A Review of Evidence for Infection Reduction With Vancomycin-treated Anterior Cruciate Ligament Grafts

Abstract

Septic arthritis after anterior cruciate ligament (ACL) reconstruction is a rare but devastating complication. Several risk factors and known sources of infection have been identified in the literature. There is growing interest and supportive evidence for a targeted invention aimed at graft decontamination, which has led some surgeons to adopt the use of antibiotic solution soaks and/or wraps applied to ACL grafts before graft implantation in an attempt to reduce the risk of postoperative infection. Despite this, adoption of this technique remains relatively low among surgeons because of a variety of factors:(1) lack of awareness, (2) confusion over optimal protocols, (3) concern for graft viability and clinical outcomes, and (4) efforts to minimize the cost of surgery. However, recently published literature demonstrates notable risk reduction for infection, acceptable safety, no detrimental effect on clinical outcomes, and overall cost-effectiveness with the use of vancomycin graft soaks and wraps. Currently, there is a lack of consensus for clinical protocols, and the protocol that is most efficacious remains unclear. The purpose of this review article was to present the current evidence for ACL graft treatment with vancomycin for the prevention of postoperative infection.

Semitendinosus tendons are commonly contaminated with skin flora during graft harvest for anterior cruciate ligament reconstruction

“…All species were susceptible to vancomycin which is coherent with the findings of Pérez-Prieto et al who reported that bacterial contamination from grafts could be completely eliminated by topical application of vancomycin [ 25 ]. Thus, clinical studies showed that the postoperative infection rate after ACL reconstruction could be significantly reduced to almost 0% by soaking the hamstring tendon graft in vancomycin before it was implanted into the knee joint [ 3 , 4 , 6 , 7 , 12 , 13 , 18 , 21 , 22 , 26 , 31 ].…”

“…In 2012, Vertullo et al introduced a technique of presoaking the graft in vancomycin before it is implanted into the knee joint [ 33 ]. Clinical studies subsequently have shown a significant reduction of postoperative infection rate after ACLR by this technique [ 3 , 4 , 6 , 7 , 12 , 13 , 18 , 21 , 22 , 26 , 31 ]. However, at the time this technique was introduced, the exact mechanism of contamination leading to knee joint infection after ACLR was unclear and to some extend still is.…”

ESSKA and EBJIS recommendations for the management of infections after anterior cruciate ligament reconstruction (ACL‐R): prevention, surgical treatment and rehabilitation

“…Additionally, recent studies have proven it to be a safe technique with no increase in re‐ruptures and a similar return‐to‐play time [10, 26, 42]. Moreover, it is a cost‐effective technique [32, 42]. However, it is important to remember that all other measures to reduce infection including behavior in the operating room must be implemented and cannot be neglected.…”