Intrawound Vancomycin Powder in Primary Total Hip Arthroplasty Increases Rate of Sterile Wound Complications

Dial, Brian; Lampley, Alexander J.; Green, Cynthia L.; Hallows, Rhett K.

doi:10.5371/hp.2018.30.1.37

Cited by 53 publications

(50 citation statements)

References 28 publications

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“…Dial et al observed a similar effect in primary hip arthroplasty, with a lowering of the infection rate from 5.5% without vancomycin to 0.7% with intrawound vancomycin powder 13 . However, sterile wound complications were seen in 4.4% of the cases treated with vancomycin, compared with 0% in the control group.…”

Section: Introductionmentioning

confidence: 76%

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

Matziolis

Brodt

Böhle

et al. 2020

Sci Rep

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Locally applied vancomycin is increasingly being used in primary hip and knee arthroplasty to reduce the risk of infection. Despite encouraging initial results, considerable debate remains on the basis of the data currently available. In particular, it has been unclear up to now whether local vancomycin is suitable to further reduce the risk of infection even if the rate of infection is already low (< 1%). In this monocentric retrospective cohort study, all primary total hip and knee arthroplasties performed between 2013 and 2018 were included. After a change in procedure at the hospital, 1 g vancomycin powder was applied intraarticularly before wound closure. The remaining perioperative procedure was constant over the investigation period. The follow-up was one year. The presence of an infection according to the currently valid MSIS criteria was defined as the endpoint. In patients with TKA two infections (0.3%) were observed under vancomycin prophylaxis in contrast to 44 infections (1.3%) in the control group (p = 0.033). In patients with THA two infections (0.5%) were observed under vancomycin prophylaxis and 48 infections (1.1%) in the control group without local vancomycin but this difference was statistically not significant. No wound complications requiring revision were observed as a result of the vancomycin. On the basis of the results of this study, intraarticular application of vancomycin powder in total hip and knee arthroplasty may be considered. Prospective randomized studies have to confirm this promising results prior a common recommendation. Level of Evidence III Retrospective cohort study. Infections after endoprosthetic hip or knee replacement, in spite of all perioperative improvements, are observed with an incidence of 1-2% 1-4. Despite the apparently low risk, efforts to further reduce the risk are sensible in light of the consequences for the patients concerned, with the potential for several follow-up operations and the often limited functional outcome. In spinal surgery, the reduction in the rate of infection through locally applied vancomycin was established more than 10 years ago and has been well documented by meta-analyses and animal experiments 5-8. The positive effect is set against minor complications caused in 0.3% of cases, mostly culture-negative seroma formation 9, so that it is even used successfully in children 10. Otte et al. were able to show that intrawound vancomycin powder lowers the infection rate after knee and hip arthroplasty from 1.6 to 0.5%, compared with a control group 11. In a subgroup analysis, the effect in revision operations was even greater, with a reduction of the infection rate from 3.9 to 0%. Patel et al. showed a reduction in the infection rate through vancomycin of 2.7-0.3% and determined a number needed to treat (NNT) of 47.5 12. Systemic side effects were not observed. The local application of vancomycin was assessed to be safe and cost-effective. Dial et al. observed a similar effect in primary hip arthroplasty, with a lowering of the infection rate...

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Section: Introductionmentioning

confidence: 76%

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

Matziolis

Brodt

Böhle

et al. 2020

Sci Rep

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“…The recruitment period differed for patients treated with intrawound vancomycin and controls in all but two studies. 27 , 33 Follow-up time was different between the two groups in two studies, 14 , 30 and one study 25 did not report follow-up time. Table II describes patient characteristics including sex, age, BMI, and comorbidities.…”

Section: Resultsmentioning

confidence: 96%

“…27 A total of 4,607 patients were included in our analyses, comprising 2,497 patients treated with intrawound vancomycin and 2,110 controls ( Table II ). All included studies reported the definition of PJI: four 13 , 28 - 30 of them determined the PJI based on the International Consensus Meeting (2013); 31 two, 25 , 26 based on the Musculoskeletal Infection Society (2011) criteria; 32 one, based on treatment method; 33 one, based on articular fluid culture; 27 and one, 14 based on Musculoskeletal Infection Society (2011) criteria and culture. Only one study 30 included patients who underwent UKA (n = 26).…”

Section: Resultsmentioning

confidence: 99%

“…All included studies reported the definition of PJI: four 13 , 28 - 30 of them determined the PJI based on the International Consensus Meeting (2013); 31 two, 25 , 26 based on the Musculoskeletal Infection Society (2011) criteria; 32 one, based on treatment method; 33 one, based on articular fluid culture; 27 and one, 14 based on Musculoskeletal Infection Society (2011) criteria and culture. Only one study 30 included patients who underwent UKA (n = 26). While a majority of studies used vancomycin alone in soft tissue, some studies employed other methods: one study included surgical intervention that coated 1 g of vancomycin onto the acetabular and femoral components immediately before implantation; 29 and in another study, 1 g to 2 g of vancomycin powder was combined with 2 g of an absorbable calcium hydroxyapatite, and then the mixture was spread in a thin layer on the articular surface of the implants before implantation.…”

Section: Resultsmentioning

confidence: 99%

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Efficacy and safety of intrawound vancomycin in primary hip and knee arthroplasty

Yang

Xie

et al. 2020

Bone & Joint Research

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Aims The efficacy and safety of intrawound vancomycin for preventing surgical site infection in primary hip and knee arthroplasty is uncertain. Methods A systematic review of the literature was conducted, indexed from inception to March 2020 in PubMed, Web of Science, Cochrane Library, Embase, and Google Scholar databases. All studies evaluating the efficacy and/or safety of intrawound vancomycin in patients who underwent primary hip and knee arthroplasty were included. Incidence of periprosthetic joint infection (PJI), superficial infection, aseptic wound complications, acute kidney injury, anaphylactic reaction, and ototoxicity were meta-analyzed. Results were reported as odds ratios (ORs) and 95% confidence intervals (CIs). The quality of included studies was assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) assessment tool. Results Nine studies involving 4,607 patients were included. Intrawound vancomycin was associated with lower incidence of PJI (30 patients (1.20%) vs 58 control patients (2.75%); OR 0.44, 95% CI 0.28 to 0.69) and simultaneous acute kidney injury (four patients (0.28%) vs four control patients (0.35%), OR 0.71, 95% CI 0.19 to 2.55). However, it did not reduce risk of superficial infection (four patients (0.67%) vs six control patients (1.60%), OR 0.60, 95% CI 0.17 to 2.12) and was associated with higher incidence of aseptic wound complications (23 patients (2.15%) vs eight in control patients (0.96%), OR 2.39, 95% CI 1.09 to 5.23). Four studies reported no anaphylactic reactions and three studies reported no ototoxicity in any patient group. Conclusion The current literature suggests that intrawound vancomycin used in primary hip and knee arthroplasty may reduce incidence of PJI, but it may also increase risk of aseptic wound complications. Cite this article: Bone Joint Res 2020;9(11):778–788.

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“…Dial et al. [16] recently showed a decreased infection rate in a series of primary hip arthroplasties but did find an increased incidence of associated sterile seroma. Results of our investigation demonstrate a significantly decreased overall infection rate (superficial plus PJI) from 2.7% to 0.57% for primary total hip and knee arthroplasty with the addition of intrawound vancomycin.…”

Section: Discussionmentioning

confidence: 95%

Intrawound vancomycin in primary hip and knee arthroplasty: a safe and cost-effective means to decrease early periprosthetic joint infection

2018

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BackgroundPeriprosthetic joint infection (PJI) is a devastating complication after hip and knee arthroplasty. Intrawound vancomycin has been described extensively in the spine literature; however, information regarding use in arthroplasty is limited. We investigate the efficacy and safety of intrawound vancomycin in arthroplasty surgery.MethodsAll primary total hip and knee arthroplasty cases (n = 460) performed by a single surgeon from April 2016 to October 2017 were reviewed. Starting in October 2016, intrawound vancomycin was used in all total joints. Baseline characteristics, infection rates, 90-day readmission, and other complications were compared between untreated subjects and those who received intrawound vancomycin. In addition, cost data were considered. Mean follow-up durations for the control and vancomycin groups were 11.3 and 7.7 months, respectively.ResultsBaseline characteristics and comorbidities were similar for the control (n = 112) and vancomycin groups (n = 348). The vancomycin cohort demonstrated decreased both overall infection rate (0.57% vs 2.7%; P = .031) and PJI rate (0.29% vs 2.7%; P = .009) compared with the untreated group. There was no statistical difference in incidence of ototoxicity or acute kidney injury. Although there was no difference in overall 90-day readmission rate, the vancomycin subset demonstrated lower readmission rate due to infection (0.57% vs 2.7%; P = .031). Based on the cost of vancomycin powder and calculated number needed to treat (NNT = 47.5), the cost to prevent 1 infection with the addition of intrawound vancomycin was $816.ConclusionsThese findings suggest that intrawound vancomycin may be a safe, cost-effective means that shows promise in reducing PJI in early follow-up. Future prospective studies are warranted.

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Intrawound Vancomycin Powder in Primary Total Hip Arthroplasty Increases Rate of Sterile Wound Complications

Cited by 53 publications

References 28 publications

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty

Efficacy and safety of intrawound vancomycin in primary hip and knee arthroplasty

Intrawound vancomycin in primary hip and knee arthroplasty: a safe and cost-effective means to decrease early periprosthetic joint infection

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