Table 3.

Studies on intraosseous regional administration (IORA) vancomycin prophylaxis in primary and revision total knee arthroplasty (TKA)

AUTHORS [REFERENCE]	YEAR	TYPE OF STUDY	RESULTS	CONCLUSIONS
Chin et al [1]	2018	PRIMARY TKA: Randomized clinical trial.	Low-dose IORA was efficacious in the high-BMI population cohort, rendering tissue concentrations of vancomycin 5-9 times higher than systemic administration.	IORA optimized timing of vancomycin administration and rendered high tissue antibiotic concentrations during TKA in a high-risk patient cohort.
Young et al [8]	2018	REVISION TKA: Randomized controlled clinical trial	IORA administration of vancomycin in individuals experiencing revision TKA led to tissue concentrations of vancomycin five to 20 times higher than systemic IV administration in spite of the lower dose. High tissue concentrations were kept throughout the procedure despite a period of tourniquet deflation.	The preliminary results of this study justified prospective cohort studies, which might focus on broader safety endpoints in more diverse patient populations.
Harper et al [2]	2020	PRIMARY AND REVISION TKA: Retrospective review of patients.	There were 100 primary and 29 revision TKA cases in the control (IV) arm and 100 primary and 19 revision TKA cases in the intervention (IORA) arm. There were fifteen 30-day adverse events and eighteen 90-day adverse events.	IORA of vancomycin had an appropriate safety profile in primary and revision TKA, eliminating the logistical challenge of timely prophylactic antibiotic administration.
Arthur et al [3]	2020	PRIMARY AND REVISION TKA: Clinical study.	IORA (500-mg dose of vancomycin suspended in a solution of 140 mL of normal saline solution) can be used even in the primary TKA setting if the individual is considered high-risk.	These authors utilized IORA during reimplantation following two-stage exchange for PJI.
Klasan et al [4]	2021	PRIMARY TKA: Retrospective review.	All individuals received 500 mg of IORA of vancomycin after tourniquet inflation and 3 × 1 g IV cefazolin in 24 hours.	IORA of vancomycin in addition to standard IV systemic cefazolin prophylaxis in TKA was safe without significant adverse effects of vancomycin.
Park et al [5]	2021	PRIMARY TKA: Retrospective review of primary TKAs: IV versus IORA vancomycin at 30-day, 90-day, and one-year follow-up.	Incidence of PJI with minimum 90-day follow-up was 1.4% (eight knees) in the IV cohort and 0.22% (one knee) in IORA cohort. This study showed a decrease in the prevalence of infection in TKA utilizing IORA vancomycin combined with a first-generation cephalosporin.	IORA delivery of vancomycin after tourniquet inflation was a safe and efficacious alternative to IV administration, eliminating the logistical challenges of timely dosing.
Parkinson et al [6]	2021	PRIMARY TKA: Retrospective comparative study (level 3 of evidence).	Although BMI, diabetes, and renal failure were identified as infection risk factors, the utilization of IORA antibiotics did not result in a lower PJI risk compared with IV antibiotics.	Surgeons should consider IORA in primary TKA to diminish the risk of early PJI.
Wells et al [10]	2022	PRIMARY TKA: Review article.	Recently, large-scale retrospective studies have shown lower PJI rates following TKA when IORA was utilized when compared to routine IV prophylaxis.	These authors proposed an evidence-based method for IORA in TKA.
Spangehl et al [7]	2022	PRIMARY TKA: Randomized clinical trial (level 1 of evidence).	Median vancomycin concentrations in tissue were significantly higher (5-15 times) at all time points in the IORA cohort. There were no adverse events related to IORA.	Low-dose vancomycin IORA accomplisheD tissue concentrations 5-15 times higher than those accomplished by IV administration.
Miltenberg et al [11]	2023	PRIMARY TKA: Systematic review.	Perioperative IORA of antibiotics in TKA rendered local tissue concentrations of antibiotics that WERE on average 10 times higher than IV administration alone.	IORA should be considered in high-risk individuals where elevated tissue antibiotic concentrations would be of a maximum benefit.
Lachiewicz [9]	2023	REVISION TKA: Prospective single-surgeon consecutive series.	In 20 patients having aseptic revision TKA, 500 mg of vancomycin in 120 mL of saline were infused into the tibia prior to incision, in addition to IV cefazolin. The knees were aspirated in the operating room prior to IV and IORA antibiotics.	In this study, there was no added benefit of IORA vancomycin infusion, but there were no infections with MRSA.

TKA, total knee arthroplasty; IV, intravenous; BMI, body mass index; PJI, periprosthetic joint infection; MRSA, methicillin-resistant Staphylococcus aureus