July 3, 2024 • 35 mins
On this episode, we discuss intraosseous administration of medications in total knee arthroplasty with Dr. Katharine Harper, an orthopedic surgeon specializing in joint reconstruction at the Washington, D.C. VA Medical Center.
Dr. Harper discusses her current role, and provides an in-depth exploration of intraosseous medication administration. During the conversation, she gives insights into the recent technique paper she had published in JBJS this year. Discover how this technique, backed by research from Houston Methodist, shows promise in reducing periprosthetic joint infections. Learn about the technical procedure, potential benefits, and considerations for integrating this method into your practice.
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Episode Transcript
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(00:00):
Music.
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Warning Center podcast. This is
Dr. Benner, and I'm here with Scott Bauman tonight for our next episode.
Last week, we talked about the surgical management of arthrofibrosis.
That was a really nice topic and a nice review of that.
So go back and check that one out. If you don't want to miss any of our previous
content, you can access our podcast via any of the podcast avenues that you utilize.
And on social media, we have Twitter and Instagram at the SKC podcast,
(00:34):
Facebook and YouTube, to the Sherwin-East Center podcast pages.
You can also email us at theskcpodcasts and gmail.com. Check out our previous
content, and if you like it, leave us a five-star review and a comment for those behind you.
Like Dr. Brenner was saying, with our previous content last week,
we discussed the surgical management of arthrofibrosis, in particular after
ACL reconstruction, and we thought that was a good episode for not only the
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orthopedic surgeons out there who are doing the surgery, but also the physical
therapists that are doing the post-operative rehab.
So we covered the surgical management, the post-op rehab, as well as a research
study that we've recently done.
So before this episode, go back to last episode and listen about the surgical
management of arthrofibrosis.
Tonight, we have an interesting topic. We're talking about intraosseous administration
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of medications in total knee arthroplasty.
This is in reference to a paper that Scott and I read on journal bone and joint
surgery on JBJS that was published recently.
And we have one of the authors from that paper. Dr.
Catherine Harper is with us tonight. night. Catherine went to the Royal College
of Surgeons in Ireland and then transitioned to the United States where she
completed an orthopedic residency in Philadelphia at Temple University and then
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went on to do a fellowship in joint reconstruction and arthroplasty at Houston
Methodist Hospital in Houston. So, Dr.
Harper, great to have you tonight and thank you for joining us.
Yeah, thank you for having me on, guys. I appreciate it and I'm excited to talk about this topic.
Dr. Harper is now an attending orthopedic surgeon joint reconstruction specialist
at the Washington, D.C. VA Medical Center.
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She's been there for five years, and she was a co-author on this paper in JBJS with Dr.
Stephen Acabo from Houston Methodist from her fellowship days.
So just tell us a little bit about yourself as we get started.
How did you get interested in orthopedic surgery? How did you get interested
in joint replacement and end up here where you are today?
Yeah, you know, when I went to Ireland for med school, I originally thought
I was going to be an ophthalmologist, kind of a divergent from orthopedics, I think.
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Those are pretty much the Yeah, they're basically the same.
And, you know, I was a second year medical student and I got to scrub in on
a shoulder arthroscopy rotator cuff repair.
And from that point on, I was hooked, abandoned ophthalmology and came in to
decide that orthopedics was for me.
I found my people, so to speak. So that's kind of how I got on the path to orthopedics.
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I was able to do a rotation in medical school at Temple.
It just felt like the right fit. I was lucky enough as an international medical
graduate to match into orthopedics, which is not a very common thing,
and made my way to Philadelphia.
It was an incredible five years of training. I absolutely loved it there. You can't.
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Can't compare to the operative experience I got there.
And joint replacements just seemed to speak to me. I love the fact that,
you know, you could make someone instantly better.
You know, you do the surgery, they're up and walking, they're moving,
they've had debilitating pain for decades.
And in several days, they're better and they're moving on with their lives and
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they're able to do everything they weren't able to do before.
So that's kind of how I decided on that. You know, how I made my way to Houston
Methodist, I don't even know if I remember at this point in time,
but the program just seemed like exactly what I was looking for in terms of
they do complex revisions, they do infections,
they do primaries, they're efficient,
you get to see everything, and the attendings who are going to teach you there
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were fantastic. So that's kind of how I made my way there.
And, you know, I've loved every minute of doing arthroplasty.
I couldn't imagine doing anything else.
In my humble personal opinion, I think it's the best subspecialty.
The show, Anika, you guys might disagree, but I think it's great.
I love it. My current practice is 100% arthroplasty.
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I do all the hip and knee replacements at the DCVA right now. I do 100% of them.
We pride ourselves in doing a fantastic job there. We are a center of excellence
for advanced hip and knee replacements.
We're one of only two VAs in the country that has that distinction and one of
the very few in the major DMV or DC, Maryland, Virginia area to have that distinction as well.
(04:43):
So that's my current practice is exclusively arthroplasty. We take care of everything.
Great stuff. You know, mine is a knee-focused practice and our clinic is all knee-focused.
But when I was a medical student, when I got started watching arthroplasty cases,
I didn't have a clue what the hell they were talking about most of the time.
They were talking about length and offset and ligament balancing and releases
and alignment and varus and valgus. I don't know what the hell they were talking about.
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And I thought, this is the dumbest thing ever. I'm never doing this until I
finally grew up a little bit in orthopedics and started to learn what all that
stuff meant and figured out, you know what, but there's a lot of decisions to
make throughout this surgery.
There's a lot of options that you have to have.
It's not just as simple as taking something out and throwing it in the trash.
It's something that you've got to rebuild and realign and restructure in a way
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that I just had no understanding of at that point. And once I learned it, it was just a lot of fun.
So I'm with you 100% on joint replacement being the way to go.
I love sports medicine cases as well. That's a little bit different than your practice.
This podcast, we're talking about knees all the time, which is all Scott and I ever talk about.
But, you know, interesting topic for us tonight, which is why I wanted to talk
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to you about intraosseous administration of medications in total knee arthroplasty.
I'll be honest with you. I've seen this about zero times in my training ever.
So the only time I ever remember seeing this was in trauma situations that they
couldn't get IV access every once in a while.
Somebody would come in off the rig with a spike in their tibia and an IO line.
And, you know, I remember as a resident going, what in the hell is that?
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And it was really all that I knew about IO administration.
So tell us about kind of how you got involved in that and how you became involved
in this study in particular.
Yeah, so my experience prior to kind of getting involved with it at Houston
Methodist was exactly the same.
You know, IO lines were for military and for trauma, and you didn't really see
them in pediatrics, I suppose, from time to time.
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You'd see a kid get an IO line for IV access.
And beyond that, I didn't ever see it have very much applicability to adults.
But the reality is that it's a very well-established medication delivery route.
It's likely underutilized outside the operating room because it's not the most
comfortable thing to have done to you.
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But inside the operating room, they're really, you know, with sedation and options
for anesthesia, there's really no reason that you wouldn't consider it as an
option for any kind of medication delivery.
So the original studies came out of the Young group,
which showed essentially proof of concept, where they showed that using an intraosseous
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route for delivery of vancomycin in particular was a unique technique.
I guess novel is the word they used, although, you know, it's kind of taking
something old and reimagining it, delivery system for the vancomycin.
Now, vancomycin in particular for joint arthroplasty, it's kind of a finicky
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drug to administer to patients, not very well tolerated via IV.
Patients are prone to getting reactions, Redman syndrome, histamine releases,
takes a long time to infuse. You're very reliant on anesthesia staying with you in terms of timing.
And it's a weight-based dose, which is difficult to convince people to actually
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bother to calculate someone's weight to give them the correct dose.
As someone who's experienced Redman syndrome firsthand, I got Redman syndrome
getting vancomycin with antibiotics after a procedure once. It was not fun.
Yeah, it's uncomfortable and it's not tolerated. I thought I was dying for a
few minutes. What is happening to me?
Yeah, exactly. Exactly. So, you know,
they started with that and they showed proof of concept through
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a few award-winning papers that showed that the concentrations at the target
site were higher when delivered intraosseously than when delivered systemically
via the traditional route of IV and without the systemic side effects that usually
made it a less attractive option.
So, Houston Methodist saw that research, was interested in expanding on it.
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They thought there was some potential there for new novel uses for it.
And so that's kind of where the idea came from, and we kind of built on that.
So the original research paper we did was a retrospective review that we showed,
you know, good outcomes and a lack of systemic side effects.
A subsequent paper that was released in, I believe, 2021, which won the Knee
(09:09):
Society Award, showed that it did decrease rates of periprosthetic joint infections
versus traditional IV antibiotic infusion.
Only recently, we also won the Hip Society Award for proving that it did the
same in the hip. So we won that last year.
So we kind of built upon that, and it's used almost 100% of the time in practice
(09:32):
at Methodist now for their arthroplasty patients.
It's simple. It's quick. It adds about 30 seconds to one minute to your operative time.
For orthopedic surgeons, certainly, we don't feel, I don't think anyone has
an aversion to throwing a needle through a piece of bone, through a cortex.
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So it's playing into our skill set where we, I think most of us feel very comfortable,
obviously administering something that way.
And it's shown to decrease your issues with delivery of vancomycin,
which is not getting the full dose in before you cut, not having the systemic
side effects and not dosing people properly.
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Dr. Harper, just as a quick background, before I got into the research side
of things, because I was a physical therapist at the office.
So my training is in physical therapy.
So Rodney, when you said you had little to no experience with this technique,
I actually felt a little bit better because we had zero education.
I have absolutely zero experience with this. And even reading it,
I thought it was a very fascinating read.
And what I was curious on and wanted your opinion on since you're the expert
(10:39):
here is what's the technical procedure for the administration in this manner?
So the JBJS article is a technique article.
So it provides kind of a nice overview of everything. It goes through videos.
It's very simple. Essentially, there are...
Disposable io needle kits that
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exist i won't give any brain brand names on
the on the podcast but there's several that are available for purchase
that are sterile able to be used
in the operating room come in different bore sizes and
different needle length sizes essentially what you do is
right before you prep and drape your knee in
your typical way that you always would you landmark the
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tibial tubercle and just medial
to the tibial tubercle is you make a
small little nick in the in the skin pass the needle flush down to bone and
you run the drill it's super simple it's really that easy it's a single directional
drill you pass it once you get through the cortex you stop because you're into
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the trabecular bone you release the inner sleeve leaf,
attach a essentially tube that comes with the kit, and then you inject the medication
that you desire from syringes.
And when you're all done, you disengage the syringe, reinsert the central needle,
and back the needle out. And that's it.
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It has advantages over things like bank powder or just injecting local fluid
into the wound because it stays within the bone, it's contained.
You don't tend to have as much spill out.
And so technically it's very simple. You can also administer a femoral side.
Essentially, you just landmark two finger breaths proximal to the patella and
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you just go off of the anterior cortex.
Same thing, make a small little nick in the incision and the skin,
go down to the bone, run the drill, same thing.
You can inject your medicine. Once you're done, you just back the drill out.
Usually those two incisions, the nice thing is that they are in line with what
your surgical incision is. So it's like you were never there.
The drill holes are smaller than any of the pins that we use for our cutting guides.
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So it's even less invasive than our pins that we use for that.
For particularly, I'll call them robust patients who have a large soft tissue
envelope, sometimes that anterior femoral cortex can be quite deep,
quite hard to get down to, in which case you can actually use the medial and
lateral femoral condyle.
As alternative landmarks to be able to inject in. The downside of that,
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obviously, is that you've moved off of your incision line.
So now you're making a separate incision away from that. But again,
it's less than a centimeter.
It's very tiny. It's just so that you don't get any soft tissue caught up in it.
And actually, Houston Methodist, they've actually discovered that eliminating
the femoral side altogether really doesn't affect concentration levels greatly.
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So a good chunk of them now are actually just instilling the medication in through
the tibia, And they're still getting good soft tissue concentrations throughout the knee joint.
Great. Good technical points. You know, for me, I do all robotics and I make two small.
Incisions just medial to the ones where I'm already going to make my main incision
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anyway for tibial pins in a place that would be an obvious place to be able
to, you know, give that kind of an infusion if we wanted to do something like that.
You mentioned a little bit some of the previous literature about this,
but just talk specifically, if you can, for a minute about what the literature
tells us about intraosseous medication administration in orthopedics and towards
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arthroplasty in particular.
So yeah, the original research was really, like I said, it was proof of concept.
We were really looking for whether or not the concentrations were actually higher,
but there weren't any end outcomes, right?
They were just showing that it was true basic science research,
taking samples, showing that the amount of vancomycin and found in this tissue
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was higher when given intraosseously than when given intravenously.
And the original research group showed that it was true in knee replacements
with the tourniquet up, in knee replacements with the tourniquet up in people with a BMI over 35.
And then showed that it stayed consistent in knee replacements without the tourniquet up.
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So that effect was able to be maintained even without blood flow restriction.
So it wasn't getting washed away as soon
as the blood flow started back through the leg it was staying there
houston methodist research i
believe was the first to show the value in
the end outcomes that we're concerned about so it was the first paper to show
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decreased in systemic complication through that retrospective review it was
also the first institution to show the decrease increase in deep periprosthetic
joint infection than 90 days by using that,
which is, you know, that's really what people care about.
You know, that's the, the, the end game is what people want where no one wants
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a joint, a periprosthetic joint infection.
It is the bane of all of our existence and anything that we can do to try and
bring our numbers down to as close as zero as we can get is something that everyone
I think is interested in.
And so being able to, to show that That is kind of proof of concept that something
theoretical where higher concentrations you would think would decrease your
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infection rate, we were able to show that it does.
And so that's kind of where this technique built upon.
Yeah. And this really builds on other types of methods of administration.
Of course, we can give it IV, but there's also a lot of talk about,
I remember in spine surgery in particular, talking about using vanc powder in the incision itself.
I've never seen that personally used in a total knee, but I know people do it.
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I've heard people talk about it at meetings.
I think it was Leo Whiteside, maybe if I remember right, that had like intra-articular
catheters that they would put vancomycin in for a period of time afterwards
to get some continuous infusion antibiotics into the the wound and then remove the catheters later.
So kind of compare and contrast it to the other kind of methods of delivery.
And what is it about the IO administration that you feel like is superior?
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Yeah. So the downside of the vancomycin powder, obviously it's,
as you said, in the spine literature, it's very well-established.
It's very popular in trauma literature.
You know, the joke is always just sprinkle some vancomycin powder on it before
you go. Sprinkle it in there.
You feel really good. Just a pinch will do, no problem. Yeah,
I really made a difference with that vancomycin powder.
So, you know, that was very popular in my training when we were in trauma.
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But the downside with the vancomycin powder is that concentrations rapidly decrease, right?
Well, it gets washed away from the tissues very quickly.
So that would be kind of the downside of the powder.
I personally do not use the vancomycin powder or have not used it in the past.
Part of me feels a little apprehensive, I suppose, about putting something that
(17:43):
potentially could be third body, foreign body in an articulation.
Now there's no literature that shows that it, you know, increases third body
wear or anything like that.
But part of me just feels a little, a little uneasy about that,
getting, you know, a glob of vancomycin kind of hardened into the,
into the articulation and what that could potentially do long term.
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However, they have shown the intrathecal catheters where the injection of vancomycin
running through the joint has shown that can decrease your periprosthetic joint
infection rates, particularly in knees.
I don't think it panned out quite as well in hips, but it did show that it decreased it in knees.
But you're sending someone home with an in situ catheter, right?
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There always is some risk associated with that. There is an infection risk with
a catheter that's running into an interarticular space, just like drains, et cetera.
A lot of people in the arthroplasty world have moved away from those things
because we don't like having something stay in the drain.
It's a little, you're relying a little bit on,
someone other than the primary surgeon managing that, if you want that catheter
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to stay in for any length of time, whether that be nursing staff,
whether that be the patient themselves, if you're still doing outpatient surgeries.
So there's room for error there. There's room for complications and mistakes.
And so the benefit of the intraosseous is that it shows.
Equivalent outcomes on the end marker, but you're keeping it contained within
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the operating room. You're keeping control of an important aspect of your perioperative
management of your patient.
You know, it's the one, I think, the one downside of, you know,
the fact that anesthesia gives our preoperative antibiotics in the golden hour.
We got to rely on someone else for what has been shown to be the single most
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important factor for preventing a perioperative infection is that golden hour antibiotic.
Antibiotic so being able to take that back into
your control just i think improves
your reliance your compliance
and your ability to be like rest assured that that not that we like to have
(19:58):
control of anything in orthopedics no i mean we're never like that how many
times did i say control in that in that speech there about controlling my patients
but yeah you know it's there's an advantage to it but that you get to oversee
everything. Yeah, absolutely.
The one issue I have with this that I wanted to ask you specifically about with
whether or not we really need vancomycin on every total knee replacement,
(20:20):
you know, you probably, you're board certified, you've had to do maintenance and certification.
One of the things that I learned from the WLA, the Web-Based Longitudinal Assessment,
I think is what that stands for, that the board has for you to not have to take
a test later on is that, you know, you have to review 15 articles that they select.
And one of them that I thought was one of the best articles that I looked at
on there. I need to know the author on this so I could cite them properly here.
(20:44):
But it was a study talking about deviation from cefazolin as the perioperative antibiotic.
And it showed that, you know, the majority of patients, which we all know that
say that they're allergic to penicillins or allergic to cephalosporins are actually
having low-grade reactions, side effects, not actually a true drug allergy.
And, you know, a lot of times we just think, well, give them Venk.
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That's a stronger antibiotic anyway, right?
Venkamycin is an even stronger antibiotic, when in reality, that study showed
that while it has a little bit better efficacy against MRSA,
it may not cover the lower-grade staph and strep as well as the cefazolin would,
and that with any deviation we had from cefazolin, which was in a pretty large percentage,
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I think it was like 25% of the time, they deviated from cefazolin as their perioperative
antibiotic, and when they educated their staff about this and really instituted
a protocol where they didn't deviate from cefazolin unless somebody had a severe
life-threatening allergy.
That they were able to decrease that deviation from cefazolin from like in the
20% to like 4%, and that that did decrease their infection rates,
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and they were less likely to have complications potentially with vancomycin.
So that was one of the questions that I had is that that was an eye-opening study for me that,
you know, the burden of proof really increased a lot for me on whether or not
we would ever deviate from giving cefazolin as our antibiotic and move on to
vancomycin with the potential for vancomycin-resistant organisms,
(22:10):
things like that down on the road.
So, you know, how do you address that potential problem and what comments do you have on that?
Yeah, you know, antibiotic stewardship is obviously a very important topic right now.
We're all becoming hyper aware of increasing resistance and not using antibiotics inappropriately.
You are correct in that the AOS and AUKUS recommendations are not to use Fancamycin
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in your standard run-of-the-mill primary joint replacement.
They're supposed to be reserved for high-risk individuals.
Granted, they leave what they define as high-risk rather free in terms of allowing
surgeon interpretation of that.
And you are correct in that the third-generation cephalosporin coverage,
(22:57):
while superior with Fancamycin for MRSA, can be inferior covering other aspects.
The interesting thing about most of these, in fact, I'm going to say all of
these research papers, but I'd have to go back and double check on all them,
is that this was actually used as an option for dual therapy.
So all of these patients did receive ANSEP via IV as they traditionally would
(23:20):
have, and they received the vancomycin as a secondary therapy through the interosseous needle.
The benefit of using a dual therapy in this manner is that the downside,
the main downside, other than what we just talked about in terms of resistance
of dual therapy, is that it's incredibly difficult on your kidneys.
(23:41):
Incidences of acute kidney injury in patients who received dual therapy,
particularly with a third-generation cephalosporin, and vancomycin were much
higher than those who did not.
And the original paper that we published that was a retrospective review showed
that the AKI rates by doing the delivery of the dual therapy in this manner
(24:03):
did not increase your AKI rates.
So it does provide an avenue of allowing dual coverage in patients who you maybe
traditionally would have been hesitant to.
And usually those are the patients who are your high risk, your dialysis patients.
Your end stage renal disease, your CKD3, your poorly controlled diabetics, your,
(24:26):
you know, all those patients who you probably would want to give vancomycin
to that you're limited by their kidney function by and large,
because you don't want to cause an acute kidney injury. So...
It provides a safer avenue of delivery for, I think, our most vulnerable patients.
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And I do not think that, and this opinion might differ from some of my co-authors,
but if you're following the party line of AUKUS,
you're not supposed to be using it in everyone, but that's because they felt
that the risk benefit profile of using it in everyone wasn't there.
So, you know, using the vancomycin in low-risk individuals did not justify the
(25:12):
potential risks of administering it and the systemic side effects that you could
get from a heavy hitter like vancomycin.
But the argument would need to be revisited, I think,
if you now have a benefit-risk profile that has changed, where those risks have
decreased and you have an option to be able to deliver this medication in a safer way.
(25:37):
Would that expand your indications?
Or, you know, the argument would be made, would, you know, bacterial stewardship
and antibiotic stewardship should still be observed.
I think some of our infectious disease colleagues would vehemently disagree
with us on this, but, you know, and
some people, I think, absolutely would still like to be able to use it.
(25:59):
But it does take care of one of those two potential issues. Obviously,
there's two really main potential problems with vancomycin administration,
we talk about side effects, kidney injuries versus antibiotic stewardship.
It definitely takes care of the, if it improves a part of that equation,
does that tip the scale in favor of giving it as opposed to not giving it?
I don't know what the answer is on that. And I'm sure that answer will come
(26:21):
as we get more and more data on this.
But I do think it's interesting that at least one of those potential downsides
is potentially, you know, is rectified by the the administration in this way.
I want to go back real quick to the conversation about the other methods of administration.
You discussed IV and bank powder and the catheters and how that contrasted with
(26:43):
the intraosseous administration.
Is this something with your total joint patients that you're using exclusively?
And if so, what do you feel like is the biggest benefit?
And if not, are there any indications where you're not using that?
And are there any contraindications for it? or there have been instances where
you feel like that's not the best method of delivery?
(27:04):
When using it, I do try to follow the recommendations for AUKUS in terms of
not using it for everyone, using it in patients who would be considered high risk.
You know, patients that I would traditionally like to give vancomycin to as
a dual therapy that I would like to kind of administer in a safer fashion.
(27:25):
In terms of who might not be a good choice, we kind of get into this a little
bit in the technique paper about people that you would maybe consider not using it in.
The super morbid obese with the soft tissue envelope that makes delivery difficult,
the reality is another benefit of this is it's high reliance,
(27:48):
easy administration, and it's fast.
And if you start eliminating those things by not being very sure you're where
you think you are because they have a large soft tissue envelope and it takes
too long because it's hard to get in and you're getting less control over it,
then that loses its appeal.
(28:09):
So that's one of the relative contraindications.
Another relative contraindication, depending on what you're dealing with,
is in situ hardware, right?
So it's not uncommon for us to administer or perform total knee arthroplasties
in patients who've had previous surgeries,
who may have plateau periarticular plates on,
(28:31):
who may have have had a previous HTO who, you know, might have a tibial nail
in or some kind of hardware that could preclude easy delivery of the antibiotic.
And so that would be another scenario. Now, Houston Methodist has also done
a series showing that it is viable and usable in revision arthroplasty cases,
(28:52):
even in the presence of in situ stems.
However, particularly with with robust cement mantles, you would have trouble
getting enough fluid to infiltrate that would probably be of any value.
So that's another scenario where you would potentially consider not using it.
(29:13):
And then of course, if someone has a true medication allergy,
probably should just skip it. Yeah.
What do you wish our listeners knew about this technique?
What are some things that you think, you know, I haven't experienced with this.
I wish the listeners knew this, this, and this about IO administration of medicines in total ease.
Yeah, so I think you're right in saying I think a lot of people have either,
(29:39):
you know, not heard about it at all or heard about it and not really seen it
and don't really feel like, oh, like, is it really worth it? Is there any point?
Like, it seems like a lot of trouble to go to and I could just give it to them.
And the point I really want to make is that it is an incredibly easy thing to
(29:59):
do at the start of your case.
The cost is not prohibitive in terms of the peel pack disposable kits that they
come with are not particularly expensive.
I think it works out to about $180 approximately per case.
(30:20):
So we're not talking like a huge robust. So your cost benefit ratio there for
just preventing even one infection in a few hundred cases is there just from
that, or, you know, the cost of doing business, so to speak,
of getting an infection.
And I think, you know, people, myself included, are a little worried to break
(30:40):
out of their routine, right?
Us arthroplasty surgeons are creatures of habit. We fear change.
We fear change. I fear change. We all fear change.
And so I get it. You know, you got something working for you and you think it's
working for me and my infection rate's pretty good.
Why would I, why would I mess with it? And why would I ruin my flow and mess
with my flow? But the same argument can be made of any new innovation.
(31:03):
And so it'll slow you down at first. But I mean, when I truly say this, it's very fast.
It takes 30 seconds a minute. You get that antibiotic in there,
you take the needle out, and you're off and running.
You don't have to change your setup. It's far less...
Disruptive to your current flow than say, adding a robot, you know,
(31:23):
you kind of brought up robotics to that.
It certainly is far less disruptive to a traditional surgeon's flow than that.
And so I think people have to be careful, you know, people say,
you know, old dogs, new tricks, I think you need to make sure that you're staying
up to date on the newest trends.
I don't think so far we have shown a ton of negative to this and we've shown
(31:46):
a lot of potential positive.
Positive and so i think it's something that people should genuinely consider
and you know if you watch the video on the technique guide you'll
see you know you'll see how how easy it
is i did it as a fellow so you know i mean fully trained uh how hard can it
be if we can do it i can do it as a fellow you know how hard can it be so it's
(32:07):
it's really not that it's not that difficult and and it has great upside potential
are there other medicines that you could minister in this way
that you see being potentially of value in the future other than vancomycin?
Yeah, I mean, you know, the reality is, is that pretty much,
and I won't speak for every medication that exists on the market,
but pretty much, you know, intraosseous access is essentially equivalent to
(32:33):
intravenous access in that almost any medication that is administered intravenously
can in theory also be administered intraosseously.
You know, maybe, you know, osteotoxic medications excluded, but we're not generally
using those in our surgeries.
So Houston Methodist right now is...
(32:54):
Researching and has published research on pain control and interosseous infusion of morphine.
Through the same needle, you inject vancomycin, you take that syringe out,
you inject the morphine, take that syringe out, and you proceed with your case.
They've shown a statistically significant decrease in morphine equivalent usage
(33:15):
postoperatively in patients who receive that.
So, you know, perioperative pain management is a huge research topic in the arthroplasty world.
The opioid epidemic is absolutely at the forefront of everyone's mind.
Anything that we can do to try and decrease our patients' pain levels and opioid
(33:38):
consumption in the post-operative period is something we should be looking at very favorably.
And the nice thing is that the access points don't have to change.
Once you get your access, it's your access and you can administer multiple medications in theory.
So morphine is the one that's currently receiving the research,
(33:59):
but I do think the potential for it is somewhat limitless.
So Dr. Harper here, as we wrap up on this topic, do you have any take-home points
for this method of delivery?
Yeah, my main take-home points are that it's simple.
It's easy to learn. We as orthopedic surgeons all already possess the skills
(34:20):
to be able to accomplish this.
The cost of performing an interosseous infusion is pretty minimal.
And the benefits potential, I think, is huge.
And so I think more people should absolutely maybe go slightly outside their
comfort zone and consider it as an option for the administration of those medications
(34:45):
that you sometimes hesitate a little bit to give in slightly unhealthier patients.
Great stuff. Well, thank you for coming on, Dr. Katherine Harper from VA Medical
Center in Washington, D.C.
Thank you so much for joining us tonight and taking some time out of your schedule
on an evening like this to come on and talk about this great topic.
And thank you for joining us.
Yeah, thank you very much for having me, guys. I appreciate being able to share
(35:08):
something I'm passionate about. up. Great, great stuff. Well,
thank you for coming again.
And if you want to catch us on previous episodes, we have a lot of previous content already up.
If you want to catch future episodes, hit that follow button so you don't miss
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(35:31):
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Music.
Music.
(00:11):
Warning Center podcast. This is
Dr. Benner, and I'm here with Scott Bauman tonight for our next episode.
Last week, we talked about the surgical management of arthrofibrosis.
That was a really nice topic and a nice review of that.
So go back and check that one out. If you don't want to miss any of our previous
content, you can access our podcast via any of the podcast avenues that you utilize.
And on social media, we have Twitter and Instagram at the SKC podcast,
(00:34):
Facebook and YouTube, to the Sherwin-East Center podcast pages.
You can also email us at theskcpodcasts and gmail.com. Check out our previous
content, and if you like it, leave us a five-star review and a comment for those behind you.
Like Dr. Brenner was saying, with our previous content last week,
we discussed the surgical management of arthrofibrosis, in particular after
ACL reconstruction, and we thought that was a good episode for not only the
(00:56):
orthopedic surgeons out there who are doing the surgery, but also the physical
therapists that are doing the post-operative rehab.
So we covered the surgical management, the post-op rehab, as well as a research
study that we've recently done.
So before this episode, go back to last episode and listen about the surgical
management of arthrofibrosis.
Tonight, we have an interesting topic. We're talking about intraosseous administration
(01:16):
of medications in total knee arthroplasty.
This is in reference to a paper that Scott and I read on journal bone and joint
surgery on JBJS that was published recently.
And we have one of the authors from that paper. Dr.
Catherine Harper is with us tonight. night. Catherine went to the Royal College
of Surgeons in Ireland and then transitioned to the United States where she
completed an orthopedic residency in Philadelphia at Temple University and then
(01:40):
went on to do a fellowship in joint reconstruction and arthroplasty at Houston
Methodist Hospital in Houston. So, Dr.
Harper, great to have you tonight and thank you for joining us.
Yeah, thank you for having me on, guys. I appreciate it and I'm excited to talk about this topic.
Dr. Harper is now an attending orthopedic surgeon joint reconstruction specialist
at the Washington, D.C. VA Medical Center.
(02:02):
She's been there for five years, and she was a co-author on this paper in JBJS with Dr.
Stephen Acabo from Houston Methodist from her fellowship days.
So just tell us a little bit about yourself as we get started.
How did you get interested in orthopedic surgery? How did you get interested
in joint replacement and end up here where you are today?
Yeah, you know, when I went to Ireland for med school, I originally thought
I was going to be an ophthalmologist, kind of a divergent from orthopedics, I think.
(02:27):
Those are pretty much the Yeah, they're basically the same.
And, you know, I was a second year medical student and I got to scrub in on
a shoulder arthroscopy rotator cuff repair.
And from that point on, I was hooked, abandoned ophthalmology and came in to
decide that orthopedics was for me.
I found my people, so to speak. So that's kind of how I got on the path to orthopedics.
(02:50):
I was able to do a rotation in medical school at Temple.
It just felt like the right fit. I was lucky enough as an international medical
graduate to match into orthopedics, which is not a very common thing,
and made my way to Philadelphia.
It was an incredible five years of training. I absolutely loved it there. You can't.
(03:10):
Can't compare to the operative experience I got there.
And joint replacements just seemed to speak to me. I love the fact that,
you know, you could make someone instantly better.
You know, you do the surgery, they're up and walking, they're moving,
they've had debilitating pain for decades.
And in several days, they're better and they're moving on with their lives and
(03:34):
they're able to do everything they weren't able to do before.
So that's kind of how I decided on that. You know, how I made my way to Houston
Methodist, I don't even know if I remember at this point in time,
but the program just seemed like exactly what I was looking for in terms of
they do complex revisions, they do infections,
they do primaries, they're efficient,
you get to see everything, and the attendings who are going to teach you there
(03:58):
were fantastic. So that's kind of how I made my way there.
And, you know, I've loved every minute of doing arthroplasty.
I couldn't imagine doing anything else.
In my humble personal opinion, I think it's the best subspecialty.
The show, Anika, you guys might disagree, but I think it's great.
I love it. My current practice is 100% arthroplasty.
(04:19):
I do all the hip and knee replacements at the DCVA right now. I do 100% of them.
We pride ourselves in doing a fantastic job there. We are a center of excellence
for advanced hip and knee replacements.
We're one of only two VAs in the country that has that distinction and one of
the very few in the major DMV or DC, Maryland, Virginia area to have that distinction as well.
(04:43):
So that's my current practice is exclusively arthroplasty. We take care of everything.
Great stuff. You know, mine is a knee-focused practice and our clinic is all knee-focused.
But when I was a medical student, when I got started watching arthroplasty cases,
I didn't have a clue what the hell they were talking about most of the time.
They were talking about length and offset and ligament balancing and releases
and alignment and varus and valgus. I don't know what the hell they were talking about.
(05:06):
And I thought, this is the dumbest thing ever. I'm never doing this until I
finally grew up a little bit in orthopedics and started to learn what all that
stuff meant and figured out, you know what, but there's a lot of decisions to
make throughout this surgery.
There's a lot of options that you have to have.
It's not just as simple as taking something out and throwing it in the trash.
It's something that you've got to rebuild and realign and restructure in a way
(05:27):
that I just had no understanding of at that point. And once I learned it, it was just a lot of fun.
So I'm with you 100% on joint replacement being the way to go.
I love sports medicine cases as well. That's a little bit different than your practice.
This podcast, we're talking about knees all the time, which is all Scott and I ever talk about.
But, you know, interesting topic for us tonight, which is why I wanted to talk
(05:49):
to you about intraosseous administration of medications in total knee arthroplasty.
I'll be honest with you. I've seen this about zero times in my training ever.
So the only time I ever remember seeing this was in trauma situations that they
couldn't get IV access every once in a while.
Somebody would come in off the rig with a spike in their tibia and an IO line.
And, you know, I remember as a resident going, what in the hell is that?
(06:11):
And it was really all that I knew about IO administration.
So tell us about kind of how you got involved in that and how you became involved
in this study in particular.
Yeah, so my experience prior to kind of getting involved with it at Houston
Methodist was exactly the same.
You know, IO lines were for military and for trauma, and you didn't really see
them in pediatrics, I suppose, from time to time.
(06:33):
You'd see a kid get an IO line for IV access.
And beyond that, I didn't ever see it have very much applicability to adults.
But the reality is that it's a very well-established medication delivery route.
It's likely underutilized outside the operating room because it's not the most
comfortable thing to have done to you.
(06:53):
But inside the operating room, they're really, you know, with sedation and options
for anesthesia, there's really no reason that you wouldn't consider it as an
option for any kind of medication delivery.
So the original studies came out of the Young group,
which showed essentially proof of concept, where they showed that using an intraosseous
(07:15):
route for delivery of vancomycin in particular was a unique technique.
I guess novel is the word they used, although, you know, it's kind of taking
something old and reimagining it, delivery system for the vancomycin.
Now, vancomycin in particular for joint arthroplasty, it's kind of a finicky
(07:35):
drug to administer to patients, not very well tolerated via IV.
Patients are prone to getting reactions, Redman syndrome, histamine releases,
takes a long time to infuse. You're very reliant on anesthesia staying with you in terms of timing.
And it's a weight-based dose, which is difficult to convince people to actually
(07:57):
bother to calculate someone's weight to give them the correct dose.
As someone who's experienced Redman syndrome firsthand, I got Redman syndrome
getting vancomycin with antibiotics after a procedure once. It was not fun.
Yeah, it's uncomfortable and it's not tolerated. I thought I was dying for a
few minutes. What is happening to me?
Yeah, exactly. Exactly. So, you know,
they started with that and they showed proof of concept through
(08:20):
a few award-winning papers that showed that the concentrations at the target
site were higher when delivered intraosseously than when delivered systemically
via the traditional route of IV and without the systemic side effects that usually
made it a less attractive option.
So, Houston Methodist saw that research, was interested in expanding on it.
(08:44):
They thought there was some potential there for new novel uses for it.
And so that's kind of where the idea came from, and we kind of built on that.
So the original research paper we did was a retrospective review that we showed,
you know, good outcomes and a lack of systemic side effects.
A subsequent paper that was released in, I believe, 2021, which won the Knee
(09:09):
Society Award, showed that it did decrease rates of periprosthetic joint infections
versus traditional IV antibiotic infusion.
Only recently, we also won the Hip Society Award for proving that it did the
same in the hip. So we won that last year.
So we kind of built upon that, and it's used almost 100% of the time in practice
(09:32):
at Methodist now for their arthroplasty patients.
It's simple. It's quick. It adds about 30 seconds to one minute to your operative time.
For orthopedic surgeons, certainly, we don't feel, I don't think anyone has
an aversion to throwing a needle through a piece of bone, through a cortex.
(09:53):
So it's playing into our skill set where we, I think most of us feel very comfortable,
obviously administering something that way.
And it's shown to decrease your issues with delivery of vancomycin,
which is not getting the full dose in before you cut, not having the systemic
side effects and not dosing people properly.
(10:14):
Dr. Harper, just as a quick background, before I got into the research side
of things, because I was a physical therapist at the office.
So my training is in physical therapy.
So Rodney, when you said you had little to no experience with this technique,
I actually felt a little bit better because we had zero education.
I have absolutely zero experience with this. And even reading it,
I thought it was a very fascinating read.
And what I was curious on and wanted your opinion on since you're the expert
(10:39):
here is what's the technical procedure for the administration in this manner?
So the JBJS article is a technique article.
So it provides kind of a nice overview of everything. It goes through videos.
It's very simple. Essentially, there are...
Disposable io needle kits that
(11:00):
exist i won't give any brain brand names on
the on the podcast but there's several that are available for purchase
that are sterile able to be used
in the operating room come in different bore sizes and
different needle length sizes essentially what you do is
right before you prep and drape your knee in
your typical way that you always would you landmark the
(11:22):
tibial tubercle and just medial
to the tibial tubercle is you make a
small little nick in the in the skin pass the needle flush down to bone and
you run the drill it's super simple it's really that easy it's a single directional
drill you pass it once you get through the cortex you stop because you're into
(11:43):
the trabecular bone you release the inner sleeve leaf,
attach a essentially tube that comes with the kit, and then you inject the medication
that you desire from syringes.
And when you're all done, you disengage the syringe, reinsert the central needle,
and back the needle out. And that's it.
(12:05):
It has advantages over things like bank powder or just injecting local fluid
into the wound because it stays within the bone, it's contained.
You don't tend to have as much spill out.
And so technically it's very simple. You can also administer a femoral side.
Essentially, you just landmark two finger breaths proximal to the patella and
(12:29):
you just go off of the anterior cortex.
Same thing, make a small little nick in the incision and the skin,
go down to the bone, run the drill, same thing.
You can inject your medicine. Once you're done, you just back the drill out.
Usually those two incisions, the nice thing is that they are in line with what
your surgical incision is. So it's like you were never there.
The drill holes are smaller than any of the pins that we use for our cutting guides.
(12:56):
So it's even less invasive than our pins that we use for that.
For particularly, I'll call them robust patients who have a large soft tissue
envelope, sometimes that anterior femoral cortex can be quite deep,
quite hard to get down to, in which case you can actually use the medial and
lateral femoral condyle.
As alternative landmarks to be able to inject in. The downside of that,
(13:18):
obviously, is that you've moved off of your incision line.
So now you're making a separate incision away from that. But again,
it's less than a centimeter.
It's very tiny. It's just so that you don't get any soft tissue caught up in it.
And actually, Houston Methodist, they've actually discovered that eliminating
the femoral side altogether really doesn't affect concentration levels greatly.
(13:38):
So a good chunk of them now are actually just instilling the medication in through
the tibia, And they're still getting good soft tissue concentrations throughout the knee joint.
Great. Good technical points. You know, for me, I do all robotics and I make two small.
Incisions just medial to the ones where I'm already going to make my main incision
(14:00):
anyway for tibial pins in a place that would be an obvious place to be able
to, you know, give that kind of an infusion if we wanted to do something like that.
You mentioned a little bit some of the previous literature about this,
but just talk specifically, if you can, for a minute about what the literature
tells us about intraosseous medication administration in orthopedics and towards
(14:21):
arthroplasty in particular.
So yeah, the original research was really, like I said, it was proof of concept.
We were really looking for whether or not the concentrations were actually higher,
but there weren't any end outcomes, right?
They were just showing that it was true basic science research,
taking samples, showing that the amount of vancomycin and found in this tissue
(14:43):
was higher when given intraosseously than when given intravenously.
And the original research group showed that it was true in knee replacements
with the tourniquet up, in knee replacements with the tourniquet up in people with a BMI over 35.
And then showed that it stayed consistent in knee replacements without the tourniquet up.
(15:06):
So that effect was able to be maintained even without blood flow restriction.
So it wasn't getting washed away as soon
as the blood flow started back through the leg it was staying there
houston methodist research i
believe was the first to show the value in
the end outcomes that we're concerned about so it was the first paper to show
(15:29):
decreased in systemic complication through that retrospective review it was
also the first institution to show the decrease increase in deep periprosthetic
joint infection than 90 days by using that,
which is, you know, that's really what people care about.
You know, that's the, the, the end game is what people want where no one wants
(15:50):
a joint, a periprosthetic joint infection.
It is the bane of all of our existence and anything that we can do to try and
bring our numbers down to as close as zero as we can get is something that everyone
I think is interested in.
And so being able to, to show that That is kind of proof of concept that something
theoretical where higher concentrations you would think would decrease your
(16:12):
infection rate, we were able to show that it does.
And so that's kind of where this technique built upon.
Yeah. And this really builds on other types of methods of administration.
Of course, we can give it IV, but there's also a lot of talk about,
I remember in spine surgery in particular, talking about using vanc powder in the incision itself.
I've never seen that personally used in a total knee, but I know people do it.
(16:34):
I've heard people talk about it at meetings.
I think it was Leo Whiteside, maybe if I remember right, that had like intra-articular
catheters that they would put vancomycin in for a period of time afterwards
to get some continuous infusion antibiotics into the the wound and then remove the catheters later.
So kind of compare and contrast it to the other kind of methods of delivery.
And what is it about the IO administration that you feel like is superior?
(16:58):
Yeah. So the downside of the vancomycin powder, obviously it's,
as you said, in the spine literature, it's very well-established.
It's very popular in trauma literature.
You know, the joke is always just sprinkle some vancomycin powder on it before
you go. Sprinkle it in there.
You feel really good. Just a pinch will do, no problem. Yeah,
I really made a difference with that vancomycin powder.
So, you know, that was very popular in my training when we were in trauma.
(17:20):
But the downside with the vancomycin powder is that concentrations rapidly decrease, right?
Well, it gets washed away from the tissues very quickly.
So that would be kind of the downside of the powder.
I personally do not use the vancomycin powder or have not used it in the past.
Part of me feels a little apprehensive, I suppose, about putting something that
(17:43):
potentially could be third body, foreign body in an articulation.
Now there's no literature that shows that it, you know, increases third body
wear or anything like that.
But part of me just feels a little, a little uneasy about that,
getting, you know, a glob of vancomycin kind of hardened into the,
into the articulation and what that could potentially do long term.
(18:04):
However, they have shown the intrathecal catheters where the injection of vancomycin
running through the joint has shown that can decrease your periprosthetic joint
infection rates, particularly in knees.
I don't think it panned out quite as well in hips, but it did show that it decreased it in knees.
But you're sending someone home with an in situ catheter, right?
(18:27):
There always is some risk associated with that. There is an infection risk with
a catheter that's running into an interarticular space, just like drains, et cetera.
A lot of people in the arthroplasty world have moved away from those things
because we don't like having something stay in the drain.
It's a little, you're relying a little bit on,
someone other than the primary surgeon managing that, if you want that catheter
(18:51):
to stay in for any length of time, whether that be nursing staff,
whether that be the patient themselves, if you're still doing outpatient surgeries.
So there's room for error there. There's room for complications and mistakes.
And so the benefit of the intraosseous is that it shows.
Equivalent outcomes on the end marker, but you're keeping it contained within
(19:14):
the operating room. You're keeping control of an important aspect of your perioperative
management of your patient.
You know, it's the one, I think, the one downside of, you know,
the fact that anesthesia gives our preoperative antibiotics in the golden hour.
We got to rely on someone else for what has been shown to be the single most
(19:35):
important factor for preventing a perioperative infection is that golden hour antibiotic.
Antibiotic so being able to take that back into
your control just i think improves
your reliance your compliance
and your ability to be like rest assured that that not that we like to have
(19:58):
control of anything in orthopedics no i mean we're never like that how many
times did i say control in that in that speech there about controlling my patients
but yeah you know it's there's an advantage to it but that you get to oversee
everything. Yeah, absolutely.
The one issue I have with this that I wanted to ask you specifically about with
whether or not we really need vancomycin on every total knee replacement,
(20:20):
you know, you probably, you're board certified, you've had to do maintenance and certification.
One of the things that I learned from the WLA, the Web-Based Longitudinal Assessment,
I think is what that stands for, that the board has for you to not have to take
a test later on is that, you know, you have to review 15 articles that they select.
And one of them that I thought was one of the best articles that I looked at
on there. I need to know the author on this so I could cite them properly here.
(20:44):
But it was a study talking about deviation from cefazolin as the perioperative antibiotic.
And it showed that, you know, the majority of patients, which we all know that
say that they're allergic to penicillins or allergic to cephalosporins are actually
having low-grade reactions, side effects, not actually a true drug allergy.
And, you know, a lot of times we just think, well, give them Venk.
(21:05):
That's a stronger antibiotic anyway, right?
Venkamycin is an even stronger antibiotic, when in reality, that study showed
that while it has a little bit better efficacy against MRSA,
it may not cover the lower-grade staph and strep as well as the cefazolin would,
and that with any deviation we had from cefazolin, which was in a pretty large percentage,
(21:26):
I think it was like 25% of the time, they deviated from cefazolin as their perioperative
antibiotic, and when they educated their staff about this and really instituted
a protocol where they didn't deviate from cefazolin unless somebody had a severe
life-threatening allergy.
That they were able to decrease that deviation from cefazolin from like in the
20% to like 4%, and that that did decrease their infection rates,
(21:48):
and they were less likely to have complications potentially with vancomycin.
So that was one of the questions that I had is that that was an eye-opening study for me that,
you know, the burden of proof really increased a lot for me on whether or not
we would ever deviate from giving cefazolin as our antibiotic and move on to
vancomycin with the potential for vancomycin-resistant organisms,
(22:10):
things like that down on the road.
So, you know, how do you address that potential problem and what comments do you have on that?
Yeah, you know, antibiotic stewardship is obviously a very important topic right now.
We're all becoming hyper aware of increasing resistance and not using antibiotics inappropriately.
You are correct in that the AOS and AUKUS recommendations are not to use Fancamycin
(22:35):
in your standard run-of-the-mill primary joint replacement.
They're supposed to be reserved for high-risk individuals.
Granted, they leave what they define as high-risk rather free in terms of allowing
surgeon interpretation of that.
And you are correct in that the third-generation cephalosporin coverage,
(22:57):
while superior with Fancamycin for MRSA, can be inferior covering other aspects.
The interesting thing about most of these, in fact, I'm going to say all of
these research papers, but I'd have to go back and double check on all them,
is that this was actually used as an option for dual therapy.
So all of these patients did receive ANSEP via IV as they traditionally would
(23:20):
have, and they received the vancomycin as a secondary therapy through the interosseous needle.
The benefit of using a dual therapy in this manner is that the downside,
the main downside, other than what we just talked about in terms of resistance
of dual therapy, is that it's incredibly difficult on your kidneys.
(23:41):
Incidences of acute kidney injury in patients who received dual therapy,
particularly with a third-generation cephalosporin, and vancomycin were much
higher than those who did not.
And the original paper that we published that was a retrospective review showed
that the AKI rates by doing the delivery of the dual therapy in this manner
(24:03):
did not increase your AKI rates.
So it does provide an avenue of allowing dual coverage in patients who you maybe
traditionally would have been hesitant to.
And usually those are the patients who are your high risk, your dialysis patients.
Your end stage renal disease, your CKD3, your poorly controlled diabetics, your,
(24:26):
you know, all those patients who you probably would want to give vancomycin
to that you're limited by their kidney function by and large,
because you don't want to cause an acute kidney injury. So...
It provides a safer avenue of delivery for, I think, our most vulnerable patients.
(24:49):
And I do not think that, and this opinion might differ from some of my co-authors,
but if you're following the party line of AUKUS,
you're not supposed to be using it in everyone, but that's because they felt
that the risk benefit profile of using it in everyone wasn't there.
So, you know, using the vancomycin in low-risk individuals did not justify the
(25:12):
potential risks of administering it and the systemic side effects that you could
get from a heavy hitter like vancomycin.
But the argument would need to be revisited, I think,
if you now have a benefit-risk profile that has changed, where those risks have
decreased and you have an option to be able to deliver this medication in a safer way.
(25:37):
Would that expand your indications?
Or, you know, the argument would be made, would, you know, bacterial stewardship
and antibiotic stewardship should still be observed.
I think some of our infectious disease colleagues would vehemently disagree
with us on this, but, you know, and
some people, I think, absolutely would still like to be able to use it.
(25:59):
But it does take care of one of those two potential issues. Obviously,
there's two really main potential problems with vancomycin administration,
we talk about side effects, kidney injuries versus antibiotic stewardship.
It definitely takes care of the, if it improves a part of that equation,
does that tip the scale in favor of giving it as opposed to not giving it?
I don't know what the answer is on that. And I'm sure that answer will come
(26:21):
as we get more and more data on this.
But I do think it's interesting that at least one of those potential downsides
is potentially, you know, is rectified by the the administration in this way.
I want to go back real quick to the conversation about the other methods of administration.
You discussed IV and bank powder and the catheters and how that contrasted with
(26:43):
the intraosseous administration.
Is this something with your total joint patients that you're using exclusively?
And if so, what do you feel like is the biggest benefit?
And if not, are there any indications where you're not using that?
And are there any contraindications for it? or there have been instances where
you feel like that's not the best method of delivery?
(27:04):
When using it, I do try to follow the recommendations for AUKUS in terms of
not using it for everyone, using it in patients who would be considered high risk.
You know, patients that I would traditionally like to give vancomycin to as
a dual therapy that I would like to kind of administer in a safer fashion.
(27:25):
In terms of who might not be a good choice, we kind of get into this a little
bit in the technique paper about people that you would maybe consider not using it in.
The super morbid obese with the soft tissue envelope that makes delivery difficult,
the reality is another benefit of this is it's high reliance,
(27:48):
easy administration, and it's fast.
And if you start eliminating those things by not being very sure you're where
you think you are because they have a large soft tissue envelope and it takes
too long because it's hard to get in and you're getting less control over it,
then that loses its appeal.
(28:09):
So that's one of the relative contraindications.
Another relative contraindication, depending on what you're dealing with,
is in situ hardware, right?
So it's not uncommon for us to administer or perform total knee arthroplasties
in patients who've had previous surgeries,
who may have plateau periarticular plates on,
(28:31):
who may have have had a previous HTO who, you know, might have a tibial nail
in or some kind of hardware that could preclude easy delivery of the antibiotic.
And so that would be another scenario. Now, Houston Methodist has also done
a series showing that it is viable and usable in revision arthroplasty cases,
(28:52):
even in the presence of in situ stems.
However, particularly with with robust cement mantles, you would have trouble
getting enough fluid to infiltrate that would probably be of any value.
So that's another scenario where you would potentially consider not using it.
(29:13):
And then of course, if someone has a true medication allergy,
probably should just skip it. Yeah.
What do you wish our listeners knew about this technique?
What are some things that you think, you know, I haven't experienced with this.
I wish the listeners knew this, this, and this about IO administration of medicines in total ease.
Yeah, so I think you're right in saying I think a lot of people have either,
(29:39):
you know, not heard about it at all or heard about it and not really seen it
and don't really feel like, oh, like, is it really worth it? Is there any point?
Like, it seems like a lot of trouble to go to and I could just give it to them.
And the point I really want to make is that it is an incredibly easy thing to
(29:59):
do at the start of your case.
The cost is not prohibitive in terms of the peel pack disposable kits that they
come with are not particularly expensive.
I think it works out to about $180 approximately per case.
(30:20):
So we're not talking like a huge robust. So your cost benefit ratio there for
just preventing even one infection in a few hundred cases is there just from
that, or, you know, the cost of doing business, so to speak,
of getting an infection.
And I think, you know, people, myself included, are a little worried to break
(30:40):
out of their routine, right?
Us arthroplasty surgeons are creatures of habit. We fear change.
We fear change. I fear change. We all fear change.
And so I get it. You know, you got something working for you and you think it's
working for me and my infection rate's pretty good.
Why would I, why would I mess with it? And why would I ruin my flow and mess
with my flow? But the same argument can be made of any new innovation.
(31:03):
And so it'll slow you down at first. But I mean, when I truly say this, it's very fast.
It takes 30 seconds a minute. You get that antibiotic in there,
you take the needle out, and you're off and running.
You don't have to change your setup. It's far less...
Disruptive to your current flow than say, adding a robot, you know,
(31:23):
you kind of brought up robotics to that.
It certainly is far less disruptive to a traditional surgeon's flow than that.
And so I think people have to be careful, you know, people say,
you know, old dogs, new tricks, I think you need to make sure that you're staying
up to date on the newest trends.
I don't think so far we have shown a ton of negative to this and we've shown
(31:46):
a lot of potential positive.
Positive and so i think it's something that people should genuinely consider
and you know if you watch the video on the technique guide you'll
see you know you'll see how how easy it
is i did it as a fellow so you know i mean fully trained uh how hard can it
be if we can do it i can do it as a fellow you know how hard can it be so it's
(32:07):
it's really not that it's not that difficult and and it has great upside potential
are there other medicines that you could minister in this way
that you see being potentially of value in the future other than vancomycin?
Yeah, I mean, you know, the reality is, is that pretty much,
and I won't speak for every medication that exists on the market,
but pretty much, you know, intraosseous access is essentially equivalent to
(32:33):
intravenous access in that almost any medication that is administered intravenously
can in theory also be administered intraosseously.
You know, maybe, you know, osteotoxic medications excluded, but we're not generally
using those in our surgeries.
So Houston Methodist right now is...
(32:54):
Researching and has published research on pain control and interosseous infusion of morphine.
Through the same needle, you inject vancomycin, you take that syringe out,
you inject the morphine, take that syringe out, and you proceed with your case.
They've shown a statistically significant decrease in morphine equivalent usage
(33:15):
postoperatively in patients who receive that.
So, you know, perioperative pain management is a huge research topic in the arthroplasty world.
The opioid epidemic is absolutely at the forefront of everyone's mind.
Anything that we can do to try and decrease our patients' pain levels and opioid
(33:38):
consumption in the post-operative period is something we should be looking at very favorably.
And the nice thing is that the access points don't have to change.
Once you get your access, it's your access and you can administer multiple medications in theory.
So morphine is the one that's currently receiving the research,
(33:59):
but I do think the potential for it is somewhat limitless.
So Dr. Harper here, as we wrap up on this topic, do you have any take-home points
for this method of delivery?
Yeah, my main take-home points are that it's simple.
It's easy to learn. We as orthopedic surgeons all already possess the skills
(34:20):
to be able to accomplish this.
The cost of performing an interosseous infusion is pretty minimal.
And the benefits potential, I think, is huge.
And so I think more people should absolutely maybe go slightly outside their
comfort zone and consider it as an option for the administration of those medications
(34:45):
that you sometimes hesitate a little bit to give in slightly unhealthier patients.
Great stuff. Well, thank you for coming on, Dr. Katherine Harper from VA Medical
Center in Washington, D.C.
Thank you so much for joining us tonight and taking some time out of your schedule
on an evening like this to come on and talk about this great topic.
And thank you for joining us.
Yeah, thank you very much for having me, guys. I appreciate being able to share
(35:08):
something I'm passionate about. up. Great, great stuff. Well,
thank you for coming again.
And if you want to catch us on previous episodes, we have a lot of previous content already up.
If you want to catch future episodes, hit that follow button so you don't miss
any of our subsequent episodes.
Again, on social media, we're at the SKC Podcast on Twitter and Instagram.
We have the Shelburne East Center Facebook and YouTube pages,
and you can email us at theskcpodcast at gmail.com.
(35:31):
Please join us again next time. If you like what you've heard,
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