Journal of Orthopedic Oncology
Open Access

One of the most dreaded complications following total joint arthroplasty (TJA) is deep infection. With the advent of highly crosslinked polyethylene and other technological advances, one of the most common reasons for revision joint arthroplasty is now deep infection. Antibiotic-loaded bone cement (ALBC) was first introduced and used in lieu of plain bone cement (PBC) by Buchholz and Englebrecht in 1970 in an effort to decrease infection rates [1]. The literature has not been clear on the effectiveness of ALBC in decreasing infection rates in TJA patients. Furthermore, studies have reported that when high doses antibiotics (>4.5 grams of antibiotic powder per 40 grams of cement) are used, mechanical complications such as hardware loosening can occur much more frequently [2-5]. Acute renal failure has also been reported in patients who received ALBC during TJA [6-9]. Moreover, with the rise of bundled payment models the potentially unnecessary costs such as that of routine ALBC use have been increasingly scrutinized by hospital systems. With this in mind, the authors recently published a retrospective review of over 4100 consecutive patients who underwent cemented primary total knee arthroplasty (TKA), total hip arthroplasty (THA), unicondylar knee arthroplasty (UKA), and hip hemiarthroplasty using either ALBC or PBC [10].

In our series, we performed a retrospective review of 4139 consecutive cases performed between 2016 and 2018 at a suburban, regional, tertiary care center. We retrospectively collected data in regards to patient demographics and any readmissions due to deep infection. During the study period there were a total of 4016 knee cases (423 ALBC, 3593 PBC) and 123 hip cases (63 ALBC, 60 PBC). There was a total of 3021 unilateral TKAs, 705 bilateral TKAs, 290 UKAs, 46 THAs, 34 hip resurfacing cases, 43 bipolar hip hemiarthroplasty cases. At our institution, the average cost for one bag of ALBC is $336.42 while one bag PBC costs an average of $72.14. There were ten total patients who were readmitted due to deep infection, all of which had undergone TKA. This resulted in an infection rate of 0.19% in the ALBC group and 0.62% PBC group, with no statistically significant difference (p=0.103). There was a diverse group of bacteria causing deep infections in both groups. The PBC group included 2 cases of Methicillin-Resistant Staphylococcus aureus (MRSA) while the ALBC group included 1 case of Extended-spectrum beta-lactamase-positive Escherichia coli and no cases of MRSA. Also, when the patients were stratified for various comorbidities (diabetes, chronic obstructive pulmonary disease, congestive heart failure, renal disease, obesity) there was no statistically significant difference in the rate of deep infection in the ALBC group versus the PBC group. A total of 778 bags of ALBC were used in 423 knee cases and 98 bags of ALBC were used in 63 hip cases. The total cost for ALBC in the knee surgery group was $261,734.76 and $32,969.16 in the hip surgery group. If PBC had been used during all index knee and hip procedures, it would have resulted in a total savings of $231,509.28 for our hospital.

One of the major limitations of this study was that there were multiple surgeons involved, each with different surgical techniques that were not controlled for. Furthermore, the patients were not randomized leading to potential cement type selection bias, however when sub stratifying the various comorbidities there was no significant difference in deep infection rates. Lastly, this review only included 4139 cases. The rate of deep infection in the literature has been shown to be less than 1-2% in primary TJA. With the rate of deep infection so low the present study may be underpowered and would require a greater number of patients in order to see if there are any significant differences between the two groups, especially when looking specifically at various comorbidities within the ALBC and PBC groups.

The study adds to the growing body of literature that is calling into question the regular use of ALBC in routine primary hip and knee arthroplasty cases. Larger, randomized, multicenter studies may be needed to further validate the findings of this study. As more hospitals transition to a bundled payment model, it becomes important for providers to decrease any unnecessary costs while increasing efficiency and maintaining high quality patient care.

The study adds to the growing body of literature that is calling into question the regular use of ALBC in routine primary hip and knee arthroplasty cases. Larger, randomized, multicenter studies may be needed to further validate the findings of this study. As more hospitals transition to a bundled payment model, it becomes important for providers to decrease any unnecessary costs while increasing efficiency and maintaining high quality patient care.