Intraosseous vancomycin results in lower superficial and deep infection rate compared with alternative intravenous methods in total knee arthroplasty: a time-stratified meta-analysis.

Abstract

Periprosthetic joint infection (PJI) remains a challenging complication in total joint arthroplasty (TJA), and concerns about antimicrobial resistance in intravenous (IV) vancomycin have renewed interest in intraosseous (IO) prophylaxis. This meta-analysis compares IO vancomycin versus IV prophylaxis in TJA with respect to overall and time-stratified PJI, organism-specific infections, wound complications, revision rates, pharmacokinetics, acute kidney injury (AKI), and deep vein thrombosis (DVT). A systematic review and meta-analysis were conducted, including clinical studies of adults undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) that compared IO vancomycin with alternative IV methods. Outcomes were pooled using random-effects models and stratified by follow up intervals (30 days, 90 days, and 1 year). Of the 13 included studies, 12 investigated TKA, comprising 6876 cases (51.6% IO group). Vancomycin concentration was significantly higher in IO group in both femoral bone and fat tissue (standardized mean difference (SMD): 0.61, 95% confidence interval (CI): 0.09-1.12; SMD: 1.53, 95% CI: 0.43-2.62, respectively). Regarding primary TKA cases, IO administration significantly reduced overall PJI (risk ratio (RR): 0.35, 95% CI: 0.17-0.72), with consistent significance at 30-day and 1-year follow up. Gram-positive infections decreased significantly (RR: 0.37, 95% CI: 0.17-0.82), whereas Gram-negative infections were comparable. Non-operative wound complications were significantly lower (RR: 0.50, 95% CI: 0.32-0.80). However, reoperation-requiring wound complications, AKI, DVT, or revision rates were comparable. Regarding revision TKA, the IO group demonstrated a significantly lower rate of non-operative wound complications (RR: 0.23) and a favorable but nonsignificant reduction in PJI. IO vancomycin prophylaxis provides substantially higher local antibiotic concentrations, lower rates of PJI and superficial wound complications without increasing renal, thrombotic, and revision risk in primary TKA.