The use of vancomycin powder in total elbow arthroplasty; can we decrease infection risk?

Despite advances in implant technology and surgical techniques in total elbow arthroplasty (TEA), there remains a relatively high risk of postoperative infection compared to shoulder arthroplasty. The purpose of this study was primarily to investigate the use of intraoperative vancomycin powder (IVP) during TEA in regard to postoperative periprosthetic joint infections (PJIs).

A retrospective longitudinal review of patients undergoing TEA over a 22-year study period was performed. A total of 299 patients over the age of 18-years undergoing primary TEA with a minimum 6 months of clinical follow-up were included. A majority of these patients were Caucasian (75.3%; n = 225), female (81.3%; n = 243), and over the age of 65 years (57.5%; n = 172). Native fracture was the most common indication for TEA (48.2%; n = 144), followed by rheumatoid arthritis (33.4%; n = 100) and osteoarthritis (12.7%; n = 38).

Seventy-eight patients (26%) received IVP based on surgeon discretion at the time of the procedure. Thirty patients who did not receive IVP went on to develop a PJI (13.5%), compared to 6 patients that did receive IVP (7.7%). However, this was not a statistically significant difference (odds ratio 0.53, P = .169). Patients who developed a PJI were more likely to be under the age of 65 (n = 22 [61.1%]; P = .016) and have rheumatoid arthritis (n = 22 [61.1%]; P = .0002). The mean body mass index for patients who developed a PJI was higher than that of those who did not (29.9 ± 8.9 vs. 27 ± 6.3; P = .029). There was also no difference in the readmission rate (P = .967) or reoperation rate (P = .368) between patients who received IVP and those who did not.

The use of IVP was associated with almost half the risk of developing a PJI during primary TEA (13.6% vs. 7.7%). However, this was not statistically significant, likely due to underpowering with a relatively small sample size of patients receiving IVP. The reduction in PJI seen in this IVP cohort has still changed the practice of the authors, who now routinely administer vancomycin powder for total elbow arthroplasty.