Spangehl Mark J, Clarke Henry D, Moore Grant A, Zhang Mei, Probst Nick E, Young Simon W
Department of Orthopaedics, Mayo Clinic, Phoenix, AZ.
Canterbury Health Laboratories, Toxicology, Christchurch, New Zealand.
J Arthroplasty. 2022 May;37(5):857-863. doi: 10.1016/j.arth.2022.01.057. Epub 2022 Jan 26.
Vancomycin use has been suggested in high risk patients undergoing total knee arthroplasty (TKA). Previous literature has shown that a lower dose (500 mg) of vancomycin given by intraosseous regional administration (IORA) achieves tissue concentrations 4-10 times higher than intravenous (IV) administration. There is increasing interest in performing TKA with limited tourniquet inflation time. The purpose of this study is to evaluate whether IORA of vancomycin can achieve effective tissue concentrations with limited tourniquet inflation time.
Based on prior power calculations, 24 patients undergoing primary TKA were randomized into 2 groups. Group IV-Systemic received weight-based (15 mg/kg) vancomycin with the tourniquet inflated for cementation only. Group IORA received 500 mg vancomycin via IORA after tourniquet inflation which remained inflated for 10 minutes, then reinflated for cementation only. Vancomycin concentrations from tissue, serum, and drain fluid were compared between the 2 groups.
Median vancomycin concentrations in tissue were significantly higher (5-15 times) at all time points in the IORA group. Concentrations in fat at the time of wound closure, after the tourniquet had been deflated for most of the procedure, were 5.2 μg/g in Group IV-Systemic and 33.1 μg/g in Group IORA (P < .001). Median bone concentrations taken just prior to cementation were 7.9 μg/g in Group IV-Systemic and 21.8 μg/g in Group IORA (P = .006). There were no complications related to IORA.
For surgeons who wish to limit tourniquet time and when indicated to use vancomycin, low-dose vancomycin IORA achieves tissue concentrations 5-15 times higher than those achieved by IV administration.
Level 1 therapeutic randomized trial.
对于接受全膝关节置换术（TKA）的高危患者，有人建议使用万古霉素。既往文献表明，通过骨内区域给药（IORA）给予较低剂量（500毫克）的万古霉素，其组织浓度比静脉注射（IV）给药高4至10倍。人们对在有限止血带充气时间下进行TKA的兴趣日益增加。本研究的目的是评估在有限止血带充气时间下，万古霉素的IORA是否能达到有效的组织浓度。
根据先前的功效计算，将24例行初次TKA的患者随机分为2组。IV-全身组接受基于体重（15毫克/千克）的万古霉素，止血带仅在骨水泥固定时充气。IORA组在止血带充气后通过IORA接受500毫克万古霉素，止血带充气10分钟，然后仅在骨水泥固定时再次充气。比较两组组织、血清和引流液中的万古霉素浓度。
IORA组在所有时间点的组织中万古霉素中位数浓度均显著更高（5至15倍）。在手术大部分过程中止血带放气后伤口闭合时，IV-全身组脂肪中的浓度为5.2微克/克，IORA组为33.1微克/克（P <.001）。骨水泥固定前采集的骨中位数浓度，IV-全身组为7.9微克/克，IORA组为21.8微克/克（P =.006）。没有与IORA相关的并发症。
对于希望限制止血带时间且有指征使用万古霉素的外科医生，低剂量万古霉素IORA可使组织浓度比静脉给药高5至15倍。
1级治疗性随机试验。
