Soaking ACL grafts in vancomycin solution (1 mg/ml) reduces the infection rate without increasing the risk for re-rupture and arthrofibrosis

Hees, Tilman; Abdelatif, Yassen; Karpinski, Katrin; Bierke, Sebastian; Häner, Martin; Park, Hi Un; Petersen, Wolf

doi:10.1007/s00402-021-04004-w

Cited by 15 publications

(18 citation statements)

References 26 publications

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“…In a slightly larger cohort of patients (n = 852) treated with 5 mg/mL vancomycin-soaked graft, Offerhaus et al reported an 11% rate of arthrofibrosis, which was higher than the 7% rate in a comparative cohort of patients with untreated grafts (n = 926). Although this did not reach statistical significance, 44 future studies should include reported rates of arthrofibrosis.…”

Section: Published Protocolsmentioning

confidence: 75%

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

LeClere

Cox

Wright

2022

J Am Acad Orthop Surg

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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.

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Section: Published Protocolsmentioning

confidence: 75%

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

LeClere

Cox

Wright

2022

J Am Acad Orthop Surg

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“…a Using the Modified Coleman Methodology Score (MCMS), Xiao et al 56 concluded that 3 of the studies 8,33,47 were of fair quality and 5 studies 6,14,38,40,53 were of poor quality. The recent study by Hees et al 19 had an MCMS of 42 and was deemed to be of poor quality. It was included in the repeated meta-analysis.…”

Section: Methodsmentioning

confidence: 99%

“…Therefore, the decision was made to exclude the study by Baron et al and to repeat the meta-analysis of the remaining 8 studies. A repeated search of the PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials databases, using the same search criteria as those of Xiao et al, 56 yielded 1 additional retrospective cohort study 19 (level 3 evidence) as of August 1, 2021. These 9 studies demonstrated zero infections with the vancomycin presoaking technique.…”

Section: Transition Probabilitiesmentioning

confidence: 99%

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Vancomycin Soaking Is Highly Cost-Effective in Primary ACLR Infection Prevention: A Cost-Effectiveness Study

et al. 2022

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Background: Although presoaking grafts in vancomycin has been demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain. Purpose: To 1) determine the cost-effectiveness of vancomycin presoaking during primary ACLR to prevent postoperative joint infections and 2) to establish the break-even cost-effectiveness threshold of the technique and determine its cost-effectiveness across various international health care settings. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A Markov model was used to determine cost-effectiveness and the incremental cost-effectiveness ratio of additional vancomycin presoaking compared with intravenous antibiotic prophylaxis alone. A repeated search of the PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials databases, using the same criteria as a recent meta-analysis, was completed. A repeated meta-analysis of 9 cohort studies (level 3 evidence) was completed to determine the odds ratio of infection with vancomycin presoaking compared with intravenous antibiotics alone. Estimated costs of the vancomycin technique, treatment of infection, and further surgery were sourced from local hospitals and literature. Transitional probabilities for further surgery, including revision reconstruction and primary arthroplasty, were obtained from the literature. Probabilistic sensitivity analyses and a 1-way sensitivity analysis were performed to evaluate the ACLR infection rate break-even threshold for which the vancomycin technique would be no longer cost-effective. Results: The vancomycin soaking technique provides expected cost savings of $660 (USA), A$581 (Australia), and €226 (Spain) per patient. There was an improvement in the quality-adjusted life-years of 0.007 compared with intravenous antibiotic prophylaxis alone (4.297 vs 4.290). If the infection rate is below 0.014% with intravenous antibiotics alone, the vancomycin wrap would no longer be cost-effective. Conclusion: The vancomycin presoaking technique is a highly cost-effective method to prevent postoperative septic arthritis after primary ACLR.

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“…Potential complications and their corresponding prevention techniques include the following: infection that can be prevented by presoaking the graft in vancomycin, 3 cartilage damage at the medial femoral condyle due to the drill bit that can be prevented by correct medial portal placement, 6 posterior blow out of the femoral tunnel (consider femoral suspensory fixation), tunnel malplacement that can be prevented if you are familiar with anatomic landmarks and if you are uncertain, check the tunnel position with the fluoroscope. 6 For postoperative rehabilitation, a 3-phase and criteriabased rehabilitation protocol is recommended.…”

Section: What About Indication?mentioning

confidence: 99%

Technique of ACL Reconstruction With Autologous Quadriceps Tendon Bone Graft and Femoral Press Fit Fixation

Petersen

Ohde

Karpinski

et al. 2022

Video Journal of Sports Medicine

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Background: Recently, there has been an increase in interest in the quadriceps tendon (QT) as an alternative autologous graft option for primary anterior cruciate ligament (ACL) reconstruction. Indication: Anterior cruciate ligament reconstruction in skeletally mature patients (high-risk patients for re-rupture and patients with medial instability). Technique Description: The QT graft is harvested with a 4-cm skin incision over the superior pole of the patella. A double knife and an oscillating saw are used to obtain the QT graft with a bone block from the patella (65 mm x 10 mm graft and 15 mm bone block). Then an arthroscopy is carried out with assessment of the ACL tear and treatment of further intraarticular injuries. ACL reconstruction begins with debridement of the femoral insertion to expose the land marks. The medial portal is used for femoral tunnel drilling with the knee in more than 110° of flexion. A special portal aiming device is introduced via the anteromedial portal and a guide wire is placed in the area of the femoral anteromedial insertion. This guide wire is gradually overdrilled with various drills and dilators of increasing size. The final diameter should be 0.5 mm smaller than the diameter of the bone block of the graft to allow for press-fit fixation. Then, the tibial tunnel is drilled using a tibial drill guide leaving the tibial stump of the original ACL intact. The graft is pulled into the joint through the tibial tunnel until the bone block stops at the femoral tunnel entrance. The bone block is then pushed through the medial portal into the femoral tunnel (press-fit fixation). The tibial fixation is performed with an interference screw and optionally with an extracortical button. Results: Prior studies with 2 years follow-up have shown that the clinical outcomes in primary and revision ACL reconstruction were not significantly different between the use of QT grafts with femoral press-fit fixation and the use of hamstring grafts with femoral suspension fixation. Discussion/Conclusion: Quadriceps tendon bone autograft and femoral press-fit fixation provides an excellent alternative as a graft choice in ACL reconstruction. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

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Soaking ACL grafts in vancomycin solution (1 mg/ml) reduces the infection rate without increasing the risk for re-rupture and arthrofibrosis

Cited by 15 publications

References 26 publications

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

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

Vancomycin Soaking Is Highly Cost-Effective in Primary ACLR Infection Prevention: A Cost-Effectiveness Study

Technique of ACL Reconstruction With Autologous Quadriceps Tendon Bone Graft and Femoral Press Fit Fixation

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