Vancomycin presoak reduces infection in anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Mingwei Hu, Yifan Zhang, Guangqian Shang, Jianjun Guo, Hao Xu, Xue Ma, Xue Yang, Shuai Xiang, Mingwei Hu, Yifan Zhang, Guangqian Shang, Jianjun Guo, Hao Xu, Xue Ma, Xue Yang, Shuai Xiang

Abstract

Purpose: To compare the effect of vancomycin presoak treatment of grafts during anterior cruciate ligament reconstruction on the incidence of postoperative infection or septic arthritis.

Methods: Studies published before May 3, 2022 investigating vancomycin presoak of grafts during anterior cruciate ligament reconstruction were searched in the PubMed and Cochrane Central Register of Controlled Trials. Studies were screened, and data on the incidence of postoperative infection or septic arthritis were extracted and included in the analysis.

Results: Thirteen studies were included for analysis after search screening, yielding a total of 31,150 participants for analysis, of whom 11,437 received graft vancomycin presoak treatment, and 19,713 did not receive treatment. Participants who received vancomycin treatment had significantly lower infection rates (0.09% versus 0.74%; OR 0.17; 95% CI 0.10, 0.30; P < 0.00001).

Conclusion: Pre-soaking of the graft with vancomycin during ACL reconstruction reduced the incidence of postoperative infection and septic arthritis.

Keywords: Anterior cruciate ligament reconstruction; Antibiotic; Infection; Sports medicine; vancomycin.

Conflict of interest statement

The authors declare no conflict of interest.

© 2023. The Author(s).

Figures

Fig. 1
Fig. 1
The selection process for inclusion and exclusion of articles
Fig. 2
Fig. 2
Forest plot of postoperative infection differences between ACL grafts soaked in vancomycin, and grafts not treated with vancomycin

References

    1. Cheng X, Liu F, Zhou D, Paulus AC. Surgical intra- and extra-articular anterior cruciate ligament reconstruction: a meta-analysis. BMC Musculoskelet Disord. 2020;21(1):414. doi: 10.1186/s12891-020-03438-4.
    1. Robinson JR, Haddad FS. ACL graft failure: surgical technique may affect outcomes. Bone Joint J. 2021;103–B(9):1439–41. doi: 10.1302/0301-620X.103B9.BJJ-2021-0919.
    1. Wang C, Ao Y, Wang J, Hu Y, Cui G, Yu J. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, presentation, treatment, and cause. Arthroscopy. 2009;25(3):243–9. doi: 10.1016/j.arthro.2008.10.002.
    1. Indelli PF, Dillingham M, Fanton G, Schurman DJ. Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2002(398):182–8.
    1. Brophy RH, Wright RW, Huston LJ, Nwosu SK, Group MK, Spindler KP. Factors associated with infection following anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2015;97(6):450–4. doi: 10.2106/JBJS.N.00694.
    1. Judd D, Bottoni C, Kim D, Burke M, Hooker S. Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy. 2006;22(4):375–84. doi: 10.1016/j.arthro.2005.12.002.
    1. Maletis GB, Inacio MC, Reynolds S, Desmond JL, Maletis MM, Funahashi TT. Incidence of postoperative anterior cruciate ligament reconstruction infections: graft choice makes a difference. Am J Sports Med. 2013;41(8):1780–5. doi: 10.1177/0363546513490665.
    1. Mariscalco MW, Magnussen RA, Mehta D, Hewett TE, Flanigan DC, Kaeding CC. Autograft versus nonirradiated allograft tissue for anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2014;42(2):492–9. doi: 10.1177/0363546513497566.
    1. Greenberg DD, Robertson M, Vallurupalli S, White RA, Allen WC. Allograft compared with autograft infection rates in primary anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2010;92(14):2402–8. doi: 10.2106/JBJS.I.00456.
    1. Bansal A, Lamplot JD, VandenBerg J, Brophy RH. Meta-analysis of the risk of Infections after Anterior Cruciate Ligament Reconstruction by Graft Type. Am J Sports Med. 2018;46(6):1500–8. doi: 10.1177/0363546517714450.
    1. Makhni EC, Steinhaus ME, Mehran N, Schulz BS, Ahmad CS. Functional Outcome and Graft Retention in patients with septic arthritis after Anterior Cruciate Ligament Reconstruction: a systematic review. Arthroscopy. 2015;31(7):1392–401. doi: 10.1016/j.arthro.2014.12.026.
    1. Pogorzelski J, Themessl A, Achtnich A, Fritz EM, Wortler K, Imhoff AB, et al. Septic arthritis after Anterior Cruciate Ligament Reconstruction: how important is graft salvage? Am J Sports Med. 2018;46(10):2376–83. doi: 10.1177/0363546518782433.
    1. Schuster P, Schulz M, Immendoerfer M, Mayer P, Schlumberger M, Richter J. Septic arthritis after arthroscopic anterior Cruciate Ligament Reconstruction: evaluation of an arthroscopic graft-retaining treatment protocol. Am J Sports Med. 2015;43(12):3005–12. doi: 10.1177/0363546515603054.
    1. Torres-Claramunt R, Pelfort X, Erquicia J, Gil-Gonzalez S, Gelber PE, Puig L, et al. Knee joint infection after ACL reconstruction: prevalence, management and functional outcomes. Knee Surg Sports Traumatol Arthrosc. 2013;21(12):2844–9. doi: 10.1007/s00167-012-2264-3.
    1. Kanj WW, Flynn JM, Spiegel DA, Dormans JP, Baldwin KD. Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery. Orthopedics. 2013;36(2):138–46. doi: 10.3928/01477447-20130122-10.
    1. Kim EK, Donnelley CA, Tiee M, Roberts HJ, Von Kaeppler E, Shearer D, et al. Prophylactic topical antibiotics in fracture repair and spinal Fusion. Adv Orthop. 2021;2021:1949877.
    1. Vertullo CJ, Quick M, Jones A, Grayson JE. A surgical technique using presoaked vancomycin hamstring grafts to decrease the risk of infection after anterior cruciate ligament reconstruction. Arthroscopy. 2012;28(3):337–42. doi: 10.1016/j.arthro.2011.08.301.
    1. Higgins JPTTJ, Chandler J, Cumpston M, Li T, Page MJ, Welch VA. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 Cochrane; 2022.
    1. Banios K, Komnos GA, Raoulis V, Bareka M, Chalatsis G, Hantes ME. Soaking of autografts with vancomycin is highly effective on preventing postoperative septic arthritis in patients undergoing ACL reconstruction with hamstrings autografts. Knee Surg Sports Traumatol Arthrosc. 2021;29(3):876–80. doi: 10.1007/s00167-020-06040-2.
    1. Baron JE, Shamrock AG, Cates WT, Cates RA, An Q, Wolf BR, et al. Graft Preparation with Intraoperative Vancomycin decreases infection after ACL Reconstruction: a review of 1,640 cases. J Bone Joint Surg Am. 2019;101(24):2187–93. doi: 10.2106/JBJS.19.00270.
    1. Bohu Y, Klouche S, Sezer HB, Herman S, Grimaud O, Gerometta A, et al. Vancomycin-soaked autografts during ACL reconstruction reduce the risk of post-operative infection without affecting return to sport or knee function. Knee Surg Sports Traumatol Arthrosc. 2020;28(8):2578–85. doi: 10.1007/s00167-020-05879-9.
    1. Carrozzo A, Saithna A, Ferreira A, Guy S, Chadli L, Monaco E, et al. Presoaking ACL grafts in Vancomycin decreases the frequency of postoperative septic arthritis: a cohort study of 29,659 patients, systematic review, and Meta-analysis from the SANTI Study Group. Orthop J Sports Med. 2022;10(2):23259671211073928.
    1. Figueroa D, Figueroa F, Calvo R, Lopez M, Goni I. Presoaking of Hamstring Autografts in Vancomycin decreases the occurrence of infection following primary Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med. 2019;7(9):2325967119871038.
    1. Hees T, Abdelatif Y, Karpinski K, Bierke S, Haner M, Park HU et al. Soaking ACL grafts in vancomycin solution (1 mg/ml) reduces the infection rate without increasing the risk for re-rupture and arthrofibrosis. Arch Orthop Trauma Surg. 2021.
    1. Offerhaus C, Balke M, Hente J, Gehling M, Blendl S, Hoher J. Vancomycin pre-soaking of the graft reduces postoperative infection rate without increasing risk of graft failure and arthrofibrosis in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(9):3014–21. doi: 10.1007/s00167-018-5323-6.
    1. Perez-Prieto D, Torres-Claramunt R, Gelber PE, Shehata TMA, Pelfort X, Monllau JC. Autograft soaking in vancomycin reduces the risk of infection after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2724–8. doi: 10.1007/s00167-014-3438-y.
    1. Phegan M, Grayson JE, Vertullo CJ. No infections in 1300 anterior cruciate ligament reconstructions with vancomycin pre-soaking of hamstring grafts. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2729–35. doi: 10.1007/s00167-015-3558-z.
    1. Schuster P, Schlumberger M, Mayer P, Eichinger M, Gesslein M, Reddemann F, et al. Soaking of the graft in vancomycin dramatically reduces the incidence of postoperative septic arthritis after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2020;28(8):2587–91. doi: 10.1007/s00167-020-05882-0.
    1. Schuster P, Schlumberger M, Mayer P, Eichinger M, Gesslein M, Richter J. Soaking of autografts in vancomycin is highly effective in preventing postoperative septic arthritis after revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2020;28(4):1154–8. doi: 10.1007/s00167-019-05820-9.
    1. Wan KH, Tang SP, Lee RH, Wong KK, Wong KK. The use of vancomycin-soaked wrapping of hamstring grafts to reduce the risk of infection after anterior cruciate ligament reconstruction: an early experience in a district general hospital. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2020;22:10–4.
    1. Perez-Prieto D, Portillo ME, Torres-Claramunt R, Pelfort X, Hinarejos P, Monllau JC. Contamination occurs during ACL graft harvesting and manipulation, but it can be easily eradicated. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):558–62. doi: 10.1007/s00167-017-4735-z.
    1. Grayson JE, Grant GD, Dukie S, Vertullo CJ. The in vitro elution characteristics of vancomycin from tendons. Clin Orthop Relat Res. 2011;469(10):2948–52. doi: 10.1007/s11999-011-1768-3.
    1. Papalia R, Cicione C, Russo F, Ambrosio L, Di Giacomo G, Vadala G et al. Does Vancomycin Wrapping in Anterior Cruciate Ligament Reconstruction Affect Tenocyte Activity In Vitro? Antibiotics (Basel). 2021;10(9).
    1. Xiao M, Leonardi EA, Sharpe O, Sherman SL, Safran MR, Robinson WH, et al. Soaking of autologous Tendon grafts in Vancomycin before Implantation does not lead to tenocyte cytotoxicity. Am J Sports Med. 2020;48(12):3081–6. doi: 10.1177/0363546520951815.
    1. Naendrup JH, Marche B, de Sa D, Koenen P, Otchwemah R, Wafaisade A, et al. Vancomycin-soaking of the graft reduces the incidence of septic arthritis following ACL reconstruction: results of a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2020;28(4):1005–13. doi: 10.1007/s00167-019-05353-1.
    1. Tong K, Wei J, Li Z, Wang H, Wen Y, Chen L. Evaluation of the efficacy of vancomycin-soaked autograft to eliminate Staphylococcus aureus Contamination after Anterior Cruciate Ligament Reconstruction: based on an infected rat model. Am J Sports Med. 2022;50(4):932–42. doi: 10.1177/03635465211068114.
    1. Rohner E, Zippelius T, Bohle S, Rohe S, Matziolis G, Jacob B. Vancomycin is toxic to human chondrocytes in vitro. Arch Orthop Trauma Surg. 2021;141(3):375–81. doi: 10.1007/s00402-020-03431-5.
    1. Shaw KA, Eichinger JK, Nadig N, Parada SA. In Vitro Effect of Vancomycin on the viability of articular chondrocytes. J Orthop Trauma. 2018;32(3):148–53. doi: 10.1097/BOT.0000000000001040.
    1. Ruelos VCB, Puzzitiello RN, Menendez ME, Pagani NR, Moverman MA, Forsythe B, et al. Vancomycin Presoaking of Anterior Cruciate Ligament Tendon Grafts is highly cost-effective for preventing infection. Arthroscopy. 2021;37(10):3152–6. doi: 10.1016/j.arthro.2021.04.005.
    1. Truong AP, Perez-Prieto D, Byrnes J, Monllau JC, Vertullo CJ. Vancomycin Soaking is highly cost-effective in primary ACLR infection Prevention: a cost-effectiveness study. Am J Sports Med. 2022;50(4):922–31. doi: 10.1177/03635465211073338.
    1. Perez-Prieto D, Perelli S, Corcoll F, Rojas G, Montiel V, Monllau JC. The vancomycin soaking technique: no differences in autograft re-rupture rate. A comparative study. Int Orthop. 2021;45(6):1407–11. doi: 10.1007/s00264-020-04805-5.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe