Intra-articular administration of vancomycin and tobramycin during primary cementless total knee arthroplasty : determination of intra-articular and serum elution profiles

Use of vancomycin powder under polyethylene in total knee arthroplasty: a technical note

Periprosthetic joint infections (PJI) remain a significant complication in total knee arthroplasty (TKA), often necessitating complex revisions. Vancomycin powder has been used intra-articularly to reduce PJI rates, but conflicting evidence suggests potential complications. This technical note introduces a novel approach: applying vancomycin powder beneath the polyethylene component during TKA, rather than directly into the joint space. We hypothesize that this technique could enhance infection prevention efficacy while minimizing complications associated with intra-articular vancomycin. We detail the indications, procedural steps, and potential complications of this method. Vancomycin powder is applied to the tibial surface before inserting the polyethylene component, maintaining the drug's proximity to potential infection sites without direct exposure to joint tissues. This approach aims to balance infection prevention with safety concerns, providing an alternative for patients at high risk for PJI. Further clinical validation is necessary to confirm the efficacy and safety of this technique.

Intra-articular injection of vancomycin after arthrotomy closure following gentamicin-impregnated bone cementation in primary total knee arthroplasty provides a high intra-articular concentration while avoiding systemic toxicity: a prospective study

BACKGROUND

This study aimed to elucidate the safety and intra-articular elution profiles of vancomycin and gentamicin bone cement in patients undergoing primary total knee arthroplasty (TKA), with a focus on serum safety thresholds and therapeutic efficacy.

METHODS

Consecutive patients who underwent unilateral primary TKA were prospectively enrolled. The implants were fixed using gentamicin-impregnated bone cement, and after arthrotomy closure, 1000 mg of vancomycin suspended in 25 mL of normal saline was directly injected into the joint. Peripheral venous blood and drain fluid samples were collected 2, 8, and 24 h postoperatively. The serum and intra-articular concentrations of vancomycin and gentamicin were analyzed using liquid chromatography-tandem mass spectrometry within 24 h.

RESULTS

Clinical data reflecting renal and liver function were recorded preoperatively, and at 24 and 72 h postoperatively. A total of 100 patients were included. At 2, 8, and 24 h postoperatively, the serum vancomycin concentration was 7.0 ± 2.0, 5.7 ± 1.8, and 3.6 ± 1.4 µg/mL, respectively, while the intra-articular concentration was 468.5 (interquartile range [IQR] 286.0 to 774.8), 139.5 (IQR 52.0 to 295.3), and 34.4 (IQR 22.2 to 56.8) µg/mL, respectively; 33.2 (IQR 19.5 to 80.5) mg vancomycin was lost in drainage fluid at 24 h postoperatively. For gentamicin, the overall intra-articular concentration was 70.4 (IQR 35.4 to 109.2), 33.8 (IQR 17.8 to 73.9), and 21.1 (IQR 12.2 to 36.0) µg/mL at 2, 8, and 24 h postoperatively, respectively, with an undetectable serum concentration. No cases of acute renal injury, liver injury, ototoxicity, or anaphylaxis were observed.

CONCLUSIONS

Intra-articular injection of 1000 mg vancomycin after arthrotomy closure combined with gentamicin-impregnated bone cement provided a therapeutic intra-articular concentration while avoiding systemic toxicity over the initial 24 h after primary TKA. Therefore, intra-articular vancomycin administration may offer a safer alternative to intravenous antibiotics, reducing systemic toxicity; however, further large-scale studies are necessary.

TRIAL REGISTRATION

ClinicalTrials. Gov (registration number: NCT05338021).

Periprosthetic joint infections: state-of-the-art

In general, periprosthetic joint infection (PJI) is regarded as one of the most common complications of total joint arthroplasty (TJA) and may lead to surgical failure, revision surgery, amputation or death. Nowadays, PJI has become a global health concern, which brings a great burden to public healthcare. In addition, there are still obstacles to achieve high success rates in the prevention, diagnosis and treatment of PJI. However, promising studies are also available with the advancements in biotechnology. This article will present an overview of the current methods used in the prevention, diagnosis and management of PJI while underlining the new technologies utilized.

Does Combined Treatment with Tranexamic Acid and Vancomycin Affect Human Chondrocytes In Vitro?

Background: The aim of our study was to examine the combined effects of tranexamic acid (TXA) and vancomycin powder (VP) on chondrocytes in vitro. Despite the use of TXA and VP being linked to a reduced risk of extensive postoperative blood loss and periprosthetic joint infections (PJIs) in TKA, the possible cytotoxic side effects on periarticular cell types remain unclear. Methods: Human chondrocytes were harvested from hyaline cartilage and expanded in monolayer culture before being simultaneously exposed to different concentrations of TXA and VP for varying exposure times. Cell viability and proliferation were assessed using an ATP assay and an Annexin 5 assay, respectively, while changes in the relative expression of chondrogenic marker genes were examined using semiquantitative RT-PCR. Results: The simultaneous exposure of chondrocytes to TXA and VP for more than 48 h led to a reduction in both cell viability and proliferation rates. When exposing chondrocytes to the lowest examined concentrations of both TXA (10 mg/mL) and VP (3 mg/mL), the observed effects were delayed until 96 h. However, our study found no dependencies of the observed effects on the concentrations tested. Further, we found no effects on the expression of chondrogenic marker genes. Conclusions: Consequently, limiting the exposure time of chondrocytes to TXA and VP in an in vitro setting to 24 h may be considered safe and could help to further improve the understanding of the safe use of substances in vivo. However, further in vitro research is required to develop a comprehensive understanding of the effects of both VP and TXA on important periarticular cell types in TKA, including chondrocytes, osteocytes, and tenocytes.

Intra-articular Vancomycin Reduces Prosthetic Infection in Primary Hip and Knee Arthroplasty

Background

Intravenous antibiotic infusion has been the standard prophylaxis for total joint arthroplasty surgery. However, infection rates still occur at 1%-2% in many series. Single-dose intra-articular antibiotics (IAAs) present a safe and potentially more effective prophylactic regime in total joint arthroplasty. This study aimed to assess the outcomes of a single-dose IAA injection on PJI rates in a single surgeon series of hip and knee arthroplasty.

Methods

We reviewed the data of all patients operated on for a primary hip or knee replacement from 2010 to 2021. From January 2018, 1 gm of vancomycin in 10 ml of saline was injected into every total joint replacement after fascial closure. A comparison was made with PJI referencing the Australian National Joint Replacement Registry data on revision for the 2 periods: 2010-2017 and 2018-2021.

Results

During the period without IAA (2010-2017) for TKR, 6 of 489 (1.2%), and for THR, 5 of 694 (0.7%) had PJI requiring revision surgery. In the period with IAA (2018-2021) for TKR, 0 of 214 (0%, P = .11), and for THR, 1 of 517 (0.2%, P = .19) PJI required revision surgery, but the overall incidence of PJI for TKR and THR was significantly reduced (P = .03).

Conclusions

A single dose of intra-articular vancomycin 1 gm injected into the total joint replacement following fascial closure reduced the incidence of deep PJI requiring a revision surgery in a single-surgeon series. These results demonstrate significant benefits to this technique which merit further larger trials.

In Vitro Evaluation of Vancomycin-Induced Toxicity in Human Primary Knee Chondrocytes

Septic arthritis as a complication of orthopaedic joint surgery can have catastrophic outcomes for patients. To minimise infection risk associated with elective orthopaedics, topical vancomycin during surgery has become increasingly common. Evidence suggests that high concentrations of vancomycin, following direct application of the drug to the joint, are toxic towards various local cell types in the joint, including chondrocytes. However, the mechanism of this vancomycin tissue toxicity is yet to be determined. The aim of this study was to evaluate the toxicity of vancomycin on chondrocytes and the mechanisms of cell death involved. Human primary knee chondrocytes were exposed to vancomycin (1.25-10 mg/mL) for 24 h and their viability assessed using the resazurin reduction assay in vitro. Specific cell death mechanisms and their contributors, including reactive oxygen species (ROS) production and apoptosis, were measured. This study showed that high concentrations of vancomycin (5 and 10 mg/mL) were toxic towards human primary knee chondrocyte cells, while lower concentrations (1.25 and 2.5 mg/mL) were not. Cell death studies found that this occurred through an apoptotic pathway. This study provides additional support that vancomycin in high doses is toxic towards chondrocytes and preliminary evidence that this toxicity occurs via apoptotic cell death mechanisms.

[Importance of local antibiotics in the prophylaxis and treatment of fracture-associated infections]

BACKGROUND

Fracture-associated infections (FRI) are a severe complication that lead to higher morbidity and high costs for the healthcare system. An effective prophylaxis and treatment of FRI are therefore of great interest.

OBJECTIVE

The aim of this review is to summarize the available evidence on the use of local antibiotics for the prophylaxis and treatment of FRI.

MATERIAL AND METHODS

A thorough search and a narrative synthesis of the available literature were performed. Their depiction is supplemented by an illustrative presentation of a case report.

RESULTS

A robust consensus definition of FRI has existed since 2018. The current use of local antibiotics for the prophylaxis and treatment of FRI in Germany is heterogeneous. There is no consensus on local antibiotic treatment of FRI. The available literature shows an advantage for the additive local antibiotic treatment of open fractures. In closed fractures there is a tendency towards an advantage especially in the presence of further risk factors (long duration of external fixation, higher degree of closed tissue damage, compartment syndrome). According to analogous data from the field of endoprosthetics, additive local antibiotic treatment could also be advantageous under closed soft tissue conditions. The evidence is insufficient to enable the recommendation for a specific antibiotic or a specific mode of application. Local and systemic adverse reactions are frequently discussed in the literature but their incidence is low.

CONCLUSION

Overall, additive local antibiotic treatment is to be recommended for open fractures and in closed fractures in the presence of other risk factors. Local and systemic adverse reactions as well as the development of antibiotic resistance must be weighed up in individual cases.

Evaluating ChatGPT responses to frequently asked patient questions regarding periprosthetic joint infection after total hip and knee arthroplasty

Background

Patients access relevant information concerning their orthopaedic surgery resources through multiple information channels before presenting for clinical treatment. Recently, artificial intelligence (AI)-powered chatbots have become another source of information for patients. The currently developed AI chat technology ChatGPT (OpenAI LP) is an application for such purposes and it has been rapidly gaining popularity, including for patient education. This study sought to evaluate whether ChatGPT can correctly answer frequently asked questions (FAQ) regarding periprosthetic joint infection (PJI).

Methods

Twelve FAQs about PJI after hip and knee arthroplasty were identified from the websites of fifteen international clinical expert centres. ChatGPT was confronted with these questions and its responses were analysed for their accuracy using an evidence-based approach by a multidisciplinary team. Responses were categorised in four groups: (1) Excellent response that did not require additional improvement; (2) Satisfactory responses that required a small amount of improvement; (3) Satisfactory responses that required moderate improvement; and (4) Unsatisfactory responses that required a large amount of improvement.

Results

From the analysis of the responses given by the chatbot, no reply received an 'unsatisfactory' rating; one did not require any correction; and the majority of the responses required low (7 out of 12) or moderate (4 out of 12) clarification. Although a few responses required minimal clarification, the chatbot responses were generally unbiased and evidence-based, even when asked controversial questions.

Conclusions

The AI-chatbot ChatGPT was able to effectively answer the FAQs of patients seeking information around PJI diagnosis and treatment. The given information was also written in a manner that can be assumed to be understandable by patients. The chatbot could be a valuable clinical tool for patient education and understanding around PJI treatment in the future. Further studies should evaluate its use and acceptance by patients with PJI.

The use of intra-articular vancomycin is safe in primary hip and knee arthroplasty

Background

The use of a single dose of intra-articular antibiotic (IAA) has been reported in reducing the rate of prosthetic joint injection after total hip and knee arthroplasty. We examine the safety of IAA in primary hip and knee replacement surgery and the blood levels and joint fluid levels of vancomycin utilising this technique.

Methods

From August to October 2021, 68 patients undergoing primary total joint arthroplasty (THA & TKA) were given 1g vancomycin intra-articularly (IA)after closure of the fascia. All patients received 2g cefazolin intravenously (IV) 30 min prior to the procedure as is our standard prophylaxis, and 21 of the patients (IA + IV) were also administered an additional 1 gm vancomycin IV. Post-operative blood vancomycin, creatinine land eGFR level monitoring was performed d1 and d3. To determine the post-operative intra-articular vancomycin levels, surgical drain fluid was sampled at day 1 and 2, in 10 patients.

Results

All patients had serum vancomycin levels measured on day 1 and 3. In the group where vancomycin was injected after fascial closure, the average blood vancomycin level day 1 was 5.2 μg/ml (range 2.0-10.9) and day 3 was <1.4 μg/ml. The average pre-op creatinine levels were 69.4 μmol/L (56.1-82.6) compared to 70.2 μmol/L (57.0-83.4) on day 1 and 66.1 μmol/L (52.6-79.6) on day 3, (p = 0.663). The average pre-op eGFR levels (ml/min/1.73 m2) were 82.2 (76.0-88.3) compared to 81.7 (75.6-87.8) on day 1 and 83.0 (76.8-89.2) on day 3 (p = 0.736). Samples of joint fluid aspirated from surgical drains on day 1 and day 2 showed average vancomycin levels of 224 μg/ml and 51 μg/ml respectively, significantly higher than the MIC for Staph aureus.

Conclusions

The use of intra-articular vancomycin is safe in primary TJA, with no renal damage and delivers levels within the joint which are highly therapeutic for at least 48 h post injection.

Intraarticular vancomycin decreased the risk of acute postoperative periprosthetic joint infection without increasing complication in primary total joint arthroplasty-a prospective study

OBJECTIVES

To investigate the preventive effect of intraarticularly administered vancomycin on acute postoperative periprosthetic joint infection (PJI) in total joint arthroplasty (TJA).

METHODS

Consecutive patients who underwent unilateral primary TJA were prospectively enrolled. The patients were divided into vancomycin group and control group according to whether 1 g of vancomycin powder suspended in 30 ml normal saline was intraarticularly administered after arthrotomy closure. Acute postoperative PJI and aseptic wound complication were evaluated within 3 months postoperatively. Vancomycin-associated toxicity including acute renal failure, ototoxicity and anaphylaxis was also evaluated.

RESULTS

In terms of demographic parameters and comorbidities, no significant difference was found between the two groups. Intra-articular vancomycin significantly lowered the risk of acute postoperative PJI after primary TJA (P = 0.015) and primary total knee arthroplasty (P = 0.031). However, for patients who underwent total hip arthroplasty, the PJI rate was comparable between the two groups. Overall, the risk of aseptic wound complication between the two groups was also similar. Vancomycin-associated acute renal injury, ototoxicity, or anaphylaxis was not observed.

CONCLUSIONS

Intra-articular injection of 1 g of vancomycin suspension after arthrotomy closure during TJA lowered the risk of acute postoperative PJI without increasing the risk of aseptic wound complication and vancomycin-associated systemic toxicity.

Local Administration of Antibiotics in Orthopedics and Traumatology

2022 marks the 50th anniversary of the development of the antibiotic loaded PMMA chain. The loading of bone cements with antibiotics was a major advance in the treatment of musculoskeletal infections and is still a proven standard today. The research and use of novel antibiotic carriers continues to be an important part of research in the context of musculoskeletal infections. The article provides an overview of the various local antibiotics available and their specifics. In addition, current adapted treatment concepts are discussed.

Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Continued Call for a Prospective Randomized Trial

BACKGROUND

Periprosthetic joint injection (PJI) is a rare, but life-altering complication of total joint arthroplasty (TJA). Though intrawound vancomycin powder (IVP) has been studied in other orthopedic subspecialties, its efficacy and safety in TJA has not been established.

METHODS

PubMed and MEDLINE databases were used to identify studies utilizing IVP in primary and revision total hip (THA) and knee arthroplasty (TKA). Postoperative PJI data were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Studies were weighted by the inverse variance of their effect estimates.

RESULTS

Overall, 16 of the 1871 studies identified were pooled for final analysis, yielding 33,731 patients totally. Of these, 17 164 received IVP. In aggregate, patients who received IVP had a decreased rate of PJI (OR 0.46, P < .05). Separately, TKA and THA patients who received IVP had lower rates of PJI (OR 0.41, P < .05 and OR 0.45, P < .05, respectively). Aggregate analysis of primary TKA and THA patients also revealed a decreased PJI rate (OR 0.44, P < .05). Pooled revision TKA and THA patients had a similar decrease in PJI rates (OR 0.30, P < .05). Although no publication bias was appreciated, these findings are limited by the low-quality evidence available.

CONCLUSION

While IVP may reduce the risk of PJI in primary and revision TJA, its widespread use cannot be recommended until higher-quality data, such as that obtained from randomized control trials, are available. This study underscores the continued need for more rigorous studies before general adoption of this practice by arthroplasty surgeons.

Adaptive antimicrobial resistance, a description of microbial variants, and their relevance to periprosthetic joint infection

Periprosthetic joint infection (PJI) is a difficult complication requiring a comprehensive eradication protocol. Cure rates have essentially stalled in the last two decades, using methods of antimicrobial cement joint spacers and parenteral antimicrobial agents. Functional spacers with higher-dose antimicrobial-loaded cement and antimicrobial-loaded calcium sulphate beads have emphasized local antimicrobial delivery on the premise that high-dose local antimicrobial delivery will enhance eradication. However, with increasing antimicrobial pressures, microbiota have responded with adaptive mechanisms beyond traditional antimicrobial resistance genes. In this review we describe adaptive resistance mechanisms that are relevant to the treatment of PJI. Some mechanisms are well known, but others are new. The objective of this review is to inform clinicians of the known adaptive resistance mechanisms of microbes relevant to PJI. We also discuss the implications of these adaptive mechanisms in the future treatment of PJI. Cite this article: Bone Joint J 2022;104-B(5):575-580.