Antibiotic Cement in Hip Hemiarthroplasties for Fracture — Recommendations We’d Bet You’re Not Following

The study's main message is interesting, but not as important as a couple of practical tips

Antibiotic Cement in Hip Hemiarthroplasties for Fracture — Recommendations We’d Bet You’re Not Following

What’s the Claim?

In what may be the largest randomized clinical trial on prophylactic antibiotics in patients having hip hemiarthroplasty for fracture, trialists from 26 centers evaluated nearly 5000 patients who received either single-antibiotic loaded cement (Palacos R+G cement, with 0.5 g gentamicin per 40 g bag) or high-dose dual-antibiotic loaded cement (Copal G+C cement, containing 1 g gentamicin and 1 g clindamycin per bag). The study found no advantage to using the high-dose dual-antibiotic cement in terms of reduction of deep surgical site infection 90 days after surgery (1·7% in the single-antibiotic loaded cement group versus 1.2% in the high-dose dual-antibiotic loaded cement group).

Adjusted analyses and per-protocol analyses supported the main finding, and deaths, complications, disposition, and mobility did not differ between the groups. Based on this, the authors recommended against using the dual-antibiotic cement.

  • Wait, you’re thinking — I don’t use antibiotic cement in my hip hemiarthroplasties for fracture. I don’t even use cement!

That’s why we’re covering this one, which came out early last year. We wanted to be sure that you didn’t miss it when it came out in Lancet. It’s a chance to talk about two things that many surgeons outside the United States are getting right, but most of us are getting wrong.

How’s It Stack Up?

Before we get to that, some context. Prior studies — some of them pretty large and well designed, though none as large nor as well designed as this one — have suggested that the high-dose dual-antibiotic cement is advantageous (this one is the best of those, if you’re curious).

What’s Our Take?

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Smart Practice: Use one antibiotic in your cement (not two), and DO use cemented implants.

We certainly agree with the main message here: We would not use high-dose dual antibiotics in bone cement for hip hemiarthroplasty surgery (nor in primary cemented THA, nor in primary cemented TKA, for that matter).

Here are two other recommendations — though they’re at odds with common practice in the United States — based on a considerable volume of strong evidence:

  1. Hip hemiarthroplasties for fragility fractures — defined as hips that broke in a fall from a standing height, not from high-energy trauma — should be cemented. There is no serious evidence on the other side of this argument any more, and more evidence than we can summarize here in favor of it. For a rundown on what's current on this, see this CORRelations post from last year, or this deeply thoughtful and well-researched guest editorial in CORR.
  2. It’s worth using antibiotics in the bone cement, and based on the current study, we'd say using one antibiotic will suffice. Robust evidence from the Northern European hip registries has convincingly demonstrated the efficacy of this practice. It’s never caught on in a broad way in the US in large part because surgeons are concerned that weakening the cement may increase the risk of loosening over the long run. But for patients with fragility fractures of the hip, the short-term risk is so much graver; the 1-year risk of death in patients whose hemiarthroplasties became infected was over 40% in one good study. And single-antibiotic cement isn’t likely to change the yield strength of cement enough to matter in patients in this population, most of whom aren’t walking fast or far.

Source

Agni NR, Costa ML, Achten J, et al. High-dose Dual-antibiotic Loaded Cement for Hip Hemiarthroplasty in the UK (WHiTE 8): A Randomised Controlled Trial. Lancet. 2023;402:196-202.