The John N. Insall Award: Higher Tissue Concentrations of Vancomycin Achieved With Intraosseous Regional Prophylaxis in Revision TKA: A Randomized Controlled Trial

Intraosseous regional antibiotic prophylaxis in total joint arthroplasty (TJA): Systematic review and meta-analysis

Background

A major catastrophic adverse event after total joint arthroplasty surgery (TJA) is the periprosthetic joint infection (PJI). In the recent years, regional antibiotic prophylaxis has gained momentum as a novel infection control strategy in total knee arthroplasty (TKA), with different purported benefits over systemic administration. The current article was planned to comprehensively review the available evidence in literature; as well as compare the safety and effectiveness of intraosseous (IO) antibiotic prophylaxis with systemic prophylaxis in patients undergoing TJA.

Methods

An independent database (5 databases: Pubmed, Scopus, Embase, Web of science and Cochrane library) search was performed (on January 1, 2024) using suitable key words [PROSPERO (registration number: CRD42023458219)]. All randomised controlled trials (RCT), prospective or retrospective studies reporting data on intraosseous vancomycin or other antibiotics during arthroplasty for prophylaxis of PJI were considered. Studies not pertaining to the topic of interest or non-clinical trials were excluded. The evaluated outcome parameters included PJI incidence, systemic antibiotic levels, minimal inhibitory concentrations, local antibiotic concentrations achieved in soft tissues (or fat) and bone; and associated complications. While the "risk of bias" was evaluated using ROB-2 tool and MINORS criteria; LibreOffice version (v)7.5.6 was utilized for data management. OpenMeta-analyst v5.26.14 and RevMan v5.4 software were employed for meta-analysis.

Results

Following our literature search, 11 studies (1 prospective series, 6 RCT and 4 retrospective studies) were finally identified. Based on our meta-analysis, there was statistically higher antibiotic concentration in the bone [mean difference (MD):25.12 μg/g;95%CI:10.32,39.91;z=3.33,p = 0.0009] and local fat tissues [MD:22.01 μg/g;95%CI:1.71,32.30;z=4.19,p < 0.0001) following IO prophylaxis, as compared with the systemic drug administration. IO prophylaxis was also associated with a significant reduction in prosthetic joint infections (PJI; April 1633 and 25/2213 patients developed PJI in IO and systemic prophylaxis groups, respectively; p = 0.006). There was significant difference in gram-positive infections between IO and systemic prophylaxis groups (2/1123 and 13/1753 g + ve infections in IO and systemic prophylaxis groups, respectively; p = 0.05). Our review and meta-analysis revealed no substantial difference in complications amongst the groups (p = 0.66).

Conclusion

IO antibiotic prophylaxis appears to be an effective and safe strategy in patients undergoing TJA. IO access provides substantially enhanced antibiotic elution into the local tissues (bone and soft tissues); and consequently, results in reduced of PJI rates after TJA (in comparison with conventional systemic antibiotic prophylaxis).

Safety and effectiveness of intraosseous regional prophylactic antibiotics in total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Intraosseous regional administration (IORA) as a widely applicable and clinically valuable route of administration has gained significant attention in the context of total knee arthroplasty (TKA) for the prophylactic administration of antibiotics. However, there is still controversy regarding its effectiveness and safety. The latest meta-analysis reports that the use of IORA for antibiotics in TKA is as safe and effective as IV administration in preventing prosthetic joint infection (PJI), but they did not separate the statistics for primary TKA and revision TKA, which may be inappropriate. There is currently a lack of evidence specifically comparing the outcomes of prophylactic antibiotic administration via IORA or IV route in primary/revision TKA, respectively, and new research evidence has emerged.

PURPOSES

In this study, we conducted a systematic review and meta-analysis with the primary objective of comparing the local drug tissue concentration and the incidence of PJI between preoperative IORA and intravenous (IV) administration of prophylactic antibiotics in TKA. Additionally, the occurrence of complications between the two administration routes was also compared.

PATIENTS AND METHODS

This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA) guidelines. Retrospective cohort studies and prospective randomized controlled trials that utilized intraosseous local drug delivery for prophylactic antibiotics in knee arthroplasty were included. English literature from PubMed, Embase, and Cochrane Library databases was searched from the inception of each database until December 2023. Two researchers independently screened the literature, assessed the quality, and extracted data according to the inclusion criteria. The primary outcomes were local antibiotic tissue concentration and postoperative PJI incidence, while the secondary outcome was the occurrence of postoperative complications. Statistical analysis was performed using Review Manager 5.3 software.

RESULTS

This study included 7 prospective randomized controlled trials and 5 retrospective cohort studies. A total of 4091 patients participated in the 12 included studies, with 1,801 cases receiving IORA and 2,290 cases in the control group. In terms of local drug tissue concentration, intraosseous infusion (IO) 500 mg vancomycin significantly increased the drug concentration in the periarticular adipose tissue (SMD: 1.36; 95% CI: 0.87-1.84; P < 0.001; I2 = 0%) and bone tissue (SMD: 0.94; 95% CI: 0.49-1.40; P < 0.001; I2 = 0%) compared to IV 1 g vancomycin. Regarding the incidence of postoperative PJI after primary TKA, IO 500 mg vancomycin was more effective in reducing the occurrence of PJI compared to IV 1 g vancomycin (OR: 0.19; 95% CI: 0.06-0.59; P < 0.001; I2 = 36%). Finally, no significant differences were found between the two groups in terms of postoperative pulmonary embolism (PE) (OR: 1.72; 95% CI: 0.22-13.69; P = 0.59; I2 = 0%) and vancomycin-related complications (OR: 0.54; 95% CI: 0.25-1.19; P = 0.44; I2 = 0%).

CONCLUSIONS

Preoperative prophylactic antibiotic administration via IORA in TKA significantly increases local drug tissue concentration without significantly increasing systemic drug-related complications compared to traditional IV administration. In primary TKA, low-dose vancomycin via IORA is more effective in reducing the incidence of PJI compared to traditional IV regimens. However, its effectiveness remains controversial in high-risk populations for PJI, such as obese, diabetic, and renal insufficiency patients, as well as in revision TKA.

Low Risk of Periprosthetic Joint Infection After Aseptic Revision Total Knee Arthroplasty With Intraosseous Vancomycin

BACKGROUND

Aseptic revisions are the most common reason for revision total knee arthroplasty (rTKA). Previous literature reports early periprosthetic joint infection (PJI) rates after aseptic rTKA to range from 3 to 9.4%. Intraosseous (IO) regional administration of vancomycin has previously been shown to produce high local tissue concentrations in primary and rTKA. However, no data exist on the effect of prophylactic IO vancomycin on early PJI rates in the setting of aseptic rTKA. The aim of this study was to determine the following: (1) what is the rate of early PJI during the first year after surgery in aseptic rTKA performed with IO vancomycin; and (2) how does this compare to previously published PJI rates after rTKA.

METHODS

A consecutive series of 117 cases were included in this study who underwent rTKA between January 2016 and March 2022 by 1 of 2 fellowship-trained adult reconstruction surgeons and received IO vancomycin at the time of surgery in addition to standard intravenous antibiotic prophylaxis. Rates of PJI at 3 months, 1 year, and the final follow-up were evaluated and compared to prior literature.

RESULTS

Follow-up at 3 months was available for 116 of the 117 rTKAs, with 1 lost to follow-up. The rate of PJI was 0% at 3 months postoperatively. Follow-up at 1 year was obtained for 113 of the 117 rTKAs, and the PJI rate remained 0%. The rate of PJI at the final follow-up of ≥ 1 year was 0.88% (95% confidence interval: -0.84 to 2.61). Previous literature reports PJI rates in aseptic rTKA to range from 3 to 9.4%.

CONCLUSIONS

Dual prophylactic antibiotics with IO vancomycin in conjunction with intravenous cephalosporins or clindamycin were associated with a substantial reduction in early PJI compared to prior published literature. These data supplement the early evidence about the potential clinical benefits of IO vancomycin for infection prevention in high-risk cases.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Intraosseous vancomycin in total knee arthroplasty]

INTRODUCTION

intravenous antibiotic prophylaxis has significantly reduced the incidence of periprosthetic joint infection (PJI) in knee surgeries. However, for patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) or those at risk of colonization, prophylaxis should include vancomycin. Intraosseous (IO) administration of vancomycin could enhance its effectiveness in total knee arthroplasty (TKA).

MATERIAL AND METHODS

a retrospective review was conducted, including 143 patients at risk of PJI scheduled for TKA who received IO vancomycin along with intravenous (IV) cefazolin, referred to as group I (GI), between May 2021 and December 2022. The occurrence of complications in the first three postoperative months was evaluated. Results were compared with 140 patients without risk factors who received standard IV prophylaxis, designated as group II (GII).

RESULTS

in GI, 500 mg of IO vancomycin was administered, injected into the proximal tibia, in addition to standard IV prophylaxis. In GII, patients received only IV cefazolin. The incidence of complications was 1.64% in GI and 1.4% in GII. The PJI rate at 90 postoperative days was 0.69% in GI and 0.71% in GII.

CONCLUSIONS

IO vancomycin administration, along with standard IV prophylaxis, provides a safe and effective alternative for patients at risk of MRSA colonization. This approach minimizes complications associated with IV vancomycin use and addresses logistical challenges of timely administration.

Intraosseous Administration of Medications in Total Knee Arthroplasty: An Opportunity for Improved Outcomes and Superior Compliance

Background

Vancomycin is a prophylactic antibiotic with bactericidal activity against methicillin-resistant Staphylococcus aureus that is commonly used in total joint replacement surgery1. In total knee arthroplasty (TKA), intraosseous infusions administered following tourniquet inflation have demonstrated improved local vancomycin concentrations with decreased systemic absorption1-3. This administration method results in no adverse reactions locally, as well as equivalent or lower systemic complications compared with other vancomycin administration methods4. Intraosseous infusion of prophylactic surgical antibiotics has been shown to be more effective than intravenous administration, with the potential for reduction in surgical site infections5.

Description

After the operative extremity has been prepared and draped in the usual sterile fashion, the limb is elevated and the tourniquet is inflated to 250 mm Hg. Prior to incision, an intraosseous vascular access system (Arrow EZ IO; Teleflex) is inserted with a power driver into the tibial tubercle region. The desired volume of the medication is injected into the tibia. The device is removed and then inserted into the anterior distal femur, centrally, just proximal to the patella. Following this, the desired volume of the medication is injected into the femur. The device is then removed, and the TKA proceeds according to the surgeon's standard technique.

Alternatives

Alternative administration methods for vancomycin include other invasive methods and noninvasive delivery. Intravenous delivery is the most traditional form of medication delivery1,2. Additional alternatives include noninvasive placement of antibiotic powder into the wound and localized soft-tissue injections of desired medications1-3.

Rationale

Opting to administer antibiotics and other medications intraosseously (rather than intravenously) has shown improved compliance with the golden-hour rule of preoperative antibiotics (especially for vancomycin)4, lower incidences of acute kidney injury or adverse systemic effects4, and improved local tissue concentrations of all medications delivered1-3.

Expected Outcomes

Expected outcomes include improved local tissue concentrations with decreased systemic concentrations of vancomycin and with no reported local or systemic adverse reactions, as well as the potential for improved infection prevention1-5. Literature regarding the use of intraosseous infusion during TKA has been thorough and very well received. A prospective, randomized study by Young et al. evaluated local and systemic concentrations of vancomycin following intraosseous versus intravenous administration. The authors found that low-dose intraosseous vancomycin resulted in tissue concentrations equal to or superior to those of systemic administration, also noting that the administration route reduced the infiltration time of the vancomycin without systemic complications1. Local concentrations at the knee were found to be 5 to 9 times greater with intraosseous infusion in patients with a body mass index of >35 kg/m2 as compared with the use of intravenous administration, with no adverse reactions systemically. Local concentrations in this patient population were also found to be comparable to those observed in patients with a lower body mass index2. A recent study assessing the use of intraosseous vancomycin showed that local concentrations of vancomycin were maintained even if the procedure continued beyond the point of tourniquet deflation, with mean concentrations being 5 times higher locally at the end of the procedure in the intraosseous versus the intravenous group3. A separate study showed no adverse systemic reactions and no incidents of acute kidney injury among patients receiving intraosseous vancomycin. An additional study showed that intraosseous administration of vancomycin decreased the incidence of postoperative joint infections compared with traditional intravenous administration5. Newer studies assessing the use of intraosseous infiltration have begun to focus on the delivery of other medications, not just antibiotics. At our institution, we have examined the benefits of intraosseously administrated morphine, which has shown a significant decrease in pain and opioid consumption up to 2 weeks postoperatively.

Important Tips

You may run into issues with the medication delivery due to the amount of resistance you encounter. If resistance is too great, you may first attempt to readjust the intraosseous needle depth to improve flow. If resistance is still high, you may consider downsizing to a 30-cc syringe in order to better infiltrate the medication.Note that if you downsize your syringe, you will require more time to infiltrate the desired amount of fluid. An additional way to save time is to open multiple syringes and have them prefilled with your desired medication so that they may be handed off once completed rather than needing to be refilled.A hemostat or pickup may be applied underneath the cuff of the intraosseous needle in order to help remove the needle from the bone. This step is sometimes required because the intraosseous handpieces do not have multidirectional trigger capabilities, and removing the needle can require an upward force to be applied.The use of midline locations allows the small incisions you make for intraosseous infusion to be incorporated into your larger knee incision, with no additional morbidity to the patient.Consider utilizing the medial and/or lateral femoral condyles as landmark locations for infusion if your patient is large. Alternatively, recent literature has shown nearly equivalent results with just the tibial infusion, so you may consider discontinuing the femoral intraosseous infusion if there are consistent issues with successfully initiating the medication delivery.

Acronyms and Abbreviations

IO = intraosseousMRSA = methicillin-resistant Staphylococcus aureusRCT = randomized controlled trialsIV = intravenousBMI = body mass indexOR = operating room.

Impact of intraosseous regional administration of tranexamic acid in total knee arthroplasty on perioperative blood loss: a protocol for a randomised controlled trial

INTRODUCTION

Total knee arthroplasty (TKA) is a common surgical intervention to treat joint diseases. However, TKA is associated with significant blood loss. Tranexamic acid (TXA) has been used to reduce perioperative bleeding and postoperative blood transfusion. This study aims to explore the effectiveness and safety of intraosseous regional administration (IORA) of TXA in TKA and compare differences in perioperative blood loss between IORA of TXA, intravenous infusion of TXA, and combined IORA and intravenous infusion of TXA.

METHODS AND ANALYSIS

This randomised controlled trial will enrol 105 patients with osteoarthritis who meet the inclusion criteria for unilateral TKA. Patients were randomly divided into three groups using the random number table method. Group A received 1.0 g of TXA via IORA, group B received 1.0 g of TXA via intravenous infusion 15 min prior to the tourniquet release, and group C received both IORA of 1.0 g of TXA and intravenous infusion of 1.0 g of TXA. The primary outcome measure is perioperative total blood loss. Secondary outcomes include bleeding events, venous thromboembolism events, inflammation reactions, other complications and knee function assessments.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of Peking Union Medical College Hospital and registered in the Chinese Clinical Trial Registry. Informed consent will be obtained from all the patients before enrolment. The trial will be conducted in accordance with the principles of the Declaration of Helsinki and the International Conference on Harmonization Good Clinical Practice guidelines. The results of this study will be disseminated through peer-reviewed publications, conference presentations and social media platforms. The findings will provide valuable insights into the use of IORA of TXA in TKA and may lead to the development of new strategies for perioperative blood management in joint replacement surgery.

TRIAL REGISTRATION NUMBER

The Ethics Committee of Peking Union Medical College Hospital (approval number: K2371); Chinese Clinical Trial Registry (trial registration number: ChiCTR2200066293).

Prolonged efficacy of cefazolin in intraosseous regional prophylaxis for total knee arthroplasty: a rabbit model study

BACKGROUND

A novel approach known as intraosseous regional administration (IORA) has emerged as a technique for delivering prophylactic antibiotics, and it results in higher tissue concentrations around the knee. It is hypothesized that IORA of cefazolin for antibiotic prophylaxis during total knee arthroplasty will result in sustained effective levels for a longer duration. The aim of the current study was to investigate temporal changes in peri-knee cefazolin blood concentrations after IORA of cefazolin.

METHODS

Twelve rabbits were randomly divided into two groups, with six rabbits in each group. In control group a single intravenous bolus injection of cefazolin (10 mL, 100 mg) was administered into the marginal ear vein. In experimental groupexperimental group the same dose of cefazolin was injected into the left tibial marrow cavity after tourniquet inflation at the base of the left thigh. Blood samples were collected periodically at different timepoints, and cefazolin concentrations were determined.

RESULTS

The intraosseous treatment resulted in significant differences in plasma cefazolin concentrations at all timepoints. Experimental group exhibited higher plasma cefazolin concentrations than control group.

CONCLUSIONS

Cefazolin in intraosseous regional prophylaxis exhibits effectiveness in intraoperative antibiotic prophylaxis by maintaining concentrations above the minimum inhibitory concentration for extended durations, rather than relying solely on high concentrations.

Intraosseous Regional Administration of Vancomycin Prophylaxis for Primary and Revision Total Knee Arthroplasty

The advantages of prophylaxis with intraosseous regional administration (IORA) of vancomycin for periprosthetic joint infection (PJI) in primary and revision total knee arthroplasty (TKA) include the ability to deliver antibiotics directly to the surgical bed and avert systemic delivery; the ability to precisely time and quickly administer vancomycin to achieve the highest concentrations at the beginning and throughout the surgical procedure; and the ability to avert several common and potentially serious adverse effects of intravenous vancomycin. Indications for IORA of vancomycin prophylaxis include the following clinical scenarios: revision TKA; obesity; diabetes; beta-lactam allergy; known colonization with methicillin-resistant Staphylococcus aureus (MRSA); individuals coming from institutions with a high MRSA incidence; previous ligamentous surgical procedure or osteotomy; current or recent smokers; in the primary TKA setting if the individual is considered high-risk as defined by the criteria above; and during reimplantation following 2-stage exchange for PJI.

Intraosseous regional prophylaxis in total knee arthroplasty

Prophylactic antibiotics are important in reducing the risk of periprosthetic joint infection (PJI) following total knee arthroplasty. Their effectiveness depends on the choice of antibiotic and the optimum timing of their administration, to ensure adequate tissue concentrations. Cephalosporins are typically used, but an increasing number of resistant organisms are causing PJI, leading to the additional use of vancomycin. There are difficulties, however, with the systemic administration of vancomycin including its optimal timing, due to the need for prolonged administration, and potential adverse reactions. Intraosseous regional administration distal to a tourniquet is an alternative and attractive mode of delivery due to the ease of obtaining intraosseous access. Many authors have reported the effectiveness of intraosseous prophylaxis in achieving higher concentrations of antibiotic in the tissues compared with intravenous administration, providing equal or enhanced prophylaxis while minimizing adverse effects. This annotation describes the technique of intraosseous administration of antibiotics and summarizes the relevant clinical literature to date.

Principles of mechanical and chemical debridement with implant retention

BACKGROUND

Periprosthetic joint infection (PJI) is one of the most common causes of early revision for total hip and knee arthroplasty. Mechanical and chemical debridement typically referred to as debridement, antibiotics, and implant retention (DAIR) can be a successful technique to eradicate PJI in acute postoperative or acute hematogenous infections. This review will focus specifically on the indications, techniques, and outcomes of DAIR.

DISCUSSION

The success of mechanical and chemical debridement, or a DAIR operation, is reliant on a combination of appropriate patient selection and meticulous technique. There are many technical considerations to take into consideration. One of the most important factors in the success of the DAIR procedure is the adequacy of mechanical debridement. Techniques are surgeon-specific and perhaps contribute to the large variability in the literature on the success of DAIR. Factors that have been shown to be associated with success include the exchange of modular components, performing the procedure within seven days or less of symptom onset, and possibly adjunctive rifampin or fluoroquinolone therapy, though this remains controversial. Factors that have been associated with failure include rheumatoid arthritis, age greater than 80 years, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease.

CONCLUSIONS

DAIR is an effective treatment option for the management of an acute postoperative or hematogenous PJI in the appropriately selected patient with well-fixed implants.

Intraosseous Regional Administration of Antibiotic Prophylaxis for Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Intraosseous regional administration (IORA) of antibiotics after tourniquet inflation has recently been introduced as a technique to deliver antibiotics directly to the surgical site among patients undergoing total knee arthroplasty (TKA).

METHODS

PubMed and Embase were queried for studies reporting on IORA for perioperative prophylaxis during TKA. Primary outcome measures were local tissue antibiotic concentrations and rates of prosthetic joint infection (PJI). Eight studies were included for analysis. Four studies (all randomized controlled trials) compared local tissue concentrations between patients receiving IORA and intravenous (IV) antibiotics. Six studies assessed the rate of PJI among patients receiving IORA versus IV antibiotics.

RESULTS

All studies found a statistically significant increase in antibiotic concentration in femoral bone and fat samples in patients who were treated with IORA (44.04 μg/g [fat] and 49.3 μg/g [bone] following 500 mg of intraosseous vancomycin) versus IV (3.5 μg/g [fat] and 5.2 μg/g [bone] following 1 g IV of vancomycin). The two studies powered to determine differences in PJI rates found a statistically significant decrease in the rate of PJI among patients receiving IORA versus IV antibiotics. The incidence of PJI in patients treated with IORA and IV antibiotics across all studies was 0.3 and 1.1%, respectively.

CONCLUSION

Perioperative IORA of antibiotics in TKA provides local tissue concentrations of antibiotics that are on average 10 times higher than IV administration alone. Although more adequately powered investigations are necessary to determine the effectiveness of IORA in reducing PJI rates, adoption of IORA should be considered in high-risk patients where elevated tissue antibiotic concentrations would be of a maximum benefit.

Antibiotic Prophylaxis in One-Stage Revision of Septic Total Knee Arthroplasty: A Scoping Review

BACKGROUND

Total knee replacement (TKA) is becoming a routine procedure in orthopedic surgery. One of the possible complications of this surgery is periprosthetic joint infection (PJI). The purpose of this study is to identify, through a literature review, which antibiotic is used as prophylaxis for septic one-stage revision TKA and what is the rationale for its use.

METHODS

We searched: MEDLINE, Embase, PsycINFO on Ovid, the Cochrane Library, and the Google Scholar Database. The searches were limited by date (January 2005 to September 2022) and to the English language. All types of original research were considered, including prospective or retrospective longitudinal studies, cross-sectional studies, and randomized trials. The specific search terms were ((antibiotic [MeSH]) AND (prophylaxis)) and (TKA OR TKR OR "Arthroplasty, Replacement, Knee" [MeSH] OR ((knee) adj2 (replace* OR arthroplasty* OR prosthe*))).

RESULTS

Despite our research efforts, we found no article capable of answering the question of which antibiotic to use as surgical prophylaxis for a septic revision one-stage TKA.

CONCLUSIONS

Although the research results are inconclusive, we would recommend using the same antibiotic prophylaxis as for primary joint replacement, i.e., cefazolin, as it was recommended for its low side effect rate and relative effectiveness.

Intraosseous regional prophylactic antibiotics decrease the risk of infection in total knee arthroplasty compared with intravenous antibiotics: a systematic review and meta-analysis

Purpose

Surgical site infection (SSI) is a rare and serious complication of total knee arthroplasty (TKA), which causes a poor prognosis for patients. The purpose of this study was to explore the effect of intraosseous (IO) antibiotics in preventing infection and complications after TKA compared with intravenous (IV) antibiotics and to provide a certain theoretical basis for clinical treatment.

Methods

The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed, Embase, Ovid, Web of Science, and the Cochrane Central Register of Controlled Trials databases about trials on IO antibiotics (into the proximal tibia before skin incision) to prevent infections in TKA from the respective inception dates to September 30, 2022. The infection occurred within 3 months after surgery. Both researchers individually screened the studies in accordance with the inclusion and exclusion criteria, performed the literature quality evaluation and data extraction, and used Stata 17 software for data analysis.

Results

Five studies that enrolled 3801 patients were included in this meta-analysis. The results showed that IO antibiotics were effective in reducing the incidence of SSI (OR: 0.25, P = 0.001) and periprosthetic joint infections (OR: 0.16, P = 0.004) relative to IV. Moreover, the percentage of infection due to Gram-positive bacteria (OR: 0.18, P = 0.025) was reduced in the IO group compared with that in IV group, but Gram-negative bacteria levels were not significantly reduced (P = 0.14). There was no difference between the two groups for other systemic adverse effects of the drug.

Conclusions

IO antibiotics in TKA are safe and effective alternatives to IV antibiotics. Large randomized clinical studies comparing infection rates and related complications with IO and IV antibiotics are required.

Intraosseous Vancomycin May Not Be Helpful in Aseptic Revision Knee Arthroplasty: A Single-Surgeon Consecutive Case Series

BACKGROUND

Infection after aseptic revision total knee arthroplasty (TKA) has been reported from 9% to 14%. Intraosseous (IO) vancomycin infusion has decreased the risk of infection after primary TKA. The results of this additional prophylaxis were evaluated in aseptic revision TKA.

METHODS

In this prospective, single-surgeon study of 20 consecutive patients having aseptic revision TKA, 500 milligrams of vancomycin in 120 mL of saline were infused into the tibia prior to incision, in addition to intravenous (IV) cefazolin. There were 18 men and 2 women who had a mean age of 67 years (range, 47-79), and mean body mass index of 34.4 (range, 25.9-51.2). The knees were aspirated in the operating room prior to IV and IO antibiotics. The outcomes were infections at 90 days requiring reoperation and complications from the infusion.

RESULTS

Three of the 20 aseptic revisions had early prosthetic joint infection, 2 with gram-negative organisms and one with coagulase-negative Staphylococcus. All had debridement, liner exchange and IV antibiotic treatment, but 1 patient eventually had an above knee amputation. No patient had total body "erythema syndrome", but 1 patient had transient facial flushing. Six patients had a transient elevation of serum creatinine including 3 with an abnormal preoperative serum creatinine.

CONCLUSION

In this small series of aseptic revision TKA, there was no added benefit of IO vancomycin infusion, but there were no infections with methicillin-resistant Staphylococcus aureus. Additional studies are needed before this technique should be routinely recommended.

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

Although there are numerous nonpatient-related factors that may help reduce infection risk, the proper use of prophylactic antibiotics is most responsible for reducing infection. The role of prophylactic antibiotics is to reduce early periprosthetic joint replacement, which is accomplished by having adequate antibiotic tissue levels at the time of skin incision. The goal of this section of the symposium is to review current antibiotic recommendations, how to manage patients with a self-reported penicillin allergy, review the use of dual antibiotics, discuss the use of antibiotics in the outpatient total joint setting, as well as very briefly discuss the administration of intraosseous antibiotics in knee arthroplasty.

Early Infection After Aseptic Revision Knee Arthroplasty: Prevalence and Predisposing Risk Factors

BACKGROUND

Although patient factors have been associated with prosthetic joint infection (PJI) after primary total knee arthroplasty, there are insufficient data on the relationship of patient and technical factors with early PJI after aseptic revision.

METHODS

This is a retrospective study of 157 aseptic revisions performed by 2 surgeons at 1 academic center. A negative intraoperative culture during revision surgery was required for inclusion. Mean follow-up time was 3.8 years (standard deviation 2.8). PJI was defined by positive aspiration or draining wound, and an additional operation within 1 year of aseptic revision. Patient demographics, medical comorbidities, and technical factors were reviewed. Data points were evaluated with univariate and adjusted multivariate regression analyses.

RESULTS

The prevalence of PJI after aseptic revision was 9% (14/157). The most common organism was Staphylococcus aureus. Initial treatment included debridement and liner exchange (11) and antibiotic spacer (3). Two patients ultimately had an above-knee amputation. Univariate analysis showed a significant difference in preoperative anemia (P < .01), transfusion (P < .01), and diabetes (P = .05) between cohorts. There was no association among the length of surgery, use of a metaphyseal cone, or the number of components revised and PJI. Adjusted logistic regression demonstrated that preoperative anemia (P < .01) was a significant risk factor for PJI.

CONCLUSION

The prevalence of early PJI was similar to other studies in the literature. Anemia was an independent predictor of PJI, while technical factors did not have an association. Medical optimization of patients should be considered prior to revision surgery.

Intraosseous Regional Administration of Prophylactic Antibiotics in Total Knee Arthroplasty

Prosthetic joint infection (PJI) after total knee arthroplasty is a devastating complication. With the development of antibiotic resistance, a safe and effective means of delivering antibiotic prophylaxis is needed. Intraosseous regional antibiotics (IORA) achieve higher local concentrations of antibiotics with fewer systemic side effects. Previous studies have proven the safety of IORA, whereas animal models have proven it to be more effective than intravenous antibiotics for preventing infection following surgery. Recently, large-scale retrospective studies have also demonstrated lower PJI rates following TKA when IORA is used when compared to routine intravenous prophylaxis. In this article, we propose an evidence-based method for the administration of intraosseous antibiotics in TKA, cover the up-to-date data supporting its use, and explore future directions for additional research.

Higher Tissue Concentrations of Vancomycin Achieved With Low-Dose Intraosseous Injection Versus Intravenous Despite Limited Tourniquet Duration in Primary Total Knee Arthroplasty: A Randomized Trial

BACKGROUND

Vancomycin use has been suggested in high risk patients undergoing total knee arthroplasty (TKA). Previous literature has shown that a lower dose (500 mg) of vancomycin given by intraosseous regional administration (IORA) achieves tissue concentrations 4-10 times higher than intravenous (IV) administration. There is increasing interest in performing TKA with limited tourniquet inflation time. The purpose of this study is to evaluate whether IORA of vancomycin can achieve effective tissue concentrations with limited tourniquet inflation time.

METHODS

Based on prior power calculations, 24 patients undergoing primary TKA were randomized into 2 groups. Group IV-Systemic received weight-based (15 mg/kg) vancomycin with the tourniquet inflated for cementation only. Group IORA received 500 mg vancomycin via IORA after tourniquet inflation which remained inflated for 10 minutes, then reinflated for cementation only. Vancomycin concentrations from tissue, serum, and drain fluid were compared between the 2 groups.

RESULTS

Median vancomycin concentrations in tissue were significantly higher (5-15 times) at all time points in the IORA group. Concentrations in fat at the time of wound closure, after the tourniquet had been deflated for most of the procedure, were 5.2 μg/g in Group IV-Systemic and 33.1 μg/g in Group IORA (P < .001). Median bone concentrations taken just prior to cementation were 7.9 μg/g in Group IV-Systemic and 21.8 μg/g in Group IORA (P = .006). There were no complications related to IORA.

CONCLUSION

For surgeons who wish to limit tourniquet time and when indicated to use vancomycin, low-dose vancomycin IORA achieves tissue concentrations 5-15 times higher than those achieved by IV administration.

LEVEL OF EVIDENCE

Level 1 therapeutic randomized trial.

Impact of tourniquet during total knee arthroplasty when tranexamic acid was used: a meta-analysis of randomized controlled trials

Introduction

The efficacy of tourniquet use during primary total knee arthroplasty (TKA) is thought to reduce intraoperative blood loss, improve surgical exposure, and optimize cement fixation. Tranexamic acid (TXA) use can decrease postsurgical blood loss and transfusion requirements. This review aimed to appraise the effects of tourniquet use in TKA for patients with tranexamic acid use.

Methods

A meta-analysis was conducted to identify relevant randomized controlled trials involving TXA plus a tourniquet (TXA-T group) and use of TXA plus no tourniquet (TXA-NT group) in TKA. Web of Science, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CNKI, and Wanfang database were searched from 2010 through October 2021.

Results

We identified 1720 TKAs (1690 patients) assessed in 14 randomized controlled trials. Compared with the TXA-NT group, the TXA-T group resulted in less intra-operative blood loss (P < 0.00001) and decreased duration of surgery (P < 0.00001), however more hidden blood loss (P = 0.0004) and less knee range of motion (P < 0.00001). No significant differences were found between two groups in terms of decrease in hemoglobin (P = 0.84), total blood loss (P = 0.79), transfusion rate (P = 0.18), drainage volume (P = 0.06), Visual Analogue Scale (VAS) at either the day of surgery (P = 0.2), 1 day (P = 0.25), 2 day (P = 0.39), 3 day (P = 0.21), 5 day (P = 0.21), 7 day (P = 0.06) or 1 month after surgery (P = 0.16), Hospital for Special Surgery (HSS) score at either 7 day (P = 0.10), 1 month (P = 0.08), 3 month (P = 0.22) or 6 month after the surgery (P = 0.92), Knee circumference (P = 0.28), length of hospital (P = 0.12), and complications such as intramuscular venous thrombosis (P = 0.81), deep venous thrombosis (P = 0.10), superficial infection (P = 0.45), deep wound infection (P = 0.64), and delayed wound healing (P = 0.65).

Conclusion

No big differences could be found by using or not tourniquet when use the TXA, though some benefits are related to operation time and less intra-operative blood loss by using tourniquet and TXA, Using the tourniquet was related to more hidden blood loss and less knee range of motion. More adequately powered and better-designed randomized controlled trials (RCTs) studies with long-term follow-up are required to validate this study.

Intraosseous Regional Prophylactic Antibiotics Decrease the Risk of Prosthetic Joint Infection in Primary TKA: A Multicenter Study

BACKGROUND

Recent studies have demonstrated that the administration of regional prophylactic antibiotics by intraosseous (IO) injection achieves tissue concentrations around the knee that are 10- to 15-fold higher than intravenous (IV) delivery of prophylactic antibiotics. It is currently unknown whether the use of regional prophylactic antibiotics for primary TKA would result in a lower risk of prosthetic joint infection (PJI).

QUESTIONS/PURPOSES

(1) Is IO injection of prophylactic antibiotics associated with a decreased risk of early (< 12 months) deep PJI compared with traditional IV prophylactic antibiotics? (2) What other patient factors are associated with an increased risk of early PJI after TKA, and do regional prophylactic antibiotics influence these risk factors? (3) Can IO antibiotics be administered to all patients, and what complications occurred from the delivery of IO prophylactic antibiotics?

METHODS

A retrospective comparative study of all primary TKAs (1909 TKAs) over a 5-year period (January 2013 to December 2017) was performed to determine the risk of early PJI. Three primary TKAs did not meet the study inclusion criteria and were excluded from the study, leaving a total of 1906 TKAs (725 IO, 1181 IV) for analysis at a minimum of 12 months after index procedure. Both cohorts exhibited similar ages, BMI, and American Society of Anesthesiologists (ASA) grades; however, a greater proportion of patients in the IO cohort were smokers (p = 0.01), while a greater proportion of patients were diabetic in the IV cohort (p = 0.006). The PJI risk between IO and IV delivery techniques was compared while adjusting for patient demographics and medical comorbidities. Complications related to IO delivery-inability to administer via IO technique, compartment syndrome, fat embolism, and red man syndrome with vancomycin use-were recorded.

RESULTS

The delivery of regional prophylactic antibiotics by the IO technique resulted in a lower PJI risk than IV prophylactic antibiotics (0.1% [1 of 725] compared with 1.4% [16 of 1181]; relative risk 0.10 [95% CI 0.01 to 0.77]; p = 0.03). BMI (β = -0.17; standard error = 0.08; p = 0.02), diabetes (β = -1.80; standard error = 0.75; p = 0.02), and renal failure (β = -2.37; standard error = 0.84; p = 0.01) were factors associated with of PJI, while smoking, sex, and ASA score were not contributing factors (p > 0.05). Although BMI, diabetes, and renal failure were identified as infection risk factors, the use of IO antibiotics in these patients did not result in a lower PJI risk compared with IV antibiotics (p > 0.05). IO antibiotics were able to be successfully administered to all patients in this cohort, and there were no complications related to the delivery of IO antibiotics.

CONCLUSION

Surgeons should consider administering regional prophylactic antibiotics in primary TKA to reduce the risk of early PJI. Future randomized prospective clinical trials are needed to validate the efficacy of regional prophylactic antibiotics in reducing the PJI risk in primary TKA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Incomplete Administration of Intravenous Vancomycin Prophylaxis is Common and Associated With Increased Infectious Complications After Primary Total Hip and Knee Arthroplasty

BACKGROUND

Vancomycin is often used as antimicrobial prophylaxis in patients undergoing total hip or knee arthroplasty. Vancomycin requires longer infusion times to avoid associated side effects. We hypothesized that vancomycin infusion is often started too late and that delayed infusion may predispose patients to increased rates of surgical site infections and prosthetic joint infections.

METHODS

We reviewed clinical data for all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients at our institution between 2013 and 2020 who received intravenous vancomycin as primary perioperative gram-positive antibiotic prophylaxis. We calculated duration of infusion before incision or tourniquet inflation, with a cutoff of 30 minutes defining adequate administration. Patients were divided into two groups: 1) appropriate administration and 2) incomplete administration. Surgical factors and quality outcomes were compared between groups.

RESULTS

We reviewed 1047 primary THA and TKA patients (524 THAs and 523 TKAs). The indication for intravenous vancomycin usage was allergy (61%), methicillin-resistant staphylococcus aureus colonization (17%), both allergy and colonization (14%), and other (8%). 50.4% of patients began infusion >30 minutes preoperatively (group A), and 49.6% began infusion <30 minutes preoperatively (group B). Group B had significantly higher rates of readmissions for infectious causes (3.6 vs 1.3%, P = .017). This included a statistically significant increase in confirmed prosthetic joint infections (2.2% vs 0.6%, P = .023). Regression analysis confirmed <30 minutes of vancomycin infusion as an independent risk factor for PJI when controlling for comorbidities (OR 5.22, P = .012).

CONCLUSION

Late infusion of vancomycin is common and associated with increased rates of infectious causes for readmission and PJI. Preoperative protocols should be created to ensure appropriate vancomycin administration when indicated.

Results of debridement, antibiotics, and implant retention for periprosthetic knee joint infection supplemented with the use of intraosseous antibiotics

AIMS

Debridement, antibiotics, and implant retention (DAIR) remains one option for the treatment of acute periprosthetic joint infection (PJI) despite imperfect success rates. Intraosseous (IO) administration of vancomycin results in significantly increased local bone and tissue concentrations compared to systemic antibiotics alone. The purpose of this study was to evaluate if the addition of a single dose of IO regional antibiotics to our protocol at the time of DAIR would improve outcomes.

METHODS

A retrospective case series of 35 PJI TKA patients, with a median age of 67 years (interquartile range (IQR) 61 to 75), who underwent DAIR combined with IO vancomycin (500 mg), was performed with minimum 12 months' follow-up. A total of 26 patients with primary implants were treated for acute perioperative or acute haematogenous infections. Additionally, nine patients were treated for chronic infections with components that were considered unresectable. Primary outcome was defined by no reoperations for infection, nor clinical signs or symptoms of PJI.

RESULTS

Mean follow-up for acute infection was 16.5 months (12.1 to 24.2) and 15.8 months (12 to 24.8) for chronic infections with unresectable components. Overall non-recurrence rates for acute infection was 92.3% (24/26) but only 44.4% (4/9) for chronic infections with unresectable components. The majority of patients remained on suppressive oral antibiotics. Musculoskeletal Infection Society (MSIS) host grade was a significant indicator of failure (p < 0.001).

CONCLUSION

The addition of IO vancomycin at the time of DAIR was shown to be safe with improved results compared to current literature using standard DAIR without IO antibiotic administration. Use of this technique in chronic infections should be applied with caution. While these results are encouraging, this technique requires longer follow-up before widespread adoption. Cite this article: Bone Joint J 2021;103-B(6 Supple A):185-190.

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

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.

Development of antibiotic resistance in periprosthetic joint infection after total knee arthroplasty

AIMS

The management of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is challenging. The correct antibiotic management remains elusive due to differences in epidemiology and resistance between countries, and reports in the literature. Before the efficacy of surgical treatment is investigated, it is crucial to analyze the bacterial strains causing PJI, especially for patients in whom no organisms are grown.

METHODS

A review of all revision TKAs which were undertaken between 2006 and 2018 in a tertiary referral centre was performed, including all those meeting the consensus criteria for PJI, in which organisms were identified. Using a cluster analysis, three chronological time periods were created. We then evaluated the antibiotic resistance of the identified bacteria between these three clusters and the effectiveness of our antibiotic regime.

RESULTS

We identified 129 PJIs with 161 culture identified bacteria in 97 patients. Coagulase-negative staphylococci (CNS) were identified in 46.6% cultures, followed by Staphylococcus aureus in 19.8%. The overall resistance to antibiotics did not increase significantly during the study period (p = 0.454). However, CNS resistance to teicoplanin (p < 0.001), fosfomycin (p = 0.016), and tetracycline (p = 0.014) increased significantly. Vancomycin had an 84.4% overall sensitivity and 100% CNS sensitivity and was the most effective agent.

CONCLUSION

Although we were unable to show an overall increase in antibiotic resistance in organisms that cause PJI after TKA during the study period, this was not true for CNS. It is concerning that resistance of CNS to new antibiotics, but not vancomycin, has increased in a little more than a decade. Our findings suggest that referral centres should continuously monitor their bacteriological analyses, as these have significant implications for prophylactic treatment in both primary arthroplasty and revision arthroplasty for PJI. Cite this article: Bone Joint J 2021;103-B(6 Supple A):171-176.

The application of topical vancomycin powder for the prevention of surgical site infections in primary total hip and knee arthroplasty: A meta-analysis

BACKGROUND

Surgical site infections (SSIs), particularly periprosthetic joint infections (PJI), following a primary total joint arthroplasty (TJA) impose a major burden by increasing morbidity, mortality, disability rate, and health expenditure. Surgeons are increasingly using topical vancomycin powder as a preventative measure, but the effectiveness of this method has been debated in TJA. Thus, we designed a meta-analysis to compare the outcomes after primary TJA between a group treated with topical vancomycin powder and an untreated control group aiming to answer: (1) whether the application of topical vancomycin powder can reduce the infection rate after primary total joint replacement; (2) are the main types of pathogens causing SSIs after the application of topical vancomycin powder different from those of patients not using topical vancomycin?

MATERIALS AND METHODS

A meta-analysis was conducted in accordance with the PRISMA guidelines. We included retrospective cohort studies and prospective randomized controlled trials of patients who underwent primary total joint arthroplasty with and without vancomycin powder application before wound closure and reported the SSI rates. The English literature in the PubMed (MEDLINE), EMBASE, Web of Science, and the Cochrane Library databases was comprehensively searched. Literature search, data extraction, and quality assessment were conducted by 2 authors. The main outcomes were SSI and PJI rates, and the secondary outcome was the bacterial spectrum. Statistical analyses were performed with the Review Manager (RevMan) Version 5.3.

RESULTS

Six retrospective cohort studies and 3 prospective cohort studies with 4512 participants were included (2354 in vancomycin group and 2158 in the control group). In the TJA group, the vancomycin powder-treatment resulted in a significantly lower proportion of patients with SSIs (relative risk [RR]=0.40, 95% confidence interval [CI]=0.27-0.61 [p<0.001]) or PJI (RR=0.37, 95% CI=0.23-0.60 (p<0.001)). In the total hip arthroplasty group, the vancomycin powder treatment decreased the rate of SSIs and PJI by 66% (RR=0.34, 95% CI=0.15-0.78 [p=0.01]) and 74% (RR=0.26, 95% CI=0.10-0.67 (p=0.005)), respectively. In the total knee arthroplasty group, the vancomycin powder decreased the rate of SSIs and PJI by 67% (RR=0.43, 95% CI=0.26-0.70 [p<0.001]) and 66% (RR=0.44, 95% CI=0.25-0.77 [p=0.004]) respectively. Staphylococcus aureus (or methicillin-sensitiveStaphylococcus aureus) (6 in vancomycin group versus 11 in control group) was the most common pathogenic bacteria, followed by Staphylococcus epidermidis (1 in vancomycin group versus 2 in control group) and methicillin-resistant Staphylococcus aureus (2 in vancomycin group versus 4 in control group). Pseudomonas aeruginosa was the main gram-negative pathogen, with 3 cases in the control group and 1 case in the vancomycin powder-treatment group.

DISCUSSION

The local application of vancomycin powder could significantly decrease the rate of SSIs and PJI in primary TJA without modifying the spectrum of bacteria involved. We recommend topical administration of the vancomycin powder before wound closure after a full evaluation of the patients.

LEVEL OF EVIDENCE

III; meta-analysis.

Intraosseous Regional Administration of Vancomycin in Primary Total Knee Arthroplasty Does Not Increase the Risk of Vancomycin-Associated Complications

BACKGROUND

Periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a rare but major complication. Owing to an increasing antibiotic resistance in bacteria causing PJI, vancomycin has been investigated as a prophylactic agent. Intraosseous regional administration (IORA) of vancomycin achieves significantly higher local tissue concentrations than systemic administration. There are limited data on IORA of vancomycin with respect to vancomycin-associated complications.

METHODS

Single-surgeon retrospective review of primary TKA was performed between January 2015 and May 2019. All patients received 500 mg of IORA of vancomycin after tourniquet inflation and 3 × 1 g intravenous cefazolin in 24 hrs. Preoperative data collected included age, gender, body mass index, American Society of Anesthesiologists (ASA) score, diabetes, and chronic kidney disease (CKD). We documented in-hospital complications and complications requiring readmission within 12 months. Primary outcome measures were the incidence of acute kidney injury (AKI), 'red man syndrome' (RMS), and neutropenia. The secondary outcome measure was PJI incidence.

RESULTS

We identified 631 primary TKAs in 556 patients, of which 331 received IORA. The mean age was 67.7 ± 8.7 years, and 57.8% were women. CKD was prevalent in 17.2% of the cohort. AKI occurred in 25 (3.9%) cases. After controlling for covariates, CKD was the only significant predictor of AKI (odds ratio = 3.035, P = .023). RMS and neutropenia were not observed in this cohort. The 90-day PJI rate was 0%, and the 1-year PJI rate was 0.2%.

CONCLUSIONS

Low-dose IORA of vancomycin in addition to standard intravenous systemic cefazolin prophylaxis in TKA is safe without significant adverse effects of vancomycin such as AKI, RMS, or neutropenia.

Vancomycin is toxic to human chondrocytes in vitro

INTRODUCTION

Vancomycin powder (VP) is a well-established topical antibiotic used in spinal surgery to prevent surgical site infections. More recently its extension to hip and knee arthroplasty was introduced. The aim of this study was to examine toxic effects of VP on the viability of human chondrocytes. Our hypothesis was that VP damages human chondrocytes in vitro with increasing concentration and length of exposure.

MATERIAL AND METHODS

Primary human chondrocytes were isolated and cultured from donated human knee joints. VP was added to these cultures with increasing concentrations (0-50 mg/ml) and length of exposure (0-336 h). Toxicity and viability were analyzed using LDH und XTT Elisa assays. Cell structure and determination of vital versus dead cells were visualized using light microscopy and fluorescence microscopy.

RESULTS

Light microscopy and fluorescence microscopy visualized defect cell structures and cell death proportional to increasing dose and length of exposure to VP. The analysis of LDH activity data showed toxic effects on chondrocytes as early as 2,5 min after exposure to VP. XTT activity data revealed a significant toxic threshold of a VP concentration above 12.5 mg/ml.

CONCLUSIONS

These results show that exposure to high VP concentrations yields to a damage of human chondrocytes in vitro. Chondrotoxicity is an immediate effect that is proportional to VP concentration. Therefore, the intraarticular use of high concentrations of vancomycin powder in the presence of native cartilage tissue must be considered critically.

Hot spots and trends in knee revision research since the 21st century: a bibliometric analysis

Background

With the popularization of knee replacement surgery in the treatment of the advanced lesions of knee joint, the amount of knee revision surgery is increasing unceasingly. Meanwhile, the continuous introduction of new clinical concepts and new technology poses a challenge to researchers and surgeons. Our study aims to inform the future scientific research and clinical treatment, by investigating the hot spots and trends of the knee revision research field with the method of bibliometric analysis.

Methods

Publications on knee revision included in the database of Web of Science Core Collection (WoSCC) between 2000 and 2018 were reviewed and MeSH terms of them were extracted from PubMed. Online bibliometric analysis website (http://bibliometric.com/), two pieces of software called “CiteSpace” and “Bibliographic Item Co-Occurrence Matrix Builder” (BICOMB) were used to analyze the publications reviewed at quantitative level. Another piece of software called “gCLUTO”, was used to investigate the hot spots with visualization techniques at qualitative level.

Results

A total of 906 publications were retrieved between 2000 and 2018. There is an increasing number of publications, from 15 in 2000 to 86 in 2018. Journal of Arthroplasty is the leading journal which has the most publications on knee revision. The United States has been the biggest contributor. Mayo Clinic became the leader among the institutions which have conducted correlational researches. David G. Lewallen, Robert L. Barrack and Michael A. Mont should be regarded as the scholars who have made outstanding contribution. Hot spots were summed up in six clusters, respectively, the solutions for infection, prostheses, the adverse effects, the surgical techniques, epidemiological characters, and the pathophysiology of the revision knee.

Conclusions

We found a growing trend in knee revision research and extracted the most contributive researchers, institutions, countries, journals, and most-cited articles worldwide. The solutions for complications, surgical applications and analysis for epidemiological characters have been the hot spots. Multi-disciplinary integration is becoming the time-trend of hot spots. Minimally invasive and navigation are directions of revision surgery. They together constitute a solid foundation and set up a fingerpost for the future scientific research and clinical treatment.

Vancomycin bone and tissue concentrations following tibial intraosseous administration - evaluated in a porcine model

Introduction. Systemic perioperative vancomycin may not provide sufficient prophylactic target-site concentrations in the prevention of prosthetic joint infections. Intraosseous vancomycin potentially provides high target-site concentrations. The objective of the present study was to evaluate the local bone and tissue concentrations following tibial intraosseous vancomycin administration in a porcine model. Methods. Eight pigs received 500 mg diluted vancomycin (50 mg/mL) through an intraosseous cannula into the proximal tibial cancellous bone. No tourniquet was applied. Microdialysis was applied for sampling of vancomycin concentrations in adjacent tibial cancellous bone, in cortical bone, in the intramedullary canal of the diaphysis, in the synovial fluid of the knee joint, and in the subcutaneous tissue. Plasma samples were obtained as a systemic reference. Samples were collected for 12 h. Results. High vancomycin concentrations were found in the tibial cancellous bone with a mean peak drug concentration of 1236 (range 28-5295)  µ g / mL , which remained high throughout the sampling period. The mean (standard deviation) peak drug concentration in plasma was 19 (2)  µ g / mL , which was obtained immediately after administration. Peak drug concentration, time to peak drug concentration, and area under the concentration-time curve were within the same range in the intramedullary canal, the synovial fluid of the knee, and the subcutaneous tissue. Conclusion. Tibial intraosseous administration of vancomycin provided high concentrations in tibial cancellous bone throughout a 12 h period but with an unpredictable and wide range of peak concentration. The systemic absorption was high and immediate, thus mirroring an intravenous administration. Low mean concentrations were found in all the remaining compartments.

Intraosseous Regional Administration of Antibiotic Prophylaxis in Total Knee Arthroplasty

Background

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA), and perioperative antibiotics are commonly administered to try to mitigate the chance of infection. Intraosseous regional administration (IORA) of prophylactic antibiotics during TKA is a method of antibiotic delivery that has been shown to achieve markedly higher tissue concentrations at much lower doses. Other advantages include ease of administration, ability to time the antibiotic delivery with the surgical start time for maximal effectiveness, and less systemic side effects. The concept is similar to a Bier block, except that IORA involves the use of antibiotics instead of local anesthetic to perfuse the limb and is given via intraosseous rather than intravenous access.

Description

After standard patient preparation and draping, the tourniquet is inflated and an intraosseous needle is inserted into the proximal medial face of the tibia, just medial and slightly above the level of the tubercle. A large syringe containing the desired antibiotic (typically 500 mg vancomycin suspended in normal saline solution) is connected to the needle and the solution is administered over 1 to 2 minutes. The intraosseous needle can then be removed and the surgical procedure proceeds as it normally would per surgeon preference and technique.

Alternatives

Systemic administration of intravenous antibiotics, vancomycin powder, and antibiotic-impregnated cement are alternative options that can be utilized during TKA.

Rationale

IORA has several distinct advantages over other methods of antibiotic delivery, including the ability to (1) deliver antibiotic directly to the surgical bed and avoid systemic delivery, (2) precisely time and quickly administer antibiotics to achieve highest concentrations at the start of and throughout the surgical procedure, and (3) avoid several common and potentially serious side effects, especially those associated with antibiotics such as vancomycin.

Expected Outcomes

This technique for antibiotic delivery achieves markedly higher tissue concentrations compared with systemic administration, without prolonged preoperative infusion times. Intraosseous delivery optimizes timing and reduces the risk of systemic side effects while simultaneously providing equal or enhanced antibiotic prophylaxis in TKA. This delivery mechanism is especially useful in patients who are at high risk for infection and in the revision TKA setting. Further, there is little to no additional risk and the use of this method does not substantially prolong operative time.

Important Tips

The proximal aspect of the tibia is the optimal injection site because the cortex is thinner in this region, making needle insertion easier. Additionally, the metaphyseal bone allows faster flow rates for the infusion. We have found that insertions made slightly more proximally are easier and have faster flow rates. Of note, although the antibiotic is infused into the tibia, as seen in the attached technique video, intraosseous administration achieves rapid uptake into the vascular tree. Therefore, all tissues distal to the tourniquet, including the femur and patella, will receive this optimal dose as well.We prefer the use of a power driver (EZ-IO; Teleflex); however, manual needles (Cook Medical) can also be utilized. Longer needles are available if needed for obese patients.Flow rates are variable and the infusion typically takes 1 to 2 minutes to complete. If the flow rate is slow, twisting and withdrawing the needle slightly (2 to 4 mm) may increase the rate. This contrasts with the 1 to 2-hour intravenous infusion time required when vancomycin is administered systemically.In our experience, intraosseous injection is still successful in the case of a previous high tibial osteotomy, although the flow rate may be slower.In complex revision cases with compromised proximal tibial bone, the medial malleolus is an alternative site for intraosseous administration.Choice of antibiotic: as vancomycin is difficult to adequately administer intravenously, it is ideally suited for IORA. We have studied and utilized a 500-mg dose of vancomycin suspended in a solution of 140 mL of normal saline solution (prepared by our pharmacy). Of note, we have not found rapid infusion of intraosseous vancomycin to cause red-man syndrome as it would with rapid systemic infusion. This is because of the lower dose of 500 mg and the use of the tourniquet, which keeps the antibiotic in the local tissues about the knee without allowing systemic exposure. All patients, regardless of weight or the size of their limb, receive the dose of 500 mg of vancomycin.As cefazolin does not have the same difficulties with intravenous administration, we continue to use standard intravenous prophylaxis with an appropriate weight-based dose of cefazolin prior to incision.Indications for IORA of vancomycin include clinical scenarios in which vancomycin would be administered intravenously. These indications include revision TKA, obesity (body mass index >40 kg/m²), diabetes, beta-lactam allergy, known colonization with methicillin-resistant Staphylococcus aureus (MRSA), patients coming from institutions with a high prevalence of MRSA, previous ligamentous surgical procedure or osteotomies, and current or recent smokers. IORA can be utilized even in the primary TKA setting if the patient is considered high-risk as defined by the criteria above. We also use IORA during reimplantation following 2-stage exchange for PJI and in patients undergoing irrigation and debridement for acute PJI when the organism has been identified preoperatively.

Controversies in Perioperative Antimicrobial Prophylaxis

Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by multidisciplinary groups of physicians and pharmacists, clinicians often deviate from recommendations. This is particularly true when recommendations are based on weak data or expert opinion. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis and to focus on the data that does exist for the recommendations being made.

Contemporary Strategies to Prevent Infection in Hip and Knee Arthroplasty

PURPOSE OF REVIEW

Prosthetic joint infection (PJI) remains a serious concern in lower limb arthroplasty. Despite the significant consequences of PJI, the assessment of the safety and efficacy of preventative measures is challenging due to a low event rate. Notwithstanding, enormous efforts have been made in this arena, and prevention strategies continue to evolve. This review provides an update on contemporary literature (published within the last 5 years) pertaining to infection prevention in primary hip and knee arthroplasty.

RECENT FINDINGS

Patient optimization has been highlighted as a critical preoperative factor in mitigating PJI risk. Recent evidence emphasizes the importance of preoperative glycaemic control, nutritional status, weight optimization and smoking cessation prior to hip and knee arthroplasty. Perioperatively, attention to detail in terms of surgical skin preparation agent and technique as well as prophylactic antibiotic agent, spectrum, dose and timing is important with statistically and clinically significant differences seen between differing strategies. Intraosseous regional antibiotic administration is an emerging technique with promising preclinical data. Dilute betadine lavage also shows promise. Data supporting bundled interventions continues to grow. A multimodal approach is required in PJI prevention, and attention to detail is important with each element. Patient optimization is critical, as is the execution of the planned perioperative infection prevention strategy.

Clinical outcome evaluation of intraosseous vancomycin in total knee arthroplasty

Background

Vancomycin is a commonly used prophylactic antibiotic for total joint replacement surgery to protect against methicillin-resistant Staphylococcus aureus. Studies have suggested intraosseous (IO) infusions provide superior local tissue antibiotic concentration compared with intravenous (IV) access in total knee arthroplasty (TKA). We reviewed patients receiving IO vancomycin before TKA, comparing complication rates to a matched group receiving IV prophylactic vancomycin.

Methods

Retrospective review of TKA patients administered IO vancomycin (500 mg vancomycin in 200 mL normal saline), September 1, 2018 to March 1, 2019, was compared with TKAs performed with prophylactic IV vancomycin, January 1, 2018 to August 31, 2018. Before incision, an IO needle was inserted into the tibial tubercle region, delivering 100 mL of the mixed vancomycin solution. The needle was then removed and inserted into the distal femur, delivering 100 mL of the solution. Evaluation included preoperative and postoperative creatinine values, tourniquet time, and knee-related 30-day and 90-day complications. Data for primary and revision TKA surgery cases were analyzed independently.

Results

There were 100 primary and 29 revision TKA cases in the control (IV) arm and 100 primary and 19 revision TKA cases in the intervention (IO) arm, comprising a study group of 248 cases. There were fifteen 30-day complications and eighteen 90-day complications overall. No significant differences in the complication rate or creatinine values were identified between IO and IV groups.

Conclusions

IO vancomycin has an adequate safety profile in primary and revision TKA, eliminating the logistical challenge of timely prophylactic antibiotic administration.

Nationwide Organism Susceptibility Patterns to Common Preoperative Prophylactic Antibiotics: What Are We Covering?

BACKGROUND

Many periprosthetic joint infections (PJIs) are caused by organisms not susceptible to first-generation cephalosporins. We sought to evaluate the national susceptibility patterns of organisms to cefazolin and, or oxacillin, clindamycin, and vancomycin using antibiogram data.

METHODS

Publically available regional and state antibiograms were evaluated for antibiotic susceptibility patterns to commonly infecting gram-positive organisms. The number of isolates tested in each antibiogram and percent of strains susceptible to oxacillin, clindamycin, and vancomycin were recorded. Oxacillin is used as a surrogate to cefazolin in antibiograms. A comparison of antibiotic susceptibilities was performed.

RESULTS

Seven state and 38 regional antibiograms were reviewed. Oxacillin was a sensitive antibiotic in 99.2 ± 4.8% of methicillin-sensitive Staphylococcus aureus (MSSA) isolates, 0 ± 0% of methicillin-resistant Staphylococcus aureus (MRSA) isolates, 44.5 ± 13.7% of coagulase-negative staphylococcus organism isolates (CNS), and 30.6 ± 10.5% of Staphylococcus epidermidis isolates. Clindamycin was a sensitive antibiotic in 75.8 ± 8.4% of MSSA isolates, 60.2 ± 13.2% of MRSA isolates, 60.3 ± 11.4% of CNS isolates, and 56.2 ± 6.5% of S epidermidis isolates. Vancomycin was a sensitive antibiotic in 99.9 ± 0.4% of MSSA isolates, 99.8 ± 0.4% of MRSA isolates, 99.8 ± 0.5% of CNS isolates, and 99.6 ± 0.7% of S epidermidis isolates. Clindamycin was significantly less sensitive in MSSA isolates as compared with oxacillin and vancomycin (P < .0001). Oxacillin was significantly less sensitive in CNS, S epidermidis, and MRSA isolates as compared with clindamycin and vancomycin (P < .0001).

CONCLUSION

The national clindamycin susceptibility pattern is limited to MSSA and may not have an optimal susceptibility profile suitable for use as a prophylactic antibiotic. Cefazolin continues to have excellent coverage against MSSA.

2019 John Charnley Award: Increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin: the value of allergy testing for antibiotic prophylaxis

AIMS

The aims of this study were to characterize antibiotic choices for perioperative total knee arthroplasty (TKA) and total hip arthroplasty (THA) prophylaxis, assess antibiotic allergy testing efficacy, and determine rates of prosthetic joint infection (PJI) based on perioperative antibiotic regimen.

PATIENTS AND METHODS

We evaluated all patients undergoing primary TKA or THA at a single academic institution between January 2004 and May 2017, yielding 29 695 arthroplasties (22 705 patients), with 3411 arthroplasties in 2576 patients (11.5%) having undergone preoperative allergy testing. A series of institutional databases were combined to identify allergy consultation outcomes, perioperative antibiotic regimen, and infection-free survivorship until final follow-up.

RESULTS

Among 2576 allergy-tested patients, 2493 patients (97%) were cleared to use cephalosporins. For the entire cohort, 28 174 arthroplasties (94.9%) received cefazolin and 1521 (5.1%) received non-cefazolin antibiotics. Infection-free survivorship was significantly higher among arthroplasties receiving cefazolin compared with non-cefazolin antibiotics, with 0.06% higher survival free of infection at one month, 0.56% at two months, 0.61% at one year, and 1.19% at ten years (p < 0.001). Overall, the risk of PJI was 32% lower in patients treated with cefazolin after adjusting for the American Society of Anesthesiologists (ASA) classification, joint arthroplasty (TKA or THA), and body mass index (BMI; p < 0.001). The number needed to treat with cefazolin to prevent one PJI was 164 patients at one year and 84 patients at ten years. Therefore, potentially 6098 PJIs could be prevented by one year and 11 905 by ten years in a cohort of 1 000 000 primary TKA and THA patients.

CONCLUSION

PJI rates are significantly higher when non-cefazolin antibiotics are used for perioperative TKA and THA prophylaxis, highlighting the positive impact of preoperative antibiotic allergy testing to increase cefazolin usage. Given the low rate of true penicillin allergy positivity, and the readily modifiable risk factor that antibiotic choice provides, we recommend perioperative testing and clearance for all patients presenting with penicillin and cephalosporin allergies. Cite this article: Bone Joint J 2019;101-B(6 Supple B):9-15.

Use of regional administration of prophylactic antibiotics in total knee arthroplasty

Prosthetic joint infection after total knee arthroplasty is an infrequent, yet serious complication. Antimicrobial prophylaxis plays an important role in reducing the rate of surgical site infections. To be effective as an antimicrobial prophylaxis, the serum, tissue and bone concentrations of the antibiotic must be greater than the target organism's minimum inhibitory concentration. As antibiotic resistance increases current intravenous prophylactic dosing has been shown to be subtherapeutic for some patients. Intravenous regional administration and intraosseous regional administration of prophylactic antibiotics are novel methods used to increase the antibiotic tissue concentrations, which may enhance the efficacy of prophylactic antibiotics in total knee arthroplasty. Currently, literature has shown both intravenous regional administration and intraosseous regional administration to be safe and effective techniques. However, there is no clinical evidence to show that it results in a reduction of prosthetic joint infection rates. This study summarizes the current knowledge base on the use of regional administration of prophylactic antibiotics in total knee arthroplasty.