Vancomycin pre-soaking of the graft reduces postoperative infection rate without increasing risk of graft failure and arthrofibrosis in ACL reconstruction

  • Christoph Offerhaus
  • Maurice Balke
  • Juliane Hente
  • Mats Gehling
  • Simon Blendl
  • Jürgen HöherEmail author



To investigate whether pre-soaking the graft in vancomycin during anterior cruciate ligament reconstruction (ACLR) reduces the postoperative infection rate and if this technique is associated with an increased rate of complications, including graft failure or arthrofibrosis.


A retrospective review of a prospective database was performed in 1779 patients who underwent ACLR over a period of 5 years, analysing the rate of postoperative deep knee infection. Group 1 and 2 both received perioperative IV antibiotics, while only group 2 underwent ACLR with grafts pre-soaked in a 5 mg/ml vancomycin solution. To analyse possible side effects associated with vancomycin use, 500 patients out of the overall study population (100 patients per year) were randomly selected and retrospectively interviewed for further postoperative complications including graft failure and arthrofibrosis as well as subjective evaluation of their knee by completing the IKDC form with a minimum mean follow-up of 37 months.


In group 1, 22 out of 926 (2%) patients suffered a postoperative deep knee infection. In contrast, there were no postoperative infections in the second group of 853 patients (0%). 16 of 22 infections (73%) were caused by coagulase-negative Staphylococcus. Statistical analysis revealed a significantly reduced postoperative infection rate when bathing the autograft in vancomycin (p < 0.01). Analysis of the random sample revealed a significant decrease of graft failure with 8 reruptures in 257 patients (3%) in the vancomycin group compared to 16 cases of graft failure in 167 patients (10%) in the control group (p < 0.05). No differences were found in the rate of postoperative arthrofibrosis, Tegner or subjective outcome scores.


Prophylactic vancomycin pre-soaking of autografts during ACLR appears to be a viable, cost-effective and safe option to reduce the rate of deep infection compared to systemic antibiotics alone.

Level of evidence



Anterior cruciate ligament Antibiotic prophylaxis Vancomycin Knee infection Graft failure Arthrofibrosis 



Anterior cruciate ligament reconstruction


Coagulase-negative Staphylococcus


Minimum inhibitory concentration








Quadriceps tendon



The authors gratefully acknowledge Nate Breznau and Ajay C. Kanakamedala for language editing.

Author contributions

JH performed the surgeries on all patients. MB and CO were assisting in surgeries and examining the patients and evaluating them clinically during follow-up. JH, MB, and CO developed the study design. JuHe, MG and SB did the patient interviews and helped analysing and interpreting literature and data. CO and JuHe performed the literature review and wrote the manuscript. CO did the statistical analysis. JH and MB were proof reading the manuscript and revising it critically. All authors have read and approved the final manuscript.


The authors did not receive any funding for the study.

Compliance with ethical standards

Conflict of interest

The authors declare no conflict of interest.

Ethical approval

Institutional ethics committee approval was obtained prior to the start of this study (University Witten/Herdecke; ID: 1792015).


  1. 1.
    Ahn JH, Lee SH (2016) Risk factors for knee instability after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 24:2936–2942CrossRefGoogle Scholar
  2. 2.
    Antoci V Jr, Adams CS, Hickok NJ, Shapiro IM, Parvizi J (2007) Antibiotics for local delivery systems cause skeletal cell toxicity in vitro. Clin Orthop Relat Res 462:200–206CrossRefGoogle Scholar
  3. 3.
    Badran MA, Moemen DM (2016) Hamstring graft bacterial contamination during anterior cruciate ligament reconstruction: clinical and microbiological study. Int Orthop 40:1899–1903CrossRefGoogle Scholar
  4. 4.
    Barker JU, Drakos MC, Maak TG, Warren RF, Williams RJ III, Allen AA (2010) Effect of graft selection on the incidence of postoperative infection in anterior cruciate ligament reconstruction. Am J Sports Med 38:281–286CrossRefGoogle Scholar
  5. 5.
    Caroom C, Tullar JM, Benton EG Jr, Jones JR, Chaput CD (2013) Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion. Spine (Phila Pa 1976) 38:1183–1187CrossRefGoogle Scholar
  6. 6.
    Conte EJ, Hyatt AE, Gatt CJ Jr, Dhawan A (2014) Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy 30:882–890CrossRefGoogle Scholar
  7. 7.
    Diaz R, Afreixo V, Ramalheira E, Rodrigues C, Gago B (2018) Evaluation of vancomycin MIC creep in methicillin-resistant Staphylococcus aureus infections—a systematic review and meta-analysis. Clin Microbiol Infect 24:97–104CrossRefGoogle Scholar
  8. 8.
    Edin ML, Miclau T, Lester GE, Lindsey RW, Dahners LE (1996) Effect of cefazolin and vancomycin on osteoblasts in vitro. Clin Orthop Relat Res 333:245–251CrossRefGoogle Scholar
  9. 9.
    Ekhtiari S, Horner NS, de Sa D, Simunovic N, Hirschmann MT, Ogilvie R et al (2017) Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: a systematic review. Knee Surg Sports Traumatol Arthrosc 25:3929–3937CrossRefGoogle Scholar
  10. 10.
    Eriksson K, Karlsson J (2016) Local vancomycin in ACL reconstruction: a modern rationale (2016) for morbidity prevention and patient safety. Knee Surg Sports Traumatol Arthrosc 24:2721–2723CrossRefGoogle Scholar
  11. 11.
    Grayson JE, Grant GD, Dukie S, Vertullo CJ (2011) The in vitro elution characteristics of vancomycin from tendons. Clin Orthop Relat Res 469:2948–2952CrossRefGoogle Scholar
  12. 12.
    Greis PE, Koch BS, Adams B (2012) Tibialis anterior or posterior allograft anterior cruciate ligament reconstruction versus hamstring autograft reconstruction: an economic analysis in a hospital-based outpatient setting. Arthroscopy 28:1695–1701CrossRefGoogle Scholar
  13. 13.
    Ho PL, Lo PY, Chow KH, Lau EH, Lai EL, Cheng VC et al (2010) Vancomycin MIC creep in MRSA isolates from 1997 to 2008 in a healthcare region in Hong Kong. J Infect 60:140–145CrossRefGoogle Scholar
  14. 14.
    Horneff JG III, Hsu JE, Voleti PB, O’Donnell J, Huffman GR (2015) Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain. J Shoulder Elb Surg 24:838–843CrossRefGoogle Scholar
  15. 15.
    Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P et al (2001) Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 29:600–613CrossRefGoogle Scholar
  16. 16.
    Judd D, Bottoni C, Kim D, Burke M, Hooker S (2006) Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 22:375–384CrossRefGoogle Scholar
  17. 17.
    Kanj WW, Flynn JM, Spiegel DA, Dormans JP, Baldwin KD (2013) Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery. Orthopedics 36:138–146CrossRefGoogle Scholar
  18. 18.
    Kartus J, Magnusson L, Stener S, Brandsson S, Eriksson BI, Karlsson J (1999) Complications following arthroscopic anterior cruciate ligament reconstruction. A 2–5-year follow-up of 604 patients with special emphasis on anterior knee pain. Knee Surg Sports Traumatol Arthrosc 7:2–8CrossRefGoogle Scholar
  19. 19.
    Kehrmann J, Kaase M, Szabados F, Gatermann SG, Buer J, Rath PM et al (2011) Vancomycin MIC creep in MRSA blood culture isolates from Germany: a regional problem? Eur J Clin Microbiol Infect Dis 30:677–683CrossRefGoogle Scholar
  20. 20.
    Kieser TM, Rose MS, Aluthman U, Montgomery M, Louie T, Belenkie I (2014) Toward zero: deep sternal wound infection after 1001 consecutive coronary artery bypass procedures using arterial grafts: implications for diabetic patients. J Thorac Cardiovasc Surg 148:1887–1895CrossRefGoogle Scholar
  21. 21.
    Maletis GB, Inacio MC, Funahashi TT (2013) Analysis of 16,192 anterior cruciate ligament reconstructions from a community-based registry. Am J Sports Med 41:2090–2098CrossRefGoogle Scholar
  22. 22.
    Maletis GB, Inacio MC, Reynolds S, Desmond JL, Maletis MM, Funahashi TT (2013) Incidence of postoperative anterior cruciate ligament reconstruction infections: graft choice makes a difference. Am J Sports Med 41:1780–1785CrossRefGoogle Scholar
  23. 23.
    Mariappan R, Manninen P, Massicotte EM, Bhatia A (2013) Circulatory collapse after topical application of vancomycin powder during spine surgery. J Neurosurg Spine 19:381–383CrossRefGoogle Scholar
  24. 24.
    Mouzopoulos G, Fotopoulos VC, Tzurbakis M (2009) Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 17:1033–1042CrossRefGoogle Scholar
  25. 25.
    Perez-Prieto D, Portillo ME, Torres-Claramunt R, Pelfort X, Hinarejos P, Monllau JC (2018) Contamination occurs during ACL graft harvesting and manipulation, but it can be easily eradicated. Knee Surg Sports Traumatol Arthrosc 26:558–562CrossRefGoogle Scholar
  26. 26.
    Perez-Prieto D, Torres-Claramunt R, Gelber PE, Shehata TM, Pelfort X, Monllau JC (2016) Autograft soaking in vancomycin reduces the risk of infection after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 24:2724–2728CrossRefGoogle Scholar
  27. 27.
    Phegan M, Grayson JE, Vertullo CJ (2016) No infections in 1300 anterior cruciate ligament reconstructions with vancomycin pre-soaking of hamstring grafts. Knee Surg Sports Traumatol Arthrosc 24:2729–2735CrossRefGoogle Scholar
  28. 28.
    Plante MJ, Li X, Scully G, Brown MA, Busconi BD, DeAngelis NA (2013) Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 21:696–701CrossRefGoogle Scholar
  29. 29.
    Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K (2005) Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy 21:948–957CrossRefGoogle Scholar
  30. 30.
    Sechriest VF II, Carney JR, Kuskowski MA, Haffner JL, Mullen MJ, Covey DC (2013) Incidence of knee sepsis after ACL reconstruction at one institution: the impact of a clinical pathway. J Bone Jt Surg Am 95:843–849 (S841-846) CrossRefGoogle Scholar
  31. 31.
    Shields MV, Abdullah L, Namdari S (2016) The challenge of Propionibacterium acnes and revision shoulder arthroplasty: a review of current diagnostic options. J Shoulder Elb Surg 25:1034–1040CrossRefGoogle Scholar
  32. 32.
    Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49Google Scholar
  33. 33.
    Tomczak H, Szalek E, Blazejewska W, Myczko K, Horla A, Grzeskowiak E (2013) The need to assay the real MIC when making the decision to eradicate Staphylococcus aureus with vancomycin. Postepy Hig Med Dosw 67:921–925CrossRefGoogle Scholar
  34. 34.
    Torres-Claramunt R, Gelber P, Pelfort X, Hinarejos P, Leal-Blanquet J, Perez-Prieto D et al (2016) Managing septic arthritis after knee ligament reconstruction. Int Orthop 40:607–614CrossRefGoogle Scholar
  35. 35.
    Trampuz A, Zimmerli W (2006) Antimicrobial agents in orthopaedic surgery: prophylaxis and treatment. Drugs 66:1089–1105CrossRefGoogle Scholar
  36. 36.
    van Yperen DT, Reijman M, van Es EM, Bierma-Zeinstra SMA, Meuffels DE (2018) Twenty-year follow-up study comparing operative versus nonoperative treatment of anterior cruciate ligament ruptures in high-level athletes. Am J Sports Med. CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Vertullo CJ, Quick M, Jones A, Grayson JE (2012) A surgical technique using presoaked vancomycin hamstring grafts to decrease the risk of infection after anterior cruciate ligament reconstruction. Arthroscopy 28:337–342CrossRefGoogle Scholar
  38. 38.
    Wang G, Hindler JF, Ward KW, Bruckner DA (2006) Increased vancomycin MICs for Staphylococcus aureus clinical isolates from a university hospital during a 5-year period. J Clin Microbiol 44:3883–3886CrossRefGoogle Scholar
  39. 39.
    Whiteside LA, Peppers M, Nayfeh TA, Roy ME (2011) Methicillin-resistant Staphylococcus aureus in TKA treated with revision and direct intra-articular antibiotic infusion. Clin Orthop Relat Res 469:26–33CrossRefGoogle Scholar
  40. 40.
    Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD (2016) Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med 44:1861–1876CrossRefGoogle Scholar
  41. 41.
    Yan H, He J, Chen S, Yu S, Fan C (2014) Intrawound application of vancomycin reduces wound infection after open release of post-traumatic stiff elbows: a retrospective comparative study. J Shoulder Elb Surg 23:686–692CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Sportsclinic Cologne, Cologne Merheim Medical CenterWitten/Herdecke UniversityCologneGermany
  2. 2.Faculty of HealthWitten/Herdecke UniversityWittenGermany

Personalised recommendations