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

Nathanael D Heckmann; Cory K Mayfield; Chris N Culvern; Daniel A Oakes; Jay R Lieberman; Craig J Della Valle

doi:10.1016/j.arth.2019.03.071

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

J Arthroplasty. 2019 Aug;34(8):1815-1822. doi: 10.1016/j.arth.2019.03.071. Epub 2019 Apr 1.

Authors

Nathanael D Heckmann¹, Cory K Mayfield², Chris N Culvern¹, Daniel A Oakes³, Jay R Lieberman³, Craig J Della Valle¹

Affiliations

¹ Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL.
² Keck School of Medicine of the University of Southern California, Los Angeles, CA.
³ Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA.

PMID: 31005433
DOI: 10.1016/j.arth.2019.03.071

Abstract

Background: Topical intrawound vancomycin has been used extensively in spine surgery to decrease surgical site infections. However, the efficacy of intrawound vancomycin in total hip (THA) and total knee arthroplasty (TKA) to prevent periprosthetic joint infection (PJI) has not been established.

Methods: The PubMed and MEDLINE databases were searched to identify studies utilizing intrawound vancomycin in primary and revision THA and TKA. Data for postoperative infection were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals. Studies were weighted by the inverse variance of their effect estimates.

Results: Of the 91 studies identified, 6 low-quality retrospective studies (level III) were pooled for further analysis. A total of 3298 patients were assessed, 1801 of which were treated with intrawound vancomycin. Overall, patients who received vancomycin had a decreased rate of PJI (OR 0.2530, P < .0001). When analyzed separately, TKA patients and THA patients who received intrawound vancomycin had lower rates of PJI (OR 0.3467, P = .0005 and OR 0.3672, P = .0072, respectively). Pooled primary TKA and THA patients receiving vancomycin saw the rate of PJI decrease (OR 0.4435, P = .0046). Pooled revision TKA and THA patients saw a similar decrease in infection rates (OR 0.2818, P = .0013). No apparent publication bias was observed; however, the results from this analysis are limited by the low quality of evidence and inherent potential for bias.

Conclusion: Intrawound vancomycin may reduce the risk of PJI in primary and revision TKA and THA. However, only low-quality evidence exists, highlighting the need for randomized controlled trials before broad adoption of this practice can be recommended given the potential implications of widespread use of vancomycin in hip and knee arthroplasty.

Keywords: infection; intrawound vancomycin; periprosthetic joint infection; topical antibiotics; total hip arthroplasty; total knee arthroplasty.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Anti-Bacterial Agents / administration & dosage
Arthritis, Infectious / etiology
Arthroplasty, Replacement, Hip / adverse effects
Arthroplasty, Replacement, Knee / adverse effects*
Humans
Odds Ratio
Prospective Studies
Prosthesis-Related Infections / drug therapy*
Prosthesis-Related Infections / etiology
Randomized Controlled Trials as Topic
Retrospective Studies
Surgical Wound Infection / drug therapy*
Surgical Wound Infection / prevention & control
Vancomycin / administration & dosage*

Substances

Anti-Bacterial Agents
Vancomycin