Hand-mixed and Premixed Antibiotic-loaded Bone Cement Have Similar Homogeneity

Since low-dose antibiotic-loaded bone cement (ALBC) was approved by the FDA for second-stage reimplantation after infected arthroplasties in 2003, commercially premixed low-dose ALBC has become available in the United States. However, surgeons continue to mix ALBC by hand. We presumed hand-mixed ALBC was not as homogeneous as commercially premixed ALBC. We assessed homogeneity by determining the variation in antibiotic elution by location in a batch, from premixed and hand-mixed formulations of low-dose ALBC. Four hand-mixed methodologies were used: (1) suspension-antibiotic powder in the liquid monomer; (2) no-mix-antibiotic powder added but not mixed with the polymer powder before adding monomer; (3) hand-stirred-antibiotic powder stirred into the polymer powder before the monomer was added; and (4) bowl-mix-antibiotic powder mixed into polymer powder using a commercial mixing bowl before the monomer was added. Antibiotic elution was measured using the Kirby-Bauer bioassay. None of the mixing methods had consistently dissimilar homogeneity of antibiotic distribution from the others. Based upon our data we conclude hand-mixed low-dose ALBC is not less homogeneous than commercially premixed formulations.