Introduction. Vancomycin is commonly added to acrylic bone cement during revision arthroplasty surgery. Proprietary cement preparations containing vancomycin are available but significantly more expensive. We investigated whether the antibiotic elution and mechanical strength of ‘home-made’ vancomycin containing bone cement was comparable to commercial vancomycin-impregnated cement. Methods. A total of 18 cement discs of constant size, containing either proprietary CopalG+V. ®. ; or ‘home-made’ CopalR+G. ®. with vancomycin added by hand, were made. Each disc contained the same antibiotic quantities (0.5g gentamycin, 2g vancomycin) and was immersed in ammonium acetate buffer in a sealed container. Fluid from each container was sampled at eight time points over a two week period. The concentration of gentamicin and vancomycin in the fluid was analysed using high performance liquid chromatography mass spectrometry. The impact strength of each PMMA cement preparation was measured using a Charpy-type impact tester. Results. Highest peak antibiotic concentrations were observed from the ‘home-made’ vancomycin containing cement, added as in the operating theatre. Overall antibiotic elution was, five-fold (vancomycin) and two-fold (gentamicin), greater from the ‘home-made’ mix compared to commercially mixed cement. However the ‘home-made’ cements showed greater variation in elution kinetics compared to the commercial mix. Use of a vacuum during mixing had no significant effect on antibiotic elution in any of the samples. Impact strength testing showed no significant differences between the groups. Discussion. Our findings suggest the addition of 2g vancomycin powder to gentamicin-impregnated bone cement in theatre, significantly increases elution of both antibiotics, with no significant loss of strength, compared to commercially prepared cement. Conclusion. We have found no significant advantages of expensive off-the-shelf vancomycin-impregnated bone cement and recommend the addition of vancomycin powder by hand when making cement beads and spacers

When using a staged approach to eradicate chronic infection after total hip replacement, systemic delivery of antibiotics after the first stage is often employed for an extended period of typically six weeks together with the use of an in situ antibiotic-eluting polymethylmethacrylate interval spacer. We report our multi-surgeon experience of 43 consecutive patients (44 hips) who received systemic vancomycin for two weeks in combination with a vancomycin- and gentamicin-eluting spacer system in the course of a two-stage revision procedure for deep infection with a median follow-up of 49 months (25 to 83).

The antibiotic-eluting articulating spacers fractured in six hips (13.9%) and dislocated in five patients (11.6%). Successful elimination of the infecting organisms occurred in 38 (92.7%) of 41 hips with three patients developing superinfection with a new organism.

We conclude that prolonged systemic antibiotic therapy may not be essential in the two-stage treatment of a total hip replacement for Gram-positive infection, provided that a high concentration of antibiotics is delivered locally using an antibiotic-eluting system.

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.

Periprosthetic infection following total hip replacement can be a catastrophic complication for the patient. The treatments available include single-stage exchange, and two-stage exchange. We present a series of 50 consecutive patients with a diagnosis of infected total hip replacement who were assessed according to a standardised protocol. Of these, 11 underwent single-stage revision arthroplasty with no recurrence of infection at a mean of 6.8 years follow-up (5.5 to 8.8). The remaining 39 underwent two-stage revision, with two recurrences of infection successfully treated by a second two-stage procedure. At five years, significant differences were found in the mean Harris Hip Scores (single-stage 87.8; two-stage 75.5; p = 0.0003) and in a visual analogue score for satisfaction (8.6; 6.9; p = 0.001) between the single- and two-stage groups. Single-stage exchange is successful in eradicating periprosthetic infection and results in excellent functional and satisfaction scores.

Identification of patients suitable for the single-stage procedure allows individualisation of care and provides as many as possible with the correct strategy in successfully tackling their periprosthetic infection

We present a series of 114 patients with microbiologically-proven chronically-infected total hip replacement, treated between 1991 and 2004 by a two-stage exchange procedure with antibiotic-loaded cement, but without the use of a prolonged course of antibiotic therapy. The mean follow-up for all patients was 74 months (2 to 175) with all surviving patients having a minimum follow-up of two years. Infection was successfully eradicated in 100 patients (87.7%), a rate which is similar to that reported by others, but where prolonged adjuvant antibiotic therapy has been used. Using the technique described, a prolonged course of systemic antibiotics does not appear to be essential and the high cost of the administration of antibiotics can be avoided.