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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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2
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Demmer W, Meyer E, Volkmer E, Ehrl D, Haas-Lützenberger EM, Kuhlmann C, Giunta RE, Wachtel N. [Perioperative Use of Antibiotics as Infection Prophylaxis in Elective Wrist Arthroscopy: A Nationwide Survey]. HANDCHIR MIKROCHIR P 2024; 56:250-256. [PMID: 38657620 DOI: 10.1055/a-2273-4864] [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: 04/26/2024] Open
Abstract
BACKGROUND Wrist arthroscopy is a standard procedure in hand surgery for the diagnosis and treatment of wrist conditions. While perioperative antibiotic prophylaxis (PAP) is not generally recommended for elective hand surgery, there is no official standard for elective wrist arthroscopy. This study aimed to determine the actual clinical use of PAP in elective wrist arthroscopy in Germany and relate it to the structural conditions of clinics performing this procedure. MATERIAL AND METHODS We conducted a systematic search of all facilities in Germany offering wrist arthroscopy. Among these, we performed an online survey using the SoSci Survey online tool via email. RESULTS PAP is more frequently administered in cases involving simultaneous bone procedures. Cephalosporins are the most commonly used antibiotics in cases of PAP administration. Hospitals administer PAP more frequently than outpatient settings, with most surveyed institutions following facility-specific internal standards for antibiotic administration. The number of arthroscopies performed in the surveyed centres does not influence antibiotic administration. CONCLUSIONS The use of PAP in wrist arthroscopies in Germany is inconsistent. The increased use in arthroscopies with bone involvement corresponds to AWMF guidelines, but a general recommendation for wrist arthroscopies, including soft tissue arthroscopies, is necessary to provide physicians with medical and legal certainty.
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Affiliation(s)
- Wolfram Demmer
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, München, Germany
| | - Emanuel Meyer
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, München, Germany
| | - Elias Volkmer
- Klinik für Handchirurgie, Helios Klinikum München West, München, Germany
| | - Denis Ehrl
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, München, Germany
- Klinik für Plastische, Wiederherstellende und Handchirurgie, Zentrum für Schwerbrandverletzte, Klinikum Nürnberg, Nürnberg, Germany
| | | | - Constanze Kuhlmann
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, München, Germany
| | - Riccardo E Giunta
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, München, Germany
| | - Nikolaus Wachtel
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, München, Germany
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3
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Cassano GD, Moretti L, Vicenti G, Buono C, Albano F, Ladogana T, Rausa I, Notarnicola A, Solarino G. Infection after Anterior Cruciate Ligament Reconstruction: A Narrative Review of the Literature. Healthcare (Basel) 2024; 12:894. [PMID: 38727451 PMCID: PMC11083079 DOI: 10.3390/healthcare12090894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Claudio Buono
- Orthopaedic & Trauma Unit, Department of Traslational Biomedicine and Neuroscience (DiBraiN), School of Medicine, University of Bari Aldo Moro, AOU Consorziale “Policlinico”, 70124 Bari, Italy; (G.D.C.); (L.M.); (G.V.); (F.A.); (T.L.); (I.R.); (A.N.); (G.S.)
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4
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Häner M, Stoffels T, Guenther D, Pfeiffer T, Imhoff A, Herbort M, Stein T, Schoepp C, Akoto R, Höher J, Scheffler S, Stöhr A, Mehl J, Niederer D, Jung T, Kittl C, Eberle C, Vernacchia C, Ellermann A, Braun PJ, Krause M, Mengis N, Müller PE, Best R, Achtnich A, Petersen W. Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment. Knee Surg Sports Traumatol Arthrosc 2024; 32:223-234. [PMID: 38293720 DOI: 10.1002/ksa.12064] [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] [Received: 11/03/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Martin Häner
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
| | | | - Daniel Guenther
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Thomas Pfeiffer
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Andreas Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | | | - Thomas Stein
- SPORTHOLOGICUM® Frankfurt am Main, Frankfurt, Germany
- Department of Sports Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Christian Schoepp
- Department of Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum, Duisburg, Germany
| | - Ralph Akoto
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | | | | | | | - Julian Mehl
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Daniel Niederer
- Department of Movement and Training Science, Faculty of Humanities and Social Sciences, Institute of Sport Science, University of Wuppertal, Wuppertal, Germany
- Institute of Occupational, Social and Environmental Medicine, Goethe University Frankfurt, Frankfurt, German
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | | | - Cara Vernacchia
- Department of Physical Medicine & Rehabilitation, Shirley Ryan Ability Lab, Chicago, Illinois, USA
- McGaw, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Philipp-Johannes Braun
- Department of Trauma and Orthopaedic Surger, BG Hospital Unfallkrankenhaus, Berlin, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Natalie Mengis
- ARCUS Sports Clinic, Pforzheim, Germany
- KSA Aarau/Spital Zofingen, Zofingen, Switzerland
| | - Peter E Müller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Raymond Best
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart, Stuttgart, Germany
- Department of Sports Medicine and Orthopaedics, University of Tuebingen, Tuebingen, Germany
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Wolf Petersen
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
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Pai SN. Arthroscopy in India Through the Medicolegal Lens: A Comprehensive Review. Indian J Orthop 2023; 57:1984-1992. [PMID: 38009181 PMCID: PMC10673772 DOI: 10.1007/s43465-023-01011-4] [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: 06/26/2023] [Accepted: 09/26/2023] [Indexed: 11/28/2023]
Abstract
Introduction With the increasing number of Arthroscopic surgeries, comes with it, the undesirable problem of litigation associated with it. Arthroscopy does possess certain unique aspects which need to be understood from the legal point of view as well. Materials and Methods We obtained information on specific medico-legal cases involving arthroscopy from books and websites containing collections of medico-legal judgments in Indian legal courts, consumer dispute redressal forums at the state and national levels, and state medical councils.. Results We assimilated and analysed all this information, combined it with our experience in the field of medical law, and have provided practical, enforceable ways to decrease the medicolegal risk for arthroscopy surgeons. Conclusion This review provides a comprehensive overview of pressing issues in relation to the medicolegal aspects of arthroscopic surgery.
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Affiliation(s)
- Satvik N. Pai
- Department of Orthopaedic Surgery, Aster RV Hospital, J P Nagar, Bangalore, India
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6
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Renz N, Madjarevic T, Ferrari M, Becker R, Ravn C, Vogely C, Pérez-Prieto D. Recommendations on diagnosis and antimicrobial treatment of infections after anterior cruciate ligament reconstruction (ACL-R) endorsed by ESSKA and EBJIS. J Infect 2023; 86:543-551. [PMID: 37019288 DOI: 10.1016/j.jinf.2023.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/18/2023] [Accepted: 03/28/2023] [Indexed: 04/05/2023]
Abstract
Infection after anterior-cruciate ligament reconstruction (ACL-R) is a rare but devastating complication affecting predominantly young and sportive individuals. A timely and correct diagnosis as well as an optimized management are paramount to circumvent serious sequelae and compromise in life quality. These recommendations are primarily intended for use by infectious disease specialists and microbiologists, but also orthopedic surgeons and other healthcare professionals who care for patients with infections after ACL-R. They are based on evidence mainly originating from observational studies and opinions of experts in the field and cover the management of infections after ACL-R with a special focus on etiology, diagnosis, antimicrobial treatment and prevention. Comprehensive recommendations on prevention, surgical treatment and rehabilitation are presented separately in a document primarily addressing orthopedics professionals.
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Affiliation(s)
- Nora Renz
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland; Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany.
| | - Tomislav Madjarevic
- University Hospital for Orthopaedic Surgery Lovran, Faculty of Medicine of the University of Rijeka, Rijeka, Croatia
| | - Matteo Ferrari
- Department of Internal Medicine, IRCCS Ospedale Galeazzi, Sant' Ambrogio, MIlan, Italy
| | - Roland Becker
- Centre for Orthopaedics and Traumatology, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Christen Ravn
- Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Charles Vogely
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniel Pérez-Prieto
- Department of Traumatology and Orthopaedic Surgery, Hospital del Mar, Barcelona, Spain; IcatKNEE, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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7
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Wachtel N, Meyer E, Volkmer E, Knie N, Lukas B, Giunta R, Demmer W. Efficacy of perioperative antibiotic prophylaxis in elective soft-tissue-only wrist arthroscopy. Bone Jt Open 2023; 4:219-225. [PMID: 37051839 PMCID: PMC10065847 DOI: 10.1302/2633-1462.44.bjo-2023-0019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Aims Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy. Methods A clinical ambispective dual-centre study was performed to determine whether PAP reduces postoperative infection rates after soft tissue-only wrist arthroscopies. Retrospective and prospective data was collected at two hospitals with departments specialized in hand surgery. During the study period, 464 wrist arthroscopies were performed, of these 178 soft-tissue-only interventions met the study criteria and were included. Signs of postoperative infection and possible adverse drug effects (ADEs) of PAP were monitored. Additionally, risk factors for surgical site infection (SSIs), such as diabetes mellitus and BMI, were obtained. Results The overall infection rate of SSI was zero. Neither in the PAP group (n = 69) nor in the control group (n = 109) were signs of postoperative infection observed. Observed symptoms of ADEs were three-times higher in the PAP group when compared to the control-group (16.3 vs 5.5%; p = 0.043). No major ADEs were observed, but one in ten patients in the PAP group reported mild to severe intestinal or hypersensitivity symptoms. Conclusion We demonstrate that the number needed to treat (NNT) with PAP to prevent one postoperative infection in soft-tissue arthroscopies of the wrist is > 109. Conversely, symptoms of ADEs were reported by one out of ten patients given PAP. Considering the high NNT to prevent postoperative infection and the large number of ADEs caused by PAP, we recommend not to use PAP routinely in soft-tissue arthroscopies of the wrist. Subsequent large-scale studies should be conducted to substantiate these results. Cite this article: Bone Jt Open 2023;4(4):219–225.
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Affiliation(s)
- Nikolaus Wachtel
- Division of Hand, Plastic, and Aesthetic Surgery, University Hospital, Munich, Germany
| | - Emanuel Meyer
- Division of Hand, Plastic, and Aesthetic Surgery, University Hospital, Munich, Germany
| | - Elias Volkmer
- Clinic of Hand Surgery, Helios Klinikum München West, Munich, Germany
| | | | - Bernhard Lukas
- Center for Hand Surgery, Microsurgery and Plastic Surgery, Schoen Clinic Munich Harlaching, Munich, Germany
| | - Riccardo Giunta
- Division of Hand, Plastic, and Aesthetic Surgery, University Hospital, Munich, Germany
| | - Wolfram Demmer
- Division of Hand, Plastic, and Aesthetic Surgery, University Hospital, Munich, Germany
- Correspondence should be sent to Wolfram Demmer. E-mail:
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Zhao D, Liang GH, Pan JK, Zeng LF, Luo MH, Huang HT, Han YH, Lin FZ, Xu NJ, Yang WY, Liu J. Risk factors for postoperative surgical site infections after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Br J Sports Med 2023; 57:118-128. [PMID: 36517215 PMCID: PMC9872252 DOI: 10.1136/bjsports-2022-105448] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The primary aim was to evaluate risk factors for surgical site infections after anterior cruciate ligament reconstruction (ACLR). The secondary aim was to investigate the surgical site infection incidence rate and the mean time to postoperative surgical site infection symptoms. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Embase and Web of Science were searched from database inception to September 2021 and updated in April 2022. ELIGIBILITY CRITERIA Quantitative, original studies reporting potential risk factors for surgical site infections after ACLR were included. RESULTS Twenty-three studies with 3871 infection events from 469 441 ACLRs met the inclusion criteria. Male sex (OR 1.78, p< 0.00001), obesity (OR 1.82, p=0.0005), tobacco use (OR 1.37, p=0.01), diabetes mellitus (OR 3.40, p=0.002), steroid use history (OR 4.80, p<0.00001), previous knee surgery history (OR 3.63, p=0.02), professional athlete (OR 4.56, p=0.02), revision surgery (OR 2.05, p=0.04), hamstring autografts (OR 2.83, p<0.00001), concomitant lateral extra-articular tenodesis (OR 3.92, p=0.0001) and a long operating time (weighted mean difference 8.12, p=0.005) were identified as factors that increased the risk of surgical site infections (superficial and deep) after ACLR. Age, outpatient or inpatient surgery, bone-patellar tendon-bone autografts or allografts and a concomitant meniscus suture did not increase the risk of surgical site infections. The incidence of surgical site infections after ACLR was approximately 1% (95% CI 0.7% to 1.2%). The mean time from surgery to the onset of surgical site infection symptoms was approximately 17.1 days (95% CI 13.2 to 21.0 days). CONCLUSION Male sex, obesity, tobacco use, diabetes mellitus, steroid use history, previous knee surgery history, professional athletes, revision surgery, hamstring autografts, concomitant lateral extra-articular tenodesis and a long operation time may increase the risk of surgical site infections after ACLR. Although the risk of surgical site infections after ACLR is low, raising awareness and implementing effective preventions for risk factors are priorities for clinicians to reduce the incidence of surgical site infections due to its seriousness.
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Affiliation(s)
- Di Zhao
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China,Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Gui-Hong Liang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China,Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jian-Ke Pan
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China,Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Ling-Feng Zeng
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China,Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Ming-Hui Luo
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China,Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - He-Tao Huang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China,Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yan-Hong Han
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China,Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Fang-Zheng Lin
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China,Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Nan-Jun Xu
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China,Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Wei-Yi Yang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China,Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jun Liu
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China,Guangdong Second Traditional Chinese Medicine Hospital (Guangdong Province Enginering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China,The fifth Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
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9
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Hunter CW, Deer TR, Jones MR, Chang Chien GC, D'Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA, Mazzola AJ, Michels JS, Layno-Moses A, Patel S, Tari J, Weisbein JS, Goulding KA, Chhabra A, Hassebrock J, Wie C, Beall D, Sayed D, Strand N. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2683-2745. [PMID: 36132996 PMCID: PMC9484571 DOI: 10.2147/jpr.s370469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.
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Affiliation(s)
- Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA.,Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Ryan S D'Souza
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Erica R Eldon
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lissa Hewan-Lowe
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jillian A Maloney
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Anthony J Mazzola
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jeanmarie Tari
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | | | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Chris Wie
- Interventional Spine and Pain, Dallas, TX, USA
| | - Douglas Beall
- Comprehensive Specialty Care, Oklahoma City, OK, USA
| | - Dawood Sayed
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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10
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di Vico G, Simonetta R, Correra G, Corona K, Proietti L, Morris BJ, Cerciello S. Popliteomeniscal fascicles tears with lateral meniscus instability: outcomes of arthroscopic surgical technique at mid-term follow-up. Arch Orthop Trauma Surg 2022; 143:2573-2579. [PMID: 35927338 DOI: 10.1007/s00402-022-04486-2] [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: 10/06/2021] [Accepted: 05/16/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE The popliteomeniscal fascicles (PMFs) are a crucial part of the posterolateral corner of the knee. They provide stability to the lateral meniscus and stabilize the joint during tibial internal rotation. The clinical diagnosis of a torn PMFs is difficult, and magnetic resonance imaging (MRI) may be inconclusive as well. The aim of the present study was to report the outcomes of a continuous series of patients affected by PMF lesions and treated with an arthroscopic repair. METHODS Seventeen patients (average age of 22 ± 3.6 years) with PMF lesions and lateral meniscus instability were prospectively enrolled. All patients were evaluated with clinical examination, International Knee Documentation Committee (IKDC), Lysholm and Tegner scores and 1.5 T MRI. All patients had the same arthroscopic procedure consisting of meniscal repair with an all-inside meniscal repair system (mean 2.2 ± 0.77 anchors) and followed with the same postoperative protocol. RESULTS All patients were available at a mean follow-up of 68 ± 24 months (range 49-84 months). Mean IKDC increased from 60.2 ± 13.5 to 83.1 ± 12, mean Lysholm score improved from 56.7 ± 8.2 to 89.8 ± 3.2, and mean Tegner score improved from 2.9 ± 1.3 to 6.5 ± 2. No intraoperative or postoperative complications were reported. MRI evaluation at 6-month follow-up showed successful healing of the menisco-popliteal fascicles in all cases. CONCLUSIONS The diagnosis and treatment of tears of the PMFs is still debated. Diagnostic confirmation of tearing of the PMFs is usually determined at the time of arthroscopy. Meniscal repair with an all-inside meniscal repair system appears to be an excellent treatment option, since it yields good functional results at mid-term follow-up, no local complications, and complete radiographic healing at 6-month follow-up MRI. Further studies are needed to confirm these promising early results. LEVEL OF EVIDENCE Case series, 4.
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Affiliation(s)
- G di Vico
- Department of Orthopaedics and Trauma Surgery, Clinica San Michele, Caserta, Maddaloni, Italy
| | - R Simonetta
- Cure Ortopediche Traumatologiche Messina, Messina, Italy
| | - G Correra
- Ospedale Cardarelli Napoli, Naples, Italy
| | - K Corona
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy.
| | | | - B J Morris
- Baptist Health Medical Group Orthopedics and Sports Medicine, Lexington, USA
| | - S Cerciello
- Casa Di Cura Villa Betania, Rome, Italy.,Marrelli Hospital, Crotone, Italy.,Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy
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11
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Cole WW, Familia M, Miskimin C, Mulcahey MK. Preoperative Optimization and Tips to Avoiding Surgical Complications Before the Incision. Sports Med Arthrosc Rev 2022; 30:2-9. [PMID: 35113836 DOI: 10.1097/jsa.0000000000000336] [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: 11/26/2022]
Abstract
In preparation for surgery, it is important for surgeons to have a detailed discussion with patients about the risks, benefits, and alternatives to surgery. Patient optimization, ensuring the patient is in the best medical condition before surgery, is also an important aspect of patient care that the surgeon must consider. Although complications cannot be eliminated, there are often opportunities to optimize patients, so these risks can be minimized based on current evidence-based medicine. To minimize the risk of complications, the surgeon should take an active role in each step of the patient's care beginning with the history and physical examination, obtaining the correct preoperative labs, and continuing through positioning, draping, and prepping before making an incision.
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Affiliation(s)
- Wendell W Cole
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
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12
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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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13
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Infection complicating 794 primary and revision arthroscopies. Accuracy of actual prophylactic procedures against infection and results from a single orthopedic center in Poland. POSTEP HIG MED DOSW 2022. [DOI: 10.2478/ahem-2022-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction
Septic arthritis after arthroscopy (SAAA) is a devasting complication which reported frequency varies about 0.04%–5.7%. The aim of the study is to analyze frequency of SAAA at one orthopedic center, risk factors and accuracy of actual prophylactic measures.
Materials and Methods
A retrospective study (level of evidence: V) includes 794 (665 primary and 129 revision) “clean” arthroscopies performed in the years 2017–2018 with confirmed joint infection during 30 days after operation without the use of non-resorbable implants and up to 1 year after procedures with non-resorbable implants. Demographic and medical data about potential risk factors of SAAA were analyzed: patients age, sex, operated joint, type of procedure, primary or revision procedure, the use of drains, usage of non-absorbable implant, time of surgery, BMI, time lapse from index operation to diagnosis of SAAA, length of hospital stay, causative microorganisms. All operations were performed by eight different but experienced surgeons, in operation theatre with vertical laminar flow with the capacity of 50 air exchanges per hour. The perioperative antibiotic prophylaxis consisted of one preoperative dose 1 g cefazolin in simple arthroscopies, which was prolonged to 24 hours with 3 doses in cases of implantation of non-absorbable implant (55.8% of patients).
Results
From 794 cases 4 have been infected: 2 after knee arthrolysis, one after ACL reconstruction and one after rotator cuff repair. There were 2 early, with manifestation within 30 days, and 2 late-onset SAAA. Infections occurred in 0.5% of all arthroscopies and in 0.47% of knee arthroscopies alone. Patients age and time of surgery have not been found significantly different in infected and non-infected cases, whereas age and time of surgery have been significantly different in revision and non-revision cases.
Conclusions
Primarily aseptic arthroscopic procedures performed with respect to actual perioperative preventive measures have a low risk of postoperative septic arthritis. The risk increases with patients age and time of operation, but not significantly.
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14
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Bartek B, Winkler T, Garbe A, Schelberger T, Perka C, Jung T. Bacterial contamination of irrigation fluid and suture material during ACL reconstruction and meniscus surgery : Low infection rate despite increasing contamination over surgery time. Knee Surg Sports Traumatol Arthrosc 2022; 30:246-252. [PMID: 33566145 PMCID: PMC8800874 DOI: 10.1007/s00167-021-06481-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 01/25/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE During knee arthroscopy, irrigation fluid from the surgical site accumulates in the sterile reservoir. Whether these fluid collections and also suture material used during the arthroscopic surgical processes show bacterial contamination over time during surgery remains unclear. The purpose of this study was to determine this contamination rate and to analyze its possible influence on postoperative infection. MATERIALS AND METHODS In this study, 155 patients were included. Fifty-eight underwent reconstruction of the anterior cruciate ligament (ACL), 63 meniscal surgery and 34 patients combined ACL reconstruction and meniscus repair. We collected pooled samples of irrigation fluid from the reservoir on the sterile drape every 15 min during the surgery. In addition, we evaluated suture material of ACL graft and meniscus repair for bacterial contamination. Samples were sent for microbiological analysis, incubation time was 14 days. All patients were seen in the outpatient department 6, 12 weeks and 12 months postoperatively and examined for clinical signs of infection. RESULTS A strong statistical correlation (R2 = 0.81, p = 0.015) was found between an advanced duration of surgery and the number of positive microbiological findings in the accumulated fluid. Suture and fixation material showed a contamination rate of 28.4% (29 cases). Despite the high contamination rate, only one infection was found in the follow-up examinations, caused by Staphylococcus lugdunensis. CONCLUSION Since bacterial contamination of accumulated fluid increases over time the contact with the fluid reservoirs should be avoided. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Benjamin Bartek
- Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany.
| | - Tobias Winkler
- Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
- Julius Wolff Institute, Berlin, Germany
- Berlin-Institute of Health Center for Regenerative Therapies, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anja Garbe
- Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
| | - Tarek Schelberger
- Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany
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15
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bourbour S, Emaneini M, Mortazavi SJ, Tahmasebi MN, yahyazadeh H, Jabalameli M, Jabalameli F. A More Positive Culture by Resin-containing Media Usage after Suspicious Arthroscopic Infections in Patients Receiving Antimicrobial Therapy. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:496-502. [PMID: 34692931 PMCID: PMC8503766 DOI: 10.22038/abjs.2020.51361.2540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/30/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although infections following arthroscopic surgery of cruciate ligament and meniscus are uncommon, they have potentially serious consequences for the graft and articular cartilage. This study aimed to investigate the efficacy of correct sampling and appropriate media, especially resin-containing media, for the detection of infections in patients receiving antibiotics under suspicion of joint infection after arthroscopic anterior cruciate ligament (ACL) and meniscal surgery. In such cases, proper sampling and the use of suitable culture media that cause the neutralization of antibiotics are very effective in isolating microorganisms from the patient samples and positive cultures. METHODS In total, 10 patients who had received antibiotics with suspected knee infection after arthroscopic ACL and meniscal surgery were identified after referral to surgeons during a period of 10 months and investigated in this study. The sample collection, culture on various media (i.e., resin-containing culture media), microbiological tests, and antibiotic susceptibility tests were performed in this study. The amplification of the mecA gene using PCR assay was accomplished for methicillin-resistant staphylococcus strains. RESULTS This study was conducted on 10 patients who underwent arthroscopic procedures and had received antibiotics. Overall, joint fluid and tissue culture were positive in 60% of the patients. The resin-containing media revealed a trend toward increased detection of bacteria. Coagulase-negative staphylococcus strains were the most frequently isolated bacteria in arthroscopic ACL surgery infections. Out of five methicillin-resistant staphylococcus strains, four strains were found that were resistant to cefoxitin and positive-mecA designated as methicillin-resistant strains. Except for one case, the rest of the staphylococcal strains were resistant to methicillin but susceptible to vancomycin. CONCLUSION Despite uncommon and low percentage of infections after arthroscopic ACL and meniscal surgery, the results of our study showed that correct sampling, appropriate cultures, especially aerobic and anaerobic resin-containing media, and microbiological testing remained useful and valuable for diagnosing bacterial infections.
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Affiliation(s)
- Samaneh bourbour
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Emaneini
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - S.M. Javad Mortazavi
- Tehran University of Medical Sciences, knee and hip surgeon, Department of Orthopedic Surgery, Imam Khomaini Hospital, Tehran, Iran
| | - Mohamad Naghi Tahmasebi
- Tehran University of Medical Sciences, knee surgeon, Department of Orthopedic Surgery, Shariati Hospital, Tehran, Iran
| | - Hooman yahyazadeh
- Orthopaedic surgeon, bone and joint reconstruction research center, University of Medical Sciences, Department of Orthopedic Surgery, Shafa Yahyaiyan Hospital, Tehran, Iran
| | - Mahmoud Jabalameli
- Orthopaedic surgeon, bone and joint reconstruction research center, University of Medical Sciences, Department of Orthopedic Surgery, Shafa Yahyaiyan Hospital, Tehran, Iran
| | - Fereshteh Jabalameli
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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16
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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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17
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Rohrer F, Maurer A, Noetzli H, Gahl B, Limacher A, Hermann T, Bruegger J. Prolonged antibiotic prophylaxis use in elective orthopaedic surgery - a cross-sectional analysis. BMC Musculoskelet Disord 2021; 22:420. [PMID: 33957917 PMCID: PMC8101240 DOI: 10.1186/s12891-021-04290-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/22/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose Surgical antibiotic prophylaxis (SAP) prevents surgical site infections (SSI). In orthopaedic surgery, the use of prolonged SAP (PSAP) has been reported in daily routine, despite guidelines advising against it. Therefore, we asked: What is the proportion of PSAP use, defined as administration of SAP ≥24 h after elective orthopaedic surgery? Are there patient- and surgery-related predictors of PSAP use? Methods This cross-sectional analysis investigated 1292 patients who underwent elective orthopaedic surgery including total joint arthroplasties at one Swiss centre between 2015 and 2017. Patient comorbidities, surgical characteristics and occurrence of SSI at 90 days in PSAP group were compared to the SAP group (< 24 h post-operative). Results PSAP use was 12% (155 of 1292). Patient-related factors associated with PSAP compared to the SAP group included older age (63 vs. 58y; p < 0.001), higher BMI (29 vs. 27 kg/m2; p < 0.001), ASA classification ≥3 (31% vs. 17%; p < 0.001) and lung disease (17% vs. 9%; p = 0.002). Surgery-related factors associated with PSAP were use of prosthetics (62% vs. 45%; p < 0.001), surgery of the knee (65% vs. 25%; p < 0.001), longer surgery duration (87 vs. 68 min; p < 0.001) and presence of drains (90% vs. 65%; p < 0.001). All four SSI occurred in the SAP group (0 vs. 4; p = 1.0). Surgeons administered PSAP with varying frequencies; proportions ranged from 0 to 33%. Conclusion PSAP use and SSI proportions were lower than reported in the literature. Several patient- and surgery-related factors associated with PSAP use were identified and some were potentially modifiable. Also, experienced surgeons seemed to implement differing approaches regarding the duration of SAP administration.
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Affiliation(s)
- Felix Rohrer
- Department of Internal Medicine, Sonnenhofspital, 3006, Bern, Switzerland. .,Centre Hospitalier Universitaire Vaudois, CHUV, 1011, Lausanne, Switzerland.
| | - Anita Maurer
- Department of Internal Medicine, Sonnenhofspital, 3006, Bern, Switzerland.,University of Bern, 3012, Bern, Switzerland
| | - Hubert Noetzli
- University of Bern, 3012, Bern, Switzerland.,Orthopaedie Sonnenhof, 3006, Bern, Switzerland
| | - Brigitta Gahl
- Clinical Trials Unit (CTU) Bern, University of Bern, 3012, Bern, Switzerland
| | - Andreas Limacher
- Clinical Trials Unit (CTU) Bern, University of Bern, 3012, Bern, Switzerland
| | - Tanja Hermann
- Department of Internal Medicine, Sonnenhofspital, 3006, Bern, Switzerland.,Stiftung Lindenhof, Campus SLB, Swiss Institute for Translational and Entrepreneurial Medicine, 3010, Bern, Switzerland
| | - Jan Bruegger
- Department of Internal Medicine, Sonnenhofspital, 3006, Bern, Switzerland.,University of Zurich, 8006, Zurich, Switzerland
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18
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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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Atherton CM, Spencer SJ, McCall K, Garcia-Melchor E, Leach WJ, Mullen M, Rooney BP, Walker C, McInnes IB, Millar NL, Akbar M. Vancomycin Wrap for Anterior Cruciate Ligament Surgery: Molecular Insights. Am J Sports Med 2021; 49:426-434. [PMID: 33406371 PMCID: PMC7859666 DOI: 10.1177/0363546520981570] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/23/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of the vancomycin wrap to pretreat the hamstring graft in anterior cruciate ligament reconstruction (ACLR) has grown in popularity since it was first described in 2012 and has significantly reduced rates of postoperative infection. However, it remains unknown if this antibiotic treatment affects the molecular composition of the graft. PURPOSE To establish whether treatment with vancomycin at 5 mg/mL, the most commonly used concentration, alters the molecular function of the hamstring graft in ACLR. STUDY DESIGN Controlled laboratory study. METHODS Surplus hamstring tendon collected after routine ACLR surgery was used for in vitro cell culture and ex vivo tissue experiments. Vancomycin was used at 5 mg/mL in RPMI or saline diluent to treat cells and tendon tissue, respectively, with diluent control conditions. Cell viability at 30, 60, and 120 minutes was assessed via colorimetric viability assay. Tendon cells treated with control and experimental conditions for 1 hour was evaluated using semiquantitative reverse transcription analysis, immunohistochemistry staining, and protein quantitation via enzyme-linked immunosorbent assay for changes in apoptotic, matrix, and inflammatory gene and protein expression. RESULTS Vancomycin treatment at 5 mg/mL significantly reduced tenocyte viability in vitro after 60 minutes of treatment (P < .05); however, this was not sustained at 120 minutes. Vancomycin-treated tendon tissue showed no significant increase in apoptotic gene expression, or apoptotic protein levels in tissue or supernatant, ex vivo. Vancomycin was associated with a reduction in inflammatory proteins from treated tendon supernatants (IL-6; P < .05). CONCLUSION Vancomycin did not significantly alter the molecular structure of the hamstring graft. Reductions in matrix protein and inflammatory cytokine release point to a potential beneficial effect of vancomycin in generating a homeostatic environment. CLINICAL RELEVANCE Vancomycin ACL wrap does not alter the molecular structure of the ACL hamstring graft and may improve graft integrity.
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Affiliation(s)
- Caroline M. Atherton
- Institute of Infection, Immunity and
Inflammation, College of Medicine, Veterinary and Life Sciences University of
Glasgow, Glasgow, UK
- Department of Orthopaedic Surgery, Queen
Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Simon J. Spencer
- Department of Orthopaedic Surgery, Queen
Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Katy McCall
- Institute of Infection, Immunity and
Inflammation, College of Medicine, Veterinary and Life Sciences University of
Glasgow, Glasgow, UK
| | - Emma Garcia-Melchor
- Institute of Infection, Immunity and
Inflammation, College of Medicine, Veterinary and Life Sciences University of
Glasgow, Glasgow, UK
| | - William J. Leach
- Department of Orthopaedic Surgery, Queen
Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Michael Mullen
- Department of Orthopaedic Surgery, Queen
Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Brian P. Rooney
- Department of Orthopaedic Surgery, Queen
Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Colin Walker
- Department of Orthopaedic Surgery, Queen
Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Iain B. McInnes
- Institute of Infection, Immunity and
Inflammation, College of Medicine, Veterinary and Life Sciences University of
Glasgow, Glasgow, UK
| | - Neal L. Millar
- Institute of Infection, Immunity and
Inflammation, College of Medicine, Veterinary and Life Sciences University of
Glasgow, Glasgow, UK
- Department of Orthopaedic Surgery, Queen
Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Moeed Akbar
- Institute of Infection, Immunity and
Inflammation, College of Medicine, Veterinary and Life Sciences University of
Glasgow, Glasgow, UK
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Identifying targets for improvement using a nationally standardized survey: Surgical antimicrobial prophylaxis in orthopedic surgery. Infect Control Hosp Epidemiol 2020; 41:1419-1428. [PMID: 32838821 DOI: 10.1017/ice.2020.320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Surgical antimicrobial prophylaxis (SAP) is commonly administered in orthopedic procedures. Research regarding SAP appropriateness for specific orthopedic procedures is limited and is required to facilitate targeted orthopedic prescriber behavior change. OBJECTIVES To describe SAP prescribing and appropriateness for orthopedic procedures in Australian hospitals. DESIGN, SETTING, AND PARTICIPANTS Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey (Surgical NAPS) audits from January 1, 2016, to April 15, 2019, were analyzed. METHODS Logistic regression identified hospital, patient and surgical factors associated with appropriateness. Adjusted appropriateness was calculated from the multivariable model. Additional subanalyses were conducted on smaller subsets to calculate the adjusted appropriateness for specific orthopedic procedures. RESULTS In total, 140 facilities contributed to orthopedic audits in the Surgical NAPS, including 4,032 orthopedic surgical episodes and 6,709 prescribed doses. Overall appropriateness was low, 58.0% (n = 3,894). This differed for prescribed procedural (n = 3,978, 64.7%) and postprocedural doses (n = 2,731, 48.3%). The most common reasons for inappropriateness, when prophylaxis was required, was timing for procedural doses (50.9%) and duration for postprocedural prescriptions (49.8%). The adjusted appropriateness of each orthopedic procedure group was low for procedural SAP (knee surgery, 54.1% to total knee joint replacement, 74.1%). The adjusted appropriateness for postprocedural prescription was also low (from hand surgery, 40.7%, to closed reduction fractures, 68.7%). CONCLUSIONS Orthopedic surgical specialties demonstrated differences across procedural and postprocedural appropriateness. The metric of appropriateness identifies targets for quality improvement and is meaningful for clinicians. Targeted quality improvement projects for orthopedic specialties need to be developed to support optimization of antimicrobial use.
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Ekdahl V, Stålman A, Forssblad M, Samuelsson K, Edman G, Kraus Schmitz J. There is no general use of thromboprophylaxis and prolonged antibiotic prophylaxis in anterior cruciate ligament reconstruction: a nation-wide survey of ACL surgeons in Sweden. Knee Surg Sports Traumatol Arthrosc 2020; 28:2535-2542. [PMID: 32025765 PMCID: PMC7429518 DOI: 10.1007/s00167-020-05851-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/10/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE The use of prophylaxis for thromboembolism and infection in anterior cruciate ligament (ACL) reconstruction is not well documented and no general guidelines have been established. The aim of this study was to evaluate the ACL surgeons' individual strategies of thromboprophylaxis, use of prolonged antibiotic prophylaxis and vancomycin-soaked ACL grafts, and if its use is supported in the current literature. Additionally, the rationale for use of tourniquet was analysed. METHODS Questionnaires were distributed to all Swedish ACL surgeons who are registered in the Swedish Knee Ligament Register (SKLR), asking about prescription of thromboprophylaxis, prolonged antibiotic prophylaxis, the use of vancomycin-soaked graft and the use of a tourniquet during surgery. The responses were assessed for agreement and the thromboprophylaxis data were analysed in relation to the 2016 SKLR data. RESULTS 115 (75%) ACL surgeons responded to the survey. 81.7% prescribed thromboprophylaxis only when risk factors, such as history of thrombosis and the use of oral contraceptives, were present. Female gender, older age and admitted patient were considered the risk factors with the lowest impact. The respondents were generally restrictive regarding the use of prolonged antibiotic prophylaxis. The use of vancomycin-soaked graft was used by only nine (8%) surgeons representing 406 (13%) of the surgeries. CONCLUSION Swedish ACL surgeons are generally restrictive using thromboprophylaxis and only when risk factors are present. However, there is a lack of consensus in how to weigh the different risk factors and it does not completely adhere to the existing literature. Prolonged antibiotic prophylaxis is rarely used and the use of vancomycin soaking of graft is very limited and applies only to a small number of surgeons. The use of tourniquet is common. There is a need for ACL-specific guidelines regarding the use of thromboprophylaxis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Victor Ekdahl
- grid.4714.60000 0004 1937 0626Karolinska Institutet, Stockholm, Sweden
| | - Anders Stålman
- grid.4714.60000 0004 1937 0626Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden ,Capio Artro Clinic, Stockholm, Sweden
| | - Magnus Forssblad
- grid.4714.60000 0004 1937 0626Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Kristian Samuelsson
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clincial Sciences, University of Gothenburg, Gothenburg, Sweden ,grid.1649.a000000009445082XDepartment of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gunnar Edman
- grid.4714.60000 0004 1937 0626Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - 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.
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Lösungen für häufige Komplikationen bei vorderer Kreuzbandoperation. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-00310-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Jefferies JG, Aithie JMS, Spencer SJ. Vancomycin-soaked wrapping of harvested hamstring tendons during anterior cruciate ligament reconstruction. A review of the 'vancomycin wrap'. Knee 2019; 26:524-529. [PMID: 31031127 DOI: 10.1016/j.knee.2019.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/18/2019] [Accepted: 04/05/2019] [Indexed: 02/06/2023]
Abstract
The practice of 'vancomycin wrapping' of harvested hamstring autografts during Anterior Cruciate Ligament Reconstruction (ACLR) surgery has gathered recent interest. This practice involves the wrapping of harvested grafts in a vancomycin-soaked swab during the preparatory phase. Different techniques are observed, and a small number of studies have shown that pre-soaking hamstring ACLR grafts in this manner dramatically reduces the post-surgical infection rate compared with standard intravenous antibiotic prophylaxis alone. However, the literature surrounding this practice is surprisingly limited and thus the basis and rationale of the 'vancomycin wrap' has established itself largely without question. The exact popularity of this practice is difficult to establish but there has been increasing disclosure of its efficacy in reducing post-operative infection in ACLR since 2012. We provide a synopsis of the current literature surrounding vancomycin and its use in 'wraps' in ACLR to help apprise the surgeon of the nature of infection in ACLR, the rationale for vancomycin, whilst considering evidence to support alternatives and discussing potential ramifications for future practice.
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Affiliation(s)
- James G Jefferies
- Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow G51 4TF, United Kingdom of Great Britain and Northern Ireland
| | - Joanna M S Aithie
- Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow G51 4TF, United Kingdom of Great Britain and Northern Ireland.
| | - Simon J Spencer
- Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow G51 4TF, United Kingdom of Great Britain and Northern Ireland
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