Significantly Lower Infection Risk for Anterior Cruciate Ligament Grafts Presoaked in Vancomycin Compared With Unsoaked Grafts: A Systematic Review and Meta-analysis

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of evidence

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

Presoaking hamstring autograft with vancomycin does not jeopardize its biomechanical properties, including graft elongation, after cyclic loading

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.

Infection after Anterior Cruciate Ligament Reconstruction: A Narrative Review of the Literature

Infection is an uncommon side effect of arthroscopic surgery, and this percentage is higher in anterior cruciate ligament reconstruction (ACLR) surgery, where graft and fixation devices are used. Infections can not only lead to high re-admission rates and poor functional recovery of the knee but can also have a significant negative impact on the patient's psychological and economic health, especially in athletes, as it can affect their sports career. It is important to be aware of the many risk factors, especially the manifestation of symptoms. These may sometimes be non-specific to the infectious pathology and common to other situations, such as the presence of a significant intra-articular hematoma. Septic arthritis after ACLR can occur at any time after surgery but typically presents acutely, while late manifestation is relatively rare. Diagnosis of infection is based on patient history, physical examination, laboratory parameters, and analysis of synovial fluid after joint aspiration, which is the gold standard for diagnosing post-operative infection. Once symptoms appear and the diagnosis seems certain, it is necessary to intervene quickly with arthroscopic debridement and long-term antibiotic treatment to try to save the graft and resolve the infectious situation to avoid graft failure and arthrofibrotic sequelae. The aim of this paper is to provide an overview of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic evaluation, and current treatment guidelines of septic arthritis after ACLR surgery by analyzing recent literature, in particular meta-analyses and systematic reviews.

Editorial Commentary: Low-Grade Infections May Contribute to Anterior Cruciate Ligament Reconstruction Graft Failure

The etiology of anterior cruciate ligament (ACL) reconstruction failure is often multifactorial, and the role of subclinical bacterial colonization in ACL reconstruction failure has not been fully elucidated. Although the presence of bacterial metabolism in and of itself does not indicate true clinical infection, low-grade infections may contribute to ACL reconstruction graft failure. Bacterial biofilms on soft tissue grafts are shown to change the crimp patterns of collagen and lower graft load to failure. In addition, bacterial DNA has been reported in 80-87% of failed ACL grafts during revision surgery compared to only 20% of primary ACL grafts. Also, higher bacterial DNA concentration is associated with tibial tunnel widening. Further study is needed to establish if any causal relationship between bacterial colonization and ACL graft failure exists. But it does seem that the circumstantial evidence is pointing to such a relationship.

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

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.

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

Background

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

Purpose

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

Study Design

Systematic review; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

Combined press-fit and extracortical fixation in patellar tendon anterior cruciate ligament reconstruction results in reliable graft fixation and early bone block incorporation

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction with bone-patellar-tendon-bone (BPTB) autograft has the potential biological advantage of direct bone-to-bone healing over soft tissue grafts. The primary aim of this study was to investigate possible graft slippage and therefore fixation strength in a modified BPTB autograft technique with suspensory fixation on both sides for primary ACL reconstruction until bony integration takes place.

METHODS

Twenty-one patients undergoing primary ACL reconstruction with a modified BPTB autograft (bone-on-bone (BOB) technique) between August 2017 and August 2019 were included in this prospective study. A computed tomography (CT) scan of the affected knee was performed directly postoperatively, as well as 3 months postoperatively. Examiner-blinded parameters for graft slippage, early tunnel widening, bony incorporation, as well as remodeling of the autologous refilled patellar harvest site were investigated.

RESULTS

A series of 21 patients treated with a BPTB autograft with this technique underwent two CT investigations. Comparison of CT scans showed no bone block displacement and therefore no graft slippage in the patient cohort. Only one patient showed signs of early tunnel enlargement. Radiological bone block incorporation took place showing bony bridging of the graft to the tunnel wall in 90% of all patients. Furthermore, 90% showed less than 1 mm bone resorption of the refilled harvest site at the patella.

CONCLUSIONS

Our findings suggest graft fixation stability and reliability of anatomic BPTB ACL reconstruction with a combined press-fit and suspensory fixation technique by absence of graft slippage within the first 3 months postoperatively.

In Vitro Study of Gentamicin Elution from Tendon Grafts

Background

Though vancomycin-soaked graft reduces the infection rate after ACL reconstruction, concerns exist regarding this usage. Gentamicin has been used for graft soakage with satisfactory clinical results but gentamicin's elution characteristics are unknown.

Methods

Thirty Bovine tendon grafts were harvested from ten limbs under sterile conditions. Three tendons from each of the limbs were allotted into three groups and soaked in either saline, gentamicin or vancomycin. Pre-soakage and post-soakage swabs were cultured. Soaked grafts were immersed in a 10 ml saline solution for 5 min (initial washout) and then in another 10 ml saline solution (sustained release) for 10 min. No 1 Whatman filter paper was immersed in the solutions and placed on culture plates streaked with coagulase-negative Staphylococcus aureus (CONS) and methicillin-resistant Staphylococcus aureus (MRSA), and inhibition was noted. The difference between the two proportions was assessed by two proportion t-test for p < 0.05.

Results

No organism was cultured in the pre-soakage or post-soakage swab in any specimen. Specimens from one limb were excluded since saline-soakage showed inhibition. Elution from gentamicin-soaked graft inhibited CONS in eight out of nine samples in initial washout and all samples in sustained release solution but inhibited MRSA only in one sample in sustained release solution and the initial washout solution. Vancomycin elution inhibited both organisms in all samples.

Conclusions

Gentamicin elution from tendon graft achieves minimal inhibitory concentration against susceptible organisms. Though its clinical utility is restricted by limited antimicrobial spectrum, and it could be used where the risk of contamination by MRSA is low.

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

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.

Influence of Staphylococcus epidermidis biofilm on the mechanical strength of soft tissue allograft

We sought to determine the impact of bacterial inoculation and length of exposure on the mechanical integrity of soft tissue tendon grafts. Cultures of Staphylococcus epidermidis were inoculated on human tibialis posterior cadaveric tendon to grow biofilms. A low inoculum in 10% growth medium was incubated for 30 min to replicate conditions of clinical infection. Growth conditions assessed included inoculum concentrations of 100, 1000, 10,000 colony-forming units (CFUs). Tests using the MTS Bionix system were performed to assess the influence of bacterial biofilms on tendon strength. Load-to-failure testing was performed on the tendons, and the ultimate tensile strength was obtained from the maximal force and the cross-sectional area. Displacements of tendon origin to maximal displacement were normalized to tendon length to obtain strain values. Tendon force-displacement and stress-strain relationships were calculated, and Young's modulus was determined. Elastic modulus and ultimate tensile strength decreased with increasing bioburden. Young's modulus was greater in uninoculated controls compared to tendons inoculated at 10,000 CFU (p = 0.0011) but unaffected by bacterial concentrations of 100 and 1000 CFU (p = 0.054, p = 0.078). Increasing bioburden was associated with decreased peak load to failure (p = 0.043) but was most significant compared to the control under the 10,000 and 1000 CFU growth conditions (p = 0.0005, p = 0.049). The presence of S. epidermidis increased elasticity and decreased ultimate tensile stress of human cadaveric tendons, with increasing effect noted with increasing bioburden.

Short-term vancomycin and buffer soaking does not change rabbit achilles tendon tensile material properties

BACKGROUND

Allograft tendons are commonly used during orthopedic surgery to reconstruct tissue that is severely damaged. Soaking the tendon in an antibiotic solution, specifically vancomycin, has been shown to lower the risk of post-operative infections. While some material properties of tendon and ligament after antibiotic soaking have previously been characterized, extensive sub-failure allograft tendon material properties after soaking in antibiotic solutions have not.

METHODS

Forty tendons were dissected from rabbits and soaked in either a phosphate buffered saline (PBS) only solution or vancomycin and PBS solution for five or 30 min. Immediately after soaking, quasi-static tensile experiments were performed in a materials testing system.

FINDINGS

Tissue nominal stress, Lagrange strain, toe-region properties and elastic modulus were characterized. For all forty tendons, the average elastic modulus was found to be 455 ± 37 MPa, the average transition strain (from toe-region to linear elastic region) was 0.0487 ± 0.0035, and the average transition stress was 9.71 ± 0.79 MPa. No statistically significant differences in any of these material properties were found across soaking medium or soaking time.

INTERPRETATION

From these results, we conclude that soaking an allograft tendon in antibiotic solution for up to 30 min prior to implantation does not change the tensile material properties of tendons, supporting current clinical practice.

Single AnteroMedial Bundle Biological Augmentation: SAMBBA Plus Technique for Combined ACL Repair and Reconstruction

This technical note presents the single-anteromedial bundle biological augmentation (SAMBBA)-plus technique, which is a combined anterior cruciate ligament (ACL) repair and ACL reconstruction. Preservation of the native ACL fibers improves vascularity by encircling the ACL graft with synovium that is abundant in vascular-derived stem cells. Retaining the proprioceptive fibers of the native ACL can improve the recovery of joint positioning.

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

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

Postoperative Infection after Anterior Cruciate Ligament Reconstruction: Prevention and Management

Infection following anterior cruciate ligament (ACL) reconstruction can be one of the most debilitating complications following ACL reconstruction. Its reported incidence is around 1%. Utilization of vancomycin for presoaking the graft is considered an established method for infection prevention. The role of other agents, such as gentamycin needs further investigation. Staphylococci are the predominant causative pathogens, while particular attention should be paid to fungal infections due to their long-standing, occult process. Recent data demonstrate that hamstrings autograft may be at an elevated risk of being contaminated leading to subsequent septic arthritis. Diagnosis is set by clinical and laboratory findings and is usually confirmed by intraoperative cultures. Treatment varies, mainly depending on the intraoperative assessment. Satisfactory outcomes have been reported with both graft retaining and removal, and the decision is made upon the arthroscopic appearance of the graft and the characteristics of the infection. Of note, early management seems to lead to superior results, while persistent infection should be managed with graft removal in an attempt to protect the articular cartilage and the knee function.

Risk Factors for Anterior Cruciate Ligament Graft Failure in Professional Athletes: An Analysis of 342 Patients With a Mean Follow-up of 100 Months From the SANTI Study Group

BACKGROUND

Anterior cruciate ligament (ACL) injuries are among the most common knee injuries sustained in elite sport, and athletes generally undergo ACL reconstruction (ACLR) to facilitate their return to sport. ACL graft rupture is a career-threatening event for elite athletes.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine the risk factors for graft failure in professional athletes undergoing ACLR. It was hypothesized that athletes who underwent combined ACLR with a lateral extra-articular procedure (LEAP) would experience significantly lower rates of graft rupture in comparison with those who underwent isolated ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Professional athletes who underwent primary ACLR with a minimum follow-up of 2 years were identified from the Santy database. Patients were excluded if they underwent major concomitant procedures, including multiligament reconstruction surgery or osteotomy. Further ipsilateral knee injury, contralateral knee injury, and any other reoperations or complications after the index procedure were identified by interrogation of the database and review of the medical notes.

RESULTS

A total of 342 athletes with a mean follow-up of 100.2 ± 51.9 months (range, 24-215 months) were analyzed. Graft failures totaling 31 (9.1%) were reported, requiring revision surgery because of symptomatic instability. The rate of graft failure was significantly higher when ACLR was not combined with a LEAP (15.5% vs 6.0%; P = .0105) and in athletes aged 21 years or younger (13.8% vs 6.6%; P = .0290). A multivariate analysis was performed using the Cox model and demonstrated that athletes undergoing an isolated ACLR were at >2-fold risk of ACL graft rupture (hazard ratio [HR], 2.678 [1.173; 4.837], P = .0164) when compared with those undergoing a combined ACLR with a LEAP. Additionally, athletes aged ≤21 years were also at >2-fold risk of graft failure (HR, 2.381 [1.313; 5.463]; P = .0068) than those aged >21 years. Sex, sport, and graft type were not found to be significant risk factors for graft failure.

CONCLUSION

Professional athletes undergoing isolated ACLR and aged ≤21 years are at >2-fold greater risk of graft failure. Orthopaedic surgeons treating elite athletes should combine an ACLR with a LEAP to improve ACL graft survivorship.

Combined Revision Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction

There has been a substantial increase in the number of revision anterior cruciate ligament (ACL) reconstructions performed in the past decade. This Technical Note describes combined revision ACL and anterolateral ligament reconstruction using outside-in drilling, which avoids the need for 2-stage revision ACL reconstruction because it allows unconstrained anatomic placement.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Editorial Commentary: Soaking Anterior Cruciate Ligament Grafts in Vancomycin Solution Lowers Infection Rates Without Lowering Functional Outcomes

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.

Rates of Infection After ACL Reconstruction in Pediatric and Adolescent Patients: A MarketScan Database Study of 44,501 Patients

BACKGROUND

Numerous studies have demonstrated an increase in the number of anterior cruciate ligament (ACL) reconstruction procedures performed in pediatric patients. Despite this, most knowledge of surgical site infection rates after these procedures are based on adult studies and data is currently limited in pediatric patients. The purpose of this study was to describe and analyze the rates of infection after ACL reconstruction among pediatric patients and adolescent patients (compared with young adult patients) utilizing the MarketScan Commercial Claims and Encounters Database.

METHODS

The Truven Health Analytics MarketScan Commercial Claims and Encounters database was assessed to access health care utilization data for privately insured individuals aged 5 to 30 years old. ACL reconstruction records performed between 2006 and 2018 were identified using Current Procedures Terminology (CPT) codes. International Classification of Diseases Ninth Revision (ICD-9), Tenth (ICD-10) codes and CPT codes were used to identify patients requiring treatment for infection. All patients had at least 180 days of insurance coverage after intervention.

RESULTS

A total of 44,501 individuals aged below 18 years old and 63,495 individuals aged 18 to 30 years old that underwent arthroscopic ACL reconstruction were identified. There were no differences in infection rates between those below 18 years old (0.52%) and those above 18 years old (0.46%, P=0.227). However, among patients below 18 years old, patients below 15 years old had a significantly lower rate of infection at 0.37% compared with adolescents (15 to 17 y old) at 0.55% (P=0.039). Among young adults, males had higher rates of infection than females (0.52% vs. 0.37%), while no difference was observed in the pediatric and adolescent population (0.58% vs. 0.47%, P=0.109).

CONCLUSION

Utilizing an insurance database, this study demonstrated that rates of infection after ACL Reconstruction in a pediatric/adolescent population are low (0.52%) and similar to rates in young adults. Infection rates after ACLR reconstruction appear to be slightly lower in patients under 15 years of age (0.37%).

LEVEL OF EVIDENCE

Level III-Retrospective comparative study.

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

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

Vancomycin Soaking Is Highly Cost-Effective in Primary ACLR Infection Prevention: A Cost-Effectiveness Study

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.

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

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

Editorial Commentary: Is It Time for the Vancomycin Wrap to Become a Universal Recommendation for the Prevention of Septic Arthritis Following Anterior Cruciate Ligament Reconstruction?

Septic arthritis is a devastating complication of anterior cruciate ligament (ACL) reconstruction, which can still occur in approximately 1% of patients despite appropriate intravenous antibiotic prophylaxis and other recommended preventative measures being undertaken. The infection is most likely secondary to the autograft becoming contaminated during harvest and preparation, introducing bacteria into the joint on insertion. Presoaking ACL grafts in 5 mg/mL vancomycin is a novel method developed to eradicate this bacterial contamination and is supported by compelling Level III evidence from multiple observational trials showing a dramatic reduction in infection rates without any evidence of increased graft failure. As such, it is time for this technique to become a universal recommendation? That said, as observational studies using a historical cohort as a comparator are at risk of various biases, Level I evidence is ultimately required for infection prophylaxis methods to be recognized as a universal recommendation in infection control guidelines. Consequently, future research endeavors on the "vancomycin wrap" should focus on randomized controlled trials, possibly nested within ACL registries.