Clinical Orthopaedics and Related Research®

, Volume 470, Issue 10, pp 2677–2683 | Cite as

Mixing Method Affects Elution and Strength of High-dose ALBC: A Pilot Study

  • Ryan Miller
  • Alex McLaren
  • Christine Leon
  • Ryan McLemore
Symposium: 2011 Musculoskeletal Infection Society



High-dose antimicrobial-loaded bone cement (ALBC) is used to treat orthopaedic infections. High-dose ALBC is not commercially available and requires surgeon directed formulation, and there are several different methods used to mix high-dose ALBC.


We asked whether the mixing method affected antimicrobial elution and mechanical properties of high-dose ALBC.


ALBC was formulated with Simplex® P bone cement and 10 g of vancomycin per batch using one of three mixing methods: (1) hand-stirred using a standard bowl and spatula, (2) bowl-mixed using a mechanical mixing bowl, and (3) dough-phase mixing where the vancomycin was left in chunks (1–5 mm) and folded into the cement during the dough phase after adding the monomer. We eluted 45 standardized test cylinders (15 per mixing technique) for 30 days under infinite sink conditions. We tested 135 (45 per mixing method) similarly eluted cylinders in axial compression to failure.


Dough-phase mixing lead to greater antimicrobial delivery, but lower compressive strength than the hand-stirred or bowl-mixed methods. Dough-phase cement released 18,570 lg of vancomycin versus 11,731 for hand-stirred and 7700 μg for bowl mixed. Compressive strength for dough-phase mixing after 30 days of elution was 36 MPa, while both hand-stirred and bowl mixed cements were 56 MPa.


Performance of high-dose ALBC was affected by mixing method. Dough-phase mixing led to greater antimicrobial delivery, but caused greater loss in compressive strength.



The authors thank Francis Calara BSE (HPLC assays and data analysis) and Mary Martin PharmD at Banner Good Samaritan Medical Center, and John Lopez and Zachary Laughrey at ASU (use of the Proteomics Laboratory and technical support for HPLC) for their contributions to this study.


  1. 1.
    Adams K, Couch L, Cierny G, Calhoun J, Mader JT. In vitro and in vivo evaluation of antibiotic diffusion from antibiotic-impregnated polymethylmethacrylate beads. Clin Orthop Relat Res. 1992;278:244–252.Google Scholar
  2. 2.
    American Society for Testing And Materials, Subcommittee F04.11. ASTM F451-08 Standard Specification for Acrylic Bone Cement. 2008.13.01. Available at: Accessed December 19, 2011.
  3. 3.
    Askew MJ, Kufel MF, Fleissner Jr. PR, Gradisar Jr. IA, Salstrom S, Tan JS. Effect of vacuum mixing on the mechanical properties of antibiotic‐impregnated polymethylmethacrylate bone cement. J Biomed Mater Res. 1990;24:573–580.PubMedCrossRefGoogle Scholar
  4. 4.
    Davies JP, O’Connor DO, Burke DW, Harris WH. Influence of antibiotic impregnation on the fatigue life of simplex P and palacos R acrylic bone cements, with and without centrifugation. J Biomed Mater Res. 1989;23:379–397.PubMedCrossRefGoogle Scholar
  5. 5.
    Diefenbeck M, Mückley T, Hofmann GO. Prophylaxis and treatment of implant-related infections by local application of antibiotics. Injury. 2006;37:S95–S104.PubMedCrossRefGoogle Scholar
  6. 6.
    Engesæter LB, Espehaug B, Lie SA, Furnes O, Havelin LI. Does cement increase the risk of infection in primary total hip arthroplasty? Revision rates in 56,275 cemented and uncemented primary THAs followed for 0–16 years in the Norwegian Arthroplasty Register. Acta Orthop. 2006;77:351–358.PubMedCrossRefGoogle Scholar
  7. 7.
    Hansen D, Jensen JS. Mixing does not improve mechanical properties of all bone cements. Manual and centrifugation-vacuum mixing compared for 10 cement brands. Acta Orthop Scand. 1992;63:13–18.PubMedCrossRefGoogle Scholar
  8. 8.
    Hanssen AD. Local antibiotic delivery vehicles in the treatment of musculoskeletal infection. Clin Orthop Relat Res. 2005;437:91–96.PubMedCrossRefGoogle Scholar
  9. 9.
    Hanssen AD, Spangehl MJ. Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop Relat Res. 2004;427:79–85.PubMedCrossRefGoogle Scholar
  10. 10.
    International Organization for Standardization. ISO 5833. Implants for surgery-acrylic resin cements 2002. Available at: Accessed December 19, 2011.
  11. 11.
    Kuechle DK, Landon GC, Musher DM, Noble PC. Elution of vancomycin, daptomycin, and amikacin from acrylic bone cement. Clin Orthop Relat Res. 1991;264:302–308.PubMedGoogle Scholar
  12. 12.
    Lautenschlager EP, Jacobs JJ, Marshall GW, Meyer PR. Mechanical properties of bone cements containing large doses of antibiotic powders. J Biomed Mater Res. 1976;10:929–938.PubMedCrossRefGoogle Scholar
  13. 13.
    Lewis G, Bhattaram A. Influence of a pre-blended antibiotic (gentamicin sulfate powder) on various mechanical, thermal, and physical properties of three acrylic bone cements. J Biomater Appl. 2006;20:377–408.PubMedCrossRefGoogle Scholar
  14. 14.
    Lewis G. Fatigue testing and performance of acrylic bone‐cement materials: state‐of‐the‐art review. J Biomed Mater Res B Appl Biomater. 2003;66:457–486.PubMedCrossRefGoogle Scholar
  15. 15.
    McLaren A, Nugent M, Economopoulos K, Kaul H, Vernon B, McLemore R. Hand-mixed and premixed antibiotic-loaded bone cement have similar homogeneity. Clin Orthop Relat Res. 2009;467:1693–1698.PubMedCrossRefGoogle Scholar
  16. 16.
    Nugent M, McLaren A, Vernon B, McLemore R. Strength of antimicrobial bone cement decreases with increased poragen fraction. Clin Orthop Relat Res. 2010;468:2101–2106.PubMedCrossRefGoogle Scholar
  17. 17.
    Van de Belt H, Neut D, Schenk W, van Horn JR, van der Mei HC, Busscher HJ. Staphylococcus aureus biofilm formation on different gentamicin-loaded polymethylmethacrylate bone cements. Biomaterials. 2001;22:1607–1611.PubMedCrossRefGoogle Scholar
  18. 18.
    Wright TM, Sullivan DJ, Arnoczky SP. The effect of antibiotic additions on the fracture properties of bone cements. Acta Orthop Scand. 1984;55:414–418.PubMedCrossRefGoogle Scholar
  19. 19.
    Xu Q, Trissel L. Stability-Indicating HPLC Methods for Drug Analysis. London, UK: Pharmaceutical Press; 2003.Google Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Ryan Miller
    • 1
  • Alex McLaren
    • 1
    • 2
  • Christine Leon
    • 2
  • Ryan McLemore
    • 1
    • 2
  1. 1.Orthopaedic ResidencyBanner Good Samaritan Medical CenterPhoenixUSA
  2. 2.Center for Interventional Biomaterials, School of Biological and Health Systems EngineeringArizona State UniversityTempeUSA

Personalised recommendations