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Rizvanovic D, Waldén M, Forssblad M, Stålman A. Influence of Surgeon Experience and Clinic Volume on Subjective Knee Function and Revision Rates in Primary ACL Reconstruction: A Study from the Swedish National Knee Ligament Registry. Orthop J Sports Med 2024; 12:23259671241233695. [PMID: 38476163 PMCID: PMC10929050 DOI: 10.1177/23259671241233695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 03/14/2024] Open
Abstract
Background Anterior cruciate ligament reconstruction (ACLR) performed by high-volume surgeons/clinics has been associated with increased graft individualization and decreased operating times, complication rates, and total costs. Purpose To investigate the influence of surgeon/clinic volume on subjective knee function and revision surgery rates at 2 years after primary ACLR. Study Design Cohort study; Level of evidence, 3. Methods Data from the Swedish National Knee Ligament Registry were used to study patients who underwent primary ACLR between 2008 and 2019. Surgeons/clinics were categorized based on a combination of total caseload volume (cutoff: 50 ACLRs/surgeon, 500 ACLRs/clinic) and annual volume (cutoff: 29 ACLRs/year/surgeon, 56 ACLRs/year/clinic). The thresholds of minimal important change (MIC), Patient Acceptable Symptom State (PASS), and treatment failure (TF) relative to the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS4 (mean score of the KOOS Pain, Symptoms, Sports/Rec, and QoL subscales) were applied. Adjusted multivariable logistic regression was performed to assess variables influencing the MIC, PASS, or TF of the KOOS and KOOS4. Adjusted Cox regression analysis was conducted to determine the hazard ratio of subsequent ACLR. Results Of 35,371 patients, 16,317 had 2-year follow-up outcome data and were included. Patients who underwent primary ACLR by high-volume surgeons had significantly higher MIC and PASS rates and lower TF rates when compared with patients who underwent the procedure by low-volume surgeons: MICKOOS4: 70.6% vs 66.3%; PASSKOOS4: 46.0% versus 38.3%; and TFKOOS4: 8.7% versus 11.8% (all P < .02). Significantly decreased odds of achieving MICKOOS4 (OR, 0.74; 95% CI, 0.62-0.88) and PASSKOOS4 (OR, 0.71; 95% CI, 0.60-0.84) were found for ACLRs performed by low-volume surgeons. Clinic volume did not influence the odds of reaching MIC, PASS, or TF. Overall, 804 patients (2.3%) underwent subsequent ACLR at <2 years, with significantly higher revision rates among patients operated on at high-volume clinics (2.5% vs 1.7%; P < .001). However, in the adjusted Cox regression, surgeon/clinic volume had no influence on subsequent ACLR rates. High-volume surgeons/clinics had decreased time to surgery, operating time, perioperative complication rates, and use of thromboprophylaxis and nonroutine antibiotics (P < .001). Conclusion Patients who underwent primary ACLR by high-volume surgeons experienced increased improvement and satisfaction regarding subjective knee function. Factors other than surgical volume influenced subsequent surgery rates. Patients might benefit from undergoing primary ACLR by high-volume providers.
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Affiliation(s)
- Dzan Rizvanovic
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
- Department of Orthopaedics, Växjö Central Hospital, Region Kronoberg, Växjö, Sweden
| | - Markus Waldén
- Unit of Public Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Capio Ortho Center Skåne, Malmö, Sweden
| | - Magnus Forssblad
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
- Ortopedi Stockholm, Stockholm, Sweden
| | - Anders Stålman
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
- Capio Artro Clinic, Sophiahemmet, Stockholm, Sweden
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Buckthorpe M, Gokeler A, Herrington L, Hughes M, Grassi A, Wadey R, Patterson S, Compagnin A, La Rosa G, Della Villa F. Optimising the Early-Stage Rehabilitation Process Post-ACL Reconstruction. Sports Med 2024; 54:49-72. [PMID: 37787846 DOI: 10.1007/s40279-023-01934-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 10/04/2023]
Abstract
Outcomes following anterior cruciate ligament reconstruction (ACLR) need improving, with poor return-to-sport rates and a high risk of secondary re-injury. There is a need to improve rehabilitation strategies post-ACLR, if we can support enhanced patient outcomes. This paper discusses how to optimise the early-stage rehabilitation process post-ACLR. Early-stage rehabilitation is the vital foundation on which successful rehabilitation post-ACLR can occur. Without high-quality early-stage (and pre-operative) rehabilitation, patients often do not overcome major aspects of dysfunction, which limits knee function and the ability to transition through subsequent stages of rehabilitation optimally. We highlight six main dimensions during the early stage: (1) pain and swelling; (2) knee joint range of motion; (3) arthrogenic muscle inhibition and muscle strength; (4) movement quality/neuromuscular control during activities of daily living (5) psycho-social-cultural and environmental factors and (6) physical fitness preservation. The six do not share equal importance and the extent of time commitment devoted to each will depend on the individual patient. The paper provides recommendations on how to implement these into practice, discussing training planning and programming, and suggests specific screening to monitor work and when the athlete can progress to the next stage (e.g. mid-stage rehabilitation entry criteria).
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Affiliation(s)
- Matthew Buckthorpe
- Faculty of Sport, Technology and Health Sciences, St Mary's University, London, TW1 4SX, Twickenham, UK.
- Education and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy.
| | - Alli Gokeler
- Exercise Science and Neuroscience, Department Exercise & Health, Faculty of Science, Paderborn University, Paderborn, Germany
| | - Lee Herrington
- Centre for Human Sciences Research, University of Salford, Salford, UK
| | - Mick Hughes
- North Queensland Physiotherapy Centre, Townsville, QLD, Australia
| | - Alberto Grassi
- II Clinica Ortopedica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Ross Wadey
- Faculty of Sport, Technology and Health Sciences, St Mary's University, London, TW1 4SX, Twickenham, UK
| | - Stephen Patterson
- Faculty of Sport, Technology and Health Sciences, St Mary's University, London, TW1 4SX, Twickenham, UK
| | - Alessandro Compagnin
- Education and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy
| | - Giovanni La Rosa
- Education and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy
| | - Francesco Della Villa
- Education and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy
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Charalambous CP, Ahmed EM, Kayali F, Nautiyal H, Kuršumović K, Sutton PM. Vancomycin Graft Presoaking in Anterior Cruciate Ligament Reconstruction Surgery Is Associated with a Lower Risk of Graft Rerupture as Compared With No Vancomycin Presoaking: Systematic Review and Meta-analysis. JBJS Rev 2023; 11:01874474-202312000-00008. [PMID: 38117914 DOI: 10.2106/jbjs.rvw.23.00145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND To determine whether there is any difference in graft rerupture rates and clinical outcomes between cases having vancomycin graft presoaking vs. no vancomycin presoaking in anterior cruciate ligament (ACL) reconstruction (ACLR). METHODS Systematic review and meta-analysis. PubMed, Embase, CINAHL, and Cochrane CENTRAL were searched. Full published studies reporting on the relation between vancomycin graft presoaking and rates of graft rerupture and/or clinical outcomes in ACLR surgery vs. no vancomycin graft presoaking were included. Data extraction and quality appraisal were performed. Meta-analysis was conducted using a random effects model. The study's protocol was prospectively registered with PROSPERO (CRD42021290608). RESULTS The literature search identified 907 records. After removing duplicates and those not meeting inclusion criteria, 8 studies were included. Meta-analysis showed that the estimated risk of hamstring graft rerupture was lower in cases presoaked with vancomycin vs. those having no presoaking (3.2% vs. 6.2% rerupture rate, risk ratio [RR] = 0.507, 95% CI, 0.39-0.737, p < 0.001). Similarly, the estimated risk of graft rerupture was lower in cases presoaked with vancomycin vs. those having no presoaking when the analysis included various ACL graft types (2.7% vs. 3.9% rerupture rate, RR = 0.557, 95% confidence interval [CI], 0.403-0.771, p < 0.001). Meta-analysis also showed that vancomycin graft presoaking was associated with similar International Knee Documentation Committee scores as compared with no presoaking when looking at hamstring grafts (estimated mean difference 0.112, 95% CI, -2.359 to 2.582, p = 0.929) or when considering various graft types (estimated mean difference 0.933, 95% CI, -0.140 to 2.006, p = 0.088). CONCLUSION Vancomycin graft presoaking is a safe practice and does not compromise ACL graft rerupture rates or clinical outcomes. LEVEL OF EVIDENCE Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Charalambos P Charalambous
- School of Medicine, University of Central, Lancashire, United Kingdom
- Blackpool Teaching Hospitals NHS Trust, Blackpool, United Kingdom
| | | | - Fatima Kayali
- University Hospitals Sussex, Western Sussex, United Kingdom
| | - Hritik Nautiyal
- Watford General Hospital, West Hertfordshire Teaching Hospitals, Watford, United Kingdom
| | | | - Paul M Sutton
- Northern General Hospital, Sheffield, United Kingdom
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Incidence and risk factors for symptomatic venous thromboembolism following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:1552-1559. [PMID: 33970293 DOI: 10.1007/s00167-021-06583-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/13/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE To determine the incidence of symptomatic venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction using a large national database and to identify corresponding independent risk factors. METHODS The Humana administrative claims database was reviewed for patients undergoing ACL reconstruction from 2007 to 2017. Patient demographics, medical comorbidities, as well as concurrent procedures were recorded. Postoperative incidence of VTE was measured by identifying symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) at 30 days, 90 days, and 1 year postoperatively. Univariate analysis and binary logistic regression were performed to determine independent risk factors for VTE following surgery. RESULTS A total of 11,977 patients were included in the study. The incidence of VTE was 1.01% (n = 120) and 1.22% (n = 146) at 30 and 90 days, respectively. Analysis of VTE events within the first postoperative year revealed that 69.6% and 84.3% of VTEs occurred within 30 and 90 days of surgery, respectively. Logistic regression identified age ≥ 45 (odds ratio [OR] = 1.88; 95% confidence interval [CI] 1.32-2.68; p < 0.001), inpatient surgery (OR = 2.07; 95% CI 1.01-4.24; p = 0.045), COPD (OR = 1.51; 95% CI 1.02-2.24; p = 0.041), and tobacco use (OR = 1.75; 95% CI 1.17-2.62; p = 0.007), as well as concurrent PCL reconstruction (OR = 3.85; 95% CI 1.71-8.67; p = 0.001), meniscal transplant (OR = 17.68; 95% CI 3.63-85.97; p < 0.001) or osteochondral allograft (OR = 15.73; 95% CI 1.79-138.43; p = 0.013) as independent risk factors for VTE after ACL reconstruction. CONCLUSIONS The incidence of symptomatic postoperative VTE is low following ACL reconstruction, with the majority of cases occurring within 90 days of surgery. Risk factors include age ≥ 45, inpatient surgery, COPD, tobacco use and concurrent PCL reconstruction, meniscal transplant or osteochondral allograft. LEVEL OF EVIDENCE III.
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Christian RA, Lander ST, Bonazza NA, Reinke EK, Lentz TA, Dodds JA, Mulcahey MK, Ford AC, Wittstein JR. Venous Thromboembolism Prophylaxis and Hormonal Contraceptive Management Practice Patterns in the Perioperative Period for Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e679-e685. [PMID: 35494294 PMCID: PMC9042882 DOI: 10.1016/j.asmr.2021.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/01/2021] [Indexed: 01/13/2023] Open
Abstract
Purpose To evaluate the venous thromboembolism (VTE) prophylaxis practices of surgeons performing anterior cruciate ligament reconstruction (ACLR) in female patients using hormonal contraceptives. Methods Our research team designed an investigational survey using branching logic that was made available to the AANA membership. The survey was designed to identify clinical decision making regarding VTE prophylaxis after ACLR in patients without risk factors for VTE, the counseling of patients about VTE risk associated with hormonal contraceptives, and the use of VTE prophylaxis after ACLR in patients taking hormonal contraceptives. Results Ninety-four respondents completed the survey. Eighty-nine respondents identified their gender (63% male and 37% female respondents). Respondents reported performing the following number of ACLRs annually: more than 50 (40%), 30 to 50 (29%), 15 to 30 (29%), and fewer than 15 (2%). Of the respondents, 62 (67%) reported that VTE developed after ACLR in their patients (male patients only, 32%; female patients only, 24%; and both male and female patients, 34%). Sixty-seven percent used chemoprophylaxis after ACLR. Surgeons who asked about hormonal contraceptive use were more likely to be women (P = .01; odds ratio [OR], 4.2). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to be women (P = .02; OR, 2.8). Surgeons who asked about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .03; OR, 2.9). Surgeons who changed their VTE prophylaxis plan as a result of asking about hormonal contraceptive use were more likely to have female patients with VTE after ACLR (P = .001; OR, 4.6). Conclusions There is no standard of care for VTE prophylaxis after ACLR. A surgeon’s own gender and prior clinical experience with VTE after ACLR may influence his or her likelihood to consider a patient’s hormonal contraceptive use regarding VTE risk after ACLR. Clinical Relevance The use of hormonal contraception is a risk factor for VTE in female patients undergoing ACLR. It is important to identify current practice patterns and the need for a standard of care.
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Affiliation(s)
- Robert A. Christian
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
- Address correspondence to Robert A. Christian, M.D., M.B.A., 622 W 168th St, PH-11-1130, New York, NY 10032, U.S.A.
| | - Sarah T. Lander
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Nicholas A. Bonazza
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Emily K. Reinke
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Trevor A. Lentz
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, U.S.A
| | - Julie A. Dodds
- Department of Orthopaedic Surgery, Michigan State University, East Lansing, Michigan, U.S.A
| | - Mary K. Mulcahey
- Department of Orthopaedic Surgery, Tulane University, New Orleans, Louisiana, U.S.A
| | - Anne C. Ford
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, U.S.A
| | - Jocelyn R. Wittstein
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
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Pang L, Li P, Li H, Tang X, Zhu J. Does anterior cruciate ligament reconstruction increase venous thromboembolism risk compared with knee meniscectomy under arthroscopy? BMC Musculoskelet Disord 2022; 23:268. [PMID: 35303852 PMCID: PMC8933879 DOI: 10.1186/s12891-022-05216-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/14/2022] [Indexed: 02/05/2023] Open
Abstract
Background This study compared the incidence of postoperative venous thromboembolism (VTE) between meniscectomy and anterior cruciate ligament reconstruction (ACLR) under arthroscopy and assessed whether ACLR increases the VTE risk compared with meniscectomy. Methods A retrospective study of prospectively collected clinical data, including data on 436 patients ranging in age from 18 to 60 years who underwent ACLR or meniscectomy surgery, was performed between October 2018 and October 2019 in our hospital. All patients underwent routine VTE screening by venous ultrasonography in postoperative week 2 and then clinical follow-up at 4 and 6 weeks post-surgery. The incidence of VTE was calculated, and clinical factors such as age, sex, body mass index (BMI), smoking, concomitant procedure, Caprini score, and duration of tourniquet use were evaluated in relation to the risk factors for VTE. Results A total of 320 patients who underwent arthroscopic ACLR or meniscectomy were available for analysis. Of these patients, 130 (40.6%) underwent ACLR, and 190 (59.4%) underwent meniscectomy. No cases of pulmonary embolism (PE) or femoral deep vein thrombosis (DVT) were reported in either group. Fourteen patients (10.8%) developed VTE in the ACLR group compared with 10 (5.3%) in the meniscectomy group, with no significant difference (p = 0.066). Among these patients, 4 (3.1%) patients in the ACL reconstruction group and 2 (1.1%) patients in the meniscectomy group had DVT confirmed by Doppler ultrasound (p > 0.05). ACLR, age, and BMI (OR = 3.129; 1.061; 1.435) tended to increase the risk of VTE, but the results were not statistically significant (p = 0.056, 0.059, 0.054). Conclusions The incidence of VTE after ACLR and meniscectomy within 6 weeks post-surgery was 10.8 and 5.3%, respectively. ACLR, age, and BMI had a tendency to increase the risk of VTE.
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Affiliation(s)
- Long Pang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Pengcheng Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hui Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Tang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jing Zhu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Carrozzo A, Saithna A, Ferreira A, Guy S, Chadli L, Monaco E, Pérez-Prieto D, Bohu Y, Vieira TD, Sonnery-Cottet B. Presoaking ACL Grafts in Vancomycin Decreases the Frequency of Postoperative Septic Arthritis: A Cohort Study of 29,659 Patients, Systematic Review, and Meta-analysis From the SANTI Study Group. Orthop J Sports Med 2022; 10:23259671211073928. [PMID: 35155711 PMCID: PMC8832611 DOI: 10.1177/23259671211073928] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 02/03/2023] Open
Abstract
Background: Presoaking anterior cruciate ligament (ACL) grafts in vancomycin has been reported to reduce the occurrence of septic arthritis (SA). However, strong recommendations for its universal use have been precluded by concerns regarding the fragility of previous meta-analyses. Purpose: The primary objective was to investigate whether presoaking ACL grafts in vancomycin was associated with a reduction in the rate of SA in a large series of patients. The secondary objective was to perform an updated systematic review and meta-analysis to determine the efficacy of vancomycin in reducing the rate of SA. Study Design: Cohort study and systematic review; Level of evidence, 3. Methods: A retrospective analysis of patients who underwent primary ACL reconstruction (ACLR) at our institution was undertaken. Rates of postoperative SA were determined and analyzed according to whether patients had received grafts presoaked in vancomycin. A systematic review of the literature and meta-analysis was performed. Odds ratios (ORs) for the risk of SA were calculated according to the inverse variance approach. Results were presented using forest plots, funnel plots, and the fragility index. Results: A total of 5300 patients underwent primary ACLR during the study period. The rate of SA was 0.34% (11/3228) in the control group and 0.05% (1/2072) in the presoaked group. There was a 5-fold greater risk of SA in patients who did not receive grafts presoaked in vancomycin (OR, 5.13 [95% CI, 1.16-48.30]; P = .04). Overall, 11 studies were included in the systematic review (29,659 ACLR procedures). The meta-analysis demonstrated a significantly greater risk of SA in those patients who did not receive grafts presoaked in vancomycin (OR, 14.39 [95% CI, 5.90-35.10]; fragility index = 23). This finding held true for the subpopulation receiving hamstring tendon grafts (fragility index = 16), but only a trend was demonstrated for bone–patellar tendon–bone grafts. Conclusion: The meta-analysis demonstrated that presoaking ACL grafts in vancomycin was associated with significant reductions in the rates of SA when all graft types were analyzed together. This finding held true specifically for hamstring tendon autografts. The fragility index of these findings allows for a strong recommendation for the universal use of vancomycin presoaking. However, it should be noted that only a trend toward reduced SA rates was demonstrated with presoaking bone–patellar tendon–bone autografts in vancomycin.
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Affiliation(s)
| | | | | | | | | | - Edoardo Monaco
- Orthopaedic and Trauma Surgery Unit, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Daniel Pérez-Prieto
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
- Catalan Institute of Traumatology and Sports Medicine, Dexeus University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Yoann Bohu
- Clinique du Sport, Paris, France
- Institut de l’Appareil Locomoteur Nollet, Paris, France
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Figueroa F, Figueroa D, Calvo R, Vaisman A, Nuñez M, Putnis S. Vancomycin Presoaking of the Graft Appears to Prevent Infection After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. HSS J 2022; 18:138-144. [PMID: 35087344 PMCID: PMC8753556 DOI: 10.1177/15563316211011682] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/20/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Francisco Figueroa
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile,Hospital Sotero del Rio, Santiago, Chile,Francisco Figueroa, MD, Clinica Alemana and Universidad del Desarrollo, Vitacura, Santiago, MD, Chile.
| | - David Figueroa
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile
| | - Rafael Calvo
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile
| | - Alex Vaisman
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile,Hospital Padre Hurtado, Santiago, Chile
| | - Marilaura Nuñez
- Clinica Alemana and Universidad del Desarrollo, Vitacura, Chile
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OMAR O, RIZVANOVIC D, WALDÉN M, ERIKSSON K, BARENIUS B, STÅLMAN A. Compensation claims following anterior cruciate ligament injuries reported to the patient insurance company in Sweden in 2005-2014. Acta Orthop 2022; 93:97-102. [PMID: 34726577 PMCID: PMC8815401 DOI: 10.1080/17453674.2021.1996102] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Patients in the Swedish healthcare system are insured against avoidable adverse events via Landstingens Ömsesidiga Försäkringsbolag (LÖF). We assessed the reasons for compensation claims reported to LÖF following an ACL injury. Patients and methods - We searched the LÖF database for compensation claims related to ACL injuries reported in 2005-2014, and cross-matched claims with the Swedish National Knee Ligament Register. We then performed a review of the medical records. Results - We identified 530 eligible claims in 2005-2014. 352 (66%) claims were accepted by LÖF and 178 claims were rejected. Accepted claims corresponded to fewer than 1% of ACL surgeries performed in the same period. The most common reasons for an accepted claim were postoperative septic arthritis followed by suboptimal surgery and delay in diagnosis and treatment. Interpretation - There are different reasons for accepting a compensation claim following an ACL injury, which represents different treatment errors that can be avoided.
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Affiliation(s)
- Osama OMAR
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm
| | - Dzan RIZVANOVIC
- Department of Orthopaedics, Växjö Central Hospital, Region Kronoberg, and Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm
| | - Markus WALDÉN
- Unit of Community Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Sweden, and Department of Orthopaedics, Hässleholm-Kristianstad Hospitals, Hässleholm
| | - Karl ERIKSSON
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm
| | - Björn BARENIUS
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm
| | - Anders STÅLMAN
- Capio Artro Clinic, and Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
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Patients return to sports and to work after successful treatment of septic arthritis following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:1871-1879. [PMID: 34870732 PMCID: PMC9159288 DOI: 10.1007/s00167-021-06819-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022]
Abstract
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.
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Kraus Schmitz J, Lindgren V, Edman G, Janarv PM, Forssblad M, Stålman A. Risk Factors for Septic Arthritis After Anterior Cruciate Ligament Reconstruction: A Nationwide Analysis of 26,014 ACL Reconstructions. Am J Sports Med 2021; 49:1769-1776. [PMID: 33764802 PMCID: PMC8182335 DOI: 10.1177/0363546521993812] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR) is a rare yet severe complication. The samples in previous studies have been small and without nationwide coverage, making analysis uncertain with a risk of bias. Conclusions to recommend preventive measures are therefore difficult to draw, and it has not been possible to perform a comprehensive risk factor analysis. PURPOSE To study the incidence of SA after ACLR in a large, nationwide population and to study the risk factors for SA after ACLR. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS All ACLRs, primary and revision, in the Swedish Knee Ligament Registry between 2006 and 2013 were linked with data from the Swedish National Board of Health and Welfare. The incidence of SA events was determined using entries from the day of surgery until 90 days postoperatively based on diagnosis codes and the prescription of antibiotics. All events of SA were verified via a review of medical records. Risk factors were analyzed based on data from the registries. Descriptive statistics were used to describe the findings, while logistic regression analysis was used for the risk analysis. RESULTS The cohort consisted of 26,014 primary and revision ACLRs. During the study period, 298 events of SA (1.1%) were identified. The high-volume units (≥500 ACLRs during the study period) had a distribution of SA between 2 and 47 (0.2%-2.9%). Independent risk factors of SA were male sex (OR, 1.65; 95% CI, 1.28-2.13), operating time ≥70 minutes (OR, 1.83; 95% CI, 1.42-2.36), hamstring tendon autograft (OR, 2.23; 95% CI, 1.21-4.08), and clindamycin as perioperative antibiotic prophylaxis (OR, 1.94; 95% CI, 1.10-3.41). CONCLUSION The incidence of SA after ACLR in this nationwide cohort was 1.1%. Male sex, hamstring tendon autografts, and a longer operating time were all independent risk factors for SA. The use of clindamycin as perioperative antibiotic prophylaxis was a risk factor compared with the use of cloxacillin. Some high-volume units had a very low infection rate (0.2%).
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Affiliation(s)
- Jesper Kraus Schmitz
- Stockholm Sports Trauma Research Center,
Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm,
Sweden,Department of Orthopaedics, Skåne
University Hospital, Malmö, Sweden,Jesper Kraus Schmitz, MD,
PhD, VO Ortopedi, Skånes Universitetssjukhus, 205 02 Malmö, Sweden (
)
| | - Viktor Lindgren
- Department of Molecular Medicine and
Surgery, Karolinska Institutet, Stockholm, Sweden,Department of Orthopaedics, Karolinska
University Hospital, Stockholm, Sweden
| | - Gunnar Edman
- Research and Development, Norrtälje
Hospital, Tiohundra AB, Norrtälje, Sweden,Department of Clinical Sciences,
Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Per-Mats Janarv
- Stockholm Sports Trauma Research Center,
Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm,
Sweden,Capio Artro Clinic, Stockholm,
Sweden
| | - Magnus Forssblad
- Stockholm Sports Trauma Research Center,
Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm,
Sweden
| | - Anders Stålman
- Stockholm Sports Trauma Research Center,
Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm,
Sweden,Capio Artro Clinic, Stockholm,
Sweden
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Xiao M, Sherman SL, Safran MR, Abrams GD. Surgeon practice patterns for pre-soaking ACL tendon grafts in vancomycin: a survey of the ACL study group. Knee Surg Sports Traumatol Arthrosc 2021; 29:1920-1926. [PMID: 32902684 DOI: 10.1007/s00167-020-06265-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/28/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE To survey members of The ACL study group to determine the current practice patterns surrounding the technique of pre-soaking ACL grafts in vancomycin. METHODS A web-based questionnaire was distributed to members of the ACL Study Group. Questions included the use of vancomycin solution for graft soaking during ACL reconstruction, their protocol for soaking the graft, vancomycin concentration utilized, graft choices, and concerns with the technique. RESULTS Sixty-six (57%) ACL surgeons completed the survey. Approximately one-third (37.9%) of respondents currently pre-soak their ACL grafts in vancomycin prior to implantation, with 60% of these surgeons being from Europe. Seventy-six percent have adopted this practice within the past 5 years. The majority of surgeons wrap the graft in a vancomycin-soaked gauze prior to implantation (56%), soak for a variable amount of time before implantation (56%), use a concentration of 5 mg/mL (68%), and soak hamstring grafts (92%). Concerns included the mechanical properties of the graft (35%), cost of vancomycin (23%), availability (12%), and antibiotic resistance (9%). CONCLUSION This survey demonstrates that 37.9% of ACL study group members currently utilize vancomycin to pre-soak ACL tendon grafts as a means to decrease post-operative infection risk, with the majority of surgeons having implemented this practice within the past 5 years. The biggest concern towards using vancomycin was the mechanical properties of the graft after soaking. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michelle Xiao
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St, Mail Code 6175, Stanford, CA, 94305, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St, Mail Code 6175, Stanford, CA, 94305, USA
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St, Mail Code 6175, Stanford, CA, 94305, USA
| | - Geoffrey D Abrams
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez St, Mail Code 6175, Stanford, CA, 94305, USA.
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Significantly Lower Infection Risk for Anterior Cruciate Ligament Grafts Presoaked in Vancomycin Compared With Unsoaked Grafts: A Systematic Review and Meta-analysis. Arthroscopy 2021; 37:1683-1690. [PMID: 33359822 DOI: 10.1016/j.arthro.2020.12.212] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/13/2020] [Accepted: 12/14/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare postoperative infection rates following ACL reconstruction performed with grafts presoaked in vancomycin versus those without vancomycin. METHODS A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for therapeutic level I to III studies that compared outcomes of presoaking ACL grafts with vancomycin versus without vancomycin in human patients. Included graft types were tendon autografts or allografts, and included studies documented infection with a minimum follow-up of 30 days. Postoperative infection rates and knee-specific patient-reported outcome scores were extracted from each study and compared between groups. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Coleman Methodology Score (MCMS). Infection rates and retear rates were pooled and weighted for meta-analysis using a random-effects model. All P values were reported with an α level of 0.05 set as significant. RESULTS The initial search yielded 144 articles (44 duplicates, 100 screened, 29 full-text review). Ten articles (21,368 subjects [7,507 vancomycin and 13,861 no vancomycin], 67% males, mean ± standard deviation age 29.5 ± 1.5 years) were included and analyzed. Eight of the 10 studies included only autografts, with 94.5% of grafts being hamstring autografts. Soaking grafts in vancomycin resulted in significantly fewer infections (0.013% versus 0.77%; odds ratio 0.07; 95% confidence interval 0.03, 0.18; P < .001). Only 2 studies included patient-reported outcomes, and both demonstrated no difference in International Knee Documentation Committee scores 1 year after surgery for patients with grafts presoaked in vancomycin versus without vancomycin. CONCLUSIONS Soaking ACL tendon grafts with vancomycin before implantation is associated with a nearly 15 times decrease in odds of infection compared with grafts not soaked in vancomycin. Few studies investigated patient-reported outcomes and retear rates after soaking ACL grafts in vancomycin. LEVEL OF EVIDENCE III, systematic review of level III studies.
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Figueroa F, Figueroa D, Calvo R, Vaisman A, Espregueira-Mendes J. Vancomycin presoaking of hamstring autografts to prevent infection in anterior cruciate ligament reconstruction: a narrative review. EFORT Open Rev 2021; 6:211-216. [PMID: 33841920 PMCID: PMC8025705 DOI: 10.1302/2058-5241.6.200059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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
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Affiliation(s)
- Francisco Figueroa
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile.,Hospital Sotero del Rio, Santiago, Chile
| | - David Figueroa
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Rafael Calvo
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Alex Vaisman
- Clinica Alemana-Universidad del Desarrollo, Santiago, Chile.,Hospital Padre Hurtado, Santiago, Chile
| | - João Espregueira-Mendes
- Clínica do Dragão, Espregueira-Mendes Sports Centre - FIFA Medical Centre of Excellence, Portugal; Dom Henrique Research Centre, Portugal; 3B's Research Group - Biomaterials, Biodegradables and Biomimetics, University of Minho, Portugal; ICVS/3B's-PT Government Associate Laboratory, Portugal; Orthopaedics Department of Minho University, Portugal
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