Methicillin-resistant Staphylococcus aureus in TKA treated with revision and direct intra-articular antibiotic infusion

BACKGROUND: Resistant organisms are difficult to eradicate in infected total knee arthroplasty. While most surgeons use antibiotic-impregnated cement in these revisions, the delivery of the drug in adequate doses is limited in penetration and duration. Direct infusion is an alternate technique.

QUESTIONS/PURPOSES: We asked whether single-stage revision and direct antibiotic infusion for infected TKA would control infection in patients with methicillin-resistant Staphylococcus aureus (MRSA) infections.

METHODS: We retrospectively reviewed 18 patients (18 knees) with MRSA with one-stage revision protocol that included débridement, uncemented revision of total knee components, and intraarticular infusion of 500 mg vancomycin via Hickman catheter once or twice daily for 6 weeks; we used no intravenous antibiotics after the first 24 hours. We monitored serum vancomycin levels to maintain levels between 3 and 10 microg/mL. Minimum followup was 27 months (range, 27–75 months). Mean followup was 62 months, (range, 27–96 months).

RESULTS: Infection was controlled at last followup in all but one patient with a recurrence of the MRSA. The patient was reoperated at 5 months; a necrotic bone fragment was removed, the knee was débrided and revised, and the antibiotic infusion protocol readministered. The patient remained free of infection 42 months postoperatively. At 2-year followup, the mean Knee Society score was 83. We observed no radiographic evidence of implant migration.

CONCLUSIONS: One-stage revision and 6 weeks of intraarticular vancomycin administration controlled infection in MRSA infected TKA with no apparent complications.

LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.