The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Effects of Antibiotic-Loaded Bone Cement on the Risk of Periprosthetic Joint Infection in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Document Type : SYSTEMATIC REVIEW

Authors
Mohammad Ali Tarahomjoy 1
Ali Khodashenas Haghighi 2
Seyed Mohamad Sajjadi Dezfouli 3
Afshin Taheriazam 4
Reza Heidari 5
Reza Mosaed 6
Hossein Fasihi 3
Mahdieh Soezi 2
Mohsen Chamanara 3
Mostafa Shahrezaee 7
1 Trauma and Surgery Research Center, Aja University of Medical Sciences, Tehran, Iran
2 Infectious Diseases Research Center, Aja University of Medical Sciences, Tehran, Iran
3 Toxicology Research Center, Aja University of Medical Sciences, Tehran, Iran
4 Department of Orthopedic Surgery, School of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
5 Molecular genetics Cancer Epidemiology Research Center, Aja University of Medical Sciences, Tehran, Iran -Medical Biotechnology Research Center, AJA University of Medical Sciences, Tehran, Iran
6 Infectious Diseases Research Center, Aja University of Medical Sciences, Tehran, Iran- Student of Research Committee, Aja University of Medical Sciences, Tehran, Iran
7 Trauma and Surgery Research Center, Aja University of Medical Science, Tehran, Iran - Biomaterial and Medicinal Chemistry Research Center, Aja University of Medical Science, Tehran, Iran
10.22038/abjs.2026.91856.4161
Abstract
Objectives: The use of antibiotic-loaded bone cement (ALBC) is a common strategy for preventing periprosthetic joint infection (PJI) after total knee arthroplasty (TKA); however, its effectiveness remains controversial. This study aimed to provide a clear, evidence-based recommendation regarding the use of ALBC versus plain bone cement (PBC) for the prevention of PJI after TKA.
Methods: This systematic review and meta-analysis was conducted in accordance with the PRISMA 2020 reporting guidelines. PubMed, Embase, and Scopus were searched to identify relevant studies evaluating PJI in patients who received ALBC versus PBC. Eligible studies were screened, selected, and assessed for risk of bias using appropriate checklists. Random-effects meta-analyses were performed to calculate odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic. The effects of antibiotic type and dose were examined through subgroup analyses. Meta-regression was performed to evaluate the effects of age, sex, follow-up duration, and diabetes mellitus on the occurrence of PJI.
Results: Eighteen studies including 72,928 TKAs (20,201 in the ALBC group and 52,727 in the PBC group) were included. The overall analysis showed no significant difference in PJI rates between the ALBC and PBC groups (OR, 0.92; 95% CI, 0.67–1.27; p = 0.6). However, cefuroxime-loaded cement was associated with a significantly lower risk of PJI (p = 0.01). In contrast, cement containing gentamicin (p = 0.08), vancomycin (p = 0.3), or tobramycin (p = 0.6) did not show a similar protective effect. Antibiotic dose, age, sex, diabetes mellitus, and follow-up duration did not appear to influence the results.
Conclusion: Most ALBC formulations were not associated with a significant reduction in the risk of PJI. Larger, dedicated trials are needed to further evaluate the effect of ALBC on PJI risk in selected patient populations.
        Level of evidence: II
Keywords
Antibiotic-loaded bone cement
Bone cement
Cefuroxime
Periprosthetic joint infection
Total knee arthroplasty
Vancomycin
Subjects
  1. Tande AJ, Patel R. Prosthetic joint infection. Clinical microbiology reviews. 2014;27(2):302-45. doi: 10.1128/CMR.00111-13
  2. Shahrezaee M, Heidari R. Cartilage Repair in 2025: Hope, Hype, or Horizon? The Archives of Bone and Joint Surgery. 2025;13(9):532-4. doi: 10.22038/abjs.2025.90121.4089.
  3. Postler A, Lützner C, Beyer F, Tille E, Lützner J. Analysis of Total Knee Arthroplasty revision causes. BMC Musculoskeletal Disorders. 2018;19(1):55. doi: 10.1186/s12891-018-1977-y.
  4. Shahrezaee M, Okhovatpour MA, Banasiri M, Sharifzadeh SR. Studying the effects of primary arthroplasty on post-treatment results among elderly patients with pertrochanteric fracture. Clinics and practice. 2018;8(1):1055. doi: 10.4081/cp.2018.1055.
  5. Schwarz EM, McLaren AC, Sculco TP, Brause B, Bostrom M, Kates SL, et al. Adjuvant antibiotic-loaded bone cement: Concerns with current use and research to make it work. Journal of Orthopaedic Research. 2021;39(2):227-39. doi: 10.1002/jor.24616. Epub 2020 Mar 2
  6. Sebastian S, Liu Y, Christensen R, Raina DB, Tägil M, Lidgren L. Antibiotic containing bone cement in prevention of hip and knee prosthetic joint infections: A systematic review and meta-analysis. J Orthop Translat. 2020;23:53-60. doi: 10.1016/j.jot.2020.04.005.
  7. Zhang J, Zhang XY, Jiang FL, Wu YP, Yang BB, Liu ZY, et al. Antibiotic-impregnated bone cement for preventing infection in patients receiving primary total hip and knee arthroplasty: A meta-analysis. Medicine (Baltimore). 2019;98(49):e18068. doi: 10.1097/MD.0000000000018068.
  8. Kato H, Hamada Y, Takano S, et al. A systematic review and meta-analysis of antibiotic-loaded bone cement for prevention of deep surgical site infections following primary total joint replacement. Journal of Infection and Chemotherapy. 2024;30(9):904-11. doi: 10.1016/j.jiac.2024.03.003.
  9. Pardo-Pol A, Fontanellas-Fes A, Pérez-Prieto D, Sorli L, Hinarejos P, Monllau JC. The Use of Erythromycin and Colistin Cement in Total Knee Arthroplasty Does Not Reduce the Incidence of Infection: A Randomized Study in 2,893 Knees With a 9-year Average Follow-Up. Journal of Arthroplasty. 2024;39(9):2280-4. doi: 10.1016/j.arth.2024.04.039. Epub 2024 Apr 17.
  10. King JD, Hamilton DH, Jacobs CA, Duncan ST. The Hidden Cost of Commercial Antibiotic-Loaded Bone Cement: A Systematic Review of Clinical Results and Cost Implications Following Total Knee Arthroplasty. Journal of Arthroplasty. 2018;33(12):3789-92. doi: 10.1016/j.arth.2018.08.009.
  11. Yayac M, Rondon AJ, Tan TL, Levy H, Parvizi J, Courtney PM. The Economics of Antibiotic Cement in Total Knee Arthroplasty: Added Cost with No Reduction in Infection Rates. J Arthroplasty. 2019;34(9):2096-101. doi: 10.1016/j.arth.2019.04.043. Epub 2019 Apr 26
  12. Jameson SS, Asaad A, Diament M, Kasim A, Bigirumurame T, Baker P, et al. Antibiotic-loaded bone cement is associated with a lower risk of revision following primary cemented total knee arthroplasty: an analysis of 731 214 cases using national joint registry data. The bone & joint journal. 2019;101-B(11):1331-47. doi: 10.1302/0301-620X.101B11.BJJ-2019-0196.R1.
  13. Tootsi K, Heesen V, Lohrengel M, Enz AE, Illiger S, Mittelmeier W, et al. The use of antibiotic-loaded bone cement does not increase antibiotic resistance after primary total joint arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2022;30(9):3208-14.
  14. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71.
  15. Chiu FY, Chen CM, Lin CF, Lo WH. Cefuroxime-impregnated cement in primary total knee arthroplasty: a prospective, randomized study of three hundred and forty knees. J Bone Joint Surg Am. 2002;84(5):759-62.
  16. Chiu FY, Lin CF, Chen CM, Lo WH, Chaung TY. Cefuroxime-impregnated cement at primary total knee arthroplasty in diabetes mellitus. A prospective, randomised study. J Bone Joint Surg Br. 2001;83(5):691-5. doi: 10.1302/0301-620x.83b5.11737.
  17. Gandhi R, Razak F, Pathy R, Davey JR, Syed K, Mahomed NN. Antibiotic bone cement and the incidence of deep infection after total knee arthroplasty. The Journal of arthroplasty. 2009;24(7):1015-8. doi: 10.1016/j.arth.2008.08.004. Epub 2008 Sep 26.
  18. Zhang L, Wu Y, Fu P, Fu Q. A retrospective cohort study on prophylactic use of antibiotic-loaded bone cement in primary total knee arthroplasty. Chin J Joint Surg. 2012;6:842-7.
  19. Hua Li YW TL. Application of antibiotic loaded bone cement in total knee arthroplasty. J Med Theor Prac. 2014;27:3311-12.
  20. Eveillard M, Mertl P, Tramier B, Eb F. Effectiveness of gentamicin-impregnated cement in the prevention of deep wound infection after primary total knee arthroplasty. Infection Control & Hospital Epidemiology. 2003;24(10):778-80. doi: 10.1086/502134.
  21. Qadir R, Sidhu S, Ochsner JL, Meyer MS, Chimento GF. Risk stratified usage of antibiotic-loaded bone cement for primary total knee arthroplasty: short term infection outcomes with a standardized cement protocol. The Journal of Arthroplasty. 2014;29(8):1622-4. doi: 10.1016/j.arth.2014.02.032. Epub 2014 Mar 5
  22. Wang H, Qiu G-X, Lin J, Jin J, Qian W-W, Weng X-S. Antibiotic bone cement cannot reduce deep infection after primary total knee arthroplasty. Orthopedics. 2015;38(6): e462-6. doi: 10.3928/01477447-20150603-52..
  23. Sanz-Ruiz P, Matas-Diez JA, Sanchez-Somolinos M, Villanueva-Martinez M, Vaquero-Martín J. Is the Commercial Antibiotic-Loaded Bone Cement Useful in Prophylaxis and Cost Saving After Knee and Hip Joint Arthroplasty? The Transatlantic Paradox. J Arthroplasty. 2017;32(4):1095-9. doi: 10.1016/j.arth.2016.11.012. Epub 2016 Nov 15.
  24. Turhan S. Does the Use of Antibiotic-Loaded Bone Cement Have an Effect on Deep Infection in Primary Total Knee Arthroplasty Practice? Surg Infect (Larchmt). 2019;20(3):244-6. doi: 10.1089/sur.2018.123. Epub 2019 Feb 1
  25. Cieremans D, Muthusamy N, Singh V, Rozell JC, Aggarwal V, Schwarzkopf R. Does antibiotic bone cement reduce infection rates in primary total knee arthroplasty? Eur J Orthop Surg Traumatol. 2023;33(8):3379-85. doi: 10.1007/s00590-023-03557-3.
  26. Hugo Alexandre de Araujo Barros Cobra, Alan de Paula Mozella , Pedro José Labronici , Amanda S Cavalcanti , João Antonio Matheus Guimarães.  Infection after primary total knee arthroplasty: a randomized controlled prospective study of the addition of antibiotics to bone cement. Revista Brasileira de Ortopedia. 2021;56(5):621-7. doi: 10.1055/s-0041-1729941.
  27. Pardo-Pol A, Fontanellas-Fes A, Pérez-Prieto D, Sorli L, Hinarejos P, Monllau JC. The Use of Erythromycin and Colistin Cement in Total Knee Arthroplasty Does Not Reduce the Incidence of Infection: A Randomized Study in 2,893 Knees With a 9-year Average Follow-Up. The Journal of Arthroplasty. 2024;39(9):2280-4. doi: 10.1016/j.arth.2024.04.039. Epub 2024 Apr 17.
  28. Namba RS, Chen Y, Paxton EW, Slipchenko T, Fithian DC. Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty. 2009;24(6 Suppl):44-7. doi: 10.1016/j.arth.2009.05.007. Epub 2009 Jul 4.
  29. Hoskins T, Shah JK, Patel J, et al. The cost-effectiveness of antibiotic-loaded bone cement versus plain bone cement following total and partial knee and hip arthroplasty. J Orthop. 2020;20:217-220. doi: 10.1016/j.jor.2020.01.029. eCollection 2020 Jul-Aug.
  30. Anis HK, Sodhi N, Faour M, et al. Effect of Antibiotic-Impregnated Bone Cement in Primary Total Knee Arthroplasty. J Arthroplasty. 2019;34(9):2091-5.e1. doi: 10.1016/j.arth.2019.04.033. Epub 2019 Apr 22
  31. Gutowski CJ, Zmistowski BM, Clyde CT, Parvizi J. The economics of using prophylactic antibiotic-loaded bone cement in total knee replacement. Bone Joint J. 2014;96-b(1):65-9. doi: 10.1302/0301-620X.96B1.31428.
  32. Hinarejos P, Guirro P, Leal J, et al. The use of erythromycin and colistin-loaded cement in total knee arthroplasty does not reduce the incidence of infection : A prospective randomized study in 3000 knees. Journal of Bone and Joint Surgery. 2013;95(9):769-74. doi: 10.2106/JBJS.L.00901.
  33. Xu T, Wu K-L, Jie K. Comprehensive meta-analysis of antibiotic-impregnated bone cement versus plain bone cement in primary total knee arthroplasty for preventing periprosthetic joint infection. Chinese Journal of Traumatology. 2022;25(06):325-330. doi: 10.1016/j.cjtee.2022.06.001.
  34. Wang J, Zhu C, Cheng T, et al. A systematic review and meta-analysis of antibiotic-impregnated bone cement use in primary total hip or knee arthroplasty. PLoS One. 2013;8(12):e82745. doi: 10.1371/journal.pone.0082745.
  35. Zhou Y, Li L, Zhou Q, et al. Lack of efficacy of prophylactic application of antibiotic-loaded bone cement for prevention of infection in primary total knee arthroplasty: results of a meta-analysis. Surgical Infections. 2015;16(2):183-7. doi: 10.1089/sur.2014.044.
  36. Kunutsor SK, Wylde V, Whitehouse MR, Beswick AD, Lenguerrand E, Blom AW. Influence of fixation methods on prosthetic joint infection following primary total knee replacement: Meta-analysis of observational cohort and randomised intervention studies. Journal of Clinical Medicine. 2019;8(6) :828. doi: 10.3390/jcm8060828.
  37. Li H-Q, Li P-C, Wei X-C, Shi J-J. Effectiveness of antibiotics loaded bone cement in primary total knee arthroplasty: a systematic review and meta-analysis. Orthopaedics & Traumatology: Surgery & Research. 2022;108(5):103295. doi: 10.1016/j.otsr.2022.103295. Epub 2022 May 10.
  38. Cao Y, Tang P, Chai H, et al. The application of antibiotic-loaded bone cement in preventing periprosthetic joint infection: an umbrella review. Journal of Orthopaedics and Traumatology. 2025;26(1):23. doi: 10.1186/s10195-025-00839-w.
  39. Preobrazhensky P, Bozhkova S, Kochish A, Tikhilov R, Kazemirsky A. Comparative analysis of pathogen structure in patients with PJI after primary total hip and knee arthroplasty. Arch Orthop Trauma Surg. 2021;141(11):1963-1969. doi: 10.1007/s00402-021-04139-w.
  40. Sogard O, Brown GA. Cost-Effectiveness of Bone Cement With and Without Antibiotics: A Broader Perspective. Journal of Orthopaedic Experience & Innovation. 2023;4(2).
The Archives of Bone and Joint Surgery
Volume 14, Issue 7
July 2026
Pages 436-447

  • Receive Date 12 October 2025
  • Revise Date 09 February 2026
  • Accept Date 07 February 2026