Background: Infection is a devastating complication in anterior cruciate ligament reconstruction (ACLR) surgery. Given the rarity of infection, pooling individual studies via meta-analysis can allow more meaningful evaluation of factors influencing infection rates. We aimed to determine the relationship of graft type and vancomycin graft presoaking to bacterial infection rates following ACLR. Methods: A systematic literature search was conducted on PubMed, Ovid MEDLINE, Embase, and CENTRAL (Cochrane Register of Controlled Trials). Included articles were those reporting on primary arthroscopic or open ACLR procedures, using hamstring (HT) or bone-patellar tendon-bone (BPTB) autografts or allografts of any type, with regard to the outcome of infection (deep infection or septic arthritis). Meta-analyses were performed to estimate the overall infection rates in ACLR surgery according to graft type and to examine the effect of presoaking grafts in vancomycin on infection rates. Results: We identified 306 bacterial infections in 68,453 grafts across 198 studies. The overall estimated ACL graft infection rate in our meta-analysis was 0.9% (95% confidence interval [CI] = 0.8% to 1.0%). HT autografts were associated with a higher infection rate (1.1%, CI = 0.9% to 1.2%) than BPTB autografts (0.7%, CI = 0.6% to 0.9%) and allografts (0.5%, CI = 0.4% to 0.8%) (Q = 15.58, p < 0.001). Presoaking HT autografts in vancomycin reduced infection rates to 0.1% (CI = 0.0% to 0.4%) (Q = 10.62, p = 0.001). Conclusions: Infection following ACLR remains a rare but serious complication. HT autografts are associated with higher infection rates than other graft types. Presoaking HT autografts in vancomycin reduces infection rates by an estimated tenfold. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic debridement combined with antibiotic therapy is an appropriate initial approach in most cases of septic arthritis following ACL reconstruction, achieving graft salvage rates of about 85%. Cite this article: Bone Joint J 2016;98-B:608-15.

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Background and Aims Understanding the impact of orthopaedic scientific research is vital in identifying facilitators and barriers to its implementation in clinical practice. A meta‐analysis was carried out which showed that presoaking hamstring (HT) autografts in vancomycin was associated with a 10‐fold reduction in infection rate in anterior cruciate ligament (ACL) reconstruction. Our aim was to determine the practice of orthopaedic surgeons with regards to vancomycin presoaking and explore whether they would adopt the findings of this meta‐analysis. Methods A paper questionnaire survey was administered to attendees of an annual EFORT podium presentation of the meta‐analysis findings. Descriptive statistics were used to summarize the characteristics of respondents and their responses. Results A total of 29 senior surgeons/subspecialists performing a median of 40 ACL reconstructions per year completed the survey of whom 7 (24.1%) had encountered an ACL graft infection in the previous 2 years and 14 (48.3%) in the previous 5 years. Only 3 (10.3%) presoaked the ACL graft with an antibiotic. About 1/4 of those who up to then did not pre‐soak the graft (6/26, 23.1%) would consider changing their practice to pre‐soaking with vancomycin, with similar findings (5/20, 25.0%) in those that used a HT autograft as their first choice. Conclusions Orthopaedic surgeons are receptive to the findings of a meta‐analysis reporting on the effectiveness of vancomycin graft presoaking in ACL reconstruction, which can thus have a substantial impact upon clinical care. Addressing concerns about vancomycin induced graft toxicity and comparing the pre‐soaking effect to that of specific intravenous antibiotic regimens may further enhance the uptake of this practice.