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PMMA BONE CEMENT: WHAT IS the ROLE of LOCAL ANTIBIOTICS? Klaus-Dieter KÜHN1,2, Elke LIEB1,3, Christof BERBERICH1

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PMMA BONE CEMENT: WHAT IS the ROLE of LOCAL ANTIBIOTICS? Klaus-Dieter KÜHN1,2, Elke LIEB1,3, Christof BERBERICH1 PROCEEDING OF N°243 COMMISSION PARITAIRE 1218T 86410 ISSN : 1148 2362 N° 243 UPDATE PMMA BONE CEMENT: WHAT IS THE ROLE OF LOCAL ANTIBIOTICS? Klaus-Dieter KÜHN1,2, Elke LIEB1,3, Christof BERBERICH1 1Heraeus Medical GmbH, Philipp-Reis-Str. 8/13, D-61273 Wehrheim 2Deptartment of Orthopaedic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria 3Klinik für Orthopädie, Center für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin INTRODUCTION sion implants. Because of cement really add benefit to European registries have the high initial release of the common practice of sys- shown longer survival data local antibiotics into the temic AB prophylaxis and to of cemented arthroplasty, joint cavity, ALBC has also AB treatment protocols in particularly when looking at Recently, PMMA bone been successfully used for cases of already established the endpoint revisions due cement has celebrated the decades for prophylactic prosthetic joint infections? to infection [1] (see Figure 50th anniversary of its cli- reasons aimed at prevention 1, 2). It has to be pointed nical use. During this time, of bacterial colonisation of Fortunately, prosthetic out, however, that important surgeons have appreciated the prosthesis. Gentamicin is joint infection (PJI) is a parameters, such as patient-, the product’s unique mecha- generally chosen because of rare pathology, but treat- pathogen- and treatment-re- nical properties for the fixa- the controlled diffusion out ment of the infection is lated risk factors can rarely tion of implants into joints of the cement mantle and often complex and increa- be compared across the and weak bone structures the broad spectrum bacte- singly difficult in view of different groups. Since larger leading to the long-term suc- ricidal effect against a wide the growing prevalence of randomised controlled clini- cess of joint prostheses after variety of gram-positive difficult-to-treat pathogens cal trials with ALBC invol- both primary and revision or gram-negative bacterial and higher patient risk fac- ving thousands of patients surgery. contaminants. However, in tors. Apart from the surgical with long clinical observa- times of increasing bacterial challenge and the impact on tion periods have not been Due to its primary fixation resistance, empiric use of the patient, PJI treatment performed, the clinical evi- purpose antibiotic loaded antibiotics (AB) has become involves high costs which dence regarding its effica- bone cement (ALBC) has a controversial discussion are often more than twice cy and safety is still limited been classified as a class III point, and it appears justified the cost of an aseptic joint and is largely derived from medical device according to ask the following ques- replacement. the analysis of registries or to the CE standard for the tion: Does the addition of retrospective single-centre fixation of primary or revi- one or several AB to bone studies. UPDATE To circumvent the problem the role and clinical evi- investigations have proven prostheses. The discussion of a low statistical power dences of ALBC in ortho- the non-toxicity of PMMA which technique is superior typically associated with cli- paedic surgery. in this indication. Thanks to is quite controversial, the nical studies of rare patholo- its outstanding compatibility more so as the decision of gies, so called surrogate mar- with human tissue, PMMA whether to use or not a bone kers and surrogate endpoints later found its place in the cement for fixation also de- are often used to evaluate the A MEDICAL fixation of femoral implants pends to a high extent on pa- efficacy of a particular treat- BLOCKBUSTER since the 1950s. tient factors [11]. However, ment concept. Therefore, in FOR A LONG it has been proven by many case of ALBC it has been TIME PMMA cement has now arthroplasty registries that proposed to evaluate their been successfully used in or- older patients (> 75 years) efficacy as local AB carrier in thopaedic surgery for more particularly benefit from than two generations. Its cemented prostheses as evi- addition to its fixation qua- Chemically, PMMA cement lity by assessing their poten- excellent biomechanical pro- denced by the lower num- is acrylic plexiglas made of perties have been evaluated bers of joint revisions [12]. tial to inhibit biofilm forma- PolyMethylMethAcrylate tion on the implant surface. in many scientific studies [2- Cementless total hip replace- (= PMMA). When this ma- 6]. The main role of cement ment (THR) is the preferred To provide an overview and terial was used in the 1940s to deepen the knowledge is to quickly stabilise the im- choice in young patients, al- in surgery for the first time, plant in bone tissue, improve though the fixation proce- of this concept, this review it was intended to fill gaps focuses in the following on the load distribution on the dure for such hip implants in the skull. Many clinical contact surface, fill and le- is often considered to be Uncemented THAs vel off the implant-bone more demanding and the ce- interface and also stiffen the mentless implants are more spongy bone around the im- expensive in comparison to plant. All these properties their cemented counterparts. improve the anchorage of In contrast to the overall the implant in bone, or more trend towards uncemented generally said, they improve THR, cemented fixation the ideal integration of a is still considered the gold foreign body in a biological standard in almost all total medium. knee replacements (TKR) worldwide, regardless of pa- Today, several million or- tient age [10,13]. thopaedic procedures are conducted worldwide and Since its introduction, more than half of them PMMA cement has been routinely use PMMA ce- combined with an AB agent, ments. Thanks to the ease which is in the majority of of use, but above all, thanks cases the aminoglycosides to the confirmed long-term gentamicin or tobramycin. Cemented THAs survivorship of cemented The first such commercial- implants, PMMA cement is ly available ALBC were in- recognised as a reliable and troduced in the 70ies in the well tolerated anchorage ma- market as pharmaceutical terial. The unique properties products. In order to fur- of PMMA cements ensure ther improve the function rapid and simple fixation of PMMA as a local drug of the joint implant, even in delivery system and to adapt patients with active osteopo- the anti-infective spectrum rosis. As proof of concept, to a special pathogen pro- international arthroplasty file, other AB than genta- registers demonstrate the ex- micin and combinations of cellent long-term outcomes at least two AB are often of a cemented prosthesis [7- added. Certain combinations 12, 107]. of AB are particularly inte- resting because of the syner- In most of these registers, gistic elution effect which Figure 1 & 2 Percentage revision due to deep infection, for uncemented THAs, and for cemented THAs, for 4 periods of primary surgery (x-axis: the results for cemented leads to a higher mutual AB years after operation, y-axis: cumulative revision rate in %) [1] prostheses are compared release. This holds true for with those for cementless e.g. vancomycin combined 2 // MAITRISE ORTHOPEDIQUE UPDATE with gentamicin [14, 15] and to the assumption that lo- sile bacterial phenotypes to that can anchor them to all clindamycin combined with cal AB in combination with AB and other antimicrobial kinds of material - metals, gentamicin [14]. The release systemic AB have a benefit agents. In addition, the slimy plastics, soil particles, medi- of the antibiotics from the (43,49,107, 108, 110). biofilm layers made of car- cal implant materials and outer cement mantle fol- bohydrates and proteins pro- necrotic tissue. The first lows the law of diffusion A broad range of gram-po- vide a safe habitat in which bacterial colonists to adhere and correlates directly with sitive and gram-negative the germs are physically and to a surface initially do so the hydrophilic properties bacteria have been identified chemically protected from by inducing weak, rever- of the cement polymers. For as causative agents of PJI. killing by the host immune sible bonds. If the colo- primary arthroplasties bone Although being rare cases, defence mechanisms [18]. nists are not immediately cement containing genta- even fungi, such as Candida, cleared from the surface, micin represents in most have been found as part of a Pathomechanisms of PJI: they can anchor themselves countries the gold standard polymicrobial infection flora Every surgical operation more permanently using for the local prevention of in immunocompromised pa- bears the risk of a bacte- cell adhesion molecules on prosthetic joint infections tients. Table 1 shows which rial contamination which their surfaces that bind other due its broad-spectrum and pathogens are most relevant may subsequently turn into cells in a process called cell strict concentration-depen- in PJI: an infection if not cleared. adhesion [19]. It is thought, dant antimicrobial effect. Joint replacement poses the that in the course of the fol- patient at a particularly high lowing hours the bacterial The main advantage of using BIOFILM risk for infections due to the pioneers facilitate the arrival PMMA as local delivery sys- FORMATION additional presence of the of other pathogens by provi- tem for AB is the finding implant or bone cement (if ding more diverse adhesion that the site of application AND BACTERIAL not loaded with AB) which sites. They
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