Comparison Between Vancomycin and Gentamicin for Intraoperative Presoaking of Hamstring Graft in Primary Anterior Cruciate Ligament Reconstruction

Bansal, Deepak; Khatri, Kavin; Dahuja, Anshul; Lakhani, Amit; Malhotra, Neeraj

doi:10.7759/cureus.22550

Cited by 6 publications

(6 citation statements)

References 27 publications

(39 reference statements)

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“…There is also the added benefit of reduced systemic effects and initial less renal excretion, ease of administration, and possible cost-effectiveness in prevention of PJI [ 5 ]. Direct application of antibiotic has been effectively used to reduce infections in spinal [ 6 ], anterior cruciate [ 7 ], trauma surgery [ 8 ], and in rat models [ 9 ]. Furthermore, there is a growing body of evidence for its use in TJR, with a number of reviews suggesting IAA importance [ [10] , [11] , [12] ].…”

Section: Introductionmentioning

confidence: 99%

Intra-articular Vancomycin Reduces Prosthetic Infection in Primary Hip and Knee Arthroplasty

Burns,

Smith,

Lynch

2024

Arthroplasty Today

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Section: Introductionmentioning

confidence: 99%

Intra-articular Vancomycin Reduces Prosthetic Infection in Primary Hip and Knee Arthroplasty

Burns,

Smith,

Lynch

2024

Arthroplasty Today

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“…The American Journal of Sports Medicine 2024;52(4):956-960 DOI: 10.1177/03635465231223138 Ó 2024 The Author(s) ACLR surgery. 2,10 Both adult and pediatric formulations of gentamycin are frequently in shortage; however, some Canadian medical centers replaced gentamycin with tobramycin during the shortage period. 13,19 Tobramycin is another possible alternative to vancomycin, and both are already used in orthopaedic applications.…”

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confidence: 99%

“…Gentamycin solution is one such possible alternative and has recently been reported to help decrease the incidence of septic arthritis after ACLR surgery. 2,10 Both adult and pediatric formulations of gentamycin are frequently in shortage; however, some Canadian medical centers replaced gentamycin with tobramycin during the shortage period. 13,19 Tobramycin is another possible alternative to vancomycin, and both are already used in orthopaedic applications.…”

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confidence: 99%

Tobramycin and Vancomycin in an In Vitro Model of Anterior Cruciate Ligament Allograft Decontamination

Bentkowski,

Blunt,

Milliron

et al. 2024

Am J Sports Med

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Background: Approximately 100,000 anterior cruciate ligament (ACL) reconstructions (ACLRs) occur annually in the United States, and postoperative surgical-site infection is a relatively rare but devastating complication, often leading to graft failure or septic arthritis of the knee, necessitating repeat surgery. Wrapping allografts in vancomycin-soaked gauze has been adopted as a common sterilization technique in the operating room to reduce surgical-site infection; however, identifying effective alternatives to vancomycin has not been extensively pursued. Hypothesis: Tobramycin would be as effective as vancomycin in reducing the concentrations of Staphylococcus epidermidis bacteria on tendon allografts. Study Design: Controlled laboratory study. Methods: S. epidermidis strain ATCC 12228 was inoculated onto the human cadaveric gracilis tendon. The tendons were wrapped in sterile gauze saturated with tobramycin or vancomycin at various experimental concentrations. Bacteria remaining on the tendon were dislodged, serially diluted, and plated for colony counting. Statistical analysis was performed utilizing 2-way analysis of variance testing. Results were considered statistically significant when P < .05. Results: Vancomycin ( P = .0001) and tobramycin ( P < .0001) reduced bacterial concentration. Tobramycin was found to produce a statistically significant reduction in bacterial concentration at concentrations as low as 0.1 mg/mL ( P < .0001 and P = .01 at 10 and 20 minutes), while vancomycin produced a statistically significant reduction at a concentration as low as 2.5 mg/mL ( P < .0001 at both 10 and 20 minutes). Conclusion: This study demonstrates that tobramycin is as effective as vancomycin in bacterial concentration reduction but can achieve this reduction level at lower doses. Further studies clarifying the biomechanical and cytotoxic effects of tobramycin on tendon tissue are indicated to solidify its use as a clinical alternative to vancomycin in ACLR. Clinical Relevance: These results will begin establishing tobramycin as an alternative to vancomycin in ACL graft decontamination. Because of relatively frequent shortages of vancomycin, establishing tobramycin as an alternative agent is a useful option for the orthopaedic surgeon.

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“…Multiple meta-analyses showed that vancomycin soaking of the ACL graft can drastically reduce the incidence of postoperative septic knee arthritis after ACL reconstruction. 2,14,17,32 However, reservations regarding this method still prevail, and in 2021, two-thirds of the members of the prestigious ACL Study Group reported that they do not soak ACL grafts in vancomycin before implantation. 33 The most common concerns are vancomycin-induced weakening of the graft and chondrotoxicity.…”

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confidence: 99%

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confidence: 99%

Vancomycin Concentrations in Synovial Fluid Do Not Reach Chondrotoxic Thresholds After Anterior Cruciate Ligament Reconstruction With Vancomycin-Soaked Autologous Soft Tissue Grafts: An In Vivo Prospective Observational Study in Humans

Pfeiffer,

Althoff,

Krombholz

et al. 2023

Am J Sports Med

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Background: Studies have revealed that vancomycin soaking of the anterior cruciate ligament (ACL) graft can drastically reduce the incidence of postoperative infections after ACL reconstruction. However, it remains unknown whether the chondrotoxic threshold of vancomycin in synovial fluid is exceeded during this process. Several studies investigated the chondrotoxic properties of vancomycin in in vitro experiments and described a concentration of 1000 µg/mL as the critical threshold. Purpose/Hypothesis: The purpose of the study was to measure the vancomycin concentration in synovial fluid after ACL reconstruction with vancomycin-soaked autografts. It was hypothesized that intra-articular vancomycin concentrations in the synovial fluid would not reach the chondrotoxic threshold of 1000 µg/mL after vancomycin soaking of autologous semitendinosus tendon and soft tissue quadriceps tendon grafts for ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: The study enrolled 10 patients undergoing ACL reconstruction using 4-strand semitendinosus tendon autografts and 10 patients undergoing ACL reconstruction using soft tissue quadriceps tendon autografts. Before implantation, each harvested graft was intraoperatively wrapped in gauze swabs that had been soaked in a 5-mg/mL vancomycin solution. After wound closure, an aspirate of 5 mL of synovial fluid was taken from each patient. The vancomycin concentration of the aspirate was analyzed using high-performance liquid chromatography–tandem mass spectrometry. Spearman rho correlation coefficients were used to identify relationships between the parameters, and the t test was used to test for differences between graft types. A P value of <.05 was considered statistically significant. Results: The study included 20 patients (14 women and 6 men; age, 29.35 ± 11.3 years). The mean vancomycin concentration measured in the synovial fluid was 23.23 ± 21.68 µg/mL, with a minimum concentration of 2.32 µg/mL and a maximum concentration of 71.56 µg/mL. No significant difference was found between the 2 graft types ( P = .911). Significant positive correlation ( r = 0.644; P < .05) was observed only between the vancomycin concentration and the mean duration from initiation of vancomycin soaking of semitendinosus tendon grafts to implantation (13.4 ± 6 minutes). No correlations were observed between the vancomycin concentration and the duration from implantation to fluid aspiration or between the vancomycin concentration and the graft diameter (median, 8.5 mm; range, 6.0-10.0 mm) for both graft types. Conclusion: Chondrotoxic vancomycin concentrations ≥1000 µg/mL were not reached in any aspiration of synovial fluid after ACL reconstruction using soft tissue autografts that were intraoperatively soaked in a 5-mg/mL vancomycin solution. Against the backdrop of multiple studies that showed significantly reduced infection rates after ACL reconstruction when vancomycin soaking was used, this study suggests that the chondrotoxic properties of this method are negligible because of its submarginal intra-articular concentrations.

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Comparison Between Vancomycin and Gentamicin for Intraoperative Presoaking of Hamstring Graft in Primary Anterior Cruciate Ligament Reconstruction

Cited by 6 publications

References 27 publications

Intra-articular Vancomycin Reduces Prosthetic Infection in Primary Hip and Knee Arthroplasty

Intra-articular Vancomycin Reduces Prosthetic Infection in Primary Hip and Knee Arthroplasty

Tobramycin and Vancomycin in an In Vitro Model of Anterior Cruciate Ligament Allograft Decontamination

Vancomycin Concentrations in Synovial Fluid Do Not Reach Chondrotoxic Thresholds After Anterior Cruciate Ligament Reconstruction With Vancomycin-Soaked Autologous Soft Tissue Grafts: An In Vivo Prospective Observational Study in Humans

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