Multiple studies have established an inverse relationship between ambient theatre temperatures and polymethyl methacrylate (PMMA) cement setting times. It is also known that allowing cement to equilibrate to ambient theatre temperatures restores expected setting characteristics. One overlooked entity is the transport and storage conditions of cement. This is important in tropical regions, where extreme temperature and humidity may cause rapid cement setting times, resulting in potentially significant intra-operative complications. This study investigated the relationship between extreme transport and storage conditions of Antibiotic Simplex cement (Stryker), and the effect on setting times at Cairns Hospital, Far North Queensland, Australia. Fifty units of cement were divided evenly into a control arm and four experimental arms. The experimental arms were designed to mimic potential transport and storage conditions. They included seven days of storage in a medication fridge, on the hospital loading dock, in a cane shed, and in a Toyota Landcruiser parked outdoors during January 2022. Humidity and temperature readings were recorded. The samples in each group were evenly distributed to equilibrate to theatre conditions for 1 hour and 24 hours. Setting time was recorded when a no. 15 scalpel blade was unable to mark the surface. All three ‘hot’ exposures setting times were significantly faster for both 1 hour (ρ=0.001) and 24 hours (ρ=0.024) equilibration times. The difference in setting times for the ‘cold’ exposure was not significant for either equilibration times (ρ=1). To our knowledge, this is the first study investigating cement setting times in tropical climates. Further studies are required to address the effect of these conditions on biomechanical strength of PMMA cement. We conclude that extreme heat and humidity during transport and storage have a statistically significant effect on cement setting times

Aim. Galleria mellonella larvae is a well-known insect infection model that has been used to test the virulence of bacterial and fungal strains as well as for the high throughput screening of antimicrobial compounds against infections. Recently, we have developed insect infection model G. mellonella larvae to study implant associated biofilm infections using small K-wire as implant material. Here, we aimed to further expand the use of G. mellonella to test other materials such as bone cement with combination of gentamicin to treat implant-associated infections. Method. The poly methyl methacrylate (PMMA) with and without gentamicin and liquid methyl methacrylate (MMA) were kindly provided by Heraeus Medical GmbH, Wehrheim. To make the bone cement implants as cubes, Teflon plate (Karl Lettenbauer, Erlangen) with specified well size was used. The Radiopaque polymer and monomer were mixed well in a bowl, applied over on to the Teflon plate and pressed with spatula to form fine and uniform cubes. After polymerization, the bone cement implants were taken out of the Teflon well plate with the help of pin. For the infection process, bone cement cubes were pre-incubated with S. aureus EDCC 5055 culture at 5×10. 6. CFU/ml for 30 min at 150 rpm shaking conditions. Later, these implants were washed with 10ml PBS and implanted in the larvae as mentioned. Survival of the larvae were observed at 37°C in an incubator. To analyze the susceptibility of the bacterial infections towards gentamicin, survival of the larvae compared with control group implanted only with bone cement. The effect of gentamicin was also measured in terms of S. aureus load in larvae on 2. nd. day. SEM analysis was performed to see the effect of gentamicin on biofilm formation on bone cement. Results. Our experiments established the G. mellonella as an excellent model to screen bone cement with antimicrobial compounds against bacterial infections. The gentamicin bone cement samples showed excellent S. aureus bacterial load reduction after the implantation in G. mellonella model. The bone cement with gentamicin showed better survival of larvae infected with S. aureus compared to control. Finally, the gentamicin also affected the biofilm formation on the bone cement surface with S. aureus. Conclusions. Thus, our work showed G. mellonella is a rapid, cheap economical pre-clinical model to study the bone cement associate bacterial infections as well as screening of the various antimicrobial compounds

Primary hip and knee joint replacements in Canada have been estimated to cost over $1.4 billion dollars annually, with revision surgery costing $177 million. The most common cause of revision arthroplasty surgery in Canada is infection. Periprosthetic joint infections (PJIs) are a devastating though preventable complication following arthroplasty. Though variably used, antibiotic laden bone cement (ALBC) has been demonstrated to decrease PJIs following primary total knee arthroplasty (TKA). Unfortunately, ALBC is costlier than regular bone cement (RBC). Therefore, the aim of this study was to determine if the routine use of ALBC in primary TKA surgery is a cost-effective practice from the perspective of the Canadian healthcare system. A decision tree was constructed using a decision analysis software (TreeAge Software, Williamstown, Massachusetts) to a two-year time horizon comparing primary TKA with either ALBC or RBC from the perspective of a single-payer healthcare system. All costs were in 2020 Canadian dollars. Health utilities were in the form of quality adjusted life years (QALYs). Model inputs for cost were derived from regional and national databases. Health utilities and probability parameters were derived from the latest literature. One-way deterministic sensitivity analysis was performed on all model parameters. The primary outcome of this analysis was an incremental cost-effectiveness ratio (ICER) with a willingness-to-pay (WTP) threshold of $50,000 per QALY. Primary TKA with ALBC (TKA-ALBC) was found to be more cost-effective compared to primary TKA with RBC (TKA-RBC). More specifically, TKA-ALBC dominated TKA-RBC as it was less costly on the long term ($11,160 vs. $11,118), while providing the same QALY (1.66). The ICER of this cost-utility analysis (CUA) was $-11,049.72 per QALY, much less than the WTP threshold of $50,000 per QALY. The model was sensitive to costs of ALBC-TKA as well as the probability of PJI following ALBC-TKA and RBC-TKA. ALBC ceased to be cost effective once the cost of ALBC was greater than $223.08 CAD per bag of cement. The routine use of ALBC in primary TKA is a cost-effective practice in the context of the Canadian healthcare system as long as the cost of ALBC is maintained at a reasonable price and the published studies to-date keep supporting the efficacy of ALBC in decreasing PJI following primary TKA. Further, this analysis is very conservative, and ALBC is likely much more cost-effective than presented. This is due to this model's revision surgery cost parameter being based on the average cost of all revision TKA surgery in Canada, regardless of etiology. Considering many PJIs require two-stage revisions, the cost parameter used in this analysis for revision surgery is an underestimate of true cost. Ultimately, this is the first cost-effectiveness study evaluating this topic from the perspective of the Canadian healthcare system and can inform future national guidelines on the subject matter

This study aimed to analyze the effect of two different techniques of cement application: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term effect of radiolucent lines (RLL) in primary fully cemented total knee arthroplasties (TKA) with patella resurfacing. 379 fully cemented TKAs (318 patients) were included in this monocentric study. Preoperative and postoperative at week 4 and 12 month after surgery all patients had a clinical and radiological examination and were administered the Oxford Knee Score (OKS). Cement was applied in two different ways among the two study groups: cement on bone surface (CoB group) or cement on bone surface and implant surface (CoBaI group). The evaluation of the presence of RLL or osteolysis was done as previously described using the updated Knee Society Radiographic Evaluation System. The mean OKS and range of motion improved significantly in both groups at the 4-week and 12-month follow-up, with no significant difference between the groups (CoB vs. CoBaI). RLL were present in 4.7% in the whole study population and were significantly higher in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up RLL were seen in 29.8% of the TKAs in the CoBaI group, whereas the incidence was lower in the CoB group (24.0% (n.s.)). There were two revisions in each group. None of these due to aseptic loosening. Our study indicated that the application of bone cement on bone surface only might be more beneficial than onto the bone surface and onto the implant surface as well in respect to the short-term presence of RLL in fully cemented primary TKA. The long-term results will be of interest, especially in respect to aseptic loosening and might guide future directions of bone cement applications in TKA

The cement in cement technique for revision total hip arthroplasty (THA) has shown good results in selected cases. However, results of its use in the revision of hemiarthroplasty to THA has not been previously reported. Between May 1994 and May 2007 28 (20 Thompson's and 8 Exeter bipolar) hip hemiarthroplasties were revised to THA in 28 patients using the cement in cement technique. All had an Exeter stem inserted at the time of revision. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford. Hip scores and radiographs were analysed post-operatively and at latest follow up. The mean age at time of hemiarthroplasty revision was 80 (35 to 93) years. The reason for revision was acetabular erosion in 12 (43%), recurrent dislocation in eight (29%), aseptic stem loosening in four (14%), periprosthetic fracture in two (7%) and infection in a further two (7%) patients. No patient has been lost to follow up. Three patients died within three months of surgery. The mean follow up of the remainder was 50 (16 to 119) months. Survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. Three cases (11%) have since undergone further revision, one for recurrent dislocation, one for infection, and one for periprosthetic fracture. The cement in cement technique can be successfully applied to revision of hip hemiarthroplasty to THA. It has a number of advantages in this elderly population including minimising bone loss, blood loss and operative time

Introduction. In cemented total hip arthroplasty (THA), proper cement mantle thickness in the femoral canal is still controversial subject. It is widely accepted that the cement mantle around a femoral stem should be at least 2 mm in thickness. But articles from France reported good long-term result with thin cement mantle. It is so called “The French paradox”. We have already reported that the greater compressive force at the cement-bone interface was seen in collarless polished tapered (CPT, Zimmer, USA) stem with thick cement mantle than that with thin cement mantle. However, the stem with thick cement mantle subsided more than with thin mantle. It may have a possibility to cause an early mechanical failure of cemented THA. We compared to stem and cement subsidence in various cement mantles using tantalum ball into cement in this study. Methods. A cemented stem model was used for this study with a CPT stem into composite femur. Three sizes of CPT stems (No. 1, No. 2 and No. 3) and one size composite femur were prepared for this study. We inserted two stems for each size, for a total of six stems. Composite femurs were reamed with a No. 3 rasp, and various size of stem was fixed with cement in each composite femur to make a various thicknesses of cement mantle. Two to three tantalum marker balls were injected into the cement in each femur before cement was hardened. 1-Hz dynamic load applied to the stems for half a-million cycles. Each 16 hours of loading was followed by 8 hours without loading. We used micro-CT before and after loading to measure the movement of the tantalum balls in three dimensions. And we analyzed occupation ratio of stem in the femoral canal by computed reconstructed three dimensional model of bone cement and stem. Results. We were able to detect a total of 13 balls in the cement for the 6 stems. The range of cement thickness in the CT slice on balls was 1.52 to 5.32 mm. Stem subsidence showed a significantly positive correlation to the thickness of cement mantle. In the horizontal plane, 8 of these 13 balls moved in an outside direction and five moved in an inside direction. The horizontal/perpendicular ratio for the tantalum balls showed a significant negative correlation to the thickness of the cement mantle. The subsidence rate (ratio of stem subsidence to ball subsistence) showed a significant negative correlation to the stem occupation ratio. The effective radial cement creep was also detected when the cement mantle was less than 2.5 mm thick and more than 60% in the occupation ratio. Conclusions. Stem subsistence was more commonly associated with cement subsidence in the thicker cement mantles and with a low stem occupation rate in CPT stems

Introduction. While fixation on the acetabular side in resurfacing implants has been uncemented, the femoral component is usually cemented. The most common causes for early revision in hip resurfacing are femoral head and or neck fractures and aseptic loosening of the femoral component. Later failures appear to be more related to adverse soft-tissue reactions due to metal wear. Little is known about the effect of cementing techniques on the clinical outcome in hip resurfacing, since retrieval analysis of failed hip resurfacing show large variations. Two cementing techniques have dominated. The indirect low viscosity (LV) technique as for the Birmingham Hip resurfacing (BHR) system and the direct high viscosity (HV) technique as for the Articular Surface replacement (ASR) system. The ASR was withdrawn from the market in 2010 due to inferior short and midterm clinical outcome. This study presents an in vitro experiment on the cement mantle parameters and penetration into ASR resurfaced femoral heads comparing both techniques. Methods. Five sets of paried frozen cadavar femura (3 male, 2 female) were used in the study. The study was approved by ethics committee. Plastic ASR replicas (DePuy, Leeds, UK), femoral head size 47Ø were used. The LV technique was used for the right femora (Group A, fig. 1 and 3) while the HV technigue was used for the left femora (Group B. Fig 2 and 4). The speciments were cut into quadrants. An initiial visual, qualitative evaluation was followed by CT analysis of cement mantle thickness and cement penetration into bone. Results. No significant differences were seen between the four quadrants within each group. The LV technigue resulted in greater cement penetration and increased cement mantle under the top proximally. The HV technique showed less penetration and lower cement mantle. See figures 1–4. Discussion. The aim was to analyze the effect of the cementing techniques used in hip resurfacing practice. The ASR implant was chosen to improve understanding of whether the implant may have been sensitive to cementing techniques and whether an analysis of cementing with the recommended HV technique may assist in explaning the high incidence of short-term ASR revisions due to fractures. Findings for the HV technigue would indicate a superior technique according to consensus in conventional arthropalsty However, this contradicts clinical evidence on resurfacing, where LV cementation has been shown tho be superior. The superficial intergration in the HV technigue may result in only a superficial integration and subsequently suboptimal fixation to bone. To view tables/figures, please contact authors directly

Background. Endoprosthetic reconstruction is an established method of treatment for primary bone tumours in children. Traditionally these were implanted with cemented intramedullary fixation. Hydroxyapatite collars at the shoulder of the implant are now standard on all extremity endoprostheses, but older cases were implanted without collars. Uncemented intramedullary fixation with hydroxyapatite collars has also been used in an attempt to reduce the incidence of problems such as aseptic loosening. Currently there are various indications that dictate which method is used. Aims. To establish long term survivorship of cemented versus uncemented endoprosthesis in paediatric patients with primary bone tumours. Methods. This was a retrospective study of 441 endoprostheses implanted in 367 consecutive patients aged 18 years or less, between 1973 and 2005. This included the use of case notes, hospital databases and a radiological review. Information obtained included patient demographics, indications for surgery, anatomical distribution and type of implants, complications and survivorship. Results. Mean age was 13.9 (range 3 - 38). 210 patients were male, 157 were female. There were 364 primaries and 77 revision implants. 161 extendable and 280 definitive prostheses. 282 patients had osteosarcoma, 54 had Ewing's sarcoma and 28 had other diagnoses. Commonest sites included 197 distal femoral replacements, 85 proximal tibial implants and 57 were in the upper limb. Kaplan-Meier survival analysis was used to compare anatomical sites and method of fixation. Upper limb implants had the best long term survival. Failure rates for distal femoral replacements were compared for cemented fixation (21.7% due to aseptic loosening) with cement plus hydroxyapatite collars (3.1%) and uncemented implants with hydroxyapatite collars (6.2%). Conclusions. In the distal femur cemented fixation with hydroxyapatite collars gave the best survivorship in definitive primary prostheses. Uncemented fixation with hydroxyapatite collars gave the best survivorship in extendable prostheses. Cemented fixation without hydroxyapatite gave the worst survivorship

The quality of femoral stem cementation has been shown to be a useful indicator of long-term survival of the total hip arthroplasty. Barrack's cementation grading is widely used but has certain limitations. It is based upon second-generation cementation technique and has high inter- and intra-observer variability. We introduce a new femoral cementation index based upon lengths of radiological lucency and cement-bone interface on AP and lateral views. Five observers graded femoral cementation of radiographs of 30 primary hip arthroplasties using Barrack's grading and the new index on two occasions and Inter- & Intra-observer reliability was assessed. We also assessed the correlation between proximal femoral anatomy (calcar-canal ratio) & structural bone quality (using cortical index) with cementation using the new index in 50 patients. Inter- and intra-observer reliability of the new index showed intraclass correlation coefficient 0.79 and 0.82 respectively and Barrack's grading system showed Kappa value- 0.20 (inter-observer) and 0.55 (intra-observer) reliability. There was poor correlation between the calcar-canal ratio and the quality of cementation [Pearson's coefficient −0.04 (p< 0.05)]. There was some correlation between the cortical index and the quality of cementation [Pearson's coefficient 0.46 (p < 0.05)]. Our new index is a reliable method of assessing femoral cementation. The anatomy of femoral canal didn't have any significant influence on the quality of cementation achieved as assessed by our new index. The femoral cortical structural quality seemed to have some positive influence on the quality of cementation

Aim. To evaluate the ability of different combinations of antibiotic loaded cement to inhibit bacteria growth and biofilm formation. Method. Cement beads were aseptically prepared using Palacos R (plain 40g PMMA cement) or Palacos R+G (40g PMMA cement containing industrially added 0.5g of gentamicin), with or without supplementary antibiotics as follows: Palacos R; Palacos R+G; Palacos R plus 1g / 2g daptomycin; Palacos R+G plus 1g / 2g of daptomycin; Palacos R plus 1g / 2g vancomcyin; and Palacos R+G plus 1g / 2g vancomycin. After production, each antibiotic loaded acrylic cement (ALAC) combination was allocated into two groups (group 1 and 2). The group 2 cement beads were initially eluted in broth at 37. o. C for 72hours then transferred to fresh broth containing a known concentration of bacteria. The group 1 samples were not eluted but directly immerse in culture broth containing bacteria. All samples were thereafter incubated at 37. o. C for 24 hours. After incubation, group 1 samples were visually assessed for bacterial growth, while for the group 2 samples, biofilm formation were quantified using ultrasonication and viable bacteria counting technique. Three proficient biofilm forming Staphylococcus epidermidis bacterial strains (1457, 1585-RA and 5179-R1) were used for all experiments and the bacteria counts were expressed as colony forming units / ml (CFU/ml). Results. In the group 1 samples, all the ALAC combinations were able to inhibit growth of all the three biofilm bacteria strains assessed except the gentamicin only samples in which biofilm growth were observed within 24hours. Meanwhile, in group 2, bacterial growth and biofilm formation by all three bacterial strains were observed on all the ALAC combinations, with the least biofilm formation being on the Palacos R+G plus 2g daptomycin combinations (mean CFU/ml: 1.04E +06) and the greatest on the gentamicin only cement (mean CFU/ml: 2.3E +07). Conclusions. Our study demonstrates that the highest antimicrobial activity of ALAC is seen in the first 24 hours. However, after 72 hours of antibiotic release, fresh bacterial exposure in fresh broth resulted in varying degrees of biofilm colonisation of all ALAC surfaces. Nonetheless, the overall biofilm formation was least on the gentamicin / daptomycin combinations and the results were statistically significant when compared to plain cement (p < 0.05, two tail t-test)

Aim. The aim of this investigation was to compare risk of infection in both cemented and cementless hemiarthroplasty (HA) as well as total hip arthroplasty (THA) following femoral neck fracture. Methods. Data collection was performed using the German Arthroplasty Registry (EPRD) In HA and THA following femoral neck fracture fixation method was divided into cemented and cementless protheses and paired according to age, sex, body mass index (BMI), and the Elixhauser score using Mahalanobis distance matching. Results. Overall in 13,612 cases of intracapsular femoral neck fracture, with 9,110 (66.9 %) HAs and 4502 (33.1 %) THAs were analyzed. Infection rate in HA was significantly reduced in cases with use of antibiotic-loaded cement compared to cementless fixated prosthesis (p=0.013). In patients with THA no statistical difference between cemented and cementless prothesis was registered, however after one year 2.4 % of infections were detected in cementless and 2.1 % in cemented THA. In the subpopulation of HA after one year 1.9 % of infections were registered in cemented and 2.8 % in cementless HA. BMI (p=0.001) and Elixhauser-Comorbidity-Score (p<0.003) were identified as risk factors of PJI, while in THA also cemented prosthesis demonstrated within the first 30 days an increased risk (HR=2.728; p=0.010). Conclusion. The rate of infection after intracapsular femoral neck fracture was significantly reduced in patients treated by antibiotic-loaded cemented hemiarthroplasty. In particular for patients with multiple risk factors for the development of a PJI the usage of antibiotic-loaded bone cement seems to be a reasonable procedure for prevention of infection

Current evidence suggests that we should be moving away from Thompson's hemiarthroplasties for patients with intracapsular hip fractures. Furthermore, the use of cement when inserting these prostheses is controversial. This study aims to show the Inverness experience. We performed a retrospective review of all NHS Highland patients who underwent a hemiarthroplasty for an intracapsular neck of femur fracture over the last 15 years. Demographics and the use of cement were documented. Further analysis of this group was performed to identify any of these patients who required revision of their prosthesis. Patients requiring revision had their case-notes reviewed to identify the cause for further surgery. From 1996 until present 2221 patients from the Highland area had a hemiarthroplasty for an intracapsular neck of femur fracture. 1708 where female (77%) and 513 male (23%). The ages ranged from 28 years to 104 years (mean 80 years, median 81). 2180 of this group had their operations in Raigmore Hospital with the remaining 41 at various centres throughout Scotland. 623 (28%)had a cemented hemiarthroplasty, with the remaining 1578 (72%) having an uncemented Thompson's hemiarthroplasty. The revision rate for the cemented group was 2% (13 of 623 patients). In the uncemented group it was 0.4% (6 of 1578). Reasons from revision included dislocation, periprosthetic fracture, infection and pain. Current evidence from some joint registers regarding the use of Thompson's hemiarthroplasty in the elderly is discouraging. The use of bone cement in this group with multiple co-morbidities is not without it's risks. Our data suggests that uncemented Thompson's hemiarthroplasties in low demand elderly patients with multiple co-morbidities can yield excellent results with less risk to the patients

Great strides have been made in the early detection and treatment of cancer which is resulting in improved survivability and more Canadians living with cancer. Approximately 80% of primary breast, lung, and prostate cancers metastasize to the spine. Poly-methyl methacrylate (PMMA) bone cement is one of the most commonly used bone substitutes in spine surgery. In clinical practice it can be loaded with various drugs, such as antibiotics or chemotheraputic drugs, as a means of local drug delivery. However, studies have shown that drugs loaded into PMMA cement tend to release in small bursts in the first 48–72 hours, and the remaining drug is trapped without any significant release over time. The objective of this study is to develop a nanoparticle-functionalized PMMA cement for use as a sustained doxorubicin delivery device. We hypothesize that PMMA cement containing mesoporous silica nanoparticles will release more doxorubicin than regular PMMA. High viscosity SmartSet ™ PMMA cement by DePuy Synthes was used in this study. The experimental group consisted of 3 replicates each containing 0.24 g of mesoporous silica nanoparticles, 1.76 g of cement powder, 1ml of liquid cement monomer and 1 mg of doxorubicin. The control group consisted 3 replicates each containing 2.0 g of cement powder, 1ml of liquid cement monomer and 1 mg of doxorubicin. The experimental group contained an average of 8.18 ± 0.008 % (W/W) mesoporous silica nanoparticles. Each replicate was casted into a cylindrical block and incubated in a PBS solution which was changed at predetermined intervals for 45 days. The concentration of eluted doxorubicin in each solution was measured using a florescent plate reader. The mechanical properties of cement were assessed by unconfined compression testing. The effect of the doxorubicin released from cement on prostate and breast tumor cell metabolic activity was assessed using the Alamar Blue test. After 45 days the experimental group released 3.24 ± 0.25 % of the initially loaded doxorubicin which was more than the 2.12 ± 0.005% released by the control group (p 0.03). There was no statistically significant difference in Young's elasticity modulus between groups (p 0.53). Nanoparticle functionalized PMMA suppressed the metabolic activity of prostate cancer by more than 50 percent but did not reach statistical significance. Nanoparticle functionalized PMMA suppressed the metabolic activity of breast cancer cells by 69 % (p < 0.05). Nanoparticle-functionalized PMMA cement can release up to 1.53 times more doxorubicin than the standard PMMA. The use of mesoporous silica nanoparticles to improve drug release from PMMA cement shows promise. In the future, in vivo experiments are required to test the efficacy of released doxorubicin on tumor cell growth

Objectives. This study is to compare the elution characteristics, antimicrobial activity, and mechanical properties of antibiotic-loaded bone cement (ALBC) loaded with powder antibiotic, powder antibiotic with inert filler (xylitol), or liquid antibiotic, particularly focusing on vancomycin and amphotericin B. Methods. Cement specimens loaded with 2 g of vancomycin or amphotericin B powder (powder group), 2 g of antibiotic powder, and 2 g of xylitol (xylitol group) or 12 ml of antibiotic solution containing 2 g of antibiotic (liquid group) were tested. Results. Vancomycin elution was enhanced by 234% in the liquid group and by 12% in the xylitol group compared with the powder group. Amphotericin B elution was enhanced by 265% in the liquid group and by 65% in the xylitol group compared with the powder group. Based on the disk-diffusion assay, the eluate samples of vancomycin–loaded ALBC of the liquid group exhibited a significantly larger inhibitory zone than samples of the powder or xylitol group. Regarding the amphotericin B–loaded ALBCs, only the eluate samples of the liquid group exhibited a clear inhibitory zone which was not observed in either xylitol nor powder groups. The ultimate compressive strength was significantly reduced in specimens containing liquid antibiotics. Conclusions. Adding vancomycin or amphotericin B antibiotic powder in distilled water before mixing with bone cement can significantly improve the antibiotic-release efficacy than that by loading ALBC with the same dose of antibiotic powder. This simple, and effective method for preparation of ALBCs can significantly improve the antibiotic-release efficacy of ALBCs

The objective of this study was to compare the elution characteristics, antimicrobial activity and mechanical properties of antibiotic-loaded bone cement (ALBC) loaded with powdered antibiotic, powdered antibiotic with inert filler (xylitol), or liquid antibiotic, particularly focusing on vancomycin and amphotericin B. Cement specimens loaded with 2 g of vancomycin or amphotericin B powder (powder group), 2 g of antibiotic powder and 2 g of xylitol (xylitol group) or 12 ml of antibiotic solution containing 2 g of antibiotic (liquid group) were tested. Vancomycin elution was enhanced by 234% in the liquid group and by 12% in the xylitol group compared with the powder group. Amphotericin B elution was enhanced by 265% in the liquid group and by 65% in the xylitol group compared with the powder group. Based on the disk-diffusion assay, the eluate samples of vancomycin-loaded ALBC of the liquid group exhibited a significantly larger inhibitory zone than samples of the powder or the xylitol group. Regarding the ALBCs loaded with amphotericin B, only the eluate samples of the liquid group exhibited a clear inhibitory zone, which was not observed in either the xylitol or the powder groups. The ultimate compressive strength was significantly reduced in specimens containing liquid antibiotics. Adding vancomycin or amphotericin B antibiotic powder in distilled water before mixing with bone cement can significantly improve the efficiency of antibiotic release than can loading ALBC with the same dose of antibiotic powder. This simple and effective method for preparation of ALBCs can significantly improve the efficiency of antibiotic release in ALBCs. We thank H.Y. Hsu for performing the bioassay

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

Abstract. Background. The aim of the present experimental study was to analyse vancomycin elution kinetics of nine bone fillers used in orthopaedic and trauma surgery over 42 consecutive days. Methods. Two allograft bone chips (carriers 1 and 2), a calcium-sulfate matrix (carrier 3), a hydroxyapatite/calcium-sulphate composite (carrier 4), four bone cements (carriers 5-8) and a pure tricalcium phosphate matrix (carrier 9), either already contained vancomycin, or were mixed with it following manufacturer's recommendations. Over 42 days, half of elution medium was substituted by the same amount of PBS at 9 distinct time points. Vancomycin concentration in obtained samples were measured with a kinetic microparticle immunoassay, and masses consecutively calculated. To enhance comparability between carriers analysed, vancomycin mass released related to overall mass within each probe was determined. Notably, elution kinetics of carriers 1 to 4 have been published previously. Results. All carriers initially released high vancomycin masses, followed by constant reduction later into the experiment. Mean initial vancomycin masses released after 4 hours were highest for carriers 1 (337.7 ± 76.2 mg), 9 (68.4 ± 4.9 mg), and 2 (49.0 ± 54.6 mg). From prefinal (35 days) to last measurement (42 days) carriers 2 (8.6 ± 4.8 mg), 1 (2.4 ± 1.0 mg), and 5 (0.1 ± 0.1 mg) had released highest vancomycin masses. Notably, all five bone cements tested only released a small percental amount of their total mass up to the last measurement (42 days; 2.1% – 9.3%), whilst allografts and resorbable synthetic bone fillers discarded high percental values (22.5% – 79.2%). Conclusions. Elution kinetics differ between 9 antibiotic-loaded bone fillers, with high vancomycin masses released by allografts and resorbable bone fillers over time. Transferred to clinical practice, these may be favoured over bone cements in case prolonged and high antibiotic release is warranted rather than mechanical stability

The development of more wear resistant biomaterials and better locking mechanisms for the polyethylene into the tibial base has significantly reduced polyethylene wear as a reason for revision TKA. Aseptic loosening is now the primary cause for revision TKA. Loosening can be caused by multifactorial operative issues: 1] patient selection, 2] implant alignment, 3] cementing technique. Furthermore, aseptic loosening occurs at a consistent rate over time. Increased cement penetration is important to counter bone resorption. Increasing penetration also improves cement mantle toughness leading to better mechanical integrity of the bone-cement interface and reduces bone-cement interface stress. It is important to recognise that a cleaner and drier interface does improve bone-cement penetration. Techniques to improve the process include better cement formulations, drilling sclerotic bone, devices and implant features to increase pressurization, using negative pressure suction ports in the tibia. We have extensive experience with CarboJet, a method of CO. 2. gas jet cleaning and drying. This experience was developed during 20 years of performing TKA with NO tourniquet. Schnetler et al found that the “use of a tourniquet in TKA causes a paradoxical increase in total blood loss”. So, NO tourniquet TKA is becoming the new paradigm for knee arthroplasty in reconstructive orthopaedics. Goldstein reported that pressurised carbon dioxide jet lavage resulted in a 35% increase in cement penetration depth when used vs. use of pulsatile saline lavage alone. Meneghini used this pressurised carbon dioxide system to study the influence of NO tourniquet use in TKA. He found a significant lowering of opioid consumption postoperatively. Another important factor in increasing the cement interdigitation is the influence of lipids which significantly weakens the bond at the interfaces. If motion is allowed during cementation there is additional loss of penetration and therefore fixation. The pressurised carbon dioxide delivered by the CarboJet system actually pushes the lipid, fatty marrow up and out of the bone allowing it to be suctioned or lap dried from the interface surface. The NO tourniquet technique and the use of carbon dioxide jet gas delivery to improve the bone-cement interface in TKA will be demonstrated

The development of more wear resistant biomaterials and better locking mechanisms for the polyethylene into the tibial base has significantly reduced polyethylene wear as a reason for revision TKA. Aseptic loosening is now the primary cause for revision TKA. Loosening can be caused by multifactorial operative issues: 1] patient selection, 2] implant alignment, 3] cementing technique. Furthermore, aseptic loosening occurs at a consistent rate over time. Increased cement penetration is important to counter bone resorption. Increasing penetration also improves cement mantle toughness leading to better mechanical integrity of the bone-cement interface and reduces bone-cement interface stress. It is important to recognise that a cleaner and drier interface does improve bone-cement penetration. Techniques to improve the process include better cement formulations, drilling sclerotic bone, devices and implant features to increase pressurization, using negative pressure suction ports in the tibia. We have extensive experience with CarboJet, a method of CO2 gas jet cleaning and drying. This experience was developed during 20 years of performing TKA with NO tourniquet. Schnetler et al found that the “use of a tourniquet in TKA causes a paradoxical increase in total blood loss”. So, NO tourniquet TKA is becoming the new paradigm for knee arthroplasty in reconstructive orthopaedics. Goldstein reported that pressurised carbon dioxide jet lavage resulted in a 35% increase in cement penetration depth when used versus use of pulsatile saline lavage alone. Another important factor in increasing the cement interdigitation is the influence of lipids which significantly weakens the bond at the interfaces. If motion is allowed during cementation there is additional loss of penetration and therefore fixation. The pressurised carbon dioxide delivered by the CarboJet system actually pushes the lipid, fatty marrow up and out of the bone allowing it to be suctioned or lap dried from the interface surface. The NO tourniquet technique and the use of carbon dioxide jet gas delivery to improve the bone-cement interface in TKA will be demonstrated

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