PMMA bone cement: what is the role of local antibiotics?
Background: Periprosthetic joint infection (PJI) remains a significant complication in orthopedic surgery, associated with high morbidity and substantial economic burden. While polymethylmethacrylate (PMMA) bone cement is established for prosthesis fixation, the routine use of antibiotic-loaded bone cement (ALBC) for infection prophylaxis and management remains a subject of clinical debate regarding efficacy and the potential for antimicrobial resistance.
Objective: This review evaluates the clinical evidence, pharmacokinetic properties, and microbiological rationale for utilizing ALBC in primary and revision arthroplasty, focusing on its role as a local drug delivery system to prevent and treat biofilm-associated infections.
Key Points: Analysis of large-scale arthroplasty registries indicates that combining systemic antibiotic prophylaxis with ALBC significantly reduces revision rates due to infection compared to either method alone. Gentamicin is the standard additive for primary procedures due to its broad-spectrum activity and favorable elution kinetics. In revision settings, high-dose ALBC containing synergistic combinations, such as gentamicin with clindamycin or vancomycin, provides high local concentrations exceeding the minimum inhibitory concentration for sessile bacteria without significant systemic toxicity. Data suggest that industrially manufactured ALBC maintains superior mechanical properties and more predictable antibiotic release profiles compared to manual admixing. Furthermore, the use of ALBC spacers in two-stage revision protocols facilitates infection eradication while maintaining joint space and function.
Conclusion: ALBC serves as an effective adjuvant in arthroplasty, providing a critical local barrier against bacterial colonization and biofilm formation. Its application is supported by registry data demonstrating improved implant survivorship and cost-effectiveness, particularly in high-risk patient populations and complex revision scenarios.
