Clinical Efficacy and Safety of Multiple High-Dose Antibiotic-Loaded Cement Spacers in the Two-Stage Revision of Gram-Positive Periprosthetic Joint Infection

Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty, typically managed through a two-stage revision protocol involving antibiotic-loaded spacers. This study aimed to evaluate the clinical outcomes and safety of a new multiple high-dose antibiotic-loaded cement (MHDALC) spacer against alternative classical antibiotic combinations for Gram-positive PJI. In this retrospective observational study of 102 patients (30 MHDALC vs. 72 control), the MHDALC cohort received spacers prepared with commercial cement (1 g clindamycin and 1 g gentamicin per 40 g) supplemented with manual additions of 4 g vancomycin and 2 g ceftazidime per 40 g of cement, while the control group received the same commercial cement supplemented with 4 g of vancomycin alone. Treatment failure was significantly lower in the MHDALC group (6.6%) compared to the control group (20.8%; p = 0.005). Furthermore, the time to second-stage reimplantation was drastically reduced in the MHDALC cohort (9.1 vs. 17.8 weeks; p = 0.001). Despite the substantially higher antibiotic load, no significant differences were observed regarding mechanical or surgical complications between the two groups (p = 1.00). In conclusion, the use of MHDALC spacers is an effective and safe strategy for treating Gram-positive PJI, significantly improving eradication rates and accelerating the transition to definitive reconstruction without compromising structural integrity.