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BACKGROUND: Intraosseous regional administration (IORA) as a widely applicable and clinically valuable route of administration has gained significant attention in the context of total knee arthroplasty (TKA) for the prophylactic administration of antibiotics. However, there is still controversy regarding its effectiveness and safety. The latest meta-analysis reports that the use of IORA for antibiotics in TKA is as safe and effective as IV administration in preventing prosthetic joint infection (PJI), but they did not separate the statistics for primary TKA and revision TKA, which may be inappropriate. There is currently a lack of evidence specifically comparing the outcomes of prophylactic antibiotic administration via IORA or IV route in primary/revision TKA, respectively, and new research evidence has emerged. PURPOSES: In this study, we conducted a systematic review and meta-analysis with the primary objective of comparing the local drug tissue concentration and the incidence of PJI between preoperative IORA and intravenous (IV) administration of prophylactic antibiotics in TKA. Additionally, the occurrence of complications between the two administration routes was also compared. PATIENTS AND METHODS: This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA) guidelines. Retrospective cohort studies and prospective randomized controlled trials that utilized intraosseous local drug delivery for prophylactic antibiotics in knee arthroplasty were included. English literature from PubMed, Embase, and Cochrane Library databases was searched from the inception of each database until December 2023. Two researchers independently screened the literature, assessed the quality, and extracted data according to the inclusion criteria. The primary outcomes were local antibiotic tissue concentration and postoperative PJI incidence, while the secondary outcome was the occurrence of postoperative complications. Statistical analysis was performed using Review Manager 5.3 software. RESULTS: This study included 7 prospective randomized controlled trials and 5 retrospective cohort studies. A total of 4091 patients participated in the 12 included studies, with 1,801 cases receiving IORA and 2,290 cases in the control group. In terms of local drug tissue concentration, intraosseous infusion (IO) 500 mg vancomycin significantly increased the drug concentration in the periarticular adipose tissue (SMD: 1.36; 95% CI: 0.87-1.84; P < 0.001; I2 = 0%) and bone tissue (SMD: 0.94; 95% CI: 0.49-1.40; P < 0.001; I2 = 0%) compared to IV 1 g vancomycin. Regarding the incidence of postoperative PJI after primary TKA, IO 500 mg vancomycin was more effective in reducing the occurrence of PJI compared to IV 1 g vancomycin (OR: 0.19; 95% CI: 0.06-0.59; P < 0.001; I2 = 36%). Finally, no significant differences were found between the two groups in terms of postoperative pulmonary embolism (PE) (OR: 1.72; 95% CI: 0.22-13.69; P = 0.59; I2 = 0%) and vancomycin-related complications (OR: 0.54; 95% CI: 0.25-1.19; P = 0.44; I2 = 0%). CONCLUSIONS: Preoperative prophylactic antibiotic administration via IORA in TKA significantly increases local drug tissue concentration without significantly increasing systemic drug-related complications compared to traditional IV administration. In primary TKA, low-dose vancomycin via IORA is more effective in reducing the incidence of PJI compared to traditional IV regimens. However, its effectiveness remains controversial in high-risk populations for PJI, such as obese, diabetic, and renal insufficiency patients, as well as in revision TKA.
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PURPOSE: Condylar constrained knee prostheses (CCK) are increasingly used in revision total knee arthroplasty (rTKA), but the clinical effectiveness and long-term survival remain a debate. The purpose of this study is to report the long-term clinical and radiographic outcome, implant survival rate, and surgical safety of revision total knee arthroplasty with condylar constrained knee prosthesis. METHODS: A retrospective cohort study was performed on patients undergoing rTKA with CCK. The cases who received rTKA with CCK from January 2005 to January 2022 were selected. The duration of operation, the estimated perioperative blood loss, and the intraoperative blood transfusion rate were recorded to evaluate surgical safety. The pain visual analog scale (VAS), range of motion (ROM), the Hospital for Special Surgery (HSS) score, the Knee Society Score (KSS), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and the Oxford knee score (OKS) was recorded to assess clinical outcome. Standard anteroposterior, lateral, skyline and long-standing AP radiographs of the lower limbs were conducted to assess radiographic outcome. Implant survival was analyzed by Kaplan-Meier survival estimates. RESULTS: Fifty-five cases were followed up for an average of 9.6 years (1-18 years), including 16 males and 38 females, with an average age of 66 and an average BMI of 26.9 kg/m2. The main reasons for revision were periprosthetic infection (32 knees, 58.2%) and aseptic loosening (13 knees, 23.6%). The duration of operation was 149 ± 56.2 min. The perioperative blood loss was 973.6 ± 421.6 ml. At the last follow-up, VAS (8.0 ± 1.1 to 1.3 ± 1.4), ROM (82.7° ± 26.1° to 108.4° ± 11.8°), HSS (45.0 ± 10.4 to 85.3 ± 8.6), KSKS (38.4 ± 12.1 to 88.5 ± 12.0), KSFS (19.6 ± 12.9 to 68.8 ± 15.1), WOMAC (67.9 ± 12.5 to 14.4 ± 9.5), and OKS (9.9 ± 4.2 to 41.6 ± 7.7) were significantly improved (P < 0.001). A total of five complications were observed, all of which were periprosthetic infection. Non-progressive radiolucent lines were observed in 26 knees (47.3%). The 10-year survival rate for no operation was 96.0%. The ten year survival rate for no revision was 98.0%. CONCLUSION: The use of CCK prosthesis for rTKA can achieve good long-term efficacy and prosthesis survival.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Masculino , Femenino , Humanos , Anciano , Artroplastia de Reemplazo de Rodilla/efectos adversos , Prótesis de la Rodilla/efectos adversos , Estudios de Seguimiento , Estudios Retrospectivos , Pérdida de Sangre Quirúrgica , Tasa de Supervivencia , Falla de Prótesis , Resultado del Tratamiento , Rango del Movimiento Articular , Articulación de la Rodilla/diagnóstico por imagen , Articulación de la Rodilla/cirugíaRESUMEN
INTRODUCTION: Total knee arthroplasty (TKA) is a common surgical intervention to treat joint diseases. However, TKA is associated with significant blood loss. Tranexamic acid (TXA) has been used to reduce perioperative bleeding and postoperative blood transfusion. This study aims to explore the effectiveness and safety of intraosseous regional administration (IORA) of TXA in TKA and compare differences in perioperative blood loss between IORA of TXA, intravenous infusion of TXA, and combined IORA and intravenous infusion of TXA. METHODS AND ANALYSIS: This randomised controlled trial will enrol 105 patients with osteoarthritis who meet the inclusion criteria for unilateral TKA. Patients were randomly divided into three groups using the random number table method. Group A received 1.0 g of TXA via IORA, group B received 1.0 g of TXA via intravenous infusion 15 min prior to the tourniquet release, and group C received both IORA of 1.0 g of TXA and intravenous infusion of 1.0 g of TXA. The primary outcome measure is perioperative total blood loss. Secondary outcomes include bleeding events, venous thromboembolism events, inflammation reactions, other complications and knee function assessments. ETHICS AND DISSEMINATION: This study has been approved by the Ethics Committee of Peking Union Medical College Hospital and registered in the Chinese Clinical Trial Registry. Informed consent will be obtained from all the patients before enrolment. The trial will be conducted in accordance with the principles of the Declaration of Helsinki and the International Conference on Harmonization Good Clinical Practice guidelines. The results of this study will be disseminated through peer-reviewed publications, conference presentations and social media platforms. The findings will provide valuable insights into the use of IORA of TXA in TKA and may lead to the development of new strategies for perioperative blood management in joint replacement surgery. TRIAL REGISTRATION NUMBER: The Ethics Committee of Peking Union Medical College Hospital (approval number: K2371); Chinese Clinical Trial Registry (trial registration number: ChiCTR2200066293).