Intraosseous vancomycin reduces 90-day periprosthetic joint infection rate after TKA
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Intraosseous delivery of vancomycin after tourniquet inflation is safe and effective for reducing periprosthetic joint infection after primary total knee arthroplasty, according to published results.
“Infection complicating primary total knee arthroplasty (TKA) is a common reason for revision surgery, hospital readmission, patient morbidity and mortality,” K. J. Park, MD, and colleagues wrote in their study. “Increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) is a particular concern.”
Park and colleagues from the department of orthopedics and sports medicine at Houston Methodist Hospital performed a retrospective review of 1,060 patients who underwent TKA between May 2016 to July 2020.
The researchers analyzed two cohorts: an IV cohort, which consisted of 572 patients who received an IV dose of 15 mg/kg of vancomycin given over an hour prior to skin incision and an intraosseous (IO) cohort, which consisted of 488 patients who received a 500 mg dose of vancomycin injected into the proximal tibia after tourniquet inflation prior to skin incision. Additionally, all patients received an additional dose of first-generation cephalosporin.
According to the study, outcome measures included incidence of periprosthetic joint infection (PJI), preoperative and postoperative serum creatinine values, and tourniquet time, as well as complications and reactions attributable to vancomycin. Outcomes were collected at 30 days, 90 days and 1 year after surgery.
Overall, Park and colleagues found no complications related to the IV dose or IO infusion; no changes in creatinine values; and no statistically significant difference in tourniquet time between the cohorts. Incidence of PJI was 1.4% (n = 8 knees) in the IV group and 0.22% (n = 1 knee) in the IO group.
“In conclusion, this preliminary report demonstrated an improved infection rate in TKA using IO vancomycin in combination with a first-generation cephalosporin,” the researchers wrote. “The technique is safe for patients, is straightforward to perform and improves efficiency of vancomycin infusion.”
Perspective
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Simon Young and colleagues have done extensive basic science and clinic work demonstrating the concentrations of vancomycin at the surgical site are substantially higher than the traditional IV route. In addition, there appears to be substantially less systemic risk (acute kidney injury) with IO administration.
The study by Parks and colleagues is one of the first to demonstrate a reduction in periprosthetic joint infection (PJI) rates with IO administration of vancomycin compared to traditional IV route. They demonstrated a nearly sevenfold reduction in the incidence of PJI with IO delivery with no systemic complications.
While the follow-up is relatively short and there are potential confounding variables that need to be accounted for, this data are encouraging and should spawn larger prospective studies with longer-term follow-up on this method of antibiotic delivery. In addition, we need to not only continue to look at this method for antibiotic prophylaxis but also its role in treatment.
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