Paper of the Week: Intraosseous Regional Prophylactic Antibiotics Decrease the Risk of Prosthetic Joint Infection in Primary TKA: A Multicenter Study

Paper of the Week: Intraosseous Regional Prophylactic Antibiotics Decrease the Risk of Prosthetic Joint Infection in Primary TKA: A Multicenter Study

ICM Philly October 12, 2021

Ben Parkinson MBBS, FRACS (Orth), FAOrthA, Peter McEwen MBBS, FRACS (Orth), FAOrthA, Matthew Wilkinson MBBS, FRACS (Orth), FAOrthA, Kaushik Hazratwala MBBS, FRACS (Orth), FAOrthA, Jorgen Hellman, FRACS (Orth), FAOrthA, Heng Khan MBBS, Andrew McLean MBBS, Yash Panwar MBBS, Kenji Doma PhD, BSpExcSci(Hons), MClinExPhys(Rehab), CSCS, AEP, NSCAM, ESSAM, Andrea Grant BSpExSci

Clin Orthop Relat Res. 2021, published online ahead of print, 2021 Aug 9
doi: 10.1097/CORR.0000000000001919

Summary by: Irfan A. Khan, ATC

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA), having the potential to cause significant functional disability, psychological detriment, and financial ramifications.1,2,3 Due to this, the study of interventions that prevent PJI remains crucial. Although it is established that perioperative antibiotics are effective at reducing PJI 4,5 and that the intraosseous (IO) regional technique for antibiotic delivery can achieve higher tissue concentrations of antibiotics compared to intravenous (IV) delivery,6,7 the optimal mode of antibiotic delivery to prevent PJI has not yet been elucidated.

Parkinson et al. retrospectively compared the risk of developing PJI after primary TKA in patients who received IO or IV prophylactic antibiotics. The primary outcome was the risk of developing PJI within one year postoperatively (early PJI);  secondary outcomes included risk factors associated with PJI development and safety of using the IO technique to administer antibiotics. Seven hundred twenty-five patients received prophylactic IO antibiotics, while 1,181 patients received prophylactic IV antibiotics. Patients receiving IO antibiotics had either 1g of cefazolin (334 patients) or 500mg of vancomycin (391 patients) injected into the proximal tibial metaphysis. Patients receiving IV antibiotics were given 2g or 3g of cefazolin (weight-dependent).

Of the 1,906 patients in this study, 17 developed PJI, with 16 occurring in the IV cohort (16 of 1,181, 1.4%) and one occurring in the IO cohort (1 of 725, 0.1%). The risk of developing early PJI was significantly lower in the IO cohort (relative risk: 0.10, 95% confidence interval 0.01 – 0.77; p = 0.03). Three risk factors were associated with increased risk of developing PJI: patient BMI over 35 (p = 0.02), presence of diabetes (p = 0.02), and presence of renal failure (p = 0.01). There were no complications related to IO antibiotic administration such as fat embolism, compartment syndrome, red man syndrome, or inability to administer the IO technique.

Parkinson et al. concluded that the use of IO regional prophylactic antibiotics in patients undergoing primary TKA resulted in a significantly lower risk of developing early PJI compared to prophylactic IV antibiotics, and that the IO technique can be utilized safely in patients. One limitation of the study is the fact that, of the 725 patients in the IO cohort, 493 patients received both IO and IV antibiotics due to hospital policy. Additionally, operative time was not included in the statistical analysis, which may influence PJI development.8


  1. Wildeman P, Rolfson O, Söderquist B, Wretenberg P, Lindgren V. What Are the Long-term Outcomes of Mortality, Quality of Life, and Hip Function after Prosthetic Joint Infection of the Hip? A 10-year Follow-up from Sweden. Clin Orthop Relat Res. 2021;479(10):2203-2213. doi:10.1097/CORR.0000000000001838
  2. Figoni AM, Lalchandani GR, Markes AR, Sing D, Hansen EN. Infection and Mechanical Complications Are Risk Factors for New Diagnosis of a Mental Health Disorder After Total Joint Arthroplasty. Arthroplast Today. 2021;10:1-5. Published 2021 Jun 21. doi:10.1016/j.artd.2021.05.019
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  6. Young SW, Zhang M, Freeman JT, Mutu-Grigg J, Pavlou P, Moore GA. The Mark Coventry Award: Higher tissue concentrations of vancomycin with low-dose intraosseous regional versus systemic prophylaxis in TKA: a randomized trial. Clin Orthop Relat Res. 2014;472(1):57-65. doi:10.1007/s11999-013-3038-z
  7. Young SW, Zhang M, Moore GA, Pitto RP, Clarke HD, Spangehl MJ. The John N. Insall Award: Higher Tissue Concentrations of Vancomycin Achieved With Intraosseous Regional Prophylaxis in Revision TKA: A Randomized Controlled Trial. Clin Orthop Relat Res. 2018;476(1):66-74. doi:10.1007/s11999.0000000000000013
  8. Blanco JF, Díaz A, Melchor FR, da Casa C, Pescador D. Risk factors for periprosthetic joint infection after total knee arthroplasty. Arch Orthop Trauma Surg. 2020;140(2):239-245. doi:10.1007/s00402-019-03304-6
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