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Vancomycin-soaking of the graft reduces the incidence of septic arthritis following ACL reconstruction: results of a systematic review and meta-analysis

  • knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

(1) To compare the incidence of post-operative septic arthritis following anterior cruciate ligament reconstruction (ACLR) between patients receiving routine pre-operative intravenous (IV) prophylaxis only intravenous (IV) infection prophylaxis and patients receiving additional graft-soaking in a vancomycin solution (5 mg/ml) perioperatively. (2) To review the literature regarding effects of graft-soaking in vancomycin solutions on outcomes, complication rates and tendon properties in ACLR.

Methods

To identify studies pertaining to routine pre-operative IV prophylaxis and additional usage of intra-operative vancomycin-soaked grafts in primary ACLR, the Cochrane Library, SCOPUS and MEDLINE were searched till June 2018 for English and German language studies of all levels of evidence following the PRISMA guidelines. Additionally, all accepted abstracts at the ESSKA 2018, ISAKOS 2017, AGA 2017 and AOSSM 2017 meetings were screened. Data regarding the incidence of septic arthritis were abstracted and combined in a meta-analysis. Data including outcome scores, complication rates and in vitro analyses of tendon properties were collected and summarized descriptively.

Results

Upon screening 785 titles, 8 studies were included. These studies examined 5,075 patients following ACLR and followed from 6 to 52 weeks post-operatively. Of those 2099 patients in the routine pre-operative IV prophylaxis group, 44 (2.1%) cases of early septic arthritis were reported. In contrast, there were no reports of septic arthritis following ACLR in 2976 cases of vancomycin-soaked grafts. The meta-analysis yielded an odds ratio of 0.04 (0.01–0.16) favouring the addition of intra-operative vancomycin-soaking of grafts. Across all available studies, no differences in clinical outcome (i.e. incidence of ACL revision, IKDC score, Tegner score), biomechanical tendon properties, or cartilage integrity between patients with and without vancomycin-soaked grafts were identified.

Conclusion

The incidence of septic arthritis following ACLR can be reduced dramatically by vancomycin-soaking the grafts intra-operatively prior to graft passage and fixation. Within the limitation confines of this study, intra-operative graft-soaking in vancomycin appears to be a safe and effective method to reduce the incidence of septic arthritis following ACLR. Still, it remains debatable if the available data facilitate the recommendation for a universal application of vancomycin-soaking for all ACLR patients or if it should be reserved for patients at risk, including the use hamstring tendons, revision cases and in the presence of medical preconditions.

Level of evidence

Level IV, systematic review of Level III and Level IV studies.

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Abbreviations

IV:

Intravenous

ACL:

Anterior cruciate ligament

ACLR:

Anterior cruciate ligament reconstruction

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Acknowledgements

We want to thank Christoph Offerhaus and Jürgen Höher et al. for the generous provision of their partially published data.

Funding

There was no external source of funding for this study.

Author information

Author notes

  1. Jan-Hendrik Naendrup and Benedikt Marche have contributed equally to this work.

Authors and Affiliations

  1. Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany

    Jan-Hendrik Naendrup, Benedikt Marche, Paola Koenen, Robin Otchwemah, Arasch Wafaisade & Thomas R. Pfeiffer

  2. Department of Orthopaedic Surgery, University of Pittsburgh-UPMC Rooney Sports Complex, 3200 S Water St, Pittsburgh, PA, 15203, USA

    Jan-Hendrik Naendrup, Darren de SA & Thomas R. Pfeiffer

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  1. Jan-Hendrik Naendrup
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Contributions

TRP and BM performed the screening of all titles, abstracts, and full texts. BM and JHN performed the abstraction of all data. JHN and TRP drafted the original manuscript. DdS, PK, RO, and AW participated in the editing of the original manuscript. TRP, DdS, PK, RO, and AW participated in the conception and design of the original study. JHN and BM have contributed equally to this work. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Thomas R. Pfeiffer.

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The authors of this study confirm that they have no conflicts of interest related to this study.

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No IRB approval was required or obtained for this study.

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Naendrup, JH., Marche, B., de SA, D. 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 28, 1005–1013 (2020). https://doi.org/10.1007/s00167-019-05353-1

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