Limited evidence suggests the use of antibiotics in the cement may reduce the risk of periprosthetic joint infections for patients undergoing cemented total hip arthroplasty (THA).

Rationale
Total hip arthroplasty is commonly done both with and without cement and with a hybrid approach where one component is cemented and one is not. This recommendation is not intended to imply when cement should be used, but rather only to address the issue of whether antibiotics should be used with cement when cement is used in total hip arthroplasty. There is one randomized controlled study (RCT) evaluating the impact of cefuroxime in cement on deep infection rates after hip and knee replacement with no significant difference in infection rates. (McQueen, 1990). The results of observational studies examining the use of antibiotic cement with total hip arthroplasty have had mixed results. Using deep infection as an outcome, studies have found decreased risk (Schrama, 2015; Dale, 2009). One author compared antibiotic cement to uncemented techniques and reported lower risk of revision for infection in the cement group. (Dale, 2009) Others have failed to show any difference in infection rates when comparing antibiotic and plain cement. (Gandhi, 2009; Dowsey, 2008).

The issue of overall revision risk and implant loosening has been examined as well. One study found the use of antibiotic cement reduced the risk of revision overall and for aseptic loosening when both components were cemented compared with hybrid or uncemented techniques (Engesaeter 2006). However, no difference in revision for infection was noted. Another study found decreased risk of revision for infection when antibiotic cement was used compared to cement without antibiotics (Dale 2012). The use of systemic antibiotics and antibiotic cement compared with systemic antibiotics alone decreased the risk of aseptic loosening, overall revision, revision for infection, and revision for loosening in observational registry studies. (Espehaug 1997 and Engesaeter 2003).

The importance of this recommendation regards the prevention of infection by using antibiotic cement as additional prophylaxis, which can have significant impact on patient function, and overall morbidity and health.

POSSIBLE HARMS OF IMPLEMENTATION
Indiscrimate use of antibiotic laden cement may have unintended consequences that were not specifically evaluated with this recommendation. Although the studies did not show increased risk of implant loosening, it is possible that cement with higher doses of antibiotics could increase risk of loosening by changing the mechanical properties of the cement fixation. Similarly, there is the potential for other effects such as antimicrobial resistance or increased costs to the healthcare system that should be considered.

FUTURE RESEARCH
Adequately powered randomized controlled trials assessing the impact of antibiotic cement on deep infection, implant survival and other patient outcomes are needed to determine which specific patient groups may benefit from this prophylactic treatment with total knee arthroplasty.
  1. (28) Engesaeter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin LI. Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the Norwegian Arthroplasty Register. Acta Orthop Scand 2003;74(6):644-651.
  2. (28) Engesaeter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin LI. Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the Norwegian Arthroplasty Register. Acta Orthop Scand 2003;74(6):644-651.
  3. Dale,H., Fenstad,A.M., Hallan,G., Havelin,L.I., Furnes,O., Overgaard,S., Pedersen,A.B., Karrholm,J., Garellick,G., Pulkkinen,P., Eskelinen,A., Makela,K., Engesaeter,L.B. Increasing risk of prosthetic joint infection after total hip arthroplasty. Acta Orthop. 2012/10; 5: 449-458
  4. Dale,H., Hallan,G., Hallan,G., Espehaug,B., Havelin,L.I., Engesaeter,L.B. Increasing risk of revision due to deep infection after hip arthroplasty. Acta Orthop. 2009/12; 6: 639-645
  5. Dowsey,M.M., Choong,P.F. Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin.Orthop.Relat.Res. 2009/6; 6: 1577-1581
  6. Engesaeter,L.B., Espehaug,B., Lie,S.A., Furnes,O., Havelin,L.I. Does cement increase the risk of infection in primary total hip arthroplasty? Revision rates in 56,275 cemented and uncemented primary THAs followed for 0- 16 years in the Norwegian Arthroplasty Register. Acta Orthop. 2006/6; 3: 351-358
  7. Espehaug,B., Engesaeter,L.B., Vollset,S.E., Havelin,L.I., Langeland,N. Antibiotic prophylaxis in total hip arthroplasty. Review of 10,905 primary cemented total hip replacements reported to the Norwegian arthroplasty register, 1987 to 1995. J.Bone Joint Surg.Br. 1997/7; 4: 590-595
  8. Gandhi,R., Razak,F., Pathy,R., Davey,J.R., Syed,K., Mahomed,N.N. Antibiotic bone cement and the incidence of deep infection after total knee arthroplasty. J.Arthroplasty 2009/10; 7: 1015-1018
  9. McQueen, M.M., Hughes,S.P., May,P., Verity,L. Cefuroxime in total joint arthroplasty. Intravenous or in bone cement. J.Arthroplasty 1990/6; 2: 169-172
  10. Schrama,J.C., Fenstad,A.M., Dale,H., Havelin,L., Hallan,G., Overgaard,S., Pedersen,A.B., Karrholm,J., Garellick,G., Pulkkinen,P., Eskelinen,A., Makela,K., Engesaeter,L.B., Fevang,B.T. Increased risk of revision for infection in rheumatoid arthritis patients with total hip replacements. Acta Orthop. 2015; 4: 469-476