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Engler ID, Fox MA, Curley AJ, Mohr DS, Dadoo S, Arner JW, Musahl V, Bradley JP. Trends in Anterior Cruciate Ligament Reconstruction Techniques and Postoperative Care Among Leaders in the Field: A Survey of the Herodicus Society. Orthop J Sports Med 2024; 12:23259671241274770. [PMID: 39421046 PMCID: PMC11483677 DOI: 10.1177/23259671241274770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/05/2024] [Indexed: 10/19/2024] Open
Abstract
Background Despite a growing body of literature regarding anterior cruciate ligament reconstruction (ACLR), there remains a wide diversity in surgical technique and clinical practice across providers. Purpose To (1) describe current ACLR practice preferences among members of the Herodicus society and (2) determine whether these preferences are influenced by years in practice and overall surgical volume. Study Design Cross-sectional study. Methods A 24-question survey investigating surgeons' practices and preferred ACLR surgical techniques was sent via email to all active Herodicus Society members. Survey responses were subdivided by years of experience and overall ACLR annual case volume. Descriptive statistics were compiled and chi-square testing was utilized to determine the significance of experience and case volume on survey responses. Results Of the 113 invited Herodicus Society members who perform ACLR, 69 (61%) completed the survey. Respondents had a mean ± SD of 30.9 ± 9.8 years of experience in clinical practice and performed a mean of 96.0 ± 50.7 primary and 21.6 ± 16.9 revision ACLR annually. Of revision cases, 72.1% were performed using a single-stage technique. Mean frequency of graft usage by surgeon was bone-patellar tendon-bone autograft (58.6%), quadriceps autograft (14.6%), hamstring tendon autograft (14.0%), and allograft (11.8%). The plurality of surgeons responded that they used anterolateral augmentation "rarely" in primary ACLR (39.1%) and "sometimes" in revision ACLR (31.9%), with the majority performing lateral extra-articular tenodesis (66.7%) rather than anterolateral ligament reconstruction (14.5%). Most surgeons would not allow a 20-year-old football player to return before 7 months after ACLR (71.0%) but highly valued return-to-sports testing to determine readiness (94.2%). Higher volume surgeons performed single-stage revision ACLR at a significantly higher rate (79.8% vs 62.9%, P = .02) and significantly differed in return-to-sports criteria, with a greater proportion relying primarily on biometric testing (P = .01). Conclusion The survey demonstrated that, in the Herodicus Society, a wide range of preferences exist regarding ACLR surgical technique. Bone-patellar tendon-bone autograft is the most frequent primary ACLR graft choice. Most participants have not embraced newer techniques such as anterolateral or suture tape augmentation. Return to sports is generally not allowed before 7 months and heavily factors-in return-to-sports testing metrics, suggesting that purely time-based criteria for return to sports is not modern practice among elite sports medicine surgeons.
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Affiliation(s)
- Ian D. Engler
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Central Maine Healthcare Orthopedics, Central Maine Medical Center, Lewiston, Maine, USA
| | - Michael A. Fox
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew J. Curley
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Damaris S. Mohr
- Department of Orthopaedic Surgery, Burke and Bradley Orthopaedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sahil Dadoo
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Justin W. Arner
- Department of Orthopaedic Surgery, Burke and Bradley Orthopaedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James P. Bradley
- Department of Orthopaedic Surgery, Burke and Bradley Orthopaedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Park HJ, Yoon C, Kang SB, Kim TW, Chang CB, Bae TS, Chang MJ, Kwak DS. Presoaking hamstring autograft with vancomycin does not jeopardize its biomechanical properties, including graft elongation, after cyclic loading. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39138856 DOI: 10.1002/ksa.12425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 07/26/2024] [Accepted: 07/31/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE Presoaking the graft with vancomycin before implantation has been shown to reduce the risk of postoperative infection after anterior cruciate ligament reconstruction (ACLR). However, the effects of presoaking on the graft biomechanical properties remain unclear. This study aimed to determine whether presoaking the graft with vancomycin affects the graft biomechanical properties and length after cyclic loading. METHODS Ten paired (20 specimens) gracilis and semitendinous tendons were harvested from fresh-frozen human cadaveric specimens. Two tendons were folded in half to make four strands, and the grafts were randomized into the vancomycin and control groups. The graft was exposed to the antibiotic solution for 15 min (5 mg/mL) and prepared by mixing 1 g of vancomycin with 200 mL of normal saline (NaCl 0.9%). The control group was soaked in normal saline for 15 min. The prepared grafts were attached to the actuator of a dynamic tensile-testing machine. All grafts were tested with 3000 cycles of cyclic loading followed by a pull-to-failure. The cyclic loading protocol consisted of position and load control blocks to simulate the graft in vivo in the postoperative phase after ACLR. RESULTS Presoaking in vancomycin did not jeopardize the biomechanical properties of the graft. In addition, presoaking with vancomycin did not elongate the grafts. No significant differences were found in the mean Young's modulus and the mean total elongation of the graft of the specimen between the vancomycin group and the control group. CONCLUSION Presoaking the graft with vancomycin jeopardized neither its biomechanical properties nor elongation even after cyclic loading in this in vitro study. It is suggested that vancomycin presoaking could be considered a safe and effective preventive measure for postoperative infections after ACLR. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Hyung Jun Park
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan, Republic of Korea
| | - Chan Yoon
- Department of Orthopedic Surgery, Seoul Bumin Hospital, Seoul, Republic of Korea
| | - Seung-Baik Kang
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Woo Kim
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chong Bum Chang
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Tae Soo Bae
- Department of Biomedical Engineering (BME), Jungwon University, Goesan-gun, Republic of Korea
| | - Moon Jong Chang
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dai-Soon Kwak
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Yoshida R, Koga H, Matsuda J, Nakamura T, Miyatake K, Katagiri H, Katakura M, Yoshihara A, Seki R, Katsumata T, Mizuno M, Watanabe K, Sekiya I, Tsuji K, Nakagawa Y. Presoaking Grafts in Vancomycin Does Not Impair Graft-Bone Healing in a Rat Anterior Cruciate Ligament Reconstruction Model. Am J Sports Med 2024; 52:1784-1793. [PMID: 38721771 DOI: 10.1177/03635465241247843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND The vancomycin presoaking technique (wherein grafts are treated with a vancomycin solution [VS] for anterior cruciate ligament reconstruction [ACLR]) reduces the infection rate after ACLR. However, the effects of this technique on graft-bone healing have not been fully elucidated. PURPOSE To investigate the effects of vancomycin presoaking on graft-bone healing in a rat ACLR model. STUDY DESIGN Controlled laboratory study. METHODS Long flexor digitorum longus tendons were obtained from 9 Wistar rats, and each was randomly allocated to the normal saline (NS) or VS groups. The grafts were immersed in sterile saline for 30 minutes in the NS group and in a 5-mg/mL VS in the VS group. The presence of time-zero graft bacterial contamination was confirmed, and the grafts were incubated in Fluidised Thioglycollate Broth for 2 weeks. ACLR was performed on the right knees of 65 male Wistar rats using the flexor digitorum longus tendons. Each graft was similarly treated. Biomechanical testing, micro-computed tomography, and histological evaluations were performed 4 and 12 weeks postoperatively. RESULTS The VS group showed significantly reduced graft contamination at time zero (P = .02). The mean maximum loads to failure were 13.7 ± 8.2 N and 11.6 ± 4.8 N in the NS and VS groups, respectively, at 4 weeks (P = .95); and 23.2 ± 13.2 N and 30.4 ± 18.0 N in the NS and VS groups, respectively, at 12 weeks (P = .35). Regarding micro-computed tomography, the mean bone tunnel volumes were 3.76 ± 0.48 mm3 and 4.40 ± 0.58 mm3 in the NS and VS groups, respectively, at 4 weeks (P = .41); and 3.51 ± 0.38 mm3 and 3.67 ± 0.35 mm3 in the NS and VS groups, respectively, at 12 weeks (P = .54). Histological semiquantitative examination revealed no clear between-group differences at any time point. CONCLUSION Presoaking grafts in vancomycin in a rat ACLR model demonstrated no discernible adverse effects on short- and midterm biomechanical, radiological, and histological investigations. CLINICAL RELEVANCE The findings provide guidance for surgeons when considering this technique.
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Affiliation(s)
- Ryu Yoshida
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Junpei Matsuda
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazumasa Miyatake
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroki Katagiri
- Department of Orthopaedic Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Mai Katakura
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Aritoshi Yoshihara
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryota Seki
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Toyohiro Katsumata
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Mitsuru Mizuno
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Ken Watanabe
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Ichiro Sekiya
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Kunikazu Tsuji
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan; Department of Cartilage Regeneration, Tokyo Medical and Dental University, Tokyo, Japan
- Investigation performed at Tokyo Medical and Dental University, Tokyo, Japan
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Rougereau G, Hassan SK, Valentin E, Jehan S, Bauer T, Baudrier N, Hardy A. Incidence of Septic Arthritis After Vancomycin Soaking of the Graft During Arthroscopic Anatomic Anterior Talofibular Ligament and Calcaneofibular Ligament Reconstruction. Orthop J Sports Med 2024; 12:23259671241228276. [PMID: 38444570 PMCID: PMC10913514 DOI: 10.1177/23259671241228276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/10/2023] [Indexed: 03/07/2024] Open
Abstract
Background Vancomycin soaking of the graft during arthroscopic anterior cruciate ligament reconstruction has been shown to be effective in reducing the rate of postoperative infection. Purpose/Hypothesis The present study aimed to (1) analyze the effect of vancomycin-soaked grafts during arthroscopic anatomic reconstruction of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) on the incidence of infection and (2) evaluate the influence of infection on functional outcomes and identify the risk factors of infection. It was hypothesized that vancomycin soaking of the graft would reduce the postoperative infection rate. Study Design Cohort study; Level of evidence, 3. Methods Consecutive patients at 2 centers who underwent ATFL/CFL reconstruction between December 2011 and July 2022 were included. All patients had undergone anterolateral arthroscopic debridement of the ankle and anatomic ATFL/CFL reconstruction with a gracilis tendon autograft. Vancomycin soaking of the graft was begun in both centers in January 2021. Complications, functional scores, return to sports (RTS) rates, and the level of return were compared between patients with and without vancomycin-soaked grafts and between patients with and without infection. Results Overall, 182 patients (48% men; mean age, 34 ± 11.9 years) were included, with a mean follow-up of 23 ± 16.1 months. The rate of postoperative infection was significantly lower in the group with vancomycin soaking versus without (0/92 [0%] vs 8/90 [8.9%]; P = .001). At the final follow-up, there were 26 complications (14.3%): 8 infections, 6 recurrent tears, and 12 peripheral neuropathies. The infections developed after a mean of 17 ± 11 days. The functional scores were excellent at the final follow-up (American Orthopaedic Foot and Ankle Society [AOFAS] Ankle-Hindfoot Score, 86.5 ± 18.7; Karlsson score, 85 ± 18.3). Patients with infection had significantly decreased AOFAS scores (52.8 ± 27.6 vs 83.3 ± 21.5; P = .003), Karlsson scores (57 ± 27.7 vs 83.6 ± 20; P = .006), and RTS rates (25% vs 77%; P = .005) versus patients without infection. Conclusion Vancomycin-soaked grafts for arthroscopic anatomic ATFL/CFL reconstruction decreased the rate of postoperative infection. Infection led to a deterioration in results. Vancomycin-soaking of the graft did not have a negative effect on functional results.
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Affiliation(s)
- Grégoire Rougereau
- Hospital Ambroise Pare, APHP, Boulogne Billancourt, France
- Hospital Pitie Salpetriere, APHP, Paris, France
| | - Sammy Kassab Hassan
- Hospital Ambroise Pare, APHP, Boulogne Billancourt, France
- Hospital Pitie Salpetriere, APHP, Paris, France
| | | | - Sacha Jehan
- Hospital Ambroise Pare, APHP, Boulogne Billancourt, France
| | - Thomas Bauer
- Hospital Ambroise Pare, APHP, Boulogne Billancourt, France
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5
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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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Mancino F, Yates PJ, Clark B, Jones CW. Use of topical vancomycin powder in total joint arthroplasty: Why the current literature is inconsistent? World J Orthop 2023; 14:589-597. [PMID: 37662663 PMCID: PMC10473911 DOI: 10.5312/wjo.v14.i8.589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/28/2023] [Accepted: 04/20/2023] [Indexed: 08/17/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a rare but terrible complication in hip and knee arthroplasty, and the use of topical vancomycin powder (VP) has been investigated as a tool to potentially reduce its incidence. However, there remains no consensus on its efficacy. Therefore, the aim of this review is to provide an overview on the application of topical vancomycin in orthopaedic surgery focusing on the recent evidence and results in total joint arthroplasty. Several systematic reviews and meta-analyses on topical VP in hip and knee arthroplasty have been recently published reporting sometimes conflicting results. Apart from all being limited by the quality of the included studies (mostly level III and IV), confounding variables are often included potentially leading to biased conclusions. If taken into consideration the exclusive use of VP in isolation, the available data, although very limited, suggest that it does not reduce the infection rate in routine primary hip and knee arthroplasty. Therefore, we still cannot advise for a routinary application. A properly powered randomized-controlled trial would be necessary to clarify the role of VP in hip and knee arthroplasty. Based on the analysis of the current evidence, the use of topical VP appears to be safe when used locally in terms of systemic adverse reactions, hence, if proven to be effective, it could bring great benefits due to its low cost and accessibility.
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Affiliation(s)
- Fabio Mancino
- Department of Orthopaedics, Fiona Stanley Hospital, Perth 6150, Australia
| | - Piers J Yates
- Department of Orthopaedics, Fiona Stanley Hospital, Perth 6150, Australia
- Department of Orthopaedics, The Orthopaedic Research Foundation of Western Australia, Perth 6010, Australia
- Department of Orthopaedics, University of Western Australia, Perth 6009, Australia
| | - Benjamin Clark
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth 6150, Australia
| | - Christopher W Jones
- Department of Orthopaedics, Fiona Stanley Hospital, Perth 6150, Australia
- Department of Orthopaedics, The Orthopaedic Research Foundation of Western Australia, Perth 6010, Australia
- Department of Orthopaedics, Curtin University, Perth 6102, Australia
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Pfeiffer TR, Althoff A, Krombholz S, Dautert M, Naendrup JH, Guenther D, Bouillon B, Thevis M. Vancomycin Concentrations in Synovial Fluid Do Not Reach Chondrotoxic Thresholds After Anterior Cruciate Ligament Reconstruction With Vancomycin-Soaked Autologous Soft Tissue Grafts: An In Vivo Prospective Observational Study in Humans. Am J Sports Med 2023:3635465231169040. [PMID: 37161935 DOI: 10.1177/03635465231169040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Studies have revealed that vancomycin soaking of the anterior cruciate ligament (ACL) graft can drastically reduce the incidence of postoperative infections after ACL reconstruction. However, it remains unknown whether the chondrotoxic threshold of vancomycin in synovial fluid is exceeded during this process. Several studies investigated the chondrotoxic properties of vancomycin in in vitro experiments and described a concentration of 1000 µg/mL as the critical threshold. PURPOSE/HYPOTHESIS The purpose of the study was to measure the vancomycin concentration in synovial fluid after ACL reconstruction with vancomycin-soaked autografts. It was hypothesized that intra-articular vancomycin concentrations in the synovial fluid would not reach the chondrotoxic threshold of 1000 µg/mL after vancomycin soaking of autologous semitendinosus tendon and soft tissue quadriceps tendon grafts for ACL reconstruction. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study enrolled 10 patients undergoing ACL reconstruction using 4-strand semitendinosus tendon autografts and 10 patients undergoing ACL reconstruction using soft tissue quadriceps tendon autografts. Before implantation, each harvested graft was intraoperatively wrapped in gauze swabs that had been soaked in a 5-mg/mL vancomycin solution. After wound closure, an aspirate of 5 mL of synovial fluid was taken from each patient. The vancomycin concentration of the aspirate was analyzed using high-performance liquid chromatography-tandem mass spectrometry. Spearman rho correlation coefficients were used to identify relationships between the parameters, and the t test was used to test for differences between graft types. A P value of <.05 was considered statistically significant. RESULTS The study included 20 patients (14 women and 6 men; age, 29.35 ± 11.3 years). The mean vancomycin concentration measured in the synovial fluid was 23.23 ± 21.68 µg/mL, with a minimum concentration of 2.32 µg/mL and a maximum concentration of 71.56 µg/mL. No significant difference was found between the 2 graft types (P = .911). Significant positive correlation (r = 0.644; P < .05) was observed only between the vancomycin concentration and the mean duration from initiation of vancomycin soaking of semitendinosus tendon grafts to implantation (13.4 ± 6 minutes). No correlations were observed between the vancomycin concentration and the duration from implantation to fluid aspiration or between the vancomycin concentration and the graft diameter (median, 8.5 mm; range, 6.0-10.0 mm) for both graft types. CONCLUSION Chondrotoxic vancomycin concentrations ≥1000 µg/mL were not reached in any aspiration of synovial fluid after ACL reconstruction using soft tissue autografts that were intraoperatively soaked in a 5-mg/mL vancomycin solution. Against the backdrop of multiple studies that showed significantly reduced infection rates after ACL reconstruction when vancomycin soaking was used, this study suggests that the chondrotoxic properties of this method are negligible because of its submarginal intra-articular concentrations.
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Affiliation(s)
- Thomas R Pfeiffer
- Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Arne Althoff
- Department of Experimental Sports Traumatology, Witten/Herdecke University, Witten, Germany
| | - Sophia Krombholz
- Center for Preventive Doping Research, Institute of Biochemistry, German Sport University Cologne, Cologne, Germany
| | - Max Dautert
- Center for Preventive Doping Research, Institute of Biochemistry, German Sport University Cologne, Cologne, Germany
| | - Jan-Hendrik Naendrup
- Department of Experimental Sports Traumatology, Witten/Herdecke University, Witten, Germany
| | - Daniel Guenther
- Department of Experimental Sports Traumatology, Witten/Herdecke University, Witten, Germany
| | - Bertil Bouillon
- Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Mario Thevis
- Center for Preventive Doping Research, Institute of Biochemistry, German Sport University Cologne, Cologne, Germany
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A Review of Evidence for Infection Reduction With Vancomycin-treated Anterior Cruciate Ligament Grafts. J Am Acad Orthop Surg 2022; 30:e1571-e1579. [PMID: 36476465 DOI: 10.5435/jaaos-d-22-00463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/10/2022] [Indexed: 12/13/2022] Open
Abstract
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.
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Pandey V, Madi S, Thonse C, Joseph C, Rajan D, Varughese J, Thilak J, Jayaprasad PS, Acharya K, Ramamurthy KG, Reddy R, Amravathi R, Rao S, Gangavarapu S, Srinivas M, Jose S, Sundararjan SR. Trends in Primary Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Practice in Adult Patients Prevalent Among Arthroscopy Surgeons of Six Southern States of India. Indian J Orthop 2022; 56:1703-1716. [PMID: 36187588 PMCID: PMC9485326 DOI: 10.1007/s43465-022-00719-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although guidelines from multiple scientific studies decide the general trend in ACLR practice, there is often a variation between scientific guidelines and actual practice. METHODS A 17-member committee comprised of sports surgeons with experience of a minimum of 10 years of arthroscopy surgery finalized a survey questionnaire consisting of concepts in ACL tear management and perioperative trends, intraoperative and post-operative practices regarding single-bundle anatomic ACLR. The survey questionnaire was mailed to 584 registered sports surgeons in six states of south India. A single, non-modifiable response was collected from each member and analyzed. RESULTS 324 responses were received out of 584 members. A strong consensus was present regarding Hamstring tendons preference for ACLR, graft diameter ≥ 7.5 mm, viewing femoral footprint through the anterolateral portal, drilling femoral tunnel from anteromedial portal guided by ridges and remnants of femoral footprint using a freehand technique, suspensory devices to fix the graft in femur and interference screw in the tibia and post-operative bracing. A broad consensus was achieved in using a brace to minimize symptoms of instability of an ACL tear and antibiotic soaking of graft. There was no consensus regarding the timing of ACLR, preferred graft in athletes, pre-tensioning, extra-articular procedure, and return to sports. There was disagreement over hybrid tibial fixation and suture tapes to augment graft. CONCLUSION Diverse practices continue to prevail in the management of ACL injuries. However, some of the consensuses reached in this survey match global practices. Contrasting or inconclusive practices should be explored for potential future research.
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Affiliation(s)
- Vivek Pandey
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Sandesh Madi
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Chirag Thonse
- Vikram Hospital, Millers Road, Bangalore, 560052 India
| | - Clement Joseph
- Arthroscopy and Sports Medicine, SRM Institute for Medical Sciences, Vadapalani, Chennai, Tamil Nadu 600 026 India
| | - David Rajan
- Ortho-One Orthopaedic Speciality Centre, Trichy Road, Singanallur, Coimbatore, Tamil Nadu 641005 India
| | | | - Jai Thilak
- Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala 682 041 India
| | - P. S. Jayaprasad
- Kamineni Hospitals, L.B. Nagar, Bahadurguda, Hyderabad, Telangana 500068 India
| | - Kiran Acharya
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | | | - Raghuveer Reddy
- Krishna Institute of Medical Sciences Secunderabad, Hyderabad, India ,Care Hospitals in Banjara Hills, Hyderabad, India ,Sai Institute of Sports Injury and Arthroscopy in Banjara Hills, Hyderabad, 500 004 India
| | - Rajkumar Amravathi
- St John’s Medical College Hospital, Sarjapur Road, Bangalore, 560034 India
| | - Sharath Rao
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Sridhar Gangavarapu
- Department of Orthopaedics, Medicover Hospitals, Gokhale Rd, Krishna Nagar, Maharani Peta, Visakhapatnam, Andhra Pradesh 530002 India
| | - Moparthi Srinivas
- Nandan Hospital, Suryarao Pet, Vijayawada, Andhra Pradesh 520002 India
| | - Sujit Jose
- Institute of Advanced Orthopaedics at MOSC Hospital and Medical College, Kolenchery, Ernakulam, Kerala 682311 India
| | - S. R. Sundararjan
- Arthroscopy and Sports Medicine, Ganga Hospital, Coimbatore, 641 043 India
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10
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Xiao M, Abrams GD. Editorial Commentary: Soaking Anterior Cruciate Ligament Grafts in Vancomycin Solution Lowers Infection Rates Without Lowering Functional Outcomes. Arthroscopy 2022; 38:1535-1536. [PMID: 35501018 DOI: 10.1016/j.arthro.2021.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 02/02/2023]
Abstract
Soaking anterior cruciate ligament grafts in vancomycin solution is done by many surgeons. Research has indicated decreased infection rates and similar anterior cruciate ligament retear rates between grafts soaked in vancomycin solution before implantation versus those without. In addition, there has been basic science evidence for tenocyte survival and viability even when exposed to vancomycin solution. The next frontier, investigating the maturation of vancomycin-soaked grafts with advanced imaging, may cause some surgeons to reconsider the practice but should not stop it, based on the available literature.
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Affiliation(s)
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- Stanford University School of Medicine (M.X.)
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11
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Truong AP, Pérez-Prieto D, Byrnes J, Monllau JC, Vertullo CJ. Vancomycin Soaking Is Highly Cost-Effective in Primary ACLR Infection Prevention: A Cost-Effectiveness Study. Am J Sports Med 2022; 50:922-931. [PMID: 35180008 DOI: 10.1177/03635465211073338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although presoaking grafts in vancomycin has been demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain. PURPOSE To 1) determine the cost-effectiveness of vancomycin presoaking during primary ACLR to prevent postoperative joint infections and 2) to establish the break-even cost-effectiveness threshold of the technique and determine its cost-effectiveness across various international health care settings. STUDY DESIGN Economic and decision analysis; Level of evidence, 2. METHODS A Markov model was used to determine cost-effectiveness and the incremental cost-effectiveness ratio of additional vancomycin presoaking compared with intravenous antibiotic prophylaxis alone. A repeated search of the PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials databases, using the same criteria as a recent meta-analysis, was completed. A repeated meta-analysis of 9 cohort studies (level 3 evidence) was completed to determine the odds ratio of infection with vancomycin presoaking compared with intravenous antibiotics alone. Estimated costs of the vancomycin technique, treatment of infection, and further surgery were sourced from local hospitals and literature. Transitional probabilities for further surgery, including revision reconstruction and primary arthroplasty, were obtained from the literature. Probabilistic sensitivity analyses and a 1-way sensitivity analysis were performed to evaluate the ACLR infection rate break-even threshold for which the vancomycin technique would be no longer cost-effective. RESULTS The vancomycin soaking technique provides expected cost savings of $660 (USA), A$581 (Australia), and €226 (Spain) per patient. There was an improvement in the quality-adjusted life-years of 0.007 compared with intravenous antibiotic prophylaxis alone (4.297 vs 4.290). If the infection rate is below 0.014% with intravenous antibiotics alone, the vancomycin wrap would no longer be cost-effective. CONCLUSION The vancomycin presoaking technique is a highly cost-effective method to prevent postoperative septic arthritis after primary ACLR.
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Affiliation(s)
- Anthony P Truong
- Department of Orthopaedics, Toowoomba Base Hospital & Gold Coast University Hospital, Toowoomba, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - Daniel Pérez-Prieto
- ICATKNEE, Hospital Universitari Dexeus, Barcelona, Spain.,Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Joshua Byrnes
- Centre for Applied Health Economics, Menzies Health Institute Queensland, School of Medicine and Dentistry, Griffith University, Brisbane, Queensland, Australia
| | - Joan C Monllau
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,Department of Orthopaedic Surgery and Traumatology, Hospital del Mar ICATKNEE, Hospital Universitari Dexeus, Barcelona, Spain
| | - Christopher J Vertullo
- Orthopaedic Surgery & Sports Medicine Centre, Gold Coast, Queensland, Australia.,Knee Research Australia, Gold Coast, Queensland, Australia.,Menzies Health, Griffith University, Brisbane, Queensland, Australia.,Australian Knee Society.,Australian Orthopaedic Association.,AOA Continuing Orthopaedic Education
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12
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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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13
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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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14
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A Current Concepts Review The role of vancomycin-soaking of the graft in anterior cruciate ligament reconstruction. J ISAKOS 2022; 7:94-98. [DOI: 10.1016/j.jisako.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/14/2021] [Accepted: 12/30/2021] [Indexed: 11/22/2022]
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15
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Editorial Commentary: Vancomycin Solution Pretreatment of Anterior Cruciate Ligament Tendon Graft Reduces Infection Rates, Is Clinically and Biomechanically Sound, and Is Cost-Effective. Arthroscopy 2021; 37:3157-3158. [PMID: 34602155 DOI: 10.1016/j.arthro.2021.05.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 02/02/2023]
Abstract
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.
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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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