Routine use of commercial antibiotic-loaded bone cement in primary total joint arthroplasty: a critical analysis of the current evidence

Antibiotic-loaded cement (ABLC) has been widely utilized as an adjuvant treatment for patients with periprosthetic joint infection (PJI) but has also evolved to play a prophylactic role against infection in primary total joint arthroplasties (TJA). Nevertheless, there is currently a paucity of studies that systematically investigated this concept. This review aimed at answering the following questions: (I) Can routine use of ABLC help reduce the current infection rates in primary TJA? (II) What are the risks associated with this approach? And (III) can routine use be justified in primary TJA from an economic standpoint? Multiple databases were queried including PubMed, EMBASE, EBSCO Host, and SCOPUS. Studies published between January 1, 1990 and March 31, 2018 were reviewed. Inclusion criteria were studies reporting: (I) clinical outcomes of routine use of ABLC in primary hip and knee arthroplasty with 2-year minimum follow-up, (II) complications related to the use of ABLC, (III) cost of using ABLC. The final analysis included 24 studies. Data from multiple studies demonstrate contradictory results for infection rates when ABLC is used in all primary procedures with a majority of studies showing similar infection rates between ABLC and plain cement. The main concerns associated with routine use of ABLC are negative effects on the mechanical stability of cement, possible systemic and local toxicity of the absorbed antibiotic, and development of resistant bacterial strains. However, current literature has not clinically validated these concerns. Lastly, with an estimated increase in 117 million dollars with the routine use of ABLC in only 50% of TJAs performed each year, it is difficult to justify the use of ABLC without clear superiority in reducing infection. The use of ABLC has undeniably changed the way orthopaedic surgeons deal with PJI today. However, the large-scale, prophylactic use of ABLC in primary TJAs requires further research and justification.