2021 Chitranjan S. Ranawat Award: Intraosseous vancomycin reduces periprosthetic joint infection in primary total knee arthroplasty at 90-day follow-up

Abstract

Aims Infection complicating primary total knee arthroplasty (TKA) is a common reason for revision surgery, hospital readmission, patient morbidity, and mortality. Increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) is a particular concern. The use of vancomycin as prophylactic agent alone or in combination with cephalosporin has not demonstrated lower periprosthetic joint infection (PJI) rates, partly due to timing and dosing of intravenous (IV) vancomycin administration, which have proven important factors in effectiveness. This is a retrospective review of a consecutive series of primary TKAs examining incidence of PJI, adverse reactions, and complications using IV versus intraosseous (IO) vancomycin at 30-day, 90-day, and one-year follow-up. Methods A retrospective review of 1,060 patients who underwent TKA between May 2016 to July 2020 was performed. There were 572 patients in the IV group and 488 in the IO group, with minimal 30 days of follow-up. Patients were followed up at regularly scheduled intervals (two, six, and 12 weeks). No differences between groups for age, sex, BMI, or baseline comorbidities existed. The IV group received an IV dose of 15 mg/kg vancomycin given over an hour preceding skin incision. The IO group received a 500 mg dose of vancomycin mixed in 150 ml of normal saline, injected into proximal tibia after tourniquet inflation, before skin incision. All patients received an additional dose of first generation cephalosporin. Evaluation included preoperative and postoperative serum creatinine values, tourniquet time, and adverse reactions attributable to vancomycin. Results Incidence of PJI with minimum 90-day follow-up was 1.4% (eight knees) in the IV group and 0.22% (one knee) in IO group (p = 0.047). This preliminary report demonstrated an reduction in the incidence of infection in TKA using IO vancomycin combined with a first-generation cephalosporin. While the study suffers from limitations of a retrospective, multi-surgeon investigation, early findings are encouraging. Conclusion IO delivery of vancomycin after tourniquet inflation is a safe and effective alternative to IV administration, eliminating the logistical challenges of timely dosing. Cite this article: Bone Joint J 2021;103-B(6 Supple A):13–17.

Pharmacological thromboprophylaxis as a risk factor for early periprosthetic joint infection following primary total joint arthroplasty

“…In this study, despite the fact that a daily dose of LMWH for 3 days and then transitioning to low-dose aspirin for 2 to 5 weeks was considered a less aggressive strategy 10 , 11 , 21 , 22 , we still observed the association between pharmacological prophylaxis and early postoperative infection events. The postoperative 30 and 90 days were two common time points to evaluate the early postoperative complications, including SSC and PJI 23 – 25 . Notably, pharmacological thromboprophylaxis was associated with multiple outcome domains in the early postoperative period, including 90-day readmission for SSC, PJI, and all 90-day PJI events.…”

What’s New in Musculoskeletal Infection

“…In a retrospective cohort study of 1,060 patients undergoing primary TKA, Park et al observed a sixfold decrease in PJI at a minimum 90-day follow-up with intraosseous vancomycin compared with intravenous vancomycin as an adjunct to intravenous cefazolin administered to all patients 67 . In a multicenter, retrospective cohort study of 1,906 patients who underwent a primary TKA, Parkinson et al found a lower risk of PJI within 1 year postoperatively with prophylactic antibiotics administered intraosseously and intravenously compared with those administered only intravenously 68 .…”

Preoperative Prophylactic Antibiotics in Total Hip and Knee Arthroplasty: What, When, and How

“…Injection of a lower dose (500 mg of vancomycin) mixed with 120 mL of normal saline achieves 6-10 times the tissue levels of a standard dose given systemically [29,30]. There is emerging evidence of a reduction in PJI with intraosseous vancomycin use without increased risk of complications [31,32].…”