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



(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.


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.


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.


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.


Anterior cruciate ligament ACL Reconstruction Infection Prevention Graft soaking Vancomycin 





Anterior cruciate ligament


Anterior cruciate ligament reconstruction



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.


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.


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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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