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. 2024 May 1;7(5):e2412898.
doi: 10.1001/jamanetworkopen.2024.12898.

Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement

Tesfaye H Leta  1   2   3   4 , Stein Atle Lie  1   5 , Anne Marie Fenstad  1 , Stein Håkon L Lygre  1   6 , Martin Lindberg-Larsen  7   8 , Alma B Pedersen  7   9 , Annette W-Dahl  10   11 , Ola Rolfson  10   12 , Erik Bülow  12   13 , Liza N van Steenbergen  14 , Rob G H H Nelissen  14   15 , Dylan Harries  16 , Richard de Steiger  17 , Olav Lutro  18 , Keijo Mäkelä  19   20 , Mikko S Venäläinen  21 , Jinny Willis  22 , Michael Wyatt  22 , Chris Frampton  22 , Alexander Grimberg  23 , Arnd Steinbrück  23 , Yinan Wu  23 , Cristiana Armaroli  24 , Maria Adalgisa Gentilini  24 , Roberto Picus  25 , Mirko Bonetti  25 , Serban Dragosloveanu  26   27   28 , Andreea E Vorovenci  26   29 , Dan Dragomirescu  26   29 , Håvard Dale  1   30 , Christian Brand  31   32 , Bernhard Christen  31   33 , Joanne Shapiro  34   35 , J Mark Wilkinson  34   36 , Richard Armstrong  34   35 , Kate Wooster  34   35 , Geir Hallan  1   30 , Jan-Erik Gjertsen  1   30 , Richard N Chang  4 , Heather A Prentice  4 , Art Sedrakyan  3 , Elizabeth W Paxton  4 , Ove Furnes  1   30
Affiliations

Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement

Tesfaye H Leta et al. JAMA Netw Open. .

Abstract

Importance: Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient.

Objective: To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement.

Design, setting, and participants: This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023.

Exposure: Primary TKA with ALBC vs plain bone cement.

Main outcomes and measures: The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes.

Results: Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement.

Conclusions and relevance: In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Leta reported receiving grants from Western Norway Health Authority during the conduct of the study. Dr Rolfson reported personal fees from LINK Sweden Educational and research consultancy, ZimmerBiomet, grants from Pfizer, research funding from Johnson & Johnson (paid to institution), and serving as Director of the Swedish Arthroplasty Register and immediate past president of the International Society of Arthroplasty Registries outside the submitted work. Dr Venäläinen reported receiving grants from State Research Funding of the Well-being Services County of Southwest Finland during the conduct of the study. Dr Christen reported member of the advisory board of the Swiss National Joint Registry, Hip and Knee, outside the submitted work. Dr Hallan reported receiving personal fees from Ortomedic, Link Norway, and Heraeus Medical. Dr Gjertsen reported receiving personal fees from LINK Norway, Ortomedic (DePutSynthes), Heraeus Medical, and Smith & Nephew outside the submitted work. Dr Furnes reported receiving personal fees from Ortomedic and Heraeus Medical outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Cohort Selection Flowchart
ALBC indicates antibiotic-loaded bone cement; TKA, total knee arthroplasty.
Figure 2.
Figure 2.. Meta-Analysis on Risk of Revision for Periprosthetic Joint Infection Following Primary Total Knee Arthroplasty With Antibiotic-Loaded Bone Cement (ALBC) vs Plain Bone Cement at 1 Year
The meta-analysis was based on result from Cox regression analysis adjusted for age, sex, year of surgery, and all other variables available in each participating registry. The size of the square corresponds to the weight of each registry based on the number of total knee arthroplasties with plain bone cement in the registry. AOANJRR indicates Australian Orthopaedic Association National Joint Replacement Registry; DKR, Danish Knee Arthroplasty Registry; EPRD, German Arthroplasty Registry; KP, Kaiser Permanente Total Joint Replacement Registry; LROI, Dutch Arthroplasty Register; NJR, National Joint Registry; NZJR, New Zealand Joint Registry; RAR, Romanian Arthroplasty Register; SIRIS, Swiss National Implant Register.
Figure 3.
Figure 3.. Meta-Analysis on Risk of Revision for All Causes Following Primary Total Knee Arthroplasty With Antibiotic-Loaded Bone Cement (ALBC) vs Plain Bone Cement at 1 Year
The meta-analysis was based on result from Cox regression analysis adjusted for age, sex, year of surgery, and all other variables available in each participating registry. The size of the square corresponds to the weight of each registry based on the number of total knee arthroplasties with plain bone cement in the registry. AOANJRR indicates Australian Orthopaedic Association National Joint Replacement Registry; DKR, Danish Knee Arthroplasty Registry; EPRD, German Arthroplasty Registry; KP, Kaiser Permanente Total Joint Replacement Registry; LROI, Dutch Arthroplasty Register; NJR, National Joint Registry; NZJR, New Zealand Joint Registry; PATN, Trento provincial register of knee prostheses (Autonomous Province of Trento, Italy); RAR, Romanian Arthroplasty Register; SIRIS, Swiss National Implant Register.
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