Paper of the Week: Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Reduce the Rate of Early Periprosthetic Joint Infection After Primary Total Knee Arthroplasty

Daniel B. Buchalter, David J. Kirby, Greg M. Teo, Richard Iorio, Vinay K. Aggarwal, William J. Long

Journal of Arthroplasty. Volume 36, Issue 1
doi: 10.1016/j.arth.2020.07.064.

Summary by Donghoon Lee, BS

Periprosthetic joint infection (PJI) affects nearly 1% of all total knee arthroplasty (TKA) cases, and remains a significant cause of morbidity in this population.¹ Any effort to reduce infections, particularly one this devastating, is of great interest to surgeons. Local application of vancomycin powder is a proven method for reducing infection rates in spine surgery.²  Additionally, povidone-iodine lavage reduces PJI in arthroplasties, showing efficacy against a variety of microbes.³ In combination, these two interventions (VIP) reduce PJI in high risk arthroplasty patients.⁴ The authors hypothesized that VIP would be effective at reducing PJI in all patients, regardless of pre-operative risk factors.

In this study, Buchalter et al. retrospectively reviewed 12,066 patients at a single institution undergoing primary TKAs from 2012-2019. At this institute, VIP was implemented in January 2014 for high risk patients. VIP was expanded to all patients in January 2016. The authors found the risk of PJI was significantly reduced by VIP in all groups (1.01% incidence pre VIP, 0.56% high-risk VIP, 0.44% all-risk VIP) at 90 days. The relative risk reduction between high-risk VIP and all-risk VIP groups was not statistically significant. No vancomycin-intermediate or MRSA, VRE, acid-fast bacteria, or fungal infections cases occurred in any of the PJI cases.

Based on their results, the authors concluded that VIP is effective at reducing early PJI in all primary TKA patients. Limitations of this study include that this was performed at a single institution and that it is retrospective in nature. In addition, historical cohorts by year are subject to institutional or community changes and the overall incidence of infections was low in this study population. Finally, only infections in a 90 day post-operative window were examined.

References:

1. Kurtz SM, Lau EC, Son MS, Chang ET, Zimmerli W, Parvizi J. Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the Medicare population. J Arthroplasty 2018;33:3238e45.
2. Sweet FA, Roh M, Sliva C. Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine (Phila Pa 1976) 2011;36:2084e8
3. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty 2012;27:27e30.
4. Iorio R, Yu S, Schwarzkopf R, Vigdorchik J, Slover J, Riesgo AM, et al. Vancomycin powder and dilute povidone iodine lavage for infection prophylaxis in high risk total joint arthroplasty. J Arthroplasty 2020;35:1933e6.