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Vancomycin-soaking of the graft reduces the incidence of septic arthritis following ACL reconstruction: results of a systematic review and meta-analysis

  • Jan-Hendrik Naendrup
  • Benedikt Marche
  • Darren de SA
  • Paola Koenen
  • Robin Otchwemah
  • Arasch Wafaisade
  • Thomas R. PfeifferEmail author
knee

Abstract

Purpose

(1) To compare the incidence of post-operative septic arthritis following anterior cruciate ligament reconstruction (ACLR) between patients receiving routine pre-operative intravenous (IV) prophylaxis only intravenous (IV) infection prophylaxis and patients receiving additional graft-soaking in a vancomycin solution (5 mg/ml) perioperatively. (2) To review the literature regarding effects of graft-soaking in vancomycin solutions on outcomes, complication rates and tendon properties in ACLR.

Methods

To identify studies pertaining to routine pre-operative IV prophylaxis and additional usage of intra-operative vancomycin-soaked grafts in primary ACLR, the Cochrane Library, SCOPUS and MEDLINE were searched till June 2018 for English and German language studies of all levels of evidence following the PRISMA guidelines. Additionally, all accepted abstracts at the ESSKA 2018, ISAKOS 2017, AGA 2017 and AOSSM 2017 meetings were screened. Data regarding the incidence of septic arthritis were abstracted and combined in a meta-analysis. Data including outcome scores, complication rates and in vitro analyses of tendon properties were collected and summarized descriptively.

Results

Upon screening 785 titles, 8 studies were included. These studies examined 5,075 patients following ACLR and followed from 6 to 52 weeks post-operatively. Of those 2099 patients in the routine pre-operative IV prophylaxis group, 44 (2.1%) cases of early septic arthritis were reported. In contrast, there were no reports of septic arthritis following ACLR in 2976 cases of vancomycin-soaked grafts. The meta-analysis yielded an odds ratio of 0.04 (0.01–0.16) favouring the addition of intra-operative vancomycin-soaking of grafts. Across all available studies, no differences in clinical outcome (i.e. incidence of ACL revision, IKDC score, Tegner score), biomechanical tendon properties, or cartilage integrity between patients with and without vancomycin-soaked grafts were identified.

Conclusion

The incidence of septic arthritis following ACLR can be reduced dramatically by vancomycin-soaking the grafts intra-operatively prior to graft passage and fixation. Within the limitation confines of this study, intra-operative graft-soaking in vancomycin appears to be a safe and effective method to reduce the incidence of septic arthritis following ACLR. Still, it remains debatable if the available data facilitate the recommendation for a universal application of vancomycin-soaking for all ACLR patients or if it should be reserved for patients at risk, including the use hamstring tendons, revision cases and in the presence of medical preconditions.

Level of evidence

Level IV, systematic review of Level III and Level IV studies.

Keywords

Anterior cruciate ligament ACL Reconstruction Infection Prevention Graft soaking Vancomycin 

Abbreviations

IV

Intravenous

ACL

Anterior cruciate ligament

ACLR

Anterior cruciate ligament reconstruction

Notes

Acknowledgements

We want to thank Christoph Offerhaus and Jürgen Höher et al. for the generous provision of their partially published data.

Author contributions

TRP and BM performed the screening of all titles, abstracts, and full texts. BM and JHN performed the abstraction of all data. JHN and TRP drafted the original manuscript. DdS, PK, RO, and AW participated in the editing of the original manuscript. TRP, DdS, PK, RO, and AW participated in the conception and design of the original study. JHN and BM have contributed equally to this work. All authors read and approved the final manuscript.

Funding

There was no external source of funding for this study.

Compliance with ethical standards

Conflict of interest

The authors of this study confirm that they have no conflicts of interest related to this study.

Ethical approval

No IRB approval was required or obtained for this study.

References

  1. 1.
    Andrews JM (2001) Determination of minimum inhibitory concentrations. J Antimicrob Chemother 48(Suppl 1):5–16CrossRefGoogle Scholar
  2. 2.
    Antoci V, 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.
    Barbier O, Danis J, Versier G, Ollat D (2015) When the tendon autograft is dropped accidently on the floor: A study about bacterial contamination and antiseptic efficacy. Knee 22:280–283CrossRefGoogle Scholar
  5. 5.
    Binnet MS, Başarir K (2007) Risk and outcome of infection after different arthroscopic anterior cruciate ligament reconstruction techniques. Arthroscopy 23:862–868CrossRefGoogle Scholar
  6. 6.
    Brand R, Kragt H (1992) Importance of trends in the interpretation of an overall odds ratio in the meta-analysis of clinical trials. Stat Med 11:2077–2082CrossRefGoogle Scholar
  7. 7.
    Brandl G, Pauzenberger L, Laky B, Anderl W (2018) Vancomycin in ACL reconstruction - a retrospective analysis of clinical outcome and occurrence of postoperative deep infection with or without graft-presoaking. Knee Surg Sports Traumatol Arthrosc 26:5–126CrossRefGoogle Scholar
  8. 8.
    Brophy RH, Wright RW, Huston LJ, Nwosu SK, Spindler KP (2015) Factors associated with infection following anterior cruciate ligament reconstruction. J Bone Joint Surg Am 97:450–454CrossRefGoogle Scholar
  9. 9.
    Burks RT, Friederichs MG, Fink B, Luker MG, West HS, Greis PE (2003) Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation. Am J Sports Med 31:414–418CrossRefGoogle Scholar
  10. 10.
    Calvo R, Figueroa D, Anastasiadis Z, Vaisman A, Olid A, Gili F, Valderrama JJ, De La Fuente P (2014) Septic arthritis in ACL reconstruction surgery with hamstring autografts. Eleven years of experience. Knee 21:717–720CrossRefGoogle Scholar
  11. 11.
    Cooper DE, Arnoczky SP, Warren RF (1991) Contaminated patellar tendon grafts: incidence of positive cultures and efficacy of an antibiotic solution soak–an in vitro study. Arthroscopy 7:272–274CrossRefGoogle Scholar
  12. 12.
    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
  13. 13.
    Efe T, Scharm A, Spies-Naumann A, Schüttler K (2017) Untersuchung zur Dosierung und biomechanischem Einfluss von lokalem Vancomycin in einem Infektmodell zur vorderen Kreuzbandplastik. AGA MunichGoogle Scholar
  14. 14.
    Granan L-P, Inacio MCS, Maletis GB, Funahashi TT, Engebretsen L (2012) Intraoperative findings and procedures in culturally and geographically different patient and surgeon populations: an anterior cruciate ligament reconstruction registry comparison between Norway and the USA. Acta Orthop 83:577–582CrossRefGoogle Scholar
  15. 15.
    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
  16. 16.
    Hiller NL, Chauhan A, Palmer M, Jain S, Sotereanos NG, Altman GT, Nistico L, Kreft R, Post JC, Demeo PJ (2015) Presence of bacteria in failed anterior cruciate ligament reconstructions. Springerplus 4:460CrossRefGoogle Scholar
  17. 17.
    Holmes N, Tong S, Davis J, Hal S (2015) Treatment of Methicillin-resistant Staphylococcus aureus: vancomycin and beyond. Semin Respir Crit Care Med 36:017–030CrossRefGoogle Scholar
  18. 18.
    Indelli PF, Dillingham M, Fanton G, Schurman DJ (2002) Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res 398:182–188CrossRefGoogle Scholar
  19. 19.
    Judd D, Bottoni C, Kim D, Burke M, Hooker S (2006) Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 22:375–384CrossRefGoogle Scholar
  20. 20.
    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
  21. 21.
    Khan M, Rothrauff BB, Merali F, Musahl V, Peterson D, Ayeni OR (2014) Management of the contaminated anterior cruciate ligament graft. Arthroscopy 30:236–244CrossRefGoogle Scholar
  22. 22.
    Kung J, Chiappelli F, Cajulis OO, Avezova R, Kossan G, Chew L, Maida CA (2010) From systematic reviews to clinical recommendations for evidence-based health care: validation of revised assessment of multiple systematic reviews (R-AMSTAR) for grading of clinical relevance. Open Dent J 4:84–91Google Scholar
  23. 23.
    Lubowitz JH (2015) Editorial commentary: hamstring autografts are more frequently associated with ACL infection. Arthroscopy 31:1402CrossRefGoogle Scholar
  24. 24.
    Makhni EC, Steinhaus ME, Mehran N, Schulz BS, Ahmad CS (2015) Functional outcome and graft retention in patients with septic arthritis after anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 31:1392–1401CrossRefGoogle Scholar
  25. 25.
    McHugh ML (2012) Interrater reliability: the kappa statistic. Biochem Med 22:276–282CrossRefGoogle Scholar
  26. 26.
    Molina ME, Nonweiller DE, Evans JA, Contaminated anterior cruciate ligament grafts: the efficacy of 3 sterilization agents. Arthroscopy 16:373–378Google Scholar
  27. 27.
    Offerhaus C, Balke M, Höher J (2018) Pre-soaking of hamstring grafts reduces risk of infection after ACL-reconstruction. A prospective study including 1500 patients. Knee Surg Sports Traumatol Arthrosc 26:5–126CrossRefGoogle Scholar
  28. 28.
    Pérez-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
  29. 29.
    Pérez-Prieto D, Torres-Claramunt R, Gelber PE, Shehata TMA, 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
  30. 30.
    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
  31. 31.
    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
  32. 32.
    Schollin-Borg M, Michaëlsson K, Rahme H (2003) Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study. Arthroscopy 19:941–947CrossRefGoogle Scholar
  33. 33.
    Schulz AP, Götze S, Schmidt HGK, Jürgens C, Faschingbauer M (2007) Septic arthritis of the knee after anterior cruciate ligament surgery: a stage-adapted treatment regimen. Am J Sports Med 35:1064–1069CrossRefGoogle Scholar
  34. 34.
    Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, Porter AC, Tugwell P, Moher D, Bouter LM (2007) Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 7:10CrossRefGoogle Scholar
  35. 35.
    Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73:712–716CrossRefGoogle Scholar
  36. 36.
    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

Copyright information

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

Authors and Affiliations

  1. 1.Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical CentreWitten/Herdecke UniversityCologneGermany
  2. 2.Department of Orthopaedic SurgeryUniversity of Pittsburgh-UPMC Rooney Sports ComplexPittsburghUSA

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