Vancomycin pre-soaking of the graft reduces postoperative infection rate without increasing risk of graft failure and arthrofibrosis in ACL reconstruction

Abstract

Purpose To investigate whether pre-soaking the graft in vancomycin during anterior cruciate ligament reconstruction (ACLR) reduces the postoperative infection rate and if this technique is associated with an increased rate of complications, including graft failure or arthrofibrosis. Methods A retrospective review of a prospective database was performed in 1779 patients who underwent ACLR over a period of 5 years, analysing the rate of postoperative deep knee infection. Group 1 and 2 both received perioperative IV antibiotics, while only group 2 underwent ACLR with grafts pre-soaked in a 5 mg/ml vancomycin solution. To analyse possible side effects associated with vancomycin use, 500 patients out of the overall study population (100 patients per year) were randomly selected and retrospectively interviewed for further postoperative complications including graft failure and arthrofibrosis as well as subjective evaluation of their knee by completing the IKDC form with a minimum mean follow-up of 37 months. Results In group 1, 22 out of 926 (2%) patients suffered a postoperative deep knee infection. In contrast, there were no postoperative infections in the second group of 853 patients (0%). 16 of 22 infections (73%) were caused by coagulase-negative Staphylococcus. Statistical analysis revealed a significantly reduced postoperative infection rate when bathing the autograft in vancomycin (p < 0.01). Analysis of the random sample revealed a significant decrease of graft failure with 8 reruptures in 257 patients (3%) in the vancomycin group compared to 16 cases of graft failure in 167 patients (10%) in the control group (p < 0.05). No differences were found in the rate of postoperative arthrofibrosis, Tegner or subjective outcome scores. Conclusion Prophylactic vancomycin pre-soaking of autografts during ACLR appears to be a viable, cost-effective and safe option to reduce the rate of deep infection compared to systemic antibiotics alone. Level of evidence III.

Presoaking of Hamstring Autografts in Vancomycin Decreases the Occurrence of Infection Following Primary Anterior Cruciate Ligament Reconstruction

“…Our study confirmed the results of previous studies 9,10,12,13,19 in that no infection in ACL reconstruction was reported with hamstring grafts presoaked with vancomycin. The infection rate in the period immediately previous to the use of this protocol was in the upper level of the reported ranges (1.7%), while no infection was noted during the use of the protocol.…”

“…Offerhaus et al 10 reported a 2% postoperative deep knee infection rate without using vancomycin-presoaked grafts and a 0% infection rate when using vancomycin-presoaked grafts. In addition, they reported that the use of vancomycin did not increase the risks of graft failure, poor clinical scores, or arthrofibrosis.…”

“…In the next years, a number of studies using the same protocol have appeared, all of them confirming the results of Vertullo and colleagues. 9,10,12,13…”

Vancomycin-soaked autografts during ACL reconstruction reduce the risk of post-operative infection without affecting return to sport or knee function

“…Several recent studies have shown that vancomycin-soaked grafts are effective in preventing infection [ 5 , 13 – 15 , 19 , 21 ]. All published studies evaluating this subject have confirmed that none of the patients developed septic arthritis when a vancomycin-soaked graft was used.…”

Advanced Anterior Cruciate Ligament Repair and Reconstruction Techniques for Different Rupture Types

“… 25 Furthermore, other studies showed, that there is no additional risk of arthrofibrosis or graft failure by the use of vancomycin for presoaking. 26 …”