antibiotic-containing bone cement

INTRODUCTION

Judicious use of perioperative antibiotics and advances in the design of operating theatres have helped to reduce the incidence of infection after primary total hip and knee replacement to 1.5% and 2.5%, respectively. However, deep infection involving a prosthetic joint can be a serious complication. What begins as clean, elective surgery can be associated with a devastating outcome such as loss of joint function, bacteremia, osteomyelitis, or amputation. Patients with chronic infections of the joint space may experience significant morbidity because of subsequent surgical procedures that may be required, immobilization, and long-term IV administration of antibiotics, all of which are associated with high direct and indirect costs.

The incorporation of antibiotic into bone cement for joint replacement surgery is a strategy that began in Europe in the 1960s as an attempt to reduce the rate of infection at surgical sites. The use of antibiotic-containing bone cement (ABC) has been controversial, because of limited evidence of efficacy, concerns about safety, and potential effects on antibiotic resistance. Prospective randomized controlled trials using ABC have been small or were conducted decades ago. The most widely quoted data are observational results from large Swedish and Norwegian arthroplasty registries, which showed a beneficial effect on revision rates, although some have argued that the impact on the already-low absolute rate of infection has been minimal. Nevertheless, premixed, commercially available ABCs are now marketed in North America and are classified as class 3 medical devices (not drugs) in Canada.
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The Calgary Health Region is a major referral centre for hip and knee arthroplasty, serving a population base of 1.2 million people in the southern and southeastern regions of Alberta. About 1680 primary hip and knee arthroplasty procedures were performed in 2004 at the region’s 3 urban acute care hospitals (D. Hawkins, Senior Analyst, Health Systems Analysis, Calgary Health Region; personal communication by telephone, December 14, 2005). On occasion, staff pharmacists are asked to provide antibiotic powder for incorporation into bone cement during orthopedic procedures, and this practice raised the question of how these antibiotics were being used. Dialogue among pharmacists across Canada through an infectious diseases electronic discussion group indicated that the use of ABCs in orthopedic surgery is a topic of high interest and that practice patterns are poorly known.

It was hypothesized that given the lack of guide­lines in the literature for the use of ABC with hip and knee arthroplasty, there would be no common practice among orthopedic surgeons in the Calgary Health Region. The objectives of this audit were therefore to quantify the prophylactic use of ABC for primary total hip and knee arthroplasty and to determine if orthopedic surgeons differed with respect to choice of antibiotic and amount incorporated into bone cement for these procedures. Finally, for orthopedic surgeons who used ABC inconsistently for these procedures, a further objective was to identify any patient factors that might be influencing their choices.
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