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Review
. 2024 Dec 11;9(4):e24.00140.
doi: 10.2106/JBJS.OA.24.00140. eCollection 2024 Oct-Dec.

Number of Doses of Systemic Antibiotic Prophylaxis May Be Reduced in Cemented Primary Knee Arthroplasty Irrespective of Use of Antibiotic in the Cement: A Multiregistry-Based Meta-Analysis

Tesfaye H Leta  1   2   3   4 , Richard N Chang  4 , Anne Marie Fenstad  1 , Stein Atle Lie  1   5 , Stein Håkon L Lygre  1   6 , Martin Lindberg-Larsen  7   8 , Alma B Pedersen  7   9 , Olav Lutro  10 , Jinny Willis  11 , Chris Frampton  11 , Michael Wyatt  11 , Serban Dragosloveanu  12   13   14 , Andreea E Vorovenci  12   15 , Dan Dragomirescu  12   15 , Håvard Dale  1   16 , Geir Hallan  1   16 , Jan-Erik Gjertsen  1   16 , Heather A Prentice  4 , Ove Furnes  1   16 , Art Sedrakyan  3 , Elizabeth W Paxton  4
Affiliations
Review

Number of Doses of Systemic Antibiotic Prophylaxis May Be Reduced in Cemented Primary Knee Arthroplasty Irrespective of Use of Antibiotic in the Cement: A Multiregistry-Based Meta-Analysis

Tesfaye H Leta et al. JB JS Open Access. .

Abstract

Background: The use of systemic antibiotic prophylaxis (SAP) and antibiotic-loaded bone cement (ALBC) is the accepted practice to reduce the risk of periprosthetic joint infection (PJI) in primary total knee arthroplasty (pTKA). However, practice varies internationally. This study's primary aim was to compare the risk of PJI revision after pTKA with ALBC + SAP vs. plain bone cement (PBC) + SAP, and the secondary aim was to assess whether the risk of PJI revision varies with the number of SAP doses.

Methods: Cohort of 289,926 pTKAs for osteoarthritis from arthroplasty registries in Denmark, New Zealand, Norway, Romania, and United States registered from 2010 to 2020. One-year revision for PJI following pTKA with ALBC + SAP vs. PBC + SAP, and single vs. multiple SAP doses was compared. We computed cumulative percent revision (1 minus Kaplan-Meier) using distributed analysis method and adjusted hazard rate ratios (HRRs) using Cox regression analyses within each registry. Advanced distributed meta-analysis was performed to summarize HRRs from all countries.

Results: Among all pTKAs, 64.4% were performed with ALBC + SAP. Each registry reported a 1-year cumulative percent revision for PJI of <1.00% for both pTKAs with ALBC + SAP (0.34%-0.80%) and with PBC + SAP (0.54%-0.69%). The distributed meta-analysis showed HRR = 1.21; (95% confidence interval [CI], 0.79-1.87) for ALBC + SAP compared with PBC + SAP. Similar risk of PJI revision was observed between pTKAs with ALBC + single vs. multiple doses of SAP: 2 doses (0.95; 95% CI, 0.68-1.33), 3 doses (1.09; 95% CI, 0.64-1.87), and 4 doses (1.23; 95% CI, 0.69-2.21). Comparable results were found for the PBC + SAP group except for higher risk of PJI revision with 4 doses of SAP (2.74; 95% CI, 1.11-6.75).

Conclusions: ALBC and PBC entailed similar risk of PJI revision when patients received SAP in pTKA, regardless of number of SAP doses. ALBC or PBC used in combination with SAP in pTKAs, with one single preoperative dose of SAP may be sufficient without compromising the patient safety.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

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Conflict of interest statement

THL received a postdoctoral grant from the Western Norway Regional Health Authority. Each participating registry used its own resources. No external funding was received in support of this work. The funder had no role in the design and conduct of the study; collection, management, analysis, and data interpretation; manuscript preparation, review, or approval; and decision to submit the manuscript for publication. Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A710).

Figures

Fig. 1
Fig. 1
Inclusion and exclusion criteria. *Excluded total knee arthroplasties (TKAs) with insufficient data to determine if inclusion criteria were met. ALBC+SAP = Antibiotic-loaded bone cement (ALBC) in combination with systemic antibiotic prophylaxis (SAP); PBC+SAP = plain bone cement with SAP.
Fig. 2
Fig. 2
Cumulative percent revision (one minus Kaplan-Meier) revision for PJI following pTKA with ALBC + SAP vs. PBC + SAP (2010-2020).a aNAR use 100% ALBC in combination with SAP. ALBC = Antibiotic-loaded bone cement, PBC = plain bone cement, PJI = periprosthetic joint infection, pTKA = primary total knee arthroplasty, and SAP = systemic antibiotic prophylaxis.
Fig. 3
Fig. 3
Meta-analysis on risk of revision for PJI following pTKA with ALBC + SAP vs. PBC + SAP.a,b aThe meta-analysis was based on result from Cox-regression analysis adjusted for age, sex, year of surgery [time period]), and all other variables available in each participating registry. bThe size of the square in the forest plot corresponds to each registeries weighted based on the number of cemented pTKA in the registry with PBC+SAP. ALBC = Antibiotic-loaded bone cement, PBC = plain bone cement, PJI = periprosthetic joint infection, pTKA = primary total knee arthroplasty, and SAP = systemic antibiotic prophylaxis.
Fig. 4
Fig. 4
Meta-analysis on risk of revision for PJI following pTKA with ALBC + SAP stratified for SAP doses.a,b aThe meta-analysis was based on result from Cox-regression analysis adjusted for age, sex, year of surgery [time period]), and all other variables available in each participating registry. bThe size of the square in the forest plot corresponds to each registeries weighted based on the number of cemented pTKA in the registry with PBC+SAP. ALBC = Antibiotic-loaded bone cement, PJI = periprosthetic joint infection, pTKA = primary total knee arthroplasty, and SAP = systemic antibiotic prophylaxis.
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