Soaking of autografts in vancomycin is highly effective in preventing postoperative septic arthritis after revision anterior cruciate ligament reconstruction

Local vancomycin administration in Orthopaedic Surgery - A systematic review of comparative studies

Background

There is still controversy surrounding the routine use of vancomycin locally in primary orthopaedic surgery procedures. Therefore, the aim of this review is to assess how local vancomycin impacts the rates and microbiology of surgical site infections.

Methods

A systematic electronic search of MEDLINE, EMBASE, and Web of Science was carried out for all comparative studies comparing locally applied vancomycin to control for primary orthopaedic surgery procedures published before August 14, 2022.

Results

A total of 61 studies with 65,671 patients were included for analysis. Forty-six studies used vancomycin powder, 12 studies with grafts soaked in vancomycin, two studies used vancomycin irrigation, and one study administered vancomycin interosseously. There were 15 studies (of 26) in spine surgery, five (of 14) in arthroplasty, ten (of 11) in sports medicine, and two (of five) in trauma surgery that found statistically significant decreases in overall infection rates when applying local vancomycin. Only one study (in spine surgery) found significant increases in infection rates with local vancomycin application. For spine surgery, local vancomycin application had the greatest proportion of gram-negative bacteria (40.7%) isolated compared to S. aureus (42.4%) in controls. In arthroplasty and trauma surgery, there were increases in the proportions of gram-negative bacteria when vancomycin was added. There were no reported systemic adverse reactions associated with local vancomycin use in any of the studies.

Conclusion

Applying local vancomycin during primary orthopaedic surgery procedures may reduce the rates of infections in multiple different orthopaedic specialties, particularly in spine surgery and sports medicine. However, careful consideration should be applied when administering local vancomycin during specific orthopaedic procedures given the heterogeneity of included studies and breadth of surgeries included in this review.

Level of evidence

Level III. A systematic review of level I - III studies.

Tobramycin and Vancomycin in an In Vitro Model of Anterior Cruciate Ligament Allograft Decontamination

BACKGROUND

Approximately 100,000 anterior cruciate ligament (ACL) reconstructions (ACLRs) occur annually in the United States, and postoperative surgical-site infection is a relatively rare but devastating complication, often leading to graft failure or septic arthritis of the knee, necessitating repeat surgery. Wrapping allografts in vancomycin-soaked gauze has been adopted as a common sterilization technique in the operating room to reduce surgical-site infection; however, identifying effective alternatives to vancomycin has not been extensively pursued.

HYPOTHESIS

Tobramycin would be as effective as vancomycin in reducing the concentrations of Staphylococcus epidermidis bacteria on tendon allografts.

STUDY DESIGN

Controlled laboratory study.

METHODS

S. epidermidis strain ATCC 12228 was inoculated onto the human cadaveric gracilis tendon. The tendons were wrapped in sterile gauze saturated with tobramycin or vancomycin at various experimental concentrations. Bacteria remaining on the tendon were dislodged, serially diluted, and plated for colony counting. Statistical analysis was performed utilizing 2-way analysis of variance testing. Results were considered statistically significant when P < .05.

RESULTS

Vancomycin (P = .0001) and tobramycin (P < .0001) reduced bacterial concentration. Tobramycin was found to produce a statistically significant reduction in bacterial concentration at concentrations as low as 0.1 mg/mL (P < .0001 and P = .01 at 10 and 20 minutes), while vancomycin produced a statistically significant reduction at a concentration as low as 2.5 mg/mL (P < .0001 at both 10 and 20 minutes).

CONCLUSION

This study demonstrates that tobramycin is as effective as vancomycin in bacterial concentration reduction but can achieve this reduction level at lower doses. Further studies clarifying the biomechanical and cytotoxic effects of tobramycin on tendon tissue are indicated to solidify its use as a clinical alternative to vancomycin in ACLR.

CLINICAL RELEVANCE

These results will begin establishing tobramycin as an alternative to vancomycin in ACL graft decontamination. Because of relatively frequent shortages of vancomycin, establishing tobramycin as an alternative agent is a useful option for the orthopaedic surgeon.

A Systematic Review and Meta-analysis of Risk Factors for an Infection After Anterior Cruciate Ligament Reconstruction

Background

Identifying risk factors for an infection after anterior cruciate ligament reconstruction (ACLR) and following targeted preventive strategies can effectively reduce this potentially serious complication.

Purpose

To perform a systematic review and meta-analysis to identify the risk factors for an infection after ACLR.

Study Design

Systematic review; Level of evidence, 4.

Methods

The PubMed, Embase, and Web of Science databases were searched from inception to September 1, 2022, for prospective and retrospective studies investigating risk factors for any type of infection after ACLR. Odds ratios (ORs) or mean differences were calculated for potential risk factors if ≥2 studies assessed the same risk factor. A qualitative analysis of variables was performed if a meta-analysis could not be conducted.

Results

A total of 17 studies with 141,991 patients were included in this review. The overall pooled infection rate was 0.86% (range, 0.24%-5.50%). There were 20 risk factors identified for analysis. Of these, 7 variables independently increased the odds of an infection after ACLR: (1) male sex (OR, 1.90 [95% CI, 1.33-2.73]), (2) diabetes (OR, 2.69 [95% CI, 1.66-4.35]), (3) hamstring tendon autograft (OR, 2.51 [95% CI, 2.03-3.10]), (4) revision ACLR (OR, 2.31 [95% CI, 1.22-4.37]), (5) professional athlete status (OR, 6.21 [95% CI, 1.03-37.38]), (6) lateral tenodesis (OR, 3.45 [95% CI, 1.63-7.28]), and (7) corticosteroid use (OR, 7.83 [95% CI, 3.68-16.63]). No significant associations were found between postoperative infections and age, body mass index, smoking, meniscal repair, or outpatient surgery.

Conclusion

This review revealed that an increased risk of infections after ACLR was associated with male sex, diabetes, hamstring tendon autograft, revision surgery, professional athlete status, lateral tenodesis, and steroid use. Knowledge of the risk factors associated with an infection after ACLR may facilitate the identification of high-risk cases and the implementation of preventive measures to mitigate the serious consequences of this complication.

Evaluation the results of anterior cruciate ligament reconstruction with or without using antibiotic solution during graft preparation

INTRODUCTION

Joint infection after Anterior Cruciate Ligament (ACL) reconstruction is an uncommon infection which can affect joint movement and function. In this study, the impact of using antibiotic during graft preparation on the results of ACL reconstruction was investigated to examine the negative effects of antibiotic solution on graft and clinical symptoms after the surgery.

METHODS

In this randomized clinical trial study, 80 patients were enrolled. In one group, the graft was placed in vancomycin solution (500 mg of vancomycin powder in 100 ml of normal saline) for 10-15 min during the surgery. In other group, the surgery was performed routinely and the graft was not placed in antibiotic solution. Intravenous antibiotic was given to both groups and they underwent ACL reconstruction surgery through arthroscopic transportal technique using their hamstring tendon. Symptoms and examinations of patients were evaluated for one year after the surgery.

RESULTS

There was no difference between two groups in terms of knee dislocation, knee lock, pain, fever, positivity of Lachman test, Anterior drawer test and pivot-shift test, knee swelling, and movement restriction in flection and extension (P > 0.05). No infection was seen in patients.

CONCLUSIONS

Placing grafts in vancomycin solution does not have negative effects on graft quality and results of ACL surgery.

Vancomycin presoak reduces infection in anterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

To compare the effect of vancomycin presoak treatment of grafts during anterior cruciate ligament reconstruction on the incidence of postoperative infection or septic arthritis.

METHODS

Studies published before May 3, 2022 investigating vancomycin presoak of grafts during anterior cruciate ligament reconstruction were searched in the PubMed and Cochrane Central Register of Controlled Trials. Studies were screened, and data on the incidence of postoperative infection or septic arthritis were extracted and included in the analysis.

RESULTS

Thirteen studies were included for analysis after search screening, yielding a total of 31,150 participants for analysis, of whom 11,437 received graft vancomycin presoak treatment, and 19,713 did not receive treatment. Participants who received vancomycin treatment had significantly lower infection rates (0.09% versus 0.74%; OR 0.17; 95% CI 0.10, 0.30; P < 0.00001).

CONCLUSION

Pre-soaking of the graft with vancomycin during ACL reconstruction reduced the incidence of postoperative infection and septic arthritis.

Risk factors for postoperative surgical site infections after anterior cruciate ligament reconstruction: a systematic review and meta-analysis

OBJECTIVES

The primary aim was to evaluate risk factors for surgical site infections after anterior cruciate ligament reconstruction (ACLR). The secondary aim was to investigate the surgical site infection incidence rate and the mean time to postoperative surgical site infection symptoms.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase and Web of Science were searched from database inception to September 2021 and updated in April 2022.

ELIGIBILITY CRITERIA

Quantitative, original studies reporting potential risk factors for surgical site infections after ACLR were included.

RESULTS

Twenty-three studies with 3871 infection events from 469 441 ACLRs met the inclusion criteria. Male sex (OR 1.78, p< 0.00001), obesity (OR 1.82, p=0.0005), tobacco use (OR 1.37, p=0.01), diabetes mellitus (OR 3.40, p=0.002), steroid use history (OR 4.80, p<0.00001), previous knee surgery history (OR 3.63, p=0.02), professional athlete (OR 4.56, p=0.02), revision surgery (OR 2.05, p=0.04), hamstring autografts (OR 2.83, p<0.00001), concomitant lateral extra-articular tenodesis (OR 3.92, p=0.0001) and a long operating time (weighted mean difference 8.12, p=0.005) were identified as factors that increased the risk of surgical site infections (superficial and deep) after ACLR. Age, outpatient or inpatient surgery, bone-patellar tendon-bone autografts or allografts and a concomitant meniscus suture did not increase the risk of surgical site infections. The incidence of surgical site infections after ACLR was approximately 1% (95% CI 0.7% to 1.2%). The mean time from surgery to the onset of surgical site infection symptoms was approximately 17.1 days (95% CI 13.2 to 21.0 days).

CONCLUSION

Male sex, obesity, tobacco use, diabetes mellitus, steroid use history, previous knee surgery history, professional athletes, revision surgery, hamstring autografts, concomitant lateral extra-articular tenodesis and a long operation time may increase the risk of surgical site infections after ACLR. Although the risk of surgical site infections after ACLR is low, raising awareness and implementing effective preventions for risk factors are priorities for clinicians to reduce the incidence of surgical site infections due to its seriousness.

A Review of Evidence for Infection Reduction With Vancomycin-treated Anterior Cruciate Ligament Grafts

Septic arthritis after anterior cruciate ligament (ACL) reconstruction is a rare but devastating complication. Several risk factors and known sources of infection have been identified in the literature. There is growing interest and supportive evidence for a targeted invention aimed at graft decontamination, which has led some surgeons to adopt the use of antibiotic solution soaks and/or wraps applied to ACL grafts before graft implantation in an attempt to reduce the risk of postoperative infection. Despite this, adoption of this technique remains relatively low among surgeons because of a variety of factors: (1) lack of awareness, (2) confusion over optimal protocols, (3) concern for graft viability and clinical outcomes, and (4) efforts to minimize the cost of surgery. However, recently published literature demonstrates notable risk reduction for infection, acceptable safety, no detrimental effect on clinical outcomes, and overall cost-effectiveness with the use of vancomycin graft soaks and wraps. Currently, there is a lack of consensus for clinical protocols, and the protocol that is most efficacious remains unclear. The purpose of this review article was to present the current evidence for ACL graft treatment with vancomycin for the prevention of postoperative infection.

Vancomycin Presoaking of Hamstring Autografts in Anterior Cruciate Ligament Reconstruction Is Associated With Higher Magnetic Resonance Imaging Graft Signal Without Influencing Clinical Outcome

PURPOSE

To present the clinical and imaging results of a series of patients undergoing anterior cruciate ligament reconstruction with vancomycin presoaking of the hamstring autograft compared with patients in the immediate period prior, when no vancomycin was used.

METHODS

This was a retrospective sequential series of patients with anterior cruciate ligament reconstruction using either a graft protocol with no vancomycin presoaking (group 1, January 2013 to October 2015) or a graft protocol with vancomycin presoaking (group 2, November 2015 to December 2018). Lysholm and International Knee Documentation Committee scores were obtained at a minimum 24-month follow-up. Graft ruptures were recorded. Between 6 and 12 months' follow-up, magnetic resonance imaging (MRI) was obtained to evaluate graft healing and integration.

RESULTS

There were 102 patients (72% male patients), with 40 in group 1 (mean age, 32.2 years) and 62 in group 2 (mean age, 32.3 years). A graft rupture occurred in 5 patients (13%) in group 1 and 6 patients (10%) in group 2 (P = .65). The median Lysholm score was 95 points (interquartile range [IQR], 86-100 points) in group 1 and 95 points (IQR, 90-100 points) in group 2 (P = .37). The median International Knee Documentation Committee score was 93 points (IQR, 82-99 points) in group 1 and 94 points (IQR, 86-99 points) in group 2 (P = .22). MRI evaluation of integration showed that 87 patients (90%) had no synovial fluid at the tunnel-graft interface, without a difference between groups (P = .24). On the basis of graft signal appearance, hyperintense grafts were found in 45 patients (46%); isointense, 45 (46%); and hypointense, 7 (7%). Group 1 had a higher prevalence of hypointense grafts, whereas group 2 had a higher prevalence of hyperintense and isointense grafts (P = .003).

CONCLUSIONS

Vancomycin presoaking of hamstring grafts increased the number of hyperintense and isointense grafts on MRI. Additionally, more hypointense grafts were noted when vancomycin was not used, suggesting the presence of more mature grafts in the non-vancomycin group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon

Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.

Evaluation of the Efficacy of Vancomycin-Soaked Autograft to Eliminate Staphylococcus aureus Contamination After Anterior Cruciate Ligament Reconstruction: Based on an Infected Rat Model

BACKGROUND

Vancomycin-soaked autograft application in anterior cruciate ligament reconstruction (ACLR) significantly reduces postoperative infection rates. However, the optimal vancomycin concentrations and time of vancomycin presoaking of autografts for preventing infection are still unknown.

PURPOSE

To evaluate the efficacy of vancomycin-soaked autografts in preventing infection in rats with ACLR.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 102 tendons of Wistar rats were harvested under sterile conditions from fresh cadaveric legs. Contamination with 2.0 × 10⁴ colony forming units per milliliter of Staphylococcus aureus and soaking in different vancomycin concentrations for different soaking times was performed in vitro. In vivo, after being contaminated with S. aureus and soaked with optimal vancomycin solution treatment and sterile saline, the grafts were implanted in rat knees to finish ACLR surgery. At 2, 4, and 12 weeks after surgery, samples were harvested to observe signs of infection and tendon-bone incorporation via general postoperative conditions, serum inflammatory markers, microbiological counting, knee radiographs, micro-computed tomography, histologic staining, scanning electron microscopy, and biomechanical testing.

RESULTS

Bacterial contamination was eliminated when at least 5 or 10 mg/mL of vancomycin was applied for 30 minutes in vitro. Rats in the vancomycin-soaked graft group (5 mg/mL of vancomycin for 30 minutes) showed no significant signs of infection and fewer positive cultures than did those without presoaking. The vancomycin-soaked graft group had reduced serum inflammatory markers, tissue scores, inflammatory reactions in the joint tissue, and radiographic evidence of periarticular osseous destruction compared with the control group. At postoperative week 12, the vancomycin-soaked graft group showed good outcomes in tendon-bone incorporation via micro-computed tomography, histologic staining, and biomechanical testing.

CONCLUSION

In a rat model of infection after ACLR, presoaking grafts in a 5-mg/mL vancomycin solution for 30 minutes could effectively prevent S. aureus contamination without affecting tendon-bone incorporation and knee function.

CLINICAL RELEVANCE

The present study could provide a specific solution for the use of vancomycin in the prevention of infection after ACLR clinically.

Vancomycin Presoaking of the Graft Appears to Prevent Infection After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background: Vancomycin presoaking of the graft has been shown to decrease infection rates in some case series of anterior cruciate ligament (ACL) reconstruction. Purpose: We sought to substantiate the efficacy of vancomycin presoaked grafts for the prevention of infection after ACL reconstruction. Methods: We performed a systematic review of Medline and OVID to assess the incidence of postoperative infection in studies comparing patients undergoing ACL reconstruction with the use of vancomycin presoaked ACL grafts and a control group of patients undergoing ACL reconstruction without the use of presoaked grafts. The efficacy of vancomycin presoaking was calculated using the Agresti-Coull confidence interval. Relative risk (RR) was calculated for every study and the total sample. Results: The 11 studies that met inclusion criteria comprised 24,298 patients. In patients with vancomycin presoaking of the graft, 1 infection was reported in 8764 cases (0.01% rate). In the studies with control groups that did not have vancomycin presoaked grafts, there were 125 infections in 15,534 ACL reconstructions (0.8% rate). The efficacy of vancomycin presoaking in preventing infection after ACL reconstruction was 99.9% (0.999%-1.000% CI). The overall RR obtained was 0.07 (0.03-0.16 CI). All included studies were retrospective cohort studies (level III). Conclusions: Vancomycin presoaking of the graft has been shown to decrease infection rates after ACL reconstruction in studies of low evidence level. This suggests the need for prospective randomized controlled trials addressing this issue so that recommendations on the routine use of vancomycin presoaking of ACL grafts can be made with confidence.

Patients return to sports and to work after successful treatment of septic arthritis following anterior cruciate ligament reconstruction

PURPOSE

To determine specific return to sports (RTS) and return to work (RTW) rates of patients with septic arthritis following anterior cruciate ligament reconstruction (ACLR), and to assess for factors associated with a diminished postoperative return to physical activity after successful eradication of the infection.

METHODS

In this study, patients who were treated for postoperative septic arthritis of the knee following anterior cruciate ligament reconstruction between 2006 and 2018 were evaluated at a minimum follow-up (FU) of 2 years. Patients' outcomes were retrospectively analyzed using standardized patient-reported outcome scores including the Lysholm score and the subjective IKDC score, as well as return to sports and return to work questionnaires to assess for the types, number, and frequency of sports performed pre- and postoperatively and to evaluate for potential occupational changes due to septic arthritis following ACLR. To assess for the signifiance of the graft at follow-up, outcomes were compared between patients with a functioning graft at FU and those without, as well as between patients with initial graft retention and those with graft removal and consecutive revision ACLR.

RESULTS

Out of 44 patients eligible for inclusion, 38 (86%) patients at a mean age of 36.2 ± 10.3 years were enrolled in this study. At a mean follow-up of 60.3 ± 39.9 months, the Lysholm score and the subjective IKDC score reached 80.0 ± 15.1 and 78.2 ± 16.6 points, respectively. The presence of a graft at FU yielded statistically superior results only on the IKDC score (p = 0.014). There were no statistically significant differences on the Lysholm score (n.s.) or on the IKDC score (n.s.) between patients with initial graft retention and those with initial removal who had undergone revision ACLR. All of the included 38 patients were able to return to sports at a median time of 8 (6-16) months after their last surgical intervention. Among patients who performed pivoting sports prior to their injury, 23 (62.2%) returned to at least one pivoting sport postoperatively. Overall, ten patients (26.3%) returned to all their previous sports at their previous frequency. The presence of a graft at FU resulted in a significantly higher RTS rate (p = 0.010). Comparing patients with initial graft retention and those with graft removal and consecutive revision ACLR, there was no statistically significant difference concerning the RTS rate (n.s.). Thirty-one patients (83.8%) were able to return to their previous work.

CONCLUSION

Successful eradication of septic arthritis following anterior cruciate ligament reconstruction allows for a postoperative return to sports and a return to work particularly among patients with ACL-sufficient knees. However, the patients' expectations should be managed carefully, as overall return rates at the pre-injury frequency are relatively low.

LEVEL OF EVIDENCE

IV.

Bacterial contamination of irrigation fluid and suture material during ACL reconstruction and meniscus surgery : Low infection rate despite increasing contamination over surgery time

PURPOSE

During knee arthroscopy, irrigation fluid from the surgical site accumulates in the sterile reservoir. Whether these fluid collections and also suture material used during the arthroscopic surgical processes show bacterial contamination over time during surgery remains unclear. The purpose of this study was to determine this contamination rate and to analyze its possible influence on postoperative infection.

MATERIALS AND METHODS

In this study, 155 patients were included. Fifty-eight underwent reconstruction of the anterior cruciate ligament (ACL), 63 meniscal surgery and 34 patients combined ACL reconstruction and meniscus repair. We collected pooled samples of irrigation fluid from the reservoir on the sterile drape every 15 min during the surgery. In addition, we evaluated suture material of ACL graft and meniscus repair for bacterial contamination. Samples were sent for microbiological analysis, incubation time was 14 days. All patients were seen in the outpatient department 6, 12 weeks and 12 months postoperatively and examined for clinical signs of infection.

RESULTS

A strong statistical correlation (R² = 0.81, p = 0.015) was found between an advanced duration of surgery and the number of positive microbiological findings in the accumulated fluid. Suture and fixation material showed a contamination rate of 28.4% (29 cases). Despite the high contamination rate, only one infection was found in the follow-up examinations, caused by Staphylococcus lugdunensis.

CONCLUSION

Since bacterial contamination of accumulated fluid increases over time the contact with the fluid reservoirs should be avoided.

LEVEL OF EVIDENCE

IV.

Editorial Commentary: Vancomycin Solution Pretreatment of Anterior Cruciate Ligament Tendon Graft Reduces Infection Rates, Is Clinically and Biomechanically Sound, and Is Cost-Effective

Prevention of postoperative infection following anterior cruciate ligament (ACL) reconstruction remains a high priority for orthopaedic surgeons. Vancomycin presoaking of ACL grafts is a biomechanically sound, clinically effective, and cost-efficient method of improving ACL reconstruction infection rates.

Does Vancomycin Wrapping in Anterior Cruciate Ligament Reconstruction Affect Tenocyte Activity In Vitro?

Knee septic arthritis is a devastating complication following anterior cruciate ligament (ACL) reconstruction. To prevent this issue, intraoperative soaking of ACL grafts with vancomycin is often performed before implantation. Although vancomycin cytotoxicity has been reported several times, little is known about its biological effect on tenocytes. The aim of this study was to evaluate the in vitro effects of vancomycin on human primary tenocytes (hTCs). hTCs were isolated from hamstring grafts of four patients undergoing ACL reconstruction. After expansion, hTCs were treated with different concentrations of vancomycin (0, 2.5, 5, 10, 25, 50 and 100 mg/mL) for 10, 15, 30 and 60 min. In vitro cytotoxicity was evaluated measuring metabolic activity, cell toxicity, and apoptosis. hTC metabolic activity was affected starting from 10 mg/mL vancomycin and decreased markedly at 100 mg/mL. Cell viability remained unaffected only at a concentration of 2.5 mg/mL vancomycin. Vancomycin cytotoxicity was detected from 10 mg/mL after 15 min and at all higher concentrations. Cells died when treated with concentrations higher than 5 mg/mL. The use of this antibiotic on tendons to prevent infections could be useful and safe for resident cells if used at a concentration of 2.5 mg/mL for up to 1 h of treatment.

Soaking of autografts with vancomycin is highly effective on preventing postoperative septic arthritis in patients undergoing ACL reconstruction with hamstrings autografts

PURPOSE

To evaluate the impact of local soaking of the autografts with vancomycin during anterior cruciate ligament (ACL) reconstruction on postoperative infection rates.

METHODS

Between 2003 and 2014 (first study period), 1,242 patients underwent ACL reconstruction using autografts, without soaking them in vancomycin solution, while between 2014 and 2019 (second study period) all ACL autografts in 593 patients were soaked in a 5-mg/ml vancomycin solution, in a territory University Hospital. The same standard treatment of perioperative IV antibiotics was applied in both groups.

RESULTS

Postoperative septic arthritis occurred in seven out of 1,242 patients (0.56%) during the first study period. Bone patellar tendon bone autograft was used in 311 (25%) patients, and hamstring tendon autograft was used in the rest 931 (75%) of the study population during this period. All infected cases were male and had a hamstrings graft implanted. There were no postoperative infections (0%) in 593 ACL reconstructions during the second study period. Bone patellar tendon bone autograft was used in 178 (30%) patients while hamstring tendon autograft was used in the rest 415 (70%) of the study population, during this period. Statistical analysis revealed a significantly reduced postoperative infection rate (p = 0.018) between the two reported periods, with the main impact referring to the use of hamstrings autograft (p = 0.031) for the first study period.

CONCLUSIONS

Septic arthritis following ACL reconstruction can be significantly reduced (or even eliminated) by soaking ACL autografts in a 5 mg/ml vancomycin solution. Of note, this strategy seems to be more effective in the setting of hamstring tendon autograft use, since the risk of postoperative knee infection is significantly higher when this type of graft is used.

Vancomycin presoaking of hamstring autografts to prevent infection in anterior cruciate ligament reconstruction: a narrative review

Hamstring autograft use has been linked to an increased risk of infection after anterior cruciate (ACL) reconstruction compared to other grafts. The absolute reason for this remains unclear, with contamination after harvesting and preparation of the graft being the most accepted hypothesis.

Using the rationale that a contaminated graft could be the main factor in postoperative septic arthritis and in an effort to maximize the antibiotic efficacy of the graft, the Vancomycin presoaking technique was developed. It has shown success in decreasing the infection rate in ACL reconstruction. In recent years, an important number of research articles using this protocol have appeared, but the technique is still not widely implemented.

Recent literature shows that Vancomycin presoaking of the graft has shown a successful decrease in the infection rate after hamstring autograft ACL reconstruction. It has also shown efficacy decreasing the infection rate in other types of grafts (patellar tendon, quadriceps tendon, allograft) and also in patients with concomitant ligament procedures or open surgeries.

Despite the positive effects of Vancomycin presoaking reducing the infection rate after ACL reconstruction, the lack of prospective randomized control trials and the heterogeneity of the different studies mean it is not feasible to recommend Vancomycin presoaking of the graft universally for every ACL reconstruction patient.

Cite this article: EFORT Open Rev 2021;6:211-216. DOI: 10.1302/2058-5241.6.200059

Effect of Vancomycin Soaking on Anterior Cruciate Ligament Graft Biomechanics

PURPOSE

To evaluate the effect of soaking of anterior cruciate ligament (ACL) grafts in vancomycin solution on graft biomechanical properties at the time of implantation.

METHODS

The central third of patellar tendons was harvested from mature bovine knees and prepared as a tendon-only graft or a bone-tendon-bone (BTB) graft. Tendons were wrapped in gauze soaked in vancomycin solution (VS) (5 mg/mL) or normal saline (NS) and left to stand for 30 minutes at room temperature, simulating graft exposure times in the operating room during ACL reconstruction. Tensile testing was carried out on a materials testing system with (1) low-magnitude loading (60 N at 3 mm/s) with repeated testing of tendon-only grafts; and (2) high-magnitude loading (600 N at 10 mm/min) of BTB grafts. For tendon-only grafts, specimens were first wrapped in NS-soaked gauze and underwent testing, with repeated testing performed after wrapping in gauze soaked in VS or buffered VS (pH 7.0). For BTB grafts, specimens were randomly assigned to treatment with VS or NS.

RESULTS

For tendon-only grafts, there was no difference in Young's modulus (YM) after soaking with VS soaking (baseline, 12.69 MPa; treatment, 16.07 ± 4.44 MPa; P = .99) or buffered VS (baseline, 12.45 ± 4.55 MPa; treatment, 15.56 ± 2.83 MPa; P = .99). For BTB grafts, there were no differences in elongation strain (VS, 46.8% ± 7.0%; NS, 31.5% ± 13.5%, P = .19) or YM (VS, 158.4 ± 15.8 MPa; NS, 158.5 ± 23.3 MPa, P = .99).

CONCLUSIONS

According to controlled biomechanical tests, vancomycin soaking of patellar tendon grafts does not adversely affect time-zero material properties.

CLINICAL RELEVANCE

This study suggests that vancomycin wrapping has no immediate adverse effects on the biomechanical properties of ACL grafts. Randomized controlled trials are warranted to validate the widespread use of vancomycin soaking of tendon grafts for infection prophylaxis during ACL reconstruction.

Editorial Commentary: Vancomycin Soaking of the Graft in Anterior Cruciate Ligament Reconstruction: A Concept on the Way to Becoming the New Gold Standard

An increasing number of surgeons adopt the concept of vancomycin soaking of the graft in anterior cruciate ligament reconstruction and report drastically reduced numbers of postoperative septic knee arthritis. This reduction of incidence is supported by in vitro data, showing no influence of vancomycin on tendon material properties. Although the applied antibiotic concentration has reported to be potent in eradicating graft contamination, no evidence of chondrotoxicity has been shown. Based on the increasing evidence, the call for randomized controlled trials stands in ethical contrast with the medical responsibility not to withhold patients an infection prophylaxis that has already been proven to be safe and effective.

The Use of Interlocking Polyetheretherketone (PEEK) Patient-Specific Facial Implants in the Treatment of Facial Deformities. A Retrospective Review of Ten Patients

PURPOSE

Polyetheretherketone (PEEK) is a versatile biocompatible material with a wide variety of clinical applications. Multiple-piece 3-dimensionally milled interlocking PEEK patient-specific implants are used in cases with restricted access or around vital structures. The interlocking joints reduce the number of fixation screws required by converting the multiple segments into 1 single implant. Stability of such joints is of paramount importance to prevent complications such as infection and implant extrusion. This retrospective study evaluates the clinical outcomes in the use of multiple-piece 3-dimensionally milled interlocking PEEK patient-specific implants as a treatment for various congenital and acquired facial deformities.

METHODS

Patients' records and clinical interviews were retrospectively reviewed.

RESULTS

A total of 10 patients were included; 6 of them (60%) were men. A planning cone beam scan (90%) or computed tomography scan (10%) were obtained following a standard protocol. All treatments were performed by a single surgeon, following a standardized approach. The follow-up time ranged from 11 to 61 months (mean = 37.1 months). No implant exposure, extrusion or removal were reported. Three patients (30%) experienced complications. Recurrent edema was observed in 1 patient (10%), another patient (10%) experienced bilateral mental nerve paresthesia, and the third patient (10%) had recurrent sinusitis, which was successfully treated with functional endoscopic sinus surgery without removing the implant.

CONCLUSION

Within the limitation of this study, 3-dimensionally milled interlocking PEEK patient-specific implants are safe, predictable, potentially save operative time, and readily adjustable. Extra stability and antislippage mechanism can be achieved by using the interlocking joint. Further studies on a larger cohort of patients is needed to confirm these results.

Soaking of Autologous Tendon Grafts in Vancomycin Before Implantation Does Not Lead to Tenocyte Cytotoxicity

BACKGROUND

Surgical site infections (SSIs) after anterior cruciate ligament (ACL) reconstruction procedures are an unfortunate complication. Soaking grafts in vancomycin before implantation has been reported to reduce the incidence of postoperative SSI after ACL reconstruction. There is potential for vancomycin to compromise graft integrity because of tenocyte toxicity.

PURPOSE

To examine the in vitro toxicity of varying doses of vancomycin on human tenocytes.

STUDY DESIGN

Controlled laboratory study.

METHODS

Human patellar tenocytes were isolated and expanded in vitro. Tenocytes in culture were exposed to vancomycin at 5 different concentrations (400, 1600, 3200, 6400, and 12,800 μg/mL) and 3 time intervals (2, 6, and 24 hours). The control for all series was tenocyte exposure to only culture medium for each time interval. After treatment, a 10% Cell Counting Kit-8 solution in cellular growth medium was applied to the cells to examine cytotoxicity. A live/dead assay was used to assess tenocyte viability through fluorescence microscopy and flow cytometry. Results were analyzed statistically using multivariable logistic regression models with Tukey honest significant difference post hoc tests.

RESULTS

Vancomycin did not cause significant changes in tenocyte viability after 2 and 6 hours of incubation at any concentration between 0 and 12,800 µg/mL. Incubation with vancomycin for 24 hours led to a significant decrease in cell viability at higher concentrations.

CONCLUSION

Tenocytes derived from human patellar tendons exposed to relatively high concentrations of vancomycin for short periods of time do not demonstrate significant cell death and toxicity.

CLINICAL RELEVANCE

Exposing tendons to vancomycin for a short period of time, such as before ACL reconstruction, is not likely to cause tenocyte toxicity because of vancomycin administration.

Lower incidence of post-operative septic arthritis following revision anterior cruciate ligament reconstruction with quadriceps tendon compared to hamstring tendons

PURPOSE

To determine and compare the incidence of post-operative septic arthritis following revision anterior cruciate ligament reconstruction (R-ACLR) with autologous quadriceps tendon (with patellar bone block) compared to autologous hamstring tendons (semitendinosus and gracilis).

METHODS

A total of 1638 isolated R-ACLR with either autologous hamstring tendons (n = 1004, 61.3%) or quadriceps tendon (n = 634; 38.7%) were performed between 2004 and 2017 and were retrospectively analysed with regard to the occurrence of post-operative septic arthritis. The technique of R-ACLR did not significantly change during the years of the study. All patients received pre-op i.v.antibiotics, but no presoaking of the grafts in vancomycin was performed in the years of the study. The individual decision of graft choice was based on graft availability, tunnel position and the presence of tunnel widening. Generally, hamstring tendons were preferred. There were no clinically relevant differences between the groups regarding gender or age. Routine follow-up examination was performed 6 weeks after the index operation (follow-up rate 96.5%), and patients unsuspicious for septic arthritis at that time were classified as non-infected.

RESULTS

Fourteen patients with septic arthritis were identified, resulting in an overall incidence of 0.85%. There was one patient with septic arthritis in the quadriceps tendon group (incidence: 0.16%) and 13 patients in the hamstring tendons group (incidence: 1.29%), respectively. The difference was significant (p = 0.013).

CONCLUSION

In this series, the incidence of post-operative septic arthritis after R-ACLR was lower when quadriceps tendon graft was used compared to hamstring tendon grafts.

LEVEL OF EVIDENCE

III.

Soaking of the graft in vancomycin dramatically reduces the incidence of postoperative septic arthritis after anterior cruciate ligament reconstruction

PURPOSE

To determine and compare the incidence of postoperative septic arthritis following anterior cruciate ligament reconstruction (ACLR) with and without soaking of the graft in vancomycin solution prior to implantation in a large single-centre case series.

METHODS

From 2004 to 2019, a total of 10,516 primary ACLR were performed and reviewed with regard to the occurrence of postoperative septic arthritis. From February 2017 onwards, all grafts were wrapped in a vancomycin-soaked (5 mg/ml) gauze swab between harvest and implantation (2294 patients, treatment group (2), prospectively followed). These were compared to 8222 patients before that date (control group (1), retrospectively evaluated). The technique of ACLR did not significantly change during the years of the study. There was no difference between the groups with regard to graft choice: Hamstring tendons were used in 99% and quadriceps tendons were used in 1% in both groups, respectively (n.s.). Routine follow-up examination was performed at 6 weeks (follow-up rate 97.1%) postoperatively. Patients with no treatment for septic arthritis at that time were classified as non-infected.

RESULTS

There were 35 cases of postoperative septic arthritis in group 1 (incidence: 0.4%), and none in group 2 (incidence 0.0%), respectively. The difference was significant (p < 0.001).

CONCLUSIONS

Soaking of the graft in vancomycin solution prior to implantation dramatically reduces the incidence of postoperative septic arthritis in primary ACLR and should, therefore, be used in prevention of this major complication.

LEVEL OF EVIDENCE

III.

Vancomycin-soaked autografts during ACL reconstruction reduce the risk of post-operative infection without affecting return to sport or knee function

PURPOSE

To compare return to sport and knee function 1 year after anterior cruciate ligament (ACL) reconstruction using autografts with and without vancomycin presoaking.

METHODS

A case-control study based on a retrospective analysis of prospective data included athletes over the age of 16 operated from 2012 to 2018 for ACL reconstruction. There were two groups of patients due to a change in treatment protocols: Group 1 « without vancomycin » before November 2016 and Group 2 « with vancomycin» after this date. In Group 2, the graft was soaked in a vancomycin solution for 10 min and then fixed into the bone tunnels. The primary evaluation criterion was the return to sport 1 year after surgery. The secondary criteria were various knee scores. The number of patients needed to perform a non-inferiority study was calculated.

RESULTS

1674 patients fulfilled the selection criteria, 1184 in Group 1 and 490 in Group 2. The series included 1112 men and 562 women, mean age 30 ± 9.7 years, 68 professional athletes, 674 competitive athletes and 932 recreational athletes. While seven patients presented with post-operative septic arthritis in Group 1, this complication was not found in Group 2. No significant difference was identified in the return to running between the two groups 1 year after surgery (75.9% vs. 76.1%, n.s.). Significantly more of the patients in Group 2 returned to their preinjury sport (p = 0.04). Knee function was comparable between the groups.

CONCLUSION

Vancomycin-soaked grafts during ACL reconstruction reduce the risk of post-operative infection of the knee without affecting the return to sport or knee function.

LEVEL OF EVIDENCE

III.

TRIAL REGISTRATION

https://clinicaltrials.gov/ , ClinicalTrials.gov Identifier: NCT02511158.