Intrawound vancomycin in primary hip and knee arthroplasty: a safe and cost-effective means to decrease early periprosthetic joint infection

Abstract

BackgroundPeriprosthetic joint infection (PJI) is a devastating complication after hip and knee arthroplasty. Intrawound vancomycin has been described extensively in the spine literature; however, information regarding use in arthroplasty is limited. We investigate the efficacy and safety of intrawound vancomycin in arthroplasty surgery.MethodsAll primary total hip and knee arthroplasty cases (n = 460) performed by a single surgeon from April 2016 to October 2017 were reviewed. Starting in October 2016, intrawound vancomycin was used in all total joints. Baseline characteristics, infection rates, 90-day readmission, and other complications were compared between untreated subjects and those who received intrawound vancomycin. In addition, cost data were considered. Mean follow-up durations for the control and vancomycin groups were 11.3 and 7.7 months, respectively.ResultsBaseline characteristics and comorbidities were similar for the control (n = 112) and vancomycin groups (n = 348). The vancomycin cohort demonstrated decreased both overall infection rate (0.57% vs 2.7%; P = .031) and PJI rate (0.29% vs 2.7%; P = .009) compared with the untreated group. There was no statistical difference in incidence of ototoxicity or acute kidney injury. Although there was no difference in overall 90-day readmission rate, the vancomycin subset demonstrated lower readmission rate due to infection (0.57% vs 2.7%; P = .031). Based on the cost of vancomycin powder and calculated number needed to treat (NNT = 47.5), the cost to prevent 1 infection with the addition of intrawound vancomycin was $816.ConclusionsThese findings suggest that intrawound vancomycin may be a safe, cost-effective means that shows promise in reducing PJI in early follow-up. Future prospective studies are warranted.

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

“…In a subgroup analysis, the effect in revision operations was even greater, with a reduction of the infection rate from 3.9 to 0%. Patel et al showed a reduction in the infection rate through vancomycin of 2.7–0.3% and determined a number needed to treat (NNT) of 47.5 12 . Systemic side effects were not observed.…”

Adjuvant antibiotic‐loaded bone cement: Concerns with current use and research to make it work

“…Although clinical observational studies have shown significant efficacy using intrawound vancomycin powder in spine surgery, a meta‐analysis indicated that prospective randomized data do not support this conclusion 56 . In the arthroplasty literature, while several retrospective observational studies have reported significantly decreased infection and reoperation rates in wounds that have been treated with vancomycin powder, 57 others have found significantly increased aseptic wound complications attributed to the vancomycin powder, possibly related to local adverse response 58 . Currently, there is no high‐level evidence to direct the use of intrawound vancomycin powder.…”

Clinical outcome evaluation of intraosseous vancomycin in total knee arthroplasty

“…The literature on the efficacy of VP in arthroplasty remains inconclusive. Although some studies have shown a decrease in overall infection rates, incidence of periprosthetic joint infection and readmission rates for infection [14], others have shown no difference in reoperation rates or infection rates [15].…”

“…Complications experienced by patients. Many surgeons continue to use VP, as most studies have determined no increased risk to the patient (ie, ototoxicity, nephrotoxicity) [14] or to implant longevity [16]. In prior studies examining soft tissue concentrations of vancomycin, IO vancomycin has reached levels of 44 mg/g in fat and 38 mg/g in bone [3], whereas intrawound VP has demonstrated 207 mg/mL concentrations within the drainage fluid at 24 hours [17].…”