Antibiotic Loaded Bone Cement in Orthopaedic Surgery

Vol 1 | Issue 1 |  July – Dec 2016 | Page 56-57 | Vikas Agashe, Aditya Menon

Authors: Vikas Agashe [1], Aditya Menon [1].

[1] P.D.Hinduja Hospital & Research Centre, , Mumbai, India.

Address of Correspondence
Dr. Vikas M. Agashe
Dr Agashe’s Maternity & surgical Nursing Home, Vrindavan, Off L.B.Shastri Marg, Kurla, Mumbai 400070

Antibiotic loaded bone cement (ALBC) is used for prevention as well as treatment of orthopaedic infections. Below is a short review of salient points and practical tips regarding antibiotic loaded cement

1. Antibiotics which can be used
i. Gram positive coverage
a. Vancomycin
b. Cefazolin
c. Clindamycin
d. Teicoplanin
e. Daptomycin

ii. Gram negative coverage
a. Gentamycin
b. Tobramycin
c. Colisitn
d. Tigecycline
e. Meropenem

2. Antibiotic must be
a. Water soluble
b. Powder form
c. Stable at temperatures up to 60 to 80degrees Celsius.

3. Effect of type of mixing
a. Manual:
More porous
Less mechanical stability
Higher chance of mantle fracture
Better elution of antibiotics due to high porosity

b. Vacuum mixing
Less porous
More stable
Less elution of antibiotics compared to manual preparation (not clinically significant)

4. Combination of two antibiotics in a spacer has a superior bactericidal activity and the antimicrobial effect lasts for a longer duration as compared to a spacer loaded with a single antibiotic [1]. This occurs due to enhanced elution of both the antibiotics, a phenomenon described as “passive opportunism” Coupling of a glycopeptides and aminoglycoside covers both gram positive and gram negative organisms thereby reducing the resistance rates.
The combination of teicoplanin with gentamycin is more superior than Vancomycin with gentamycin

5. Amount of antibiotic
a. Must not exceed 10% of the total volume of cement
b. Higher than 10 % may affect the mechanical strength of the cement mantle in arthroplasty
c. Higher concentration of antibiotics can be used if PMMA is used as a temporary spacer
d. Primary arthroplasty: Mix less than 2 grams of antibiotics with 40 grams of PMMA.
e. Temporary spacer in trauma or periprosthetic infections > 2grams (up to 6 to 8 grams) of antibiotic can be used with 40 grams of PMMA [2,3].

5. Biomechanical properties:
Studies show that addition of antibiotics to the commonly used brands (Simplex, Palacos, CMW1 and CMW 3) did not show any significant difference in the fatigue strength as compared to the same brand without any antibiotic [3]. Clinically significant differences in biomechanical properties are seen only when high doses of >4.5gm per 40 gms PMMA are used

6. Tips and tricks to prepare cement beads [4]
a. 22 or 24 gauge stainless steel wire is braided by holding a loop with clamps at either ends and twisting it.
b. Bead size must not exceed 8mm
c. Keep a gap between 2 successive beads
d. Surface area of the beads can be increased by making multiple pits on the surface using a 1.5mm k wire as the PMMA starts to set
e. Suction drain if used may be kept closed and opened every 6 to 8 hours for only 15 minutes to allow periodic drainage of the wound

7. Cement mixing recommendation
A. Sumant Samuel et al [4]
a. Add liquid monomer to methylmethacrylate powder in a bowl
b. Commence hand mixing with a spatula
c. Add appropriate amount of antibiotic powder to the cement when in early ‘dough’ phase immediately after wetting the cement
d. Mix in standard fashion at 1 revolution/ second to obtain a homogenous compound

B. Oschner et al [5]
a. Fill bowl with appropriate amount of antibiotic powder ( eg. 2grams)
b. Grind to a fine powder
c. Mix equal amount of cement polymer powder (2 grams) to the bowl
d. Mix thoroughly
e. Add an equal amount of cement polymer powder subsequently so as to double the total amount in the bowl till all the polymer powder is used up
f. Pour liquid monomer
g. Blend as usual

Careful attention has to be paid to dose and method of mixing for preparation of antibiotic loaded cement. It is an effective tool when used properly for proper indications


To conclude, lumbar disc herniations are major cause of lower back-related disability in working-age group. Fortunately, around 80 % of patients do well with non-operative treatment while surgery is reserved for a small and specific fraction of patients. There is a wide range of modalities in non-operative management of lumbar disc herniations inspite of lack of evidence for any specific modality better than other. In cases of clinico radiological mismatch epidural steroids is preferred modality of treatment. Whenever an operative treatment is opted we don’t believe in prophylactic fusion. Instability should be given a chance. Fusion is performed only in limited and specific patients. Pedicle screws fixation along with posterolateral fusion (PLF) is a preferred modality of treatment.


1. Hsu YM, Liao CH, Wei YH, Fang HW, Hou HH, Chen CC, Chang CH. Daptomycin-loaded polymethylmethacrylate bone cement for joint arthroplasty surgery. Artif Organs. 2014 Jun;38(6):484-92.
2. Bistolfi A, Massazza G, Verné E, Massè A, Deledda D, Ferraris S, Miola M, Galetto F, Crova M. Antibiotic-loaded cement in orthopedic surgery: a review. ISRN Orthop. 2011 Aug 7;2011:290851
3. Cancienne JM, Burrus MT, Weiss DB, Yarboro SR. Applications of Local Antibiotics in Orthopedic Trauma. Orthop Clin North Am. 2015 Oct;46(4):495 510.
4. Samuel S, Ismavel R, Boopalan PR, Matthai T. Practical considerations in the making and use of high-dose antibiotic-loaded bone cement. Acta Orthop Belg. 2010 Aug;76(4):543-5.
5. Oschner P, Borens O, Trampuz A, Zimmerli W. Infections of the musculoskeletal system: Basic principles, prevention, diagnosis and treatment: 1st edition, 2014. Swiss Orthopedic and Swiss society for Infectious diseases expert group “Infections of the musculoskeletal system”

How to Cite this article: Agashe V, Menon A. Antibiotic Loaded Bone Cement in Orthopaedic Surgery  Journal of  Clinical Orthopaedics July – Dec 2016; 1(1):56-57

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