Antibiotic Impregnated Cement: Short-term Gain for Long-term Pain

Ross K. Leighton, M.D., FRCSC
Halifax, NS

The reason total joint arthroplasty has gained wide-spread support is due to its successful long-term outcomes. This, along with its number one position in cost effectiveness, has propelled it to take a prominent role in health care.

Anything that drives up the cost (antibiotic cement) or potentially reduces the long-term outcome (weakening of the cement mantle by mixing it with antibiotics), may reduce total joint arthroplasty's impact on the general population and reduce its elevated position in health care.

We know that any addition of antibiotics will reduce the strength of the cement mantle. How much is too much is unknown at this time. The long-term outcomes in North America have all been achieved without antibiotic cement. Is the "potential" short-term reduction in the infection rate worth early loosening of our components?

Dr. Steven MacDonald would have you believe that the effect of antibiotic cement can be seen in the Swedish Joint Registry. This, despite the fact that the Registry is a retrospective study with very minimal measurements taken of the population. The main outcome is revision!

There is truly concern that the blanket use of prolonged antibiotic therapy around total joint arthroplasty has lead to the emergence of selected resistant organisms on our wards. Methicillin Resistant Staph Aureous, resistant Strep infections and gram negative infections are rampant in large centres in Canada and the United States.

Mike Chapman in the 90's warned us of an antibiotic honeymoon. This is now coming to a head with the reduction in good standard OR protocol and a dependence on preop antibiotics, and now with antibiotics extended for six weeks (antibiotic cement) postop. This is setting us up for a crisis of gigantic proportions. We should be piloting better peri-operative techniques to reduce all operative infections, not just the ones requiring cement. If antibiotic impregnated cement is considered superior, are we to assume that our cementless patients are receiving inferior care?

If we, as a surgical specialty, are truly concerned about the infection rate we should be exerting our influence on the operative environment.

We should be very concerned with:

  1. The preoperative preparation of the patient and the operative site.
  2. Our operative environment: gloves, boots, waterproof gowns, space suits etc.
  3. Preoperative scrub in the OR - what, if anything, is the best?
  4. Alcohol versus betadine paint. Alcohol is still the best in most studies.
  5. "In and Out" of personal in the OR during the surgery. This has always had a "huge effect" in all studies but seems to have been neglected in most North American OR's.
  6. Postoperative dressing changes with clean trays and gloves etc. Clean technique with procedures done as prescribed for proper patient care.

Finally, with all of the above, a return to sterile and clean techniques should be engineered. With these techniques as a baseline, a prospective, randomized, muticentred, well powered study should be conducted to determine if this more expensive technique (antibiotic cement) truly makes a difference.

Just as in our present economic crisis, our quest for short-term quick gains may lead to long-term pain: early total joint failures secondary to weaker cement, or the emergence of ultra resistant bacteria.

Hopefully this debate will lead to better OR techniques and a reduced infection rate in all of our operating theatres.

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