Antibiotic Prophylaxis in Total Hip Arthroplasty

Abstract

We have assessed the effect of different regimes of antibiotic prophylaxis on the survival of total hip implants, comparing antibiotics administered both systemically and in the bone cement, systemically only, in the bone cement only and with no antibiotics given.We studied 10 905 primary cemented total hip replacements, performed for osteoarthritis of the hip and reported to the Norwegian arthroplasty register between 1987 and 1995. Cox-estimated failure-rate ratios (FRR) are presented with adjustment for gender, age, the brand of cement, the prosthesis, the type of operating theatre and the operating time.For revisions performed for infection (39 operations), the lowest rate of revision was found among patients receiving antibiotic-containing cement plus systemic antibiotics (n = 5804). The revision rate for the 4586 patients receiving systemic antibiotics only was 4.3 times greater (95% CI 1.7 to 11.0, p = 0.001); in 239 with antibiotics in the bone cement only it was 6.3 times greater (CI 1.6 to 25.0, p = 0.003); and in the 276 who did not receive antibiotics it was by 11.5 times greater (CI 2.1 to 63.0, p = 0.002). Adjustment for the total amount of systemic antibiotic administered did not change the results. We also observed an increased revision rate for aseptic loosening (109 operations) comparing the systemic-only (FRR = 1.8, CI 1.1 to 2.9, p = 0.01) and the cement-only regimes (FRR = 2.6, CI 1.2 to 5.9, p = 0.02) with the combined dosage.Our findings show that systemic antibiotics combined with antibiotic-containing bone cement led to fewer revisions than the other methods.

Adherent Endotoxin on Orthopedic Wear Particles Stimulates Cytokine Production and Osteoclast Differentiation

“…For example, inclusion of antibiotics in the polymethylmethacrylate cement has been reported to reduce the incidence of aseptic loosening of orthopedic implants by approximately 50%. (39) Our results should stimulate development of additional approaches designed to reduce the activity of adherent endotoxin in patients with orthopedic implants.…”

“…(37,38) The potential importance of subclinical levels of bacteria is emphasized by a Norwegian study of over 10,000 total hip replacements showing that inclusion of antibiotics in the bone cement used for fixation of the implant reduced the frequency of aseptic loosening by approximately 50%. (39) A third source of adherent endotoxin is systemic endotoxin, (40) which is derived most likely from intestinal flora, minor infections, or dental procedures. (41) The high affinity of wear particles for endotoxin (25) may allow significant amounts of systemic endotoxin to bind to wear particles that are generated in patients.…”

Does endotoxin contribute to aseptic loosening of orthopedic implants?

“…The potential importance of bacteria in aseptic loosening is emphasized by a Norwegian study of Ͼ20,000 total hip replacements showing that inclusion of antibiotics in the PMMA cement used for fixation of the implant reduces the frequency of aseptic loosening. 72,73 The likely explanation for these findings is that relatively rapid elution of the antibiotics from the PMMA reduces bacterial biofilm formation 74,75 thereby allowing host bone cells to win the "race to the surface." 76 We have begun to extend the studies described in the previous paragraph demonstrating the presence of bacteria by examining the presence of endotoxin per se in periprosthetic tissue from patients with aseptic loosening.…”

Femoral Cementing Techniques: Current Trends in the UK

“…This is a positive trend, considering reports of reduced revision rates with the use of high viscosity cement for aseptic loosening 5 and antibiotic-containing cement in combination with systemic antibiotics for septic loosening. 6 The polymerisation of cement is highly dependent on the ambient room temperature and the starting temperature of the components. 1 Over two-thirds of the surgeons in the survey identified inconsistencies with the setting of the cement.…”