Total Joint Arthroplasty Periprosthetic Joint Infections Are Not Reduced With Intraoperative Vancomycin: A Large National Database Study

Aim Cephalosporins are the primary prophylactic antibiotic given in primary total hip and knee arthroplasty (THA, TKA). Interest exists in augmenting this effect using intraoperative vancomycin (intrawound, intraosseous, or intravenous). No consensus has been reached given low statistical power of prior studies related to low periprosthetic joint infection (PJI) rates. This study aims to identify differences in 90-day infectious/medical complications or 5-year revision-free survival among patients who did, versus those who did not, receive intraoperative vancomycin alongside cefazolin. Methods Within a national database, adult patients undergoing primary THA or TKA January 2010 to April 2023 for osteoarthritis indications who received same-day cefazolin prophylaxis were identified for inclusion. Exclusion criteria included prior methicillin-resistant Staphylococcus aureus or PJI, any infection within 90-days prior to surgery, and any antibiotic prescription within 90 days before or 3 days after surgery. A 1:1 match was performed on the remaining patients who did or did not have the addition of intraoperative vancomycin (J-3370) based on age, sex, Elixhauser Comorbidity Index, body mass index (BMI) greater than 40mg/kg2, type II diabetes status, insulin use, smoking status, and geographic region. Multivariable logistic regressions were then performed to compare 90-day complications. Sub-analyses were done for the high-risk groups. Kaplan-Meier analysis and log-rank tests were used to evaluate five-year revision-free survival. Significance was defined as P < 0.003, per Bonferroni correction. Results Among 78,778 THA patients, intraoperative vancomycin was used for 20,841 (26.5%), yielding 17,051 per matched group. Among 171,274 TKA patients, intraoperative vancomycin was used for 49,145 (28.7%), yielding 43,569 per matched group. In TKA and THA patients, intraoperative vancomycin was not associated with reduced 90-day odds of either superficial surgical site infection or PJI, nor with increased odds of any other adverse event. This remained true for “high-risk” groups including BMI of 40mg/kg2 or more, smoking, diabetes, insulin, and age above 75. The five-year revision-free survival was comparable between both matched groups. Conclusion Intraoperative vancomycin was not significantly associated with lower odds of SSI, 90-day PJI, and did not show differences in 5-year revision-free survival. To our knowledge, this study represents the largest single-study (121,240 matched patients) of vancomycin use in total joint arthroplasty patients.