Antibiotic-Loaded Bone Cement in Hemiarthroplasty Following Fractured Neck of Femur (FNOF) – New Insights

Fractured neck of femur (FNOF) often leads to disability and is associated with high morbidity and mortality.1

Hemiarthroplasty is considered a good treatment option, particularly in the elderly population.
However, despite improvements in theatre and treatment standards, periprosthetic joint infection (PJI) remains one of the most relevant complications in hemiarthroplasty.2,3
The findings of the prospective WHiTE 8 trial, published on June 21 2023 in Lancet, now add valuable insights into the management of cemented hemiarthroplasty and infection prevention in FNOF patients.4

Adding Antibiotics Effectively Prevents PJI

The WHiTE 8 study included 4,936 patients aged 60 years or older from 26 hospitals in the United Kingdom (UK). 
In this study, fixation of hip prostheses with high dose dual antibiotic-loaded bone cement (DALBC) was associated with a PJI rate in the “intention to treat analysis” at 90 days post randomization of 1.2% vs. 1.7% when using single antibiotic-loaded bone cement (SALBC) (p = 0.16).
In the “as treated analysis” with 1.1% vs. 1.8% respectively results were very close to demonstrating a significant effect (p = 0.077).
The overall very low PJI rates in this study support the benefit of using antibiotic-loaded bone cement in hemiarthroplasty presented in previous studies.17,18
The low PJI level in the WHiTE 8 high dose dual antibiotic-loaded bone cement group is in line with previous studies which demonstrated almost identical infection rates for high dose dual antibiotic-loaded bone cement between 1.1% and 1.2% for hemiarthroplasty with high dose dual vs. single antibiotic-loaded bone cement.5-7, 17
Of note, it has to be taken into account that these studies covered longer observation periods of 12 months compared to 90 days in the WHiTE 8 study.8 *

Variable Risk of Infection

Theatre standards, perioperative prophylaxis, as well as patient-related risk factors contribute to the occurrence of PJI.9
The prevalence of infection varies according to location and type of hip arthroplasty, reaching up to 2% in primary surgery and 4% after revision.10
Epidemiological studies point to considerable variations in PJI rates and standards of care for infection control across different settings and health services worldwide.11

PJI Reducation – the Common Goal

In addition to patient-related factors perioperative variables such as operating room traffic, timing of surgery, selection of prophylactic antibiotics and surgical site preparation should be evaluated and optimized prior to surgery to decrease rates of PJI12.
Even stricter infection prevention measures implemented during the COVID pandemic may additionally have favorably influenced PJI rates with infections becoming an exception.
Experts agree that rapid access to surgery and coordinated care are essential in order to help patients recover faster and regain mobility.13,14
All efforts should be made to lower the burden of PJI, in particular in a multimorbid high-risk population such as hip hemiarthroplasty patients.
In fact, there is evidence that improvements in infection control translate into decreased risk of reoperation due to surgical site infection such as seen in a large Danish cohort study.15

Increasing Clinical Experience with Combined Local Antibiotics

To this end, a whole range of actions must be taken into consideration.
Among others, antibiotic-loaded bone cement constitutes one significant aspect of local infection prevention.
Indeed, experienced orthopaedic surgeons worldwide have increasingly adapted standard procedures to using antibiotic-loaded bone cement, including dual antibiotic-loaded bone cement, when providing hip hemiarthroplasty in patients with FNOF.
Due to the growing number of arthroplasties, the number of patients with PJI is expected to further increase.
There is an urgent need to lower the burden of PJI faced by practicing clinicians, institutions, and patients as well as a need for infection-related revision surgery.16

* In a comment on the WHiTE 8 trial results Tarabichi and Parvizi emphasise that WHiTE 8 is the largest randomised controlled trial in a large number of sites on the efficacy of prophylactic antibiotics in patients undergoing hemiarthroplasty.8 They discuss, however, that at least 12 months of follow-up would be necessary in order to truly determine the efficacy of DALBC in preventing the development of deep surgical site infection.