Topically applied vancomycin powder has been used to decrease surgical site infection rates in spinal surgeries, however, randomized controlled trials in total joint arthroplasty are lacking. Application of vancomycin powder topically in the surgical site has theoretical benefit including high local concentration. In this study, we aimed to determine whether intra-operative topical antibiotics are safe and effective as IV antibiotics in preventing post-surgical site infections.

The trial was a randomized controlled, double blind, non-inferiority study. All patients received pre-operative IV antibiotics (cefazolin or vancomycin) within 60 minutes of skin incision. The controlled group received two doses of post-operative IV antibiotics (two grams cefazolin or one gram vancomycin if cefazolin allergy). In the treatment group, the orthopaedic surgeon applied one gram vancomycin powder (500mg applied directly on the prosthesis and 500mg applied above the closed joint capsule). The incidence of acute surgical site infection was defined as positive deep cultures within 42 days of procedure. All patients with evidence of infection underwent joint aspiration for culture.

After one year, 80 patients had received the topical vancomycin treatment and 85 patients had received the standard treatment. In the topical vancomycin group versus the controlled group, the average age was 64 vs 66, average BMI was 35.7 vs 33.4, number of males 33 vs 29, number of females 47 vs 56, and diabetic patients 16 vs 13. The number of infections in the topical vancomycin group was three vs zero in the post-operative IV antibiotic treatment group.

One Tailed Z-test P Value = 0.03. This study statistically demonstrated inferiority of topical vancomycin in comparison to the use of IV antibiotics post-operatively in preventing deep wound infections in TKA. The authors would caution against the sole use of intra-operative vancomycin in TKA to prevent post-operative infection.

Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. ERAS allows for the incorporation of evidence based practices and incorporated a comprehensive assessment of the patient's journey through the surgical process from pre-operative screening through to post-operative care. The purpose of this study was to determine if optimisation of ERAS protocol with pre-operative screening and incorporating patient-specific factors into their post operative care would improve length of stay (LOS) and readmission rates following total joint arthroplasty (TJA) in a Canadian community hospital setting.

The study collected clinical, demographic data and the physical status perioperative using the American Society of Anaesthesiologists (ASA) classification on 508 patients who underwent TJA between January and August 2015 and compared similar data from the same time frame in the previous calendar year prior to implementation of the pathway. Cohorts were analysed for length of stay (LOS), readmission rates, Pre-operative assessments (completed by anaesthesia, nursing and pharmacy), relevant labs, patient history (surgery, medical, social), and patient values were all considered when developing a specific patient plan for care post-operatively. A post-operative management tool was used to optimise pain control, post-operative nausea and vomiting, bowel management, diabetes blood glucose control, venous thromboembolism prophylaxis, as well as monitoring parameters specific to patient medical history (e.g. respiratory, cardiac). While in hospital, physiotherapy and nursing were consulted by the pharmacist to assess whether patient's post op management needed to be altered to optimise mobilisation and recovery in hospital. The average patient's LOS and readmission rates in 30 days was analysed to assess the change after implementation of the post-operative management tool based on patient specific factors.

A total of 508 patients (mean age: 66 years), ASA classification was 3 or greater for 430 patients. The patients were assessed for LOS, readmission rates in 30 days. The mean LOS decreased from 3.6 to 3.3 days after optimisation of the ERAS protocol (student t test p=0.021). The 30-day readmission rate decreased from 2.9% to 1.4% post intervention (z test p=0.087) when compared to the same time period in the previous calendar year prior to protocol implementation. Overall, the cost savings to optimising the ERAS protocol for the hospital is substantial; with approximately $238 saved per patient.

Pre-operative screening and incorporating patient-specific factors into an individualised care plan to optimise the ERAS protocol for TJA reduced mean length of stay without a concomitant increase in readmission rates with significant cost saving.