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Higher Cefazolin Concentrations with Intraosseous Regional Prophylaxis in TKA

  • Symposium: Papers Presented at the Annual Meetings of the Knee Society
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Prophylactic antibiotics reduce the risk of deep infection after primary TKA. However, conventional systemic dosing may not provide adequate tissue concentrations against more resistant organisms such as coagulase-negative staphylococci. Regional intravenous administration of antibiotics after tourniquet inflation achieves far higher tissue concentrations but requires foot vein cannulation. The intraosseous route may offer a rapid and reliable method of regional administration.

Questions/Purposes

We compared tissue concentrations of cefazolin achieved with systemic versus regional intraosseous administration.

Methods

Twenty-two patients undergoing primary TKA were randomized into two groups. Group 1 received 1 g cefazolin systemically 10 minutes before tourniquet inflation. Group 2 received 1 g cefazolin intraosseously in 200 mL of normal saline through a tibial cannula after tourniquet inflation and before skin incision. Subcutaneous fat and femoral bone samples were taken at set intervals during the procedure and antibiotic concentrations measured using a validated technique involving high-performance liquid chromatography.

Results

The overall mean tissue concentration of cefazolin in subcutaneous fat was 186 ug/g in the intraosseous group and 11 ug/g in the systemic group. The mean tissue concentration in bone was 130 ug/g in the intraosseous group and 11 ug/g in the systemic group. These differences were consistent across all sample time points throughout the procedure.

Conclusions

Intraosseous regional administration can achieve concentrations of antibiotic in tissue an order of magnitude higher than systemic administration. Further work is required to determine if this translates into increased efficacy in preventing infection, particularly against coagulase-negative staphylococci.

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References

  1. Bengtson S, Knutson K. The infected knee arthroplasty. A 6-year follow-up of 357 cases. Acta Orthop Scand. 1991;62:301–311.

    Article  PubMed  CAS  Google Scholar 

  2. Blom AW, Brown J, Taylor AH, Pattison G, Whitehouse S, Bannister GC. Infection after total knee arthroplasty. J Bone Joint Surg Br. 2004;86:688–691.

    Article  PubMed  CAS  Google Scholar 

  3. Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery. 1961;50:161–168.

    PubMed  CAS  Google Scholar 

  4. Carlsson AK, Lidgren L, Lindberg L. Prophylactic antibiotics against early and late deep infections after total hip replacements. Acta Orthop Scand. 1977;48:405–410.

    Article  PubMed  CAS  Google Scholar 

  5. Craig WA. Pharmacokinetic/pharmacodynamic parameters: rationale for antibacterial dosing of mice and men. Clin Infect Dis. 1998;26:1–10.

    Article  PubMed  CAS  Google Scholar 

  6. Cunha BA, Gossling HR, Pasternak HS, Nightingale CH, Quintiliani R. The penetration characteristics of cefazolin, cephalothin, and cephradine into bone in patients undergoing total hip replacement. J Bone Joint Surg Am. 1977;59:856–859.

    PubMed  CAS  Google Scholar 

  7. Davis N, Curry A, Gambhir AK, Panigrahi H, Walker CR, Wilkins EG, Worsley MA, Kay PR. Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg Br. 1999;81:886–889.

    Article  PubMed  CAS  Google Scholar 

  8. de Lalla F, Novelli A, Pellizzer G, Milocchi F, Viola R, Rigon A, Stecca C, Dal Pizzol V, Fallani S, Periti P. Regional and systemic prophylaxis with teicoplanin in monolateral and bilateral total knee replacement procedures: study of pharmacokinetics and tissue penetration. Antimicrob Agents Chemother. 1993;37:2693–2698.

    Article  PubMed  Google Scholar 

  9. de Lalla F, Viola R, Pellizzer G, Lazzarini L, Tramarin A, Fabris P. Regional prophylaxis with teicoplanin in monolateral or bilateral total knee replacement: an open study. Antimicrob Agents Chemother. 2000;44:316–319.

    Article  PubMed  Google Scholar 

  10. Fletcher N, Sofianos D, Berkes MB, Obremskey WT. Prevention of perioperative infection. J Bone Joint Surg Am. 2007;89:1605–1618.

    Article  PubMed  Google Scholar 

  11. Friedman RJ, Friedrich LV, White RL, Kays MB, Brundage DM, Graham J. Antibiotic prophylaxis and tourniquet inflation in total knee arthroplasty. Clin Orthop Relat Res. 1990;260:17–23.

    PubMed  Google Scholar 

  12. Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2001;1:CD000244.

    Google Scholar 

  13. Hasan M, Kissoon N, Khan T, Saldajeno V, Goldstein J, Murphy S. Intraosseous infusion and pulmonary fat embolism. Pediatr Crit Care Med. 2001;2:133–138.

    Article  PubMed  Google Scholar 

  14. Hill C, Flamant R, Mazas F, Evrard J. Prophylactic cefazolin versus placebo in total hip replacement. Report of a multicentre double-blind randomised trial. Lancet. 1981;1:795–796.

    Article  PubMed  CAS  Google Scholar 

  15. Hoddinott C, Lovering AM, Fernando HC, Dixon JH, Reeves DS. Determination of bone and fat concentrations following systemic cefamandole and regional cefuroxime administration in patients undergoing knee arthroplasty. J Antimicrob Chemother. 1990;26:823–829.

    Article  PubMed  CAS  Google Scholar 

  16. Josefson A. A new method of treatment—intraosseous injection. Acta Med Scand. 1934;81:550–554.

    Article  Google Scholar 

  17. Lazzarini L. Regional and systemic prophylaxis with teicoplanin in total knee arthroplasty. J Arthroplasty. 2003;18:342–346.

    Article  PubMed  Google Scholar 

  18. Mattson S, Bourve L, Pearce S, Hurtig M, Burger J, Black W. Intraosseous gentamicin perfusion of the distal metacarpus in standing horses. Vet Surg. 2004;33:180–186.

    Article  PubMed  Google Scholar 

  19. Miller BS, Harper WP, Hughes JS, Sonnabend DH, Walsh WR. Regional antibiotic prophylaxis in elbow surgery. J Shoulder Elbow Surg. 2004;13:57–59.

    Article  PubMed  Google Scholar 

  20. Nickinson R, Board T, Gambhir A, Porter M, Kay P. The microbiology of the infected knee arthroplasty. Int Orthop. 2010;34:505–510.

    Article  PubMed  CAS  Google Scholar 

  21. Phillips JE, Crane TP, Noy M, Elliott TSJ, Grimer RJ. The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. J Bone Joint Surg Br. 2006;88:943–948.

    Article  PubMed  CAS  Google Scholar 

  22. Rubio-Martínez L, López-Sanromán J, Cruz AM, Santos M, San Román F. Medullary plasma pharmacokinetics of vancomycin after intravenous and intraosseous perfusion of the proximal phalanx in horses. Vet Surg. 2005;34:618–624.

    Article  PubMed  Google Scholar 

  23. Scheuch BC, Van Hoogmoed LM, Wilson WD, Snyder JR, MacDonald MH, Watson ZE, Steffey EP. Comparison of intraosseous or intravenous infusion for delivery of amikacin sulfate to the tibiotarsal joint of horses. Am J Vet Res. 2002;63:374–380.

    Article  PubMed  CAS  Google Scholar 

  24. Schurman DJ, Hirshman HP, Kajiyama G, Moser K, Burton DS. Cefazolin concentrations in bone and synovial fluid. J Bone Joint Surg Am. 1978;60:359–362.

    PubMed  CAS  Google Scholar 

  25. Shavit I, Hoffmann Y, Galbraith R, Waisman Y. Comparison of two mechanical intraosseous infusion devices: a pilot, randomized crossover trial. Resuscitation. 2009;80:1029–1033.

    Article  PubMed  Google Scholar 

  26. Tobias JD, Ross AK. Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use. Anesth Analg. 2010;110:391–401.

    Article  PubMed  Google Scholar 

  27. Waisman M, Roffman M, Bursztein S, Heifetz M. Intraosseous regional anesthesia as an alternative to intravenous regional anesthesia. J Trauma. 1995;39:1153–1156.

    Article  PubMed  CAS  Google Scholar 

  28. Yamada K, Matsumoto K, Tokimura F, Okazaki H, Tanaka S. Are bone and serum cefazolin concentrations adequate for antimicrobial prophylaxis? Clin Orthop Relat Res. 2011;469:3486–3494.

    Article  PubMed  Google Scholar 

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Acknowledgments

We thank Irene Zeng, MSc (Hons), for her assistance with statistical analysis, Grant Moore, BSc (Hons), for his assistance with laboratory analysis, and the charitable trust Clinical Research and effective practice (CCRep) for their funding support. We also thank Vidicare (San Antonio, TX, USA) for supplying the intraosseous needles without charge.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland, 1640, New Zealand

    Simon W. Young FRACS & Brendan Coleman FRACS

  2. Department of Orthopaedics, Whangarei Hospital, Whangarei, New Zealand

    Kelly G. Vince MD

  3. Clinical Pharmacology, Department of Medicine, University of Otago—Christchurch, Christchurch, New Zealand

    Mei Zhang PhD

  4. Clinical Microbiology, Auckland City Hospital, Auckland, New Zealand

    Joshua T. Freeman FRCPA

Authors
  1. Simon W. Young FRACS
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  2. Mei Zhang PhD
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  3. Joshua T. Freeman FRCPA
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  4. Kelly G. Vince MD
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  5. Brendan Coleman FRACS
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Corresponding author

Correspondence to Simon W. Young FRACS.

Additional information

The institution of one of the authors (MZ) received funding from the Centre for Clinical Research and effective practice (CCRep), a charitable trust with no relationship to the subject of this article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

Procedures and sample collection were performed at Middlemore Hospital, Auckland, New Zealand. Sample analysis was performed at Canterbury Health Laboratories, Christchurch, New Zealand.

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Young, S.W., Zhang, M., Freeman, J.T. et al. Higher Cefazolin Concentrations with Intraosseous Regional Prophylaxis in TKA. Clin Orthop Relat Res 471, 244–249 (2013). https://doi.org/10.1007/s11999-012-2469-2

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  • DOI: https://doi.org/10.1007/s11999-012-2469-2

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