Summary

The incidence of septic arthritis following ACLR can be reduced dramatically by vancomycin-soaking the grafts intra-operatively prior to graft passage and fixation.

Abstract

The purpose of this review was to compare the incidence of postoperative septic arthritis following anterior cruciate ligament reconstruction (ACLR) between patients receiving routine pre-operative intravenous (IV) prophylaxis only intravenous (IV) infection prophylaxis and patients receiving additional graft-soaking in a vancomycin solution (5 mg/ml) perioperatively. Second, to review the literature regarding effects of graft-soaking in vancomycin solutions on outcomes, complication rates and tendon properties in ACLR.

Methods

To identify studies pertaining to routine pre-operative IV prophylaxis and additional usage of intra-operative vancomycin-soaked grafts in primary ACLR, the Cochrane Library, SCOPUS and MEDLINE were searched to June 2018 for English and German language studies of all levels of evidence following the PRISMA guidelines. Additionally, all accepted abstracts at the ESSKA 2018, ISAKOS 2017, AGA 2017 and AOSSM 2017 meetings were screened. Data regarding the incidence of septic arthritis were abstracted and combined in a meta-analysis. Data including outcome scores, complication rates and in vitro analyses of tendon properties were collected and summarized descriptively.

Results

Upon screening 785 titles, eight studies were included. These studies examined 5,075 patients following ACLR and followed from six to 52 weeks post- operatively. Of those 2,099 patients in the routine pre-operative IV prophylaxis group, 44 (2.1%) cases of early septic arthritis were reported. In contrast, there were no reports of septic arthritis following ACLR in 2976 cases of vancomycin-soaked grafts. The meta-analysis yielded an odds ratio of 0.04 (0.01-0.16) favoring the addition of intra-operative vancomycin-soaking of grafts. Across all available studies, no differences in clinical outcome (i.e. incidence of ACL-revision, IKDC score, Tegner score), biomechanical tendon properties, or cartilage integrity between patients with and without vancomycin-soaked grafts were identified.

Conclusion

The incidence of septic arthritis following ACLR can be reduced dramatically by vancomycin-soaking the grafts intra-operatively prior to graft passage and fixation. Within the limitation confines of this study, intra-operative graft-soaking in vancomycin appears to be a safe and effective method to reduce the incidence of septic arthritis following ACLR. Still, it remains debatable if the available data facilitate the recommendation for a universal application of vancomycin-soaking for all ACLR patients or if it should be reserved for patients at risk.