Intraosseous Vancomycin for Acute Periprosthetic Knee Infection: A Retrospective Study
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Published:
Oct 27, 2025
Keywords:
Periprosthetic joint infection, knee, intraosseous vancomycin, debridement, implant retention
Main Article Content
Abstract
Introduction: Periprosthetic joint infection (PJI) is an uncommon but serious complication after total knee arthroplasty (TKA), with significant clinical and healthcare implications. This study evaluated the effectiveness of the debridement, antibiotics, and implant retention (DAIR) protocol combined with intraosseous vancomycin administration and modular component exchange in controlling acute infection and improving functional outcomes.
Materials and Methods: We conducted a retrospective study across three institutions, including 12 patients (7 women, 5 men; mean age, 72.4 ± 6.3 years) with acute PJI treated with DAIR between February 2022 and June 2023. The mean interval between primary TKA and the DAIR procedure was 12.3 days. A standardizedprotocol was applied, consisting of intraosseous vancomycin delivery, modular component exchange, and pathogen-directed antibiotic therapy.
Results: The mean surgical time was 95 ± 10 minutes. Infection control was achieved in 11 of 12 cases (91.6%), with one reinfection requiring two-stage revision. The Knee Society Score improved significantly from 42.5 ± 5.8 preoperatively to 88.6 ± 6.3 at 1 year (p < 0.001).
Conclusion: The DAIR protocol with intraosseous vancomycin and modular component exchange appears to be a promising strategy for managing acute periprosthetic knee infection. Larger studies are needed to confirm these preliminary results.
Materials and Methods: We conducted a retrospective study across three institutions, including 12 patients (7 women, 5 men; mean age, 72.4 ± 6.3 years) with acute PJI treated with DAIR between February 2022 and June 2023. The mean interval between primary TKA and the DAIR procedure was 12.3 days. A standardizedprotocol was applied, consisting of intraosseous vancomycin delivery, modular component exchange, and pathogen-directed antibiotic therapy.
Results: The mean surgical time was 95 ± 10 minutes. Infection control was achieved in 11 of 12 cases (91.6%), with one reinfection requiring two-stage revision. The Knee Society Score improved significantly from 42.5 ± 5.8 preoperatively to 88.6 ± 6.3 at 1 year (p < 0.001).
Conclusion: The DAIR protocol with intraosseous vancomycin and modular component exchange appears to be a promising strategy for managing acute periprosthetic knee infection. Larger studies are needed to confirm these preliminary results.
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Martínez, W. F., Bochatey, E. J., & Lopreite, F. A. (2025). Intraosseous Vancomycin for Acute Periprosthetic Knee Infection: A Retrospective Study. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 90(5), 438-445. https://doi.org/10.15417/issn.1852-7434.2025.90.5.2164
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Clinical Research
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References
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10. Duque A, Post Z, Lutz R, Orozco F, Pulido S, Ong A. Is there still a role for irrigation and debridement with liner
exchange in acute periprosthetic total knee infection? J Arthroplasty 2017;32(4):1280-4. https://doi.org/10.1016/j.arth.2016.10.029
11. Bradbury T, Fehring T, Taunton M, Hanssen A, Azzam K, Parvizi J, et al. The fate of acute methicillin-resistant
Staphylococcus aureus periprosthetic knee infections treated by open debridement and retention of components. J Arthroplasty 2009;24(6 Suppl):101-4. https://doi.org/10.1016/j.arth.2009.04.028
12. Riesgo AM, Park BK, Herrero CP, Yu S, Schwarzkopf R, Iorio R. Vancomycin povidone-iodine protocol improves
survivorship of periprosthetic joint infection treated with irrigation and debridement. J Arthroplasty 2018;33(3):847-50. https://doi.org/10.1016/j.arth.2017.10.044
13. McQuivey K, Bingham J, Chung A, Clarke H, Schwartz A, Pollock J, et al. The double DAIR: A 2-stage debridement with prosthesis-retention protocol for acute periprosthetic joint infections. JBJS Essent Surg Tech
2021;11(1):e19.00071-e19.00071. https://doi.org/10.2106/JBJS.ST.19.00071
14. Siquiera MBP, Saleh A, Klika AK, O’Rourke C, Schmitt S, Higuera CA, et al. Chronic suppression of periprosthetic joint infections with oral antibiotics increases infection-free survivorship. J Bone Joint Surg Am 2015;97(15):1220-32. https://doi.org/10.2106/jbjs.n.00999
15. Cortes-Penfield N, Krsak M, Damioli L, Henry M, Seidelman J, Hewlett A, et al. How we approach suppressive
antibiotic therapy following debridement, antibiotics, and implant retention for prosthetic joint infection. Clin Infect Dis 2024;78(1):188-98. https://doi.org/10.1093/cid/ciad484
16. 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. https://doi.org/10.1007/s11999-013-3038-z
17. Chin SJ, Moore GA, Zhang M, Clarke HD, Spangehl MJ, Young SW. The AAHKS clinical research award: Intraosseous regional prophylaxis provides higher tissue concentrations in high BMI patients in total knee
arthroplasty: A randomized trial. J Arthroplasty 2018;33(7S):S13-S18. https://doi.org/10.1016/j.arth.2018.03.013
18. Martínez W, Tillet F, Bochatey E, Lopreite F. Vancomicina intraósea en artroplastía total de rodilla. Acta Ortop Mex 2024;38(3):172-8. https://doi.org/10.35366/115812
19. Kildow B, Patel S, Otero J, Fehring K, Curtin B, Springer B, et al. Results of debridement, antibiotics, and implant retention for periprosthetic knee joint infection supplemented with the use of intraosseous antibiotics. Bone Joint J 2021;103-B(6 Suppl A):185-90. https://doi.org/10.1302/0301-620X.103B6.BJJ-2020-2278.R1
2. Fehring TK, Odum SM, Berend KR, Jiranek WA, Parvizi J, Bozic KJ, et al. Failure of irrigation and débridement for
early postoperative periprosthetic infection. Clin Orthop Relat Res 2013;471(1):250-7. https://doi.org/10.1007/s11999-012-2373-9
3. Qu G-X, Zhang C-H, Yan S-G, Cai Z-Z. Debridement, antibiotics, and implant retention for periprosthetic knee
infections: a pooling analysis of 1266 cases. J Orthop Surg Res 2019;14:358. https://doi.org/10.1186/s13018-019-1378-4
4. Son WS, Shon OJ, Lee DC, Park SJ, Yang HS. Efficacy of open debridement and polyethylene exchange in strictly
selected patients with infection after total knee arthroplasty. Knee Surg Relat Res 2017;29(3):172.
https://doi.org/10.5792/ksrr.16.040
5. Svensson K, Rolfson O, Nauclér E, Lazarinis S, Sköldenberg O, Schilcher J, et al. Exchange of modular components improves success of debridement, antibiotics, and implant retention. JB JS Open Access 2020;5(4):e20.00110. https://doi.org/10.2106/JBJS.OA.20.00110
6. Young SW, Zhang M, Freeman JT, Vince KG, Coleman B. Higher cefazolin concentrations with intraosseous regional prophylaxis in TKA. Clin Orthop Relat Res 2013;(471):244-9. https://doi.org/10.1007/s11999-012-2469-2
7. Diaz-Ledezma C, Higuera CA, Parvizi J. Success after treatment of periprosthetic joint infection: A delphi-based
international multidisciplinary consensus infection. Clin Orthop Relat Res 2013;471(7):2374-82.
https://doi.org/10.1007/s11999-013-2866-1
8. Urish KL, Bullock AG, Kreger AM, Shah NB, Jeong K, Rothenberger SD; Infected Implant Consortium. A multicenter study of irrigation and debridement in total knee arthroplasty periprosthetic joint infection: treatment failure is high. J Arthroplasty 2018l;33(4):1154-9. https://doi.org/10.1016/j.arth.2017.11.029
9. Qasim SN, Swann A, Ashford R. The DAIR (debridement, antibiotics and implant retention) procedure for infected total knee replacement - a literature review. SICOT J 2017;3:2. https://doi.org/10.1051/sicotj/2016038
10. Duque A, Post Z, Lutz R, Orozco F, Pulido S, Ong A. Is there still a role for irrigation and debridement with liner
exchange in acute periprosthetic total knee infection? J Arthroplasty 2017;32(4):1280-4. https://doi.org/10.1016/j.arth.2016.10.029
11. Bradbury T, Fehring T, Taunton M, Hanssen A, Azzam K, Parvizi J, et al. The fate of acute methicillin-resistant
Staphylococcus aureus periprosthetic knee infections treated by open debridement and retention of components. J Arthroplasty 2009;24(6 Suppl):101-4. https://doi.org/10.1016/j.arth.2009.04.028
12. Riesgo AM, Park BK, Herrero CP, Yu S, Schwarzkopf R, Iorio R. Vancomycin povidone-iodine protocol improves
survivorship of periprosthetic joint infection treated with irrigation and debridement. J Arthroplasty 2018;33(3):847-50. https://doi.org/10.1016/j.arth.2017.10.044
13. McQuivey K, Bingham J, Chung A, Clarke H, Schwartz A, Pollock J, et al. The double DAIR: A 2-stage debridement with prosthesis-retention protocol for acute periprosthetic joint infections. JBJS Essent Surg Tech
2021;11(1):e19.00071-e19.00071. https://doi.org/10.2106/JBJS.ST.19.00071
14. Siquiera MBP, Saleh A, Klika AK, O’Rourke C, Schmitt S, Higuera CA, et al. Chronic suppression of periprosthetic joint infections with oral antibiotics increases infection-free survivorship. J Bone Joint Surg Am 2015;97(15):1220-32. https://doi.org/10.2106/jbjs.n.00999
15. Cortes-Penfield N, Krsak M, Damioli L, Henry M, Seidelman J, Hewlett A, et al. How we approach suppressive
antibiotic therapy following debridement, antibiotics, and implant retention for prosthetic joint infection. Clin Infect Dis 2024;78(1):188-98. https://doi.org/10.1093/cid/ciad484
16. 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. https://doi.org/10.1007/s11999-013-3038-z
17. Chin SJ, Moore GA, Zhang M, Clarke HD, Spangehl MJ, Young SW. The AAHKS clinical research award: Intraosseous regional prophylaxis provides higher tissue concentrations in high BMI patients in total knee
arthroplasty: A randomized trial. J Arthroplasty 2018;33(7S):S13-S18. https://doi.org/10.1016/j.arth.2018.03.013
18. Martínez W, Tillet F, Bochatey E, Lopreite F. Vancomicina intraósea en artroplastía total de rodilla. Acta Ortop Mex 2024;38(3):172-8. https://doi.org/10.35366/115812
19. Kildow B, Patel S, Otero J, Fehring K, Curtin B, Springer B, et al. Results of debridement, antibiotics, and implant retention for periprosthetic knee joint infection supplemented with the use of intraosseous antibiotics. Bone Joint J 2021;103-B(6 Suppl A):185-90. https://doi.org/10.1302/0301-620X.103B6.BJJ-2020-2278.R1