Guideline-Directed Administration of Prophylactic Antibiotic-Loaded Bone Cement in Total Knee Arthroplasty Does Not Lower Infection Rate

Abstract

Background:

Periprosthetic joint infection (PJI) is a major complication following total knee arthroplasty (TKA). Antibiotic-loaded cement (ALBC) is commonly used as a preventative measure, though it remains controversial. Despite guidelines from organizations including the American Academy of Orthopedic Surgeons (AAOS) and the International Consensus Meeting on Musculoskeletal Infection (ICM), ALBC usage in primary TKA varies. The purpose of this study was to evaluate the effectiveness of guideline-directed ALBC utilization in reducing PJI in primary TKA.

Patients and Methods:

A retrospective cohort study was conducted at a single center, including 6,429 primary cemented TKAs performed between 2019 and 2022. ALBC was used in 21.6% of cases. PJI rates were analyzed using univariate, multivariate, and propensity score-matched analyses. Adherence to guidelines from New England Baptist Hospital (NEBH), AAOS, and ICM was assessed. Cost analysis was performed to compare differences between ALBC and plain cement.

Results:

The incidence of PJI was 0.22%, with no significant difference between ALBC (0.43%) and plain cement (0.16%) groups. Multivariate analysis revealed no significant predictors of PJI, including ALBC use (p > 0.05). Adherence to guidelines was low across all criteria, ranging from 23.5% (ICM) to 41% (NEBH), and did not reduce PJI risk. Cost analysis showed $210,000 in ALBC use.

Conclusions:

Guideline-directed ALBC use did not significantly reduce PJI rates in primary TKA, and overall adherence to guidelines was limited. Had all primary TKA cases in this analysis utilized plain cement, the hospital would have saved more than $200,000 on primary TKA alone. These findings suggest that current criteria guiding ALBC use in primary TKA for PJI prophylaxis may overestimate its value.