Intraosseous Vancomycin for Primary Total Knee Arthroplasty Is Associated With a Lower Rate of Postoperative Acute Kidney Injury Than Intravenous Vancomycin

Background Perioperative vancomycin administration can be difficult to time and can lead to adverse systemic effects. Intraosseous vancomycin (IOV) is becoming increasingly utilized for total knee arthroplasty (TKA) prophylaxis. The primary purpose was to compare the rate of acute kidney injury (AKI) following primary TKA that utilized IOV or intravenous vancomycin (IVV). Methods A single-institution retrospective review was conducted on 4,184 primary TKAs from July 2016 to November 2024 that received IOV (1,297 cases) or IVV (2,887 cases) as part of antibiotic prophylaxis. All included patients had a basic metabolic panel on postoperative day 1. Patients were excluded if they had a solid organ transplant, were on dialysis, or received a blood transfusion following TKA. An AKI was defined as a creatinine increase of 0.3 mg/dL from baseline. Data were analyzed using independent samples t -tests and Ch i-square analyses. Logistic regressions were used to identify significant risk factors for AKI. Results The rate of AKI was lower in the IOV than the IVV group (1.9 versus 3.3%, P = 0.017). Patients who developed AKI had longer hospitalizations (59.9 ± 39.1 hours versus 42.1 ± 33.3, P < 0.001) and a higher likelihood of discharge to skilled nursing facilities (10.1 versus 3.0%, P < 0.001) than non-AKI patients. Logistic regression demonstrated that IVV (odds ratio [OR]: 1.87; 95% confidence interval [CI] 1.09 to 3.21), body mass index (OR 1.09; 95% CI 1.05 to 1.13), and postoperative blood urea nitrogen (OR 1.29; 95% CI 1.24 to 1.35) were significantly associated with AKI. There were no adverse events observed due to the IOV technique. Conclusions The use of IOV was associated with a significantly lower rate of AKI following primary TKA when compared to IVV. Administering vancomycin with an IO technique avoids the difficulties of incomplete administration prior to incision and reduces systemic side effects.