Increasing the Elution of Vancomycin from High-Dose Antibiotic-Loaded Bone Cement: A Novel Preparation Technique

Background: Antibiotic bone cement is commonly used in staged revision arthroplasty as well as the treatment of open fractures. Multiple factors affect antibiotic elution from bone cement. This study was performed to investigate the effect of two variables, the quantity of liquid monomer and the timing of antibiotic addition, on the ultimate elution of antibiotic from bone cement. Methods: Vancomycin-loaded Simplex P and SmartSet MV bone cement was prepared with three different methods: a common surgical technique, a mixing technique that doubled the amount of liquid monomer, and a novel technique that delayed antibiotic addition until after thirty seconds of polymerization. Cylinders of a standardized size were created from each preparation. The elution profiles of five cylinders from each preparation were measured over six weeks with use of high-performance liquid chromatography. Cylinders were tested in compression to quantify strength. Results: Delayed antibiotic addition resulted in significantly greater cumulative elution over six weeks (p < 0.0001), with minimal reduction in strength, compared with the other groups. Doubling the liquid monomer significantly reduced cumulative elution over six weeks compared with either of the other techniques (p < 0.0001). Vancomycin elution from Simplex P was 52% greater and vancomycin elution from SmartSet MV was 25% greater in the delayed-antibiotic-addition groups than it was in the corresponding standard surgical technique groups. The majority of the antibiotic was released over the first week in all groups. Conclusions: High-dose-antibiotic bone cement prepared with delayed antibiotic addition increased vancomycin elution compared with the standard surgical preparation. Incorporating additional liquid monomer decreased vancomycin elution from high-dose-antibiotic cement. We recommend preparing high-dose-antibiotic bone cement with the delayed-antibiotic-addition technique and not incorporating additional liquid monomer.