Vancomycin Graft Presoaking in Anterior Cruciate Ligament Reconstruction Surgery Is Associated with a Lower Risk of Graft Rerupture as Compared With No Vancomycin Presoaking: Systematic Review and Meta-analysis.

BACKGROUND: To determine whether there is any difference in graft rerupture rates and clinical outcomes between cases having vancomycin graft presoaking vs. no vancomycin presoaking in anterior cruciate ligament (ACL) reconstruction (ACLR). METHODS: Systematic review and meta-analysis. PubMed, Embase, CINAHL, and Cochrane CENTRAL were searched. Full published studies reporting on the relation between vancomycin graft presoaking and rates of graft rerupture and/or clinical outcomes in ACLR surgery vs. no vancomycin graft presoaking were included. Data extraction and quality appraisal were performed. Meta-analysis was conducted using a random effects model. The study's protocol was prospectively registered with PROSPERO (CRD42021290608). RESULTS: The literature search identified 907 records. After removing duplicates and those not meeting inclusion criteria, 8 studies were included. Meta-analysis showed that the estimated risk of hamstring graft rerupture was lower in cases presoaked with vancomycin vs. those having no presoaking (3.2% vs. 6.2% rerupture rate, risk ratio [RR] = 0.507, 95% CI, 0.39-0.737, p < 0.001). Similarly, the estimated risk of graft rerupture was lower in cases presoaked with vancomycin vs. those having no presoaking when the analysis included various ACL graft types (2.7% vs. 3.9% rerupture rate, RR = 0.557, 95% confidence interval [CI], 0.403-0.771, p < 0.001). Meta-analysis also showed that vancomycin graft presoaking was associated with similar International Knee Documentation Committee scores as compared with no presoaking when looking at hamstring grafts (estimated mean difference 0.112, 95% CI, -2.359 to 2.582, p = 0.929) or when considering various graft types (estimated mean difference 0.933, 95% CI, -0.140 to 2.006, p = 0.088). CONCLUSION: Vancomycin graft presoaking is a safe practice and does not compromise ACL graft rerupture rates or clinical outcomes. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

The impact of a meta-analysis on orthopaedic surgeons' practice with regards to vancomycin graft pre-soaking in anterior cruciate ligament reconstruction: A paper questionnaire survey study.

Background and Aims: Understanding the impact of orthopaedic scientific research is vital in identifying facilitators and barriers to its implementation in clinical practice. A meta-analysis was carried out which showed that presoaking hamstring (HT) autografts in vancomycin was associated with a 10-fold reduction in infection rate in anterior cruciate ligament (ACL) reconstruction. Our aim was to determine the practice of orthopaedic surgeons with regards to vancomycin presoaking and explore whether they would adopt the findings of this meta-analysis. Methods: A paper questionnaire survey was administered to attendees of an annual EFORT podium presentation of the meta-analysis findings. Descriptive statistics were used to summarize the characteristics of respondents and their responses. Results: A total of 29 senior surgeons/subspecialists performing a median of 40 ACL reconstructions per year completed the survey of whom 7 (24.1%) had encountered an ACL graft infection in the previous 2 years and 14 (48.3%) in the previous 5 years. Only 3 (10.3%) presoaked the ACL graft with an antibiotic. About 1/4 of those who up to then did not pre-soak the graft (6/26, 23.1%) would consider changing their practice to pre-soaking with vancomycin, with similar findings (5/20, 25.0%) in those that used a HT autograft as their first choice. Conclusions: Orthopaedic surgeons are receptive to the findings of a meta-analysis reporting on the effectiveness of vancomycin graft presoaking in ACL reconstruction, which can thus have a substantial impact upon clinical care. Addressing concerns about vancomycin induced graft toxicity and comparing the pre-soaking effect to that of specific intravenous antibiotic regimens may further enhance the uptake of this practice.

Lateral compression type 1 (LC1) pelvic ring injuries: a spectrum of fracture types and treatment algorithms.

Lateral compression type 1 (LC1) fractures are the commonest pelvic ring injury. However, they represent a heterogenous spectrum of injury mechanisms and fracture patterns, resulting in a lack of strong evidence for a universally agreed treatment algorithm. Although consensus exists that LC1 fractures have a preserved posterior ligamentous complex and are vertically stable, controversy persists around defining internal rotational instability. As such, treatment strategies extend from routine non-operative management through to dynamic imaging such as examination under anaesthetic (EUA) or stress radiographs to guide fixation algorithm. Multiple protocols sit between these two, all with slightly different thresholds for advocating surgery or otherwise, exemplifying a broad lack of consensus that is not seen for other, more severe, grades of pelvic ring injury. In the following review we discuss the evolving concepts of pelvic ring instability and management, starting from a historical perspective, through to current trends and controversies in LC1 fracture treatment. Emerging directions for research and emerging pharmacological and surgical treatments/technologies are also considered and expert commentary from 3 leading centres provided. The distinction is made between LC1 fracture arising from high-energy trauma and those following low-energy falls from standing height (so-called fragility fractures of the pelvis-FFP), since these two patient groups have different functional requirements and medical vulnerabilities. Issues pertaining to FFP are considered separately.

Comparison of outcomes after different methods of fixation for extracapsular hip fractures: An observational study.

OBJECTIVE: Optimal management of intertrochanteric fractures using either sliding hip screws (SHS) or Intramedullary nail (IMN) fixation has long been disputed and the optimal length of a 'short nail' has yet to be clarified. Our aim was to investigate functional outcomes in patients who have undergone either sliding hip screw fixation or intramedullary fixation using varied lengths of nails to assess potential superiority. DESIGN: We retrospectively reviewed data from consecutive patients with trochanteric hip fractures between January 2010 - July 2019. Fracture fixation was performed with four different devices; SHS, 220mm and 175mm Targon PFT nails or 180mm Short Affixus Hip Fracture Nails. There was no significant difference in the patient demographics in each treatment group. MAIN OUTCOME MEASURES: Patients were followed up for 1 year post operatively to determine if there were differences in mobility and pain with the different fixation methods. RESULTS: There was no significant difference in the overall complication rate between methods of fixation. Overall Intramedullary nail fixation resulted in an improved mean pain score compared to SHS (mean difference 0.25, 95% CI 0.11 - 0.39, p=0.0005). On sub-analysis this was only statistically significant in 220mm Targon nails (mean difference 0.35, CI 0.19-0.57, p=0.0010) and not for the other two nails. In addition, there was a significant difference in mobility score (mean difference 0.38, CI 0.12-0.63, p=0.0036). On sub-analysis this was only statistically significant favouring the for 220 mm Targon nail (mean difference 0.57, CI 0.27-0.87, p=0.0002). CONCLUSION: We advise caution in interpreting the results of studies between different nails and SHS, as not all nails appear to be the same. Design features of modern nails such as length, proximal diameter, the use of a compression screw, lag screw interface within the nail and valgus inclination may all play a role in functional outcomes.

Relationship of Graft Type and Vancomycin Presoaking to Rate of Infection in Anterior Cruciate Ligament Reconstruction: A Meta-Analysis of 198 Studies with 68,453 Grafts.

BACKGROUND: Infection is a devastating complication in anterior cruciate ligament reconstruction (ACLR) surgery. Given the rarity of infection, pooling individual studies via meta-analysis can allow more meaningful evaluation of factors influencing infection rates. We aimed to determine the relationship of graft type and vancomycin graft presoaking to bacterial infection rates following ACLR. METHODS: A systematic literature search was conducted on PubMed, Ovid MEDLINE, Embase, and CENTRAL (Cochrane Register of Controlled Trials). Included articles were those reporting on primary arthroscopic or open ACLR procedures, using hamstring (HT) or bone-patellar tendon-bone (BPTB) autografts or allografts of any type, with regard to the outcome of infection (deep infection or septic arthritis). Meta-analyses were performed to estimate the overall infection rates in ACLR surgery according to graft type and to examine the effect of presoaking grafts in vancomycin on infection rates. RESULTS: We identified 306 bacterial infections in 68,453 grafts across 198 studies. The overall estimated ACL graft infection rate in our meta-analysis was 0.9% (95% confidence interval [CI] = 0.8% to 1.0%). HT autografts were associated with a higher infection rate (1.1%, CI = 0.9% to 1.2%) than BPTB autografts (0.7%, CI = 0.6% to 0.9%) and allografts (0.5%, CI = 0.4% to 0.8%) (Q = 15.58, p < 0.001). Presoaking HT autografts in vancomycin reduced infection rates to 0.1% (CI = 0.0% to 0.4%) (Q = 10.62, p = 0.001). CONCLUSIONS: Infection following ACLR remains a rare but serious complication. HT autografts are associated with higher infection rates than other graft types. Presoaking HT autografts in vancomycin reduces infection rates by an estimated tenfold. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.