Use of regional administration of prophylactic antibiotics in total knee arthroplasty

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).

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.

Poly(methyl methacrylate) Bone Cement Composite Can Be Refilled with Antibiotics after Implantation in Femur or Soft Tissue

While periprosthetic joint infections (PJIs) result in a small percentage of patients following arthroplasties, they are challenging to treat if they spread into bone and soft tissue. Treatment involves delivering antibiotics using poly(methyl methacrylate) (PMMA) bone cement. However, antibiotic release is insufficient for prolonged infections. Previous work demonstrated efficacy of incorporating insoluble cyclodextrin (CD) microparticles into PMMA to improve antibiotic release and allow for post-implantation drug refilling to occur in a tissue-mimicking model. To simulate how antibiotic refilling may be possible in more physiologically relevant models, this work investigated development of bone and muscle refilling models. The bone refilling model involved embedding PMMA-CD into rabbit femur and administering antibiotic via intraosseous infusion. Muscle tissue refilling model involved implanting PMMA-CD beads in bovine muscle tissue and administering antibiotic via tissue injection. Duration of antimicrobial activity of refilled PMMA-CD was evaluated. PMMA-CD composite in bone and muscle tissue models was capable of being refilled with antibiotics and resulted in prolonged antimicrobial activity. PMMA-CD provided sustained and on-demand antimicrobial activity without removal of implant if infection develops. Intraosseous infusion appeared to be a viable technique to enable refilling of PMMA-CD after implantation in bone, reporting for the first time the ability to refill PMMA in bone.

Local antibiotics in primary hip and knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Infection is a truly devastating complication of total joint arthroplasty, causing most patients to undergo a revision surgery, and to bear significant psychological and financial burden. The purpose of this study is to systematically evaluate the literature to determine the efficacy and complication profile of local antibiotic application in primary total joint arthroplasty.

METHODS

All studies of primary total joint arthroplasty which assessed local antibiotics in any form other than antibiotic-impregnated cement as an intervention were included. Studies that reported at least one outcome related to infection and were available in full text in English were eligible for inclusion. Studies which included both primary and revision cases but did not report the stratified data for each type of surgery and studies on fracture populations were excluded.

RESULTS

A total of 9 studies involving 3,714 cases were included. The pooled deep infection rate was 1.6% in the intervention groups and 3.5% in the control groups. Meta-analysis revealed a RR of 0.53 (95%CI: 0.35-0.79, p = 0.002) with no heterogeneity (I² = 0%) for infection in the intervention groups. Meta-analysis revealed a non-significant reduction in superficial infection rates in the intervention groups; however, there was a significant increase in aseptic wound complications in the intervention groups.

CONCLUSION

Local antibiotic application results in a moderate reduction in deep infection rates in primary total joint arthroplasty, with no significant impact on superficial infection rates. However, local antibiotic application may be associated with a moderate increase in aseptic wound complications.

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.