Local vancomycin in ACL reconstruction: a modern rationale (2016) for morbidity prevention and patient safety

Abstract

treatment has become the first line of treatment unless contraindicated.It is obvious that, with improved results in both the short and long term [function and risk of osteoarthritis (OA)] and a simultaneous reduced risk of complications and morbidity related to the procedure, more people could benefit from surgery. For this reason, reducing morbidity after ACL reconstructive procedures must be a significant part of the "ACL holy grail".The incidence of deep post-operative infection following an ACL reconstruction varies between 0.14 and 1.7 % in different studies [2,12]. The majority of the present studies report an incidence of just below 1 %. Moreover, there are some signs that hamstring grafts are slightly more likely to be infected compared with patellar tendon (BTB) grafts. In terms of pathogens, coagulase-negative staphylococcus (CNS) appears to be the dominant species, followed by staphylococcus aureus and propionebacterium acne. The most likely aetiology is graft contamination from the patient's own skin flora.The potential consequences of a deep infection can obviously be devastating, with the need for graft and hardware removal, and in many patients, a second stage ACL-R 4 to 6 months later. However, in most cases, repeated washouts and long-term antibiotics cure the infection, and the graft may survive. The two major concerns following deep infection after ACL-R are graft survival and long-term graft function, but also the increased likelihood of long-term OA. In a recent publication by Boström Windhamre et al. [1], 27 of 43 reported infected ACL-Rs were compared with matched controls in terms of activity, time to recovery and knee function. The infection rate was estimated at 0.98 %.The recovery time was significantly longer, and the Tegner activity level was lower, while the KOOS values at a mean of 60 months post-operatively revealed no ACL reconstruction (ACL-R) in 2016 still faces two major challenges. The first is to improve the surgical technique and consequently the overall results, and the second is to minimise the morbidity of the procedure. The fact is that, if significant improvements in both these areas can be achieved, we would most probably offer surgical treatment (repair or reconstruction) as the first line of treatment to most young and middle-aged patients sustaining an ACL rupture. This argument could be compared with tibial fractures or other traumatic conditions, where surgical

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

“…Deep infection following anterior cruciate ligament reconstruction (ACLR) is around 1% (range 0.14-1.7%) 1,2,3 and 0.5% undergo re-operation for infection 4 . Most frequent organisms are coagulase-negative Staphylococcus (CNS) followed by Staphylococcus aureus and Propionebacterium acne 1 . The most common source of graft contamination is the patient's skin flora 1 .…”

“…Most frequent organisms are coagulase-negative Staphylococcus (CNS) followed by Staphylococcus aureus and Propionebacterium acne 1 . The most common source of graft contamination is the patient's skin flora 1 . Repeated washouts and long-term antibiotics allow graft survival in many cases 1 .…”

“…The most common source of graft contamination is the patient's skin flora 1 . Repeated washouts and long-term antibiotics allow graft survival in many cases 1 . However, it is necessary at times to remove the graft and hardware and perform revision ACLR surgery 1 .…”

“…After sepsis, the main concerns are graft survival, long-term function, and osteoarthritis prevention 1 . Osteoarthritis risk is low 5,6,7 .…”

Does Vancomycin Wrapping in Anterior Cruciate Ligament Reconstruction Affect Tenocyte Activity In Vitro?

“…A common practice to avoid knee septic arthritis after ACLR is the “vancomycin wrap”, first described by Vertullo and colleagues [ 15 ], involving the soaking of the graft for 10–15 min within a sterile gauze swab previously saturated with 5 mg/mL vancomycin [ 16 , 17 , 18 ]. Vancomycin was first described in 1952 and approved by the FDA in 1958 as an antibiotic active against Gram-positive and penicillin-resistant Staphylococci .…”