Skip to main content
JDRS · Open access journal
Joint Diseases and
Related Surgery
Online manuscript submissionSubmit a manuscript e-ISSN 2687-4792

Original Article · Open access

Balancing strength and sterility: An in vitro assessment of the mechanical and antibacterial properties of bone cement loaded with various antibiotics

PDF Cite this article

Tarik Elma

Department of Orthopedics and Traumatology, Private Medline Adana Hospital, Adana, Türkiye

ORCID: 0000-0003-4800-3983

Hakan Yusuf Selek

Department of Orthopedics and Traumatology, Gazi University Faculty of Medicine, Ankara, Türkiye

ORCID: 0000-0002-1125-7915

Mehmet Ali Tokgoz

Department of Orthopedics and Traumatology, Gazi University Faculty of Medicine, Ankara, Türkiye

ORCID: 0000-0002-4056-3743

Ali Ekber Yapar

Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Türkiye

ORCID: 0000-0003-2227-2173

Tugba Cuhadar

Department of Medical Microbiology, Gazi University Faculty of Medicine, Ankara, Türkiye

ORCID: 0000-0002-6760-340X

Abstract

Objectives: This study aims to determine the antimicrobial efficacy and mechanical strength of antibiotic-loaded cement samples in which daptomycin, vancomycin, teicoplanin, meropenem and piperacillin-tazobactam agents were mixed at different doses and to investigate the differences between agents and between doses.

Materials and methods: We prepared standardized bone cement samples incorporating vancomycin, teicoplanin, daptomycin, piperacillin-tazobactam, and meropenem at concentrations ranging from 0.625 to 15%. Samples underwent six-week phosphate-buffered saline immersion simulating physiological conditions. Mechanical testing employed four-point bending analysis following ISO 5833 standards. Antimicrobial efficacy was assessed using liquid microdilution against Staphylococcus aureus and Pseudomonas aeruginosa over 21 days.

Results: All antibiotics demonstrated strong negative correlation between concentration and mechanical strength (r=–0.883 to –0.914, p<0.001). Critical threshold emerged at 5% antibiotic concentration, above which mechanical integrity was significantly compromised. Daptomycin and meropenem maintained superior mechanical properties at effective antimicrobial concentrations. At 2-g doses, daptomycin achieved significantly higher strength than piperacillin-tazobactam and teicoplanin (p=0.021). All antibiotics except low-dose piperacillin-tazobactam maintained complete antimicrobial efficacy throughout 21-day testing. Electron microscopy revealed increased porosity, which correlated with reduced mechanical strength, particularly in piperacillin-tazobactam and teicoplanin groups.

Conclusion: Antibiotic selection significantly impacts both mechanical and antimicrobial properties of bone cement. Daptomycin and meropenem offer optimal balance of antimicrobial efficacy and mechanical integrity. These findings provide evidence-based guidelines for antibiotic selection in resistant infection management while maintaining structural requirements.

Declarations

Author Contributions

Conceptualization, T.E., M.A.T., H.Y.S.; Methodology, visualization: T.E., T.C.; Validation, T.E., H.Y.S., M.A.T.; Formal analysis, T.C., A.E.Y.; Investigation, supervision, writing, review and editing: T.E., H.Y.S.; Resources, writing, original draft preparation: T.E.; Data curation, T.E., A.E.Y.; Funding acquisition, H.Y.S. All authors have read and agreed to the published version of the manuscript.

Conflict of Interest

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Financial Disclosure

The authors received no financial support for the research and/or authorship of this article.

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

  1. Malchau H, Herberts P, Ahnfelt L. Prognosis of total hip replacement in Sweden. Follow-up of 92,675 operations performed 1978-1990. Acta Orthop Scand 1993;64:497-506. DOI: 10.3109/17453679308993679.
  2. Samelis PV, Papagrigorakis E, Sameli E, Mavrogenis A, Savvidou O, Koulouvaris P. Current concepts on the application, pharmacokinetics and complications of antibiotic-loaded cement spacers in the treatment of prosthetic joint infections. Cureus 2022;14:e20968. DOI: 10.7759/cureus.20968.
  3. Li HQ, Li PC, Wei XC, Shi JJ. Effectiveness of antibiotics loaded bone cement in primary total knee arthroplasty: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2022;108:103295. DOI: 10.1016/j.otsr.2022.103295.
  4. Kuehn KD, Ege W, Gopp U. Acrylic bone cements: composition and properties. Orthop Clin North Am 2005;36:17-28, v. DOI: 10.1016/j.ocl.2004.06.010.
  5. Bibbo C. Treatment of the infected extended ankle arthrodesis after tibiotalocalcaneal retrograde nailing. Tech Foot Ankle Surg 2002;1:74-86. DOI: 10.1097/01.BTF.0000024381.53146.D4.
  6. Mader JT, Calhoun J, Cobos J. In vitro evaluation of antibiotic diffusion from antibiotic-impregnated biodegradable beads and polymethylmethacrylate beads. Antimicrob Agents Chemother 1997;41:415-8. DOI: 10.1128/AAC.41.2.415.
  7. Chang Y, Chen WC, Hsieh PH, Chen DW, Lee MS, Shih HN, et al. In vitro activities of daptomycin-, vancomycin-, and teicoplanin-loaded polymethylmethacrylate against methicillin-susceptible, methicillin-resistant, and vancomycin-intermediate strains of Staphylococcus aureus. Antimicrob Agents Chemother 2011;55:5480-4. DOI: 10.1128/AAC.05312-11.
  8. Pelletier MH, Malisano L, Smitham PJ, Okamoto K, Walsh WR. The compressive properties of bone cements containing large doses of antibiotics. J Arthroplasty 2009;24:454-60. DOI: 10.1016/j.arth.2007.10.023.
  9. Paz E, Sanz-Ruiz P, Abenojar J, Vaquero-Martín J, Forriol F, Del Real JC. Evaluation of elution and mechanical properties of high-dose antibiotic-loaded bone cement: Comparative "In Vitro" study of the influence of vancomycin and cefazolin. J Arthroplasty 2015;30:1423-9. DOI: 10.1016/j.arth.2015.02.040.
  10. Miller R, McLaren A, Leon C, McLemore R. Mixing method affects elution and strength of high-dose ALBC: A pilot study. Clin Orthop Relat Res 2012;470:2677-83. DOI: 10.1007/s11999-012-2351-2.
  11. Shiramizu K, Lovric V, Leung A, Walsh WR. How do porosity-inducing techniques affect antibiotic elution from bone cement? An in vitro comparison between hydrogen peroxide and a mechanical mixer. J Orthop Traumatol 2008;9:17-22. DOI: 10.1007/s10195-008-0099-y.
  12. Lewis G, Janna S. Estimation of the optimum loading of an antibiotic powder in an acrylic bone cement: Gentamicin sulfate in SmartSet HV. Acta Orthop 2006;77:622-7. DOI: 10.1080/17453670610012700.
  13. He Y, Trotignon JP, Loty B, Tcharkhtchi A, Verdu J. Effect of antibiotics on the properties of poly(methylmethacrylate)- based bone cement. J Biomed Mater Res 2002;63:800-6. DOI: 10.1002/jbm.10405.
  14. Nelson RC, Hoffman RO, Burton TA. The effect of antibiotic additions on the mechanical properties of acrylic cement. J Biomed Mater Res 1978;12:473-90. DOI: 10.1002/jbm.820120403.
  15. Persson C, Baleani M, Guandalini L, Tigani D, Viceconti M. Mechanical effects of the use of vancomycin and meropenem in acrylic bone cement. Acta Orthop 2006;77:617- 21. DOI: 10.1080/17453670610012692.
  16. Carpenter CF, Chambers HF. Daptomycin: Another novel agent for treating infections due to drug-resistant grampositive pathogens. Clin Infect Dis 2004;38:994-1000. DOI: 10.1086/383472.
  17. Samuel S, Mathew BS, Veeraraghavan B, Fleming DH, Chittaranjan SB, Prakash JA. In vitro study of elution kinetics and bio-activity of meropenem-loaded acrylic bone cement. J Orthop Traumatol 2012;13:131-6. DOI: 10.1007/s10195-012-0191-1.
  18. Loh KW, Ayob KA, Abbas AA, Selvaratnam V. Eradication of Salmonella enteritidis periprosthetic hip infection using a custom-made articulating spacer: A case report. Jt Dis Relat Surg 2025;36:757-62. DOI: 10.52312/jdrs.2025.2342.
  19. Klekamp J, Dawson JM, Haas DW, DeBoer D, Christie M. The use of vancomycin and tobramycin in acrylic bone cement: biomechanical effects and elution kinetics for use in joint arthroplasty. J Arthroplasty 1999;14:339-46. DOI: 10.1016/s0883-5403(99)90061-x.
  20. Cerretani D, Giorgi G, Fornara P, Bocchi L, Neri L, Ceffa R, et al. The in vitro elution characteristics of vancomycin combined with imipenem-cilastatin in acrylic bone-cements: A pharmacokinetic study. J Arthroplasty 2002;17:619-26. DOI: 10.1054/arth.2002.32184.