Antibiotic-loaded cement spacers: a comprehensive review

SUMMARYPeriprosthetic joint infections (PJIs) have become a costly complication of total joint arthroplasty, and the incidence continues to rise, given an increasing elderly population requiring total knee and total hip replacements. Traditionally, two-stage exchange (TSE) is the standard of care to combat chronic PJIs. The first stage of a TSE is defined by the removal of the prosthesis with implantation of an antibiotic-loaded cement spacer. There is a lack of guidance regarding the dosing of antimicrobials in cement spacers and a lack of safety data available in the infectious diseases literature. This paper aims to provide a comprehensive review of antibiotic-loaded cement spacers (ALCS) by reviewing published literature from peer-reviewed journals dating from 1988 to 2024 and discussing the authors' clinical experience. It was noted that with improvements to ALCS over the years, associated complications also evolved. Not only do mechanical challenges such as increased joint subluxation persist, but also complications of nephrotoxicity and allergic reactions occur due to unknown levels of systemic absorption of antibiotics. A multidisciplinary approach involving orthopedic surgeons, infectious diseases specialists, and pharmacists, in conjunction with patient-specific anti-microbial spacer dosing, would likely lead to improved outcomes in patients with chronic PJIs.