Editorial Commentary: Vancomycin Soaking of the Graft in Anterior Cruciate Ligament Reconstruction: A Concept on the Way to Becoming the New Gold Standard

Pfeiffer, Thomas

doi:10.1016/j.arthro.2020.12.214

Cited by 6 publications

(5 citation statements)

References 22 publications

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“…Even now it appears to be difficult to withhold this method from high-risk patients, in particular against the backdrop of multiple level 2 and 3 studies, including .20,000 patients who showed drastically reduced incidence of septic knee arthritis after ACL reconstruction. 22,32 CONCLUSION Chondrotoxic vancomycin concentrations !1000 mg/mL were not reached in any aspiration of synovial fluid after ACL reconstruction using soft tissue autografts that were intraoperatively soaked in a 5-mg/mL vancomycin solution. Against the backdrop of multiple studies showing significantly reduced infection rates after ACL reconstruction when using vancomycin soaking, this study suggests that the chondrotoxic properties of this method are negligible because of its submarginal intra-articular concentrations.…”

Section: Discussionmentioning

confidence: 99%

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Vancomycin Concentrations in Synovial Fluid Do Not Reach Chondrotoxic Thresholds After Anterior Cruciate Ligament Reconstruction With Vancomycin-Soaked Autologous Soft Tissue Grafts: An In Vivo Prospective Observational Study in Humans

Pfeiffer,

Althoff,

Krombholz

et al. 2023

Am J Sports Med

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Background: Studies have revealed that vancomycin soaking of the anterior cruciate ligament (ACL) graft can drastically reduce the incidence of postoperative infections after ACL reconstruction. However, it remains unknown whether the chondrotoxic threshold of vancomycin in synovial fluid is exceeded during this process. Several studies investigated the chondrotoxic properties of vancomycin in in vitro experiments and described a concentration of 1000 µg/mL as the critical threshold. Purpose/Hypothesis: The purpose of the study was to measure the vancomycin concentration in synovial fluid after ACL reconstruction with vancomycin-soaked autografts. It was hypothesized that intra-articular vancomycin concentrations in the synovial fluid would not reach the chondrotoxic threshold of 1000 µg/mL after vancomycin soaking of autologous semitendinosus tendon and soft tissue quadriceps tendon grafts for ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: The study enrolled 10 patients undergoing ACL reconstruction using 4-strand semitendinosus tendon autografts and 10 patients undergoing ACL reconstruction using soft tissue quadriceps tendon autografts. Before implantation, each harvested graft was intraoperatively wrapped in gauze swabs that had been soaked in a 5-mg/mL vancomycin solution. After wound closure, an aspirate of 5 mL of synovial fluid was taken from each patient. The vancomycin concentration of the aspirate was analyzed using high-performance liquid chromatography–tandem mass spectrometry. Spearman rho correlation coefficients were used to identify relationships between the parameters, and the t test was used to test for differences between graft types. A P value of <.05 was considered statistically significant. Results: The study included 20 patients (14 women and 6 men; age, 29.35 ± 11.3 years). The mean vancomycin concentration measured in the synovial fluid was 23.23 ± 21.68 µg/mL, with a minimum concentration of 2.32 µg/mL and a maximum concentration of 71.56 µg/mL. No significant difference was found between the 2 graft types ( P = .911). Significant positive correlation ( r = 0.644; P < .05) was observed only between the vancomycin concentration and the mean duration from initiation of vancomycin soaking of semitendinosus tendon grafts to implantation (13.4 ± 6 minutes). No correlations were observed between the vancomycin concentration and the duration from implantation to fluid aspiration or between the vancomycin concentration and the graft diameter (median, 8.5 mm; range, 6.0-10.0 mm) for both graft types. Conclusion: Chondrotoxic vancomycin concentrations ≥1000 µg/mL were not reached in any aspiration of synovial fluid after ACL reconstruction using soft tissue autografts that were intraoperatively soaked in a 5-mg/mL vancomycin solution. Against the backdrop of multiple studies that showed significantly reduced infection rates after ACL reconstruction when vancomycin soaking was used, this study suggests that the chondrotoxic properties of this method are negligible because of its submarginal intra-articular concentrations.

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Section: Discussionmentioning

confidence: 99%

“…Even now it appears to be difficult to withhold this method from high-risk patients, in particular against the backdrop of multiple level 2 and 3 studies, including >20,000 patients who showed drastically reduced incidence of septic knee arthritis after ACL reconstruction. 22 , 32 …”

Section: Discussionmentioning

confidence: 99%

Vancomycin Concentrations in Synovial Fluid Do Not Reach Chondrotoxic Thresholds After Anterior Cruciate Ligament Reconstruction With Vancomycin-Soaked Autologous Soft Tissue Grafts: An In Vivo Prospective Observational Study in Humans

Pfeiffer,

Althoff,

Krombholz

et al. 2023

Am J Sports Med

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“…A 2021 editorial by Pfeiffer, supported by 22 bibliographical references, reported that increasing numbers of surgeons using vancomycin graft soaking in ACLR had resulted in a significant reduction in post-operative septic knee arthritis 38 . In vitro findings show no detrimental effect of vancomycin on tendon properties 16 .…”

Section: Discussion Vancoymicin Wrap: Should It Be the New Gold Standard?mentioning

confidence: 99%

“…Despite the positive effects of vancomycin pre-soaking in reducing ACLR infection rate, the lack of prospective randomized control trials and the heterogeneity of the different reported surgical groups makes it not possible to advise vancomycin pre-soaking of the graft globally for all ACLR subjects 38 .…”

Section: Discussion Vancoymicin Wrap: Should It Be the New Gold Standard?mentioning

confidence: 99%

The role of vancomycin-soaking of the graft in anterior cruciate ligament reconstruction

Rodríguez-Merchán¹,

Ribbans²

2022

Journal of ISAKOS

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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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“…The use of vancomycin powder in this way, supported by much level III evidence, has been associated with a decreased rate of infection without affecting the rate of failure of the graft or the functional outcomes. 20-23…”

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confidence: 99%

Vancomycin powder in total joint replacement

Mancino,

Gant,

Meek

et al. 2023

Bone Joint J

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Editorial Commentary: Vancomycin Soaking of the Graft in Anterior Cruciate Ligament Reconstruction: A Concept on the Way to Becoming the New Gold Standard

Cited by 6 publications

References 22 publications

Vancomycin Concentrations in Synovial Fluid Do Not Reach Chondrotoxic Thresholds After Anterior Cruciate Ligament Reconstruction With Vancomycin-Soaked Autologous Soft Tissue Grafts: An In Vivo Prospective Observational Study in Humans

Vancomycin Concentrations in Synovial Fluid Do Not Reach Chondrotoxic Thresholds After Anterior Cruciate Ligament Reconstruction With Vancomycin-Soaked Autologous Soft Tissue Grafts: An In Vivo Prospective Observational Study in Humans

The role of vancomycin-soaking of the graft in anterior cruciate ligament reconstruction

Vancomycin powder in total joint replacement

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