Abstract
The use of antibiotic-loaded cement has become a well-accepted method to develop high local antibiotic concentrations in orthopedic surgery. A new surgical technique has been established in our department in order to further increase the local antibiotic concentration, when implanting a prosthesis during revision surgery. By additional superficial vancomycin coating of the bone cement, high local antibiotic concentrations are generated. They should reach inhibiting and bactericidal concentrations of the respective pathogen during the first days after surgery.
The aim of this study was to state the safety of this method by analyzing postoperative serum and drain vancomycin concentrations. Attention was focused on possible systemic side effects. To determine nephrotoxicity, creatinine levels were also measured.
In total 32 revision operations (hip n=10, knee n=22) with additional superficial vancomycin coating were performed between 05/2013 and 04/2015. Procedures with removal of the prosthesis following temporary spacer implantation were excluded. In nine cases a one-stage procedure was performed, while in the others an arthroplasty or arthrodesis was performed after temporary spacer explantation. Vancomycin powder (2 grams) was added superficially to the surface of the bone cement and pressed onto manually before curing. Postoperative Vancomycin levels were measured in serum and the drain on day 1 to 5 or until the drain has been removed. In total 90 blood serum samples and 100 drain fluid samples were obtained.
The highest median vancomycin level from the drain was documented on postoperative day 1 with a value of 555.3 μg/mL (range 66.1 – 1081.8), continually decreasing until postoperative day 4. The highest value was documented on the second postoperative day with 2170.0 μg/mL. On the first postoperative day, a median serum vancomycin level of 3.35 μg/mL was present (range <2.0 – 8.5), while from postoperative day 2 to 5 a median level less than 2.0 μg/mL (range <2.0 – 7.2) was documented.
Anaphylactic reaction, red man syndrome or fever and chills were not observed after the surgical procedure. Furthermore, no subjective hearing loss was reported. Only in one case, a creatinine increase of 0.5 mg/dL from baseline value was detected. In this case the patient suffered preoperatively from a chronic kidney insufficiency.
In total two reinfections occurred, one after explanting a spacer with subsequent hip total endoprosthesis, the other one after a one-stage hip revision.
Superficial Vancomycin Coating of bone cement in orthopedic revision surgery represents a safe method to increase local inhibiting vancomycin concentrations.
