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.
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.
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.
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
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Anterior cruciate ligament reconstruction
Minimum inhibitory concentration
Ahn JH, Lee SH (2016) Risk factors for knee instability after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 24:2936–2942
Antoci V Jr, Adams CS, Hickok NJ, Shapiro IM, Parvizi J (2007) Antibiotics for local delivery systems cause skeletal cell toxicity in vitro. Clin Orthop Relat Res 462:200–206
Badran MA, Moemen DM (2016) Hamstring graft bacterial contamination during anterior cruciate ligament reconstruction: clinical and microbiological study. Int Orthop 40:1899–1903
Barker JU, Drakos MC, Maak TG, Warren RF, Williams RJ III, Allen AA (2010) Effect of graft selection on the incidence of postoperative infection in anterior cruciate ligament reconstruction. Am J Sports Med 38:281–286
Caroom C, Tullar JM, Benton EG Jr, Jones JR, Chaput CD (2013) Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion. Spine (Phila Pa 1976) 38:1183–1187
Conte EJ, Hyatt AE, Gatt CJ Jr, Dhawan A (2014) Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy 30:882–890
Diaz R, Afreixo V, Ramalheira E, Rodrigues C, Gago B (2018) Evaluation of vancomycin MIC creep in methicillin-resistant Staphylococcus aureus infections—a systematic review and meta-analysis. Clin Microbiol Infect 24:97–104
Edin ML, Miclau T, Lester GE, Lindsey RW, Dahners LE (1996) Effect of cefazolin and vancomycin on osteoblasts in vitro. Clin Orthop Relat Res 333:245–251
Ekhtiari S, Horner NS, de Sa D, Simunovic N, Hirschmann MT, Ogilvie R et al (2017) Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: a systematic review. Knee Surg Sports Traumatol Arthrosc 25:3929–3937
Eriksson K, Karlsson J (2016) Local vancomycin in ACL reconstruction: a modern rationale (2016) for morbidity prevention and patient safety. Knee Surg Sports Traumatol Arthrosc 24:2721–2723
Grayson JE, Grant GD, Dukie S, Vertullo CJ (2011) The in vitro elution characteristics of vancomycin from tendons. Clin Orthop Relat Res 469:2948–2952
Greis PE, Koch BS, Adams B (2012) Tibialis anterior or posterior allograft anterior cruciate ligament reconstruction versus hamstring autograft reconstruction: an economic analysis in a hospital-based outpatient setting. Arthroscopy 28:1695–1701
Ho PL, Lo PY, Chow KH, Lau EH, Lai EL, Cheng VC et al (2010) Vancomycin MIC creep in MRSA isolates from 1997 to 2008 in a healthcare region in Hong Kong. J Infect 60:140–145
Horneff JG III, Hsu JE, Voleti PB, O’Donnell J, Huffman GR (2015) Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain. J Shoulder Elb Surg 24:838–843
Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P et al (2001) Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 29:600–613
Judd D, Bottoni C, Kim D, Burke M, Hooker S (2006) Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 22:375–384
Kanj WW, Flynn JM, Spiegel DA, Dormans JP, Baldwin KD (2013) Vancomycin prophylaxis of surgical site infection in clean orthopedic surgery. Orthopedics 36:138–146
Kartus J, Magnusson L, Stener S, Brandsson S, Eriksson BI, Karlsson J (1999) Complications following arthroscopic anterior cruciate ligament reconstruction. A 2–5-year follow-up of 604 patients with special emphasis on anterior knee pain. Knee Surg Sports Traumatol Arthrosc 7:2–8
Kehrmann J, Kaase M, Szabados F, Gatermann SG, Buer J, Rath PM et al (2011) Vancomycin MIC creep in MRSA blood culture isolates from Germany: a regional problem? Eur J Clin Microbiol Infect Dis 30:677–683
Kieser TM, Rose MS, Aluthman U, Montgomery M, Louie T, Belenkie I (2014) Toward zero: deep sternal wound infection after 1001 consecutive coronary artery bypass procedures using arterial grafts: implications for diabetic patients. J Thorac Cardiovasc Surg 148:1887–1895
Maletis GB, Inacio MC, Funahashi TT (2013) Analysis of 16,192 anterior cruciate ligament reconstructions from a community-based registry. Am J Sports Med 41:2090–2098
Maletis GB, Inacio MC, Reynolds S, Desmond JL, Maletis MM, Funahashi TT (2013) Incidence of postoperative anterior cruciate ligament reconstruction infections: graft choice makes a difference. Am J Sports Med 41:1780–1785
Mariappan R, Manninen P, Massicotte EM, Bhatia A (2013) Circulatory collapse after topical application of vancomycin powder during spine surgery. J Neurosurg Spine 19:381–383
Mouzopoulos G, Fotopoulos VC, Tzurbakis M (2009) Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 17:1033–1042
Perez-Prieto D, Portillo ME, Torres-Claramunt R, Pelfort X, Hinarejos P, Monllau JC (2018) Contamination occurs during ACL graft harvesting and manipulation, but it can be easily eradicated. Knee Surg Sports Traumatol Arthrosc 26:558–562
Perez-Prieto D, Torres-Claramunt R, Gelber PE, Shehata TM, Pelfort X, Monllau JC (2016) Autograft soaking in vancomycin reduces the risk of infection after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 24:2724–2728
Phegan M, Grayson JE, Vertullo CJ (2016) No infections in 1300 anterior cruciate ligament reconstructions with vancomycin pre-soaking of hamstring grafts. Knee Surg Sports Traumatol Arthrosc 24:2729–2735
Plante MJ, Li X, Scully G, Brown MA, Busconi BD, DeAngelis NA (2013) Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 21:696–701
Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K (2005) Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy 21:948–957
Sechriest VF II, Carney JR, Kuskowski MA, Haffner JL, Mullen MJ, Covey DC (2013) Incidence of knee sepsis after ACL reconstruction at one institution: the impact of a clinical pathway. J Bone Jt Surg Am 95:843–849 (S841-846)
Shields MV, Abdullah L, Namdari S (2016) The challenge of Propionibacterium acnes and revision shoulder arthroplasty: a review of current diagnostic options. J Shoulder Elb Surg 25:1034–1040
Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49
Tomczak H, Szalek E, Blazejewska W, Myczko K, Horla A, Grzeskowiak E (2013) The need to assay the real MIC when making the decision to eradicate Staphylococcus aureus with vancomycin. Postepy Hig Med Dosw 67:921–925
Torres-Claramunt R, Gelber P, Pelfort X, Hinarejos P, Leal-Blanquet J, Perez-Prieto D et al (2016) Managing septic arthritis after knee ligament reconstruction. Int Orthop 40:607–614
Trampuz A, Zimmerli W (2006) Antimicrobial agents in orthopaedic surgery: prophylaxis and treatment. Drugs 66:1089–1105
van Yperen DT, Reijman M, van Es EM, Bierma-Zeinstra SMA, Meuffels DE (2018) Twenty-year follow-up study comparing operative versus nonoperative treatment of anterior cruciate ligament ruptures in high-level athletes. Am J Sports Med. https://doi.org/10.1177/0363546517751683363546517751683
Vertullo CJ, Quick M, Jones A, Grayson JE (2012) A surgical technique using presoaked vancomycin hamstring grafts to decrease the risk of infection after anterior cruciate ligament reconstruction. Arthroscopy 28:337–342
Wang G, Hindler JF, Ward KW, Bruckner DA (2006) Increased vancomycin MICs for Staphylococcus aureus clinical isolates from a university hospital during a 5-year period. J Clin Microbiol 44:3883–3886
Whiteside LA, Peppers M, Nayfeh TA, Roy ME (2011) Methicillin-resistant Staphylococcus aureus in TKA treated with revision and direct intra-articular antibiotic infusion. Clin Orthop Relat Res 469:26–33
Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD (2016) Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med 44:1861–1876
Yan H, He J, Chen S, Yu S, Fan C (2014) Intrawound application of vancomycin reduces wound infection after open release of post-traumatic stiff elbows: a retrospective comparative study. J Shoulder Elb Surg 23:686–692
The authors gratefully acknowledge Nate Breznau and Ajay C. Kanakamedala for language editing.
The authors did not receive any funding for the study.
Conflict of interest
The authors declare no conflict of interest.
Institutional ethics committee approval was obtained prior to the start of this study (University Witten/Herdecke; ID: 1792015).
About this article
Cite this article
Offerhaus, C., Balke, M., Hente, J. et al. 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 27, 3014–3021 (2019). https://doi.org/10.1007/s00167-018-5323-6
- Anterior cruciate ligament
- Antibiotic prophylaxis
- Knee infection
- Graft failure