIs (72%; p = 0.098). Conclusion. Aggressive surgical debridement with a high local concentration of targeted antibiotics at the time of first-stage revision surgery for PJI of the hip, without prolonged systemic antibiotics, provides a high rate of success, responsible antibiotic stewardship, and reduced hospital costs. Cite this article: Bone Joint J 2023;105-B(5):511–517

Introduction. Periprosthetic joint infection (PJI) is a serious problem and requires great effort and cost for its treatment. Treatment options may vary from resection arthroplasty, retention of prosthesis with debridement, one stage revision and two stage revision with handmade antibiotic impregnated cement spacer or with prefabricated antibiotic loaded cement spacer. Two stage revision remains the gold standard for the treatment of periprosthetic joint infection after Total Hip Arthroplasty (THA). This study was aimed to find the efficacy and cost effectiveness of handmade antibiotic impregnated articulating cement spacer over commercially available prefabricated antibiotic loaded cement spacer for the treatment of deep PJI of hip prosthesis and to evaluate its functional outcome. Material and methods. A total of 23 PJI patients were enrolled in this prospective cohort study. In the two stages of revision, the first stage consisted of thorough debridement, implant removal and implantation of handmade articulating antibiotic impregnated cement spacer. The second stage surgery consisted of removal of cement spacer, thorough debridement and implantation of new prosthesis. All patients were followed for a period of 24 months. Results. A total of 23 patients (15 males and 8 females) underwent two stage revision arthroplasty for chronic periprosthetic joint infection. The mean age of the patient was 57 years. The handmade antibiotic impregnated cement spacer was retained for 16– 20 weeks. Common organism observed was coagulase negative staphylococci followed by Staphylococcus aureus. After an average follow up of 2 years, 20 patients with PJI remained clinically free of infection. In 2 patients there was recurrence of infection. Conclusion. We conclude that two stage revision by hand made cement spacer is successful in eradication of infection with satisfactory functional outcome. Furthermore, these handmade cement spacer are cost effective and their efficacy may be comparable to commercially available prefabricated spacer