Abstract
Purpose
To determine and compare the incidence of postoperative septic arthritis following anterior cruciate ligament reconstruction (ACLR) with and without soaking of the graft in vancomycin solution prior to implantation in a large single-centre case series.
Methods
From 2004 to 2019, a total of 10,516 primary ACLR were performed and reviewed with regard to the occurrence of postoperative septic arthritis. From February 2017 onwards, all grafts were wrapped in a vancomycin-soaked (5 mg/ml) gauze swab between harvest and implantation (2294 patients, treatment group (2), prospectively followed). These were compared to 8222 patients before that date (control group (1), retrospectively evaluated). The technique of ACLR did not significantly change during the years of the study. There was no difference between the groups with regard to graft choice: Hamstring tendons were used in 99% and quadriceps tendons were used in 1% in both groups, respectively (n.s.). Routine follow-up examination was performed at 6 weeks (follow-up rate 97.1%) postoperatively. Patients with no treatment for septic arthritis at that time were classified as non-infected.
Results
There were 35 cases of postoperative septic arthritis in group 1 (incidence: 0.4%), and none in group 2 (incidence 0.0%), respectively. The difference was significant (p < 0.001).
Conclusions
Soaking of the graft in vancomycin solution prior to implantation dramatically reduces the incidence of postoperative septic arthritis in primary ACLR and should, therefore, be used in prevention of this major complication.
Level of evidence
III.
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References
Dodson V, Majmundar N, Swantic V, Assina R (2019) The effect of prophylactic vancomycin powder on infections following spinal surgeries: a systematic review. Neurosurg Focus 46:E11
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
Frank M, Schmucker U, David S, Matthes G, Ekkernkamp A, Seifert J (2008) Devastating femoral osteomyelitis after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16:71–74
Gande A, Rosinski A, Cunningham T, Bhatia N, Lee YP (2019) Selection pressures of vancomycin powder use in spine surgery: a meta-analysis. Spine J 19:1076–1084
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
Hey HW, Thiam DW, Koh ZS, Thambiah JS, Kumar N, Lau LL et al (2017) Is intraoperative local vancomycin powder the answer to surgical site infections in spine surgery? Spine 42:267–274 (Phila Pa 1976)
Indelli PF, Dillingham M, Fanton G, Schurman DJ (2002) Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res 1:182–188
Makhni EC, Steinhaus ME, Mehran N, Schulz BS, Ahmad CS (2015) Functional outcome and graft retention in patients with septic arthritis after anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 31:1392–1401
Mester B, Ullerich F, Ohmann T, Glombitza M, Schoepp C (2017) Ankylosis of the knee after septic arthritis following anterior cruciate ligament reconstruction in a 13-year-old male. Orthop Traumatol Surg Res 103:619–622
Mouzopoulos G, Fotopoulos VC, Tzurbakis M (2009) Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 17:1033–1042
Offerhaus C, Balke M, Hente J, Gehling M, Blendl S, Hoher J (2019) 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
Perez-Prieto D, Torres-Claramunt R, Gelber PE, Shehata TMA, 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
Pogorzelski J, Themessl A, Achtnich A, Fritz EM, Wortler K, Imhoff AB et al (2018) Septic arthritis after anterior cruciate ligament reconstruction: how important is graft salvage? Am J Sports Med 46:2376–2383
Schroeder JE, Girardi FP, Sandhu H, Weinstein J, Cammisa FP, Sama A (2016) The use of local vancomycin powder in degenerative spine surgery. Eur Spine J 25:1029–1033
Schuster P, Schlumberger M, Mayer P, Eichinger M, Gesslein M, Richter J (2019) Soaking of autografts in vancomycin is highly effective in preventing postoperative septic arthritis after revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-019-05820-9
Schuster P, Schulz M, Immendoerfer M, Mayer P, Schlumberger M, Richter J (2015) Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: evaluation of an arthroscopic graft-retaining treatment protocol. Am J Sports Med 43:3005–3012
Schuttler KF, Scharm A, Stein T, Heyse TJ, Lohoff M, Sommer F et al (2019) Biomechanical and microbiological effects of local vancomycin in anterior cruciate ligament (ACL) reconstruction: a porcine tendon model. Arch Orthop Trauma Surg 139:73–78
Torres-Claramunt R, Pelfort X, Erquicia J, Gil-Gonzalez S, Gelber PE, Puig L et al (2013) Knee joint infection after ACL reconstruction: prevalence, management and functional outcomes. Knee Surg Sports Traumatol Arthrosc 21:2844–2849
Van Tongel A, Stuyck J, Bellemans J, Vandenneucker H (2007) Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. Am J Sports Med 35:1059–1063
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 C, Lee YH, Siebold R (2014) Recommendations for the management of septic arthritis after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 22:2136–2144
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Schuster, P., Schlumberger, M., Mayer, P. 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 28, 2587–2591 (2020). https://doi.org/10.1007/s00167-020-05882-0
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DOI: https://doi.org/10.1007/s00167-020-05882-0