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Intraosseous regional administration in TKA allows use of low dose vancomycin
Surgeons injected vancomycin into a cannula placed in the tibia below the inflated thigh tourniquet.
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CHICAGO — Low-dose intraosseous regional administration of vancomycin in patients undergoing primary total knee arthroplasty produced four to five times the antibiotic concentration in subcutaneous fat and bone samples compared to systemic administration using higher doses of the prophylactic agent, according to results of a recently presented study.
“Intraosseous regional administration optimizes timing of vancomycin administration, allowing the use of a lower dose which may reduce the risk of systemic side effects, while still achieving tissue concentrations of four-times higher than standard administration,” Simon W. Young, FRACS, of Auckland City, New Zealand, said.
Young presented the Mark Coventry Award-winning research at the Specialty Day Meeting of The Knee Society.
Randomized study
Young and colleagues randomized 30 patients to receive vancomycin during total knee arthroplasty (TKA) in one of the following ways:
- systemic administration of vancomycin (1 g) given during a 1-hour infusion timed to finish prior to surgery;
- intraosseous regional administration (IORA) of 250 mg vancomycin; or
- IORA of 500 mg vancomycin.
Patients in both groups that received vancomycin via IORA had a bolus injection “via a tibial ontraosseous cannula, just after tourniquet inflation and prior to skin incision,” Young said.
Image: Young SW
Surgeons performed TKA as normal in all study groups and collected subcutaneous fat and bone samples at various times during the procedures. They processed the samples with a technique that incorporated liquid chromatography.
Higher tissue concentration
The investigators found mean tissue subcutaneous concentrations of vancomycin in the 250 mg IORA group that were four- to five-times greater than in the systemic administration group.
“When we looked at samples of the femoral bone [samples], we saw a similar pattern,” Young said.
Patients in all of the groups had well-functioning TKAs at the 1-year clinical follow-up.
“One patient in the 1 g systemic group developed itching and a rash half way into the infusion consistent with ‘red man syndrome.’ The infusion was stopped and the patient was withdrawn from the study,” Young said. “We saw no cases of ‘red man syndrome’ in either of the intraosseous groups even after tourniquet deflation, although the anesthetist had an antihistamine available in case it was needed.”
One patient in the 500 mg IORA group had a superficial deep vein thrombosis and calf pain, which was successfully treated, based on the study results.
Disadvantages to IORA included an additional 2 minutes to 3 minutes of tourniquet time and the cost of needles, which Young noted was about $100US for his center. – by Gina Brockenbrough, MA
- Reference:
- Young SW. Higher tissue concentrations of vancomycin with low-dose intraosseous regional prophylaxis TKA — A randomized trial. Presented at: Knee Society Specialty Day Meeting; March 23, 2013. Chicago.
- For more information:
- Simon W. Young, FRACS, can be reached at Department of Orthopaedics, North Shore Hospital, Private Bag 93503, Takapuna, Auckland 0740, New Zealand; email: simonwyoung@gmail.com.
Disclosure: Young has no relevant financial disclosures.