Intraosseous Regional Administration of Antibiotic Prophylaxis in Total Knee Arthroplasty

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA), and perioperative antibiotics are commonly administered to try to mitigate the chance of infection. Intraosseous regional administration (IORA) of prophylactic antibiotics during TKA is a method of antibiotic delivery that has been shown to achieve markedly higher tissue concentrations at much lower doses. Other advantages include ease of administration, ability to time the antibiotic delivery with the surgical start time for maximal effectiveness, and less systemic side effects. The concept is similar to a Bier block, except that IORA involves the use of antibiotics instead of local anesthetic to perfuse the limb and is given via intraosseous rather than intravenous access. After standard patient preparation and draping, the tourniquet is inflated and an intraosseous needle is inserted into the proximal medial face of the tibia, just medial and slightly above the level of the tubercle. A large syringe containing the desired antibiotic (typically 500 mg vancomycin suspended in normal saline solution) is connected to the needle and the solution is administered over 1 to 2 minutes. The intraosseous needle can then be removed and the surgical procedure proceeds as it normally would per surgeon preference and technique. Systemic administration of intravenous antibiotics, vancomycin powder, and antibiotic-impregnated cement are alternative options that can be utilized during TKA. IORA has several distinct advantages over other methods of antibiotic delivery, including the ability to (1) deliver antibiotic directly to the surgical bed and avoid systemic delivery, (2) precisely time and quickly administer antibiotics to achieve highest concentrations at the start of and throughout the surgical procedure, and (3) avoid several common and potentially serious side effects, especially those associated with antibiotics such as vancomycin. This technique for antibiotic delivery achieves markedly higher tissue concentrations compared with systemic administration, without prolonged preoperative infusion times. Intraosseous delivery optimizes timing and reduces the risk of systemic side effects while simultaneously providing equal or enhanced antibiotic prophylaxis in TKA. This delivery mechanism is especially useful in patients who are at high risk for infection and in the revision TKA setting. Further, there is little to no additional risk and the use of this meth