The role of antibiotic-loaded bone cement in complicated knee arthroplasty: relevance of gentamicin allergy and benefit from revision surgery, a case control follow-up study and algorithmic approach

Abstract Background Antibiotic-loaded (particularly gentamicin) bone cement (BC) is widely used in total joint arthroplasty (TJA) to prevent periprosthetic infections (PPIs), but may itself cause implant failure. In light of a complete lack in literature, the objective was to assess the clinical relevance of gentamicin allergy for failure of cemented total knee arthroplasties in 25 out of 250 patients with positive patch test reactions to gentamicin and otherwise unexplained symptoms by evaluating benefits from revision with change to gentamicin-free cement. Methods 15 of these 25 patients and their treating orthopaedic surgeons agreed to a re-assessment. They were surveyed regarding interim course of therapy and symptoms, including re-assessment of the Knee Injury and Osteoarthritis Outcome Score (KOOS), and underwent follow-up clinical and radiographic investigations. The initial use of gentamicin-loaded BC was reaffirmed by review of the primary implantation operative reports and respective implant passports. Primary and follow-up KOOS scores were analyzed regarding benefits from revision surgery by comparing nine patients with revision to six without revision. Results Mean follow-up time was 38 months. The entirety of patients experienced an improvement of self-reported symptoms, with revision surgery (i.e. switching to gentamicin-free BC or uncemented total knee arthroplasty) yielding significantly greater improvement (p=0.031): the nine revised patients reported a significant symptom relief (p=0.028), contrary to the six unrevised patients (p=0.14). Interestingly, the decision to proceed with revision surgery was significantly correlated with higher symptom severity (p=0.05). Conclusion In symptomatic total knee arthroplasty with gentamicin allergy, uncemented revision arthroplasty or change to gentamicin-free BC provides significant symptom relief.